Every finding on record at University Park Nursing And Rehabilitation Center

Based on observations, clinical record review, staff interview, and policy review the facility failed to disinfect a mechanical lift after use between 2 of 2 residents (#37, #55) and failed to use appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and enteric isolation precautions for 2 of 2 residents (#13, #75). The facility reported a census of 74 residents. Findings include:During a continuous observation that began on 3/03/2026 at 6:37 AM, Staff K, Certified Nurse Aide (CNA) transported a mechanical lift from a storage room to Resident #54's room.At 6:40 AM, Staff K transported the mechanical lift from Resident #54's room to Resident #55's room. The mechanical lift was not sanitized between resident use.At 6:50 AM, Staff J, CNA transported the mechanical lift from Resident #55's room and took it to Resident #37's room. The mechanical lift was not sanitized between resident use.At 6:56 AM, Staff J transported the mechanical lift from Resident #37's room and placed it in the shower room. The mechanical lift was not sanitized after resident use.At 7:02 AM, Staff J stated the mechanical lifts should be sanitized before and after resident use. She also stated should've sanitized the mechanical lift between residents but didn't. 2. Resident #75's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of hemiplegia (one-sided body paralysis caused by brain or spinal cord damage), asthma, and enterocolitis (inflammation of the small intestines and colon) due to clostridium difficile (C-diff - toxin producing bacteria that sheds spores). It revealed he required setup assistance with eating, supervision with oral hygiene, moderate assistance with bathing, sitting-to-lying, and lying-to-sitting, maximal assistance with footwear, bed mobility, sit-to-stand, and car and shower transfers, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It further revealed the resident received an antibiotic during the 7-day look-back period.The Electronic Health Record (EHR) revealed the resident was receiving a daily antibiotic dated 2/04/26 for C-diff.The Care Plan revised 1/21/26 indicated the resident was on enteric isolation due to C-diff and directed staff to post appropriate signs outside of room to ensure visitors check with nursing prior to entering.During a continuous observation that began on 3/02/26 at 8:26 AM, Staff L, Registered Nurse (RN) entered Resident #75's room to administer medications without putting on PPE. She stated he was still receiving antibiotics and being seen by an Infectious Disease physician.At 8:32 AM, Staff M, Activities Director (AD) entered the resident's room without PPE and delivered his mail. She exited his room and entered the next resident's room.An Enteric Contact Precautions (infection control measures for pathogens spread by feces) sign was attached at the resident's room entrance. It directed staff to wear a gown and gloves upon entry and to wash hands with soap and water. 3.Resident #13's MDS dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of obstructive uropathy (urine flow blockage), seizure disorder, and ulcerative colitis (bowel inflammation that causes ulcers). It indicated she required supervision with eating, moderate assistance with all forms of non-ambulatory mobility, and maximal assistance with all other ADLs and ambulatory mobility. It further revealed she had a urinary catheter and a feeding tube.On 3/04/26 at 7:00 AM, Staff N, Registered Nurse (RN) entered Resident #13's room to disconnect the feeding tube and administer medications. She performed hand hygiene in the resident's room and donned gloves. She stopped the tube feeding and disconnected it. She used a 50ml plunger and performed an air test for placement. She flushed the tube with 30 milliliters (mL) water. She attempted to administer medications through the feeding tube but could not get the medications through the tube. She removed the gloves, performed hand hygiene and notified the DON. She did not put on any other PPE throughout the process. An Enhanced Barrier Precautions (EBP) sign was attached to the resident's door.At 7:25 AM, Staff N stated she believed the EBP was for the other resident who shared Resident #13's room.On 3/04/26 at 2:15 PM, the Director of Nursing (DON) stated staff should sanitize equipment before and after resident use and should follow isolation precautions.A policy titled Infection Prevention and Control Program Policy and Procedure dated 1/01/26 indicated all staff are responsible for following all policies and procedures related to the program. It also indicated all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.A policy titled Management of C. Difficile Infection dated 2025 indicated all staff are to wear gloves and a gown upon entry into the resident's room and while providing care for the resident with C. difficile infection. It also indicated hand hygiene shall be performed by handwashing with soap and water in accordance with facility policy for hand hygiene.The EBP sign directed staff to wear gloves and a gown for the followingHigh-Contact Resident Care Activities.DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomyWound Care: any skin opening requiring a dressing

Based on observation, electronic health record (EHR) review, staff interviews, and policy review, the facility failed to assure a medication error rate of less than 5%. A total of 27 ordered medications were reviewed with two errors, an error rate of 7.4%. The facility reported a census of 74. Findings include: During an observation on 3/4/26 at 7:55 AM, Staff B, Licensed Practical Nurse, prepared at total of 8 different medications for Resident #33. Staff B obtained one Omeprazole 20 milligrams (mg) pill from the resident's medication card as well as one Omeprazole 20mg pill from an over-the-counter floor stock bottle. Staff B also obtained two Vitamin D3 125 micrograms (mcg)/500 International Units (IU) pills from an over-the-counter floor stock bottle. These medications along with 6 others were administered to Resident #33. During reconciliation of the observed medication pass with current Physician Orders for Resident #33, the following was noted: 1.Omeprazole 20mg ordered for 1 capsule daily; 2.Vitamin D 1.25mg (50,000 IU) ordered for 1 capsule one time a week. In an interview at 3/4/26 at 8:30 AM, Staff B confirmed Resident #33's Omeprazole order at 20mg (1 pill). Upon further discussion, Staff B realized they should have administered the pill from the medication card only and not also from the stock bottle. In an interview on 3/4/26 at 10:25 AM, Staff C, Pharmacist, confirmed the Vitamin D order at 1.25mg weekly. Staff C explained this is sent via a resident-specific medication card.In a follow-up interview on 3/4/26 at 10:45 AM, Staff B acknowledged the Vitamin D pill should have been from the medication card and not the stock bottle. The undated policy Medication Administration noted the following: 1.Ensure the six rights of medications administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 2. Review the Medication Administration Record (MAR) to identify medication to administer 3. Compare the medication source (bubble pack, bottle, etc) with the MAR to verify resident name, medication name, form, dose, route, and time 4. Administer medication as ordered in accordance with manufacturer specifications

Based on clinical record review, staff and resident interview, and facility policy review, the facility failed to provide showers for dependent residents in 1 of 18 resident's reviewed for activities of daily living (ADLs) (Resident #58). The facility reported a census of 74. Findings include: The Minimum Data Set (MDS) for Resident #58, completed on 02/25/2025, recorded the resident's Brief Interview for Mental Status (BIMS) score as 14, which indicated intact cognition. It documented the following relevant diagnoses: Diabetes Mellitus (diabetes), and arthritis. It documented the resident was a below-the-knee amputee and had reduced mobility and a need for assistance with personal cares. It documented the resident entered the facility on 11/28/2025. The Care Plan for Resident #58, last revised on 03/02/2026, documented the resident required two-person assistance for bathing and showering, and instructed staff members to encourage the resident to bathe or shower twice weekly. Review of bath and shower records from 12/01/2025 through 03/01/2026 revealed the following: Resident #58 had a bed bath as requested on 12/05/2026From 12/06-12/14 there is no documentation about refusals, and no documentation to show the resident received a bath, shower, or bed bath in this timeframe. Resident #58 had a shower on 12/15/2025From 12/16/2025 through 01/11/2026 there is no documentation about refusals, and no documentation to show the resident received a bath, shower, or bed bath in this timeframe. Resident #58 was given a shower on 01/15/2026 Resident #58 refused a shower on 01/19/2026Resident #58 refused a shower on 01/26/2026. There are no documented showers or refusals from 01/19/2026 until 01/26/2026. Resident #58 was given a shower on 02/02/2026From 02/09/2026 through 03/01/2026 there is no documentation about refusals, and no documentation to shower the resident received a bath, shower, or bed bath in this timeframe. A review of the Kardex Plan of Care (POC) Response history with a lookback period of the last 30 days documented only one day in the last 30 days. 02/20/2026, and documented the resident did not receive a shower or bath on this date. Review of the Nursing Progress Notes from 11/28/2025 through 03/05/2026 documented two bath or shower refusals, once on 12/05/2025 in which the resident asked for a bed bath, and once on 01/19/2026. In an interview on 03/01/2026 at 02:07 PM with Resident #58, he stated he had only been offered and given two showers and one bed bath since he entered the facility. In an interview on 03/05/2026 at 09:47 AM with the Assistance Director of Nursing (ADON), she stated the facility had given surveyors all of the documentation they were aware of regarding baths and showers on 03/04/2026 and again on 03/05/2026. She stated refusals might also be documented in the nursing progress notes. In an interview on 03/05/2026 at 10:28 AM with Staff O, Certified Nurse Aide (CNA), she stated bath and shower sheets are how the facility and CNAs keep track of showers for residents. When a resident has a bath or if they refuse they document on the shower sheets. Nurses sign off on the shower sheets and then enter a nursing progress note if there was a refusal. She stated Resident #58 is supposed to be showered twice a week, but does refuse. She stated if there is no shower sheet, there is no way to prove the resident refused or received a shower. In an interview on 03/05/2026 at 10:39 AM with Staff P, CNA, she stated the nurses and CNAs sign off on the bed bath sheets to document if a resident got or refused a shower. She stated she doesn't know if the nurse documents anything after signing the sheet. She stated they do not use the Kardex or Pocket Plan of Care, they use bath sheets. She stated it is expected of her that she fill out and sign a bath sheet every time she offers a resident a bath, even if they refuse, because she documents the refusal on the sheet. In an interview on 03/05/2026 at 10:46 AM with Staff Q, Licensed Practical Nurse (LPN), she stated refusals and baths are documented on the bath sheets. She confirmed both nurses and CNAs are required to sign off on the bath sheets. She stated that if she did not see a bath sheet for a resident her assumption is that a bath was not offered. In an interview on 03/05/2026 at 10:01 AM with the Director of Nursing (DON), she stated her expectations for staff members is that they fill out a bath sheet for every bath, shower, or refusal. She stated if it isn't documented the facility cannot prove a resident was given or refused a shower. She stated when she questioned staff members they admitted they had been forgetting to fill out refusals for Resident #58. Review of a facility provided document titled Resident Showers, with no known implementation or review date, stated Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. It contained no information regarding shower sheets or how to document refusals.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to correctly position a resident in a mechanical lift during transfer for 1 of 3 residents (#14), failed to lock the wheelchair during resident transfers for 2 of 3 residents (#44, #55), and failed to attach foot pedals on the wheelchair while transporting a resident for 1 of 1 resident (#69). The facility reported a census of 74 residents.Findings include:1.Resident #14's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of hemiplegia (one-sided body paralysis caused by brain or spinal cord damage), diabetes mellitus, and a stroke. It revealed he was independent with eating and oral hygiene, was dependent with toileting, and required maximal assistance with all other Activities of Daily Living (ADLs) and all forms of mobility.The Care Plan initiated 10/24/24 directed staff to transfer the resident with an EZ Stand (mechanical device used to transfer a resident in a standing position).On 3/01/26 at 10:15 AM, Staff D, Certified Nursing Aide (CNA) and Staff E, CNA transferred Resident #14 in an EZ Stand. Staff E positioned the EZ Stand in front of the resident's wheelchair, opened the EZ Stand legs, positioned the sling around the resident's back, and fastened it to the EZ Stand. The resident's knees were not touching the shin pads as Staff D raised the resident from his wheelchair.2.Resident #44's MDS assessment dated [DATE] identified a BIMS score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia and Down Syndrome. It revealed he required supervision with walking 10 feet, moderate assistance with eating, lying-to-sitting, and sitting-to-lying, maximal assistance with all other ADLs, toilet and shower transfers, and bed mobility, and was dependent with sit-to-stand and chair-to-chair transfers.The Care Plan revised 2/11/26 directed staff to use a mechanical lift for resident transfers.On 3/02/26 at 8:40 AM, Staff F, CNA and Staff G, contract staff transferred Resident #44 in a mechanical lift from his bed to his Broda chair (specialized chair with enhanced support features). Staff F held the resident's support sling while Staff F lowered the resident onto the Broda chair. Staff F pressed her foot down on the mechanical lift frame to stabilize it then locked it as the resident got closer to the chair. The Broda chair was unlocked throughout the transfer process.On 3/02/26 at 9:23 AM, Staff F and Staff G transferred Resident #44 from his Broda chair to a recliner in front of the nurses' station. The Broda chair's rear right wheel was not locked during the resident's transfer.3.Resident #69's MDS assessment dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, seizure disorder, and mild intellectual disabilities. It revealed he required supervision with eating and was dependent in all other ADLs and mobility.The Care Plan revised 9/10/22 revealed the resident did not ambulate but used a wheelchair that he can self-propel.On 3/01/26 at 2:42 PM, Staff H, CNA transported Resident #69 in his wheelchair without foot pedals. Staff H and Staff I, CNA transferred the resident from his wheelchair to his bed with a mechanical lift. The wheelchair was unlocked during the transfer process.Staff H and Staff I stated the wheelchair should be locked when transferring a resident to or from it. Staff H also stated they did not notice the wheelchair was unlocked. She further added the resident should not have been transported in his wheelchair without his foot pedals.4.Resident #55's MDS assessment dated [DATE] identified a BIMS score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of hemiplegia, diabetes mellitus, and chronic obstructive pulmonary disease (COPD). It revealed she required supervision with eating and was dependent with all other ADLs and mobility.The Care Plan revised 12/17/25 directed staff to use a mechanical lift with 2-person assistance for resident transfers.On 3/03/26 at 6:43 AM, Staff J, CNA and Staff K, CNA transferred Resident #55 with a mechanical lift from her bed to a wheelchair. Staff K raised the resident in the mechanical lift sling while Staff J positioned the wheelchair between the mechanical lift's legs. Staff K lowered the resident into the wheelchair. The wheelchair was unlocked throughout the transfer process.At 7:02 AM, Staff J stated the wheelchair should be locked when transferring a resident in or out of it but she forgot to lock it.At 7:05 AM, Staff K stated wheelchairs should be locked when transferring residents in or out of them.A policy titled Mechanical Lift Policy and Procedure dated 9/01/25 directed staff to perform a test lift before full transfer by raising the resident 2 inches off the surface to check sling fit, attachment security, and weight distribution.The facility did not provide a policy regarding locking wheelchairs or transferring residents in a wheelchair without foot pedals.On 3/04/26 at 2:15 PM, the Director of Nursing (DON) stated staff should lock the brakes on wheelchairs during resident transfers and follow the policy with resident transfers.

Based on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 1 of 13 residents (Resident #6) reviewed. The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) of 00 indicating severe cognitive impairment. MDS also indicated diagnosis of dysphagia, oropharyngeal phase. Review of EHR titled, Physician Orders for Resident #6 documented a regular diet of pureed texture. Review of EHR titled, Care Plan for Resident #6 documented a diet of puree consistency with thin liquids. Review of document titled, University Park FW 2024-2025, Week 3 Tuesday at noon documented a puree menu of 1 serving (8 oz) puree chili, 1 serving (1 each) puree cinnamon roll, 1 serving puree tossed salad, puree brownie/cinnamon buttercream frosting and 8 oz beverage. Review of untitled document dated Tuesday May 6, 2025 for Resident #6 documented diet of pureed - No Added Salt with menu items 1 serving puree chili, 1 serving puree cinnamon roll, 1 serving puree tossed salad/dressing, 1 serving puree brownie/cinnamon buttercream frosting and 8oz beverage. On 5/6/25 at 12:35 PM Staff A, Dietary Aide acknowledged her intention was to serve Resident #6 who was on a puree diet one 4oz scoop of chili for lunch. On 5/6/25 at 12:45 am Staff B, Dietary Manager acknowledged the puree measured to 4 cups and Staff A should serve all residents with a puree diet two 4oz scoops for the appropriate serving size. Staff B stated he did not tell her that she needed to use 2 scoops prior to lunch service. Staff B acknowledged it was his error that led to the incorrect serving size. During a continuous observation of lunch service on 5/6/25 Staff A completed hand hygiene, served all regular diets, Resident #6 was served two 4oz scoops of chili. Staff A stated at that time that was all Resident #6 received for lunch. Staff B stated no Resident #6 also needed to get the puree vegetables and dessert. Staff A then gave Resident #6 puree vegetables and dessert. Observation at that time of pureed cinnamon roll sitting on the table and remained unserved. Staff A acknowledged she was done with lunch service at that time. On 5/6/25 at 12:56 PM Staff B acknowledged Staff A stated she was done serving and had not served the cinnamon roll, cinnamon cream cheese frosted brownie or the vegetable. Staff B acknowledged he had to tell Staff A to serve the pureed dessert and pureed vegetable and that the pureed cinnamon roll was never served during any of the service. Review of undated policy titled, Portion Control documented food will be served according to standard portion sizes to ensure adequate serving of food and to provide portions that are equal in size for those residents that do not require specialized dietary modifications. Residents on diets that require portion variations will have the required information either stated on their tray card or it can be found on the diet spreadsheet under the diet they were on. On 5/7/25 at 4:00 PM the Administrator stated the facility's expectation was the meal would have been served according to the menu.

Based on observation, Electronic Heath Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a surgical wound, a pressure wound and a resident with a wound vacuum, that were on Enhanced Barrier Precautions (EBP) for 3 of 3 reviewed (Resident #3, #4, and #7). The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. MDS also indicated Resident #3 had an unstageable pressure ulcer. Review of Resident #3's EHR dated 5/5/25 titled, Weekly Pressure Wound Assessment documented an unstageable pressure wound present on the left heel that measured 3/6 cm length x 1.1 cm width x 0.1 depth. Review of Resident #3's EHR titled, Care Plan documented Resident #3 required EBP related to the presence of a chronic wound - pressure ulcer. Observation on 5/6/25 at 8:32 AM of dressing change for Resident #3 by Staff C, Licensed Practical Nurse (LPN) completed hand hygiene, did not apply gown, removed boot from left foot, removed gloves, completed hand hygiene, applied gloves, opened dressing packages, removed gloves, completed hand hygiene, applied gloves, removed sock from left foot, applied barrier under foot, removed gloves, completed hand hygiene, applied gloves, removed dressing, removed gloves, completed hand hygiene, applied gloves, area cleansed with wound wash, area allowed to dry, betadine applied to area, 4 x 4 gauze dressing applied to area, gauze wrap applied to left heel, gloves removed, hand hygiene completed, gloves applied, sock applied, Prevalon boot applied, gloves removed, hand hygiene completed, left room cleansed bedside table, and hand hygiene completed. 2. The MDS dated [DATE] documented Resident #4 had a BIMS of 15 indicating no cognitive impairment. MDS also indicated Resident #4 had a stage 3 pressure ulcer and surgical wounds. Review of Resident #4's HER titled, Care Plan documented Resident #4 required BP related to the presence of wounds (pressure ulcer). The HER titled, Care Plan also documented Resident #4 had surgical incisions to both lower extremities. 3. The MDS dated [DATE] documented Resident #7 had a BIMS of 15 indicating no cognitive impairment. MDS also indicated Resident #7 had a surgical wound. Review or Resident #7's HER titled Care Plan documented Resident #7 Required BP related to the presence of a chronic wound - surgical wound. Observation on 5/5/25 at 9:45 AM of Staff D, Certified Nurse Assistant (CNA)/Certified Medication Assistant (CMA) and Staff E, CNA in room [ROOM NUMBER] transfer Resident #4. Both staff completed hand hygiene, applied gloves, did not apply gowns, placed full body transfer sling under Resident #4 in bed, Staff D asked Resident #4 to cross her arms, full body sling supported by Staff E, Staff E placed Wheelchair under Resident #4, Resident #4 lowered into the wheelchair, lift cloth removed by Staff E. Both staff removed gloves, Staff D completed hand hygiene, Staff E threw her gloves away, did not complete hand hygiene, left Resident #4's room, walked down the hall to the next resident's room with full body mechanical lift. Staff E entered Resident #7's room. Staff E applied gloves, applied lift cloth to lift, Staff D supported left cloth with resident for transfer from wheelchair to bed, Staff E utilized lift controls. EBP equipment noted outside Resident #7's room. Resident #7 laid down in bed and lift cloth removed. Staff D placed Resident #7's wound vacuum on the foot of Resident #7's bed. Staff D removed Resident #7's brief, Staff E assisted the resident in turning to the left, brief was replaced, Resident #7 was currently having a bowel movement. Both staff removed gloves and completed hand hygiene On 5/6/25 at 2:41 PM the Director of Nursing (DON) stated Resident #3 had a 3 drawer outside of his room on 5/1/25 with a sign reflecting the need to wear EBP outside the room. The DON acknowledged Resident #3 had a care plan for EBP in place. The DON stated the staff should have worn gowns and gloves in Resident #4's room. The DON acknowledged that the staff should have completed hand hygiene after care with Resident #4, completed hand hygiene when entered Resident #7's room and then applied gowns in Resident #7's room. The DON acknowledged Resident #7 also had a care plan in place for EBP to be worn in the room with personal care. Review of policy dated 3/25/24 titled, Enhanced Barrier Precautions documented Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs). EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied before performing high-contact resident care activities. Personal protective equipment (PPE) was changed before caring for another resident. Examples of high-contact resident care activities requiring the use of a gown and gloves include dressing, transferring, providing hygiene, changing briefs, and wound care. Review of policy revised 8/19 titled, Handwashing/Hand Hygiene documented hand hygiene should be utilized during the following situations: before and after direct contact with residents, before handling clean or soiled dressings, after contact with a resident's intact skin, and before and after entering isolation precaution settings On 5/7/25 at 4:00 PM the Administrator stated the facility's expectation was gowns would have been worn in rooms where residents had enhanced barrier precautions in place. The Administrator stated the facility's expectation was that hand hygiene would have been completed before resident care, when moving from contaminated areas of the body to non-contaminated areas and after resident care.

Based on documentation review, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to document temperatures of food in the kitchen prior to distribution. The facility reported a census of 76 residents. Findings include: Reviewed the kitchen meal temperature logs for 3 months. 4 meal temperatures out of 90 meals were not recorded in November. 8 meal temperatures out of 93 meals were not recorded in December. 25 meal temperatures out of 78 meals were not recorded in January On 1/29/25 at 12:30 PM the Dietary Director expected that all temperatures would be completed in the kitchen prior to distributing the food to the dining rooms, and completed in the dining rooms prior to serving. The Dietary Director stated he further expected that all temperatures were to be logged on the appropriate log forms whether the kitchen or dining rooms. The Dietary Director acknowledged with incomplete documentation it was unknown if the temperatures were taken prior to food distribution or serving, and the food had reached the required temperatures. On 1/29/25 at 1:20 PM the Administrator expected all food temperature logs be kept current to document temperatures taken in the kitchen and in the dining rooms. The Administrator concurred documentation is required to prove the food temperatures were taken prior to food distribution or serving. The facility policy, Food Preparation and Service, revised October 2017 revealed specific temperatures/times required for specific foods to be reached to inactivate pathogenic microorganisms. The document further revealed dietary staff would adhere to proper practices to prevent the spread of foodborne illness. The Food and Drug Administration Food Code 2022 revealed the person in charge of the kitchen should be provide daily oversight of the employees ' routine monitoring of the cooking temperatures.

Based on observations, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility placed cooking utensils on countertops, and delivered drinks uncovered. The facility reported a census of 76 residents. Findings include: Observation on 1/27/25 at 9:45 AM revealed the ice machine had a light pink substance throughout. Continuous observation on 1/28/25 at 9:53 revealed Staff A placed a scraper on a countertop without a barrier during the preparation of pureed meat. During the preparation of mashed potatoes Staff A placed the whisk on the countertop without a barrier. Continuous observation on 1/28/25 at 12:07 PM revealed room tray service initiated. A room service tray left the dining room with 3 drinks uncovered. During preparation of the second tray, Staff B, Certified Nursing Assistant (CNA), stated forgot to put lids on the drinks. Observed a tray with uncovered drinks leave the dining room and enter the hallway when the Registered Dietitian stopped the delivery, and directed the staff to return to the dining room to cover the drinks. During an interview 1/27/25 at 2:56 PM, Resident #84 stated he eats in his room. He said he wondered if the State was here today because his drinks had a cover over them for lunch and normally they do not, he said his drinks are served to him without a cover normally. On 1/29/25 at 12:30 PM the Dietary Director stated he was not aware of the ice machine needing to be monitored and cleaned as he was new to the position. The staff stated cooking utensils could be set on the countertops if the countertops were wiped off. The Dietary Manager stated he was not aware of when the last time the counters were wiped off prior to setting the utensils on them. The staff stated all liquids on room trays were to be covered prior to delivery. On 1/29/25 at 1:20 PM the Administrator stated she expected the ice machine to be kept in a clean manner and maintenance should be responsible for this. The Administrator stated she would be fine with utensils on counters if the counters had been wiped down, but could not guarantee when the counters had been wiped or if things had been set on them prior to staff setting utensils on them. The Administrator stated that cups should have lids on them prior to carrying them down the hall from the dining rooms on the floors. The facility policy, Ice Machines and Ice Storage Chests, revised January 2012 revealed the facility would have procedures for cleaning and disinfecting the ice machine adhering to the manufacturer's instructions. It further revealed the ice machine will be used and maintained to assure a safe and sanitary supply of ice. The facility policy, Food Preparation and Service, revised October 2017 revealed food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.

Based on personnel document review, staff interviews, and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 17 residents. Findings include: On [DATE] a request for documentation from the facility revealed the Dietary Director did not have the required certification. On [DATE] at 12:30 PM the Dietary Director confirmed he had been in the position for 3 weeks and had not completed the certification requirement yet. The Dietary Director stated he had previously held a Serve Safe Certification, but it had expired. The staff stated he was currently enrolled in the necessary coursework to complete the certification. On [DATE] at 1:20 PM the Administrator acknowledged the Dietary Manager was a new employee and had not completed his certification, but was currently taking the necessary coursework. The facility did not have a policy related to having a certified dietary manager. The Food and Drug Administration Food Code 2022 revealed the person in charge of the kitchen must be a certified food protection manager who has shown proficiency in required information through passing a test that is part of an accredited program.

Based on observation, staff interviews and policy review, the facility failed to maintain resident living areas in good repair and provide a homelike environment. The facility reported a census of 76 residents. Findings include: During an observation 1/27/25 at 12:00 PM, Resident #27 and #34's shared bathroom had wall damage on the floor board, a hole in the wall and the border coming off by the floor, with a large gap and hole in the wall. During an observation 1/27/25 at 12:58 PM, Resident #19 and #81's shared bathroom had a hole in the bathroom door in the middle, on the outside of the door. The bottom of the bathroom door was observed to be falling apart, with jagged edging and splintered wood. There was a hole along the floor board in the bathroom, by the sink. During an observation 1/29/25 at 12:30 PM, with the Administrator present, Resident #27 and #34's bathroom was observed, as well as Resident #19 and 81's bathroom. The Administrator advised she was not aware of the condition of the bathroom with damage to the walls in the bathrooms in more than one area and damage to the bathroom door. The Administrator stated the facility uses a tracking system called TELS to report, track and monitor repairs and maintenance issues. Staff are to use the TELS system to report repairs and maintenance issues. The Administrator pulls the report from TELS to see how timely repairs are fixed. The Administrator stated the damage to the floor and wall in the bathrooms is not homelike and stated an expectation this be repaired. The Administrator acknowledged the damage to the bottom of the door could be a safety concern with the wood being jagged and splintered. The Administrator is unaware if this damage was reported in TELS. During an interview 1/29/25 at 1:58 PM, the Administrator stated the damage to the bathrooms and doors were not reported in TELS and maintenance was not notified of the damage. The Administrator stated an expectation this damage be reported and be repaired. Review of the facility policy Quality of Life-Homelike Environment, with a revision date of May 2017, documented residents are provided with a safe, clean, comfortable and homelike environment.

Based on record review, staff interviews, and policy review, the facility failed to ensure residents were free from misappropriation of resident property for 1 of 1 resident's reviewed (Resident #35). The facility reported a census of 76 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) for Resident #35, dated 1/22/25, a Brief Interview for Mental Status (BIMS) was not conducted as the resident is rarely/never understood. The resident had diagnoses to include Debility, Cardiorespiratory Conditions, heart failure, renal insufficiency and Non-Alzheimer's Dementia. The Care Plan for Resident #35, with a revision date of 8/7/24, included the resident had the potential for diversional activity due to cognitive impairment and/or physical assistance needed. Interventions included to encourage ongoing family involvement and provide for social interaction opportunities. The Care Plan further included Resident #35 was the recipient of an allegation of abuse: theft of cellphone, with a revision date of 11/7/24. Interventions included encourage visits with Social Services/designee to promote healing/recovery, notification to local Law Enforcement as required, replacement of items evaluated by facility, staff to provide for separation from perpetrator of the allegation. Staff member suspended and terminated. The facility has ordered a cellphone holder to be worn around neck if desired. During an interview 1/28/25 at 9:53 AM, Resident #35's daughter, who is the responsible party and emergency contact for the resident, stated the facility offered to replace the phone that was stolen. She advised they did not have a passcode on the phone that was stolen because it was easier for Resident #35 to use it without the passcode. The daughter stated the family did not want to have criminal charges pressed against the staff who stole his phone. The daughter stated they realized the phone was missing around the end of October when she tried to Facetime her father and he did not answer. She thought the phone was dead or just misplaced, but they could not locate the phone in his room or at the facility. About a week later the family decided to activate an old phone they had and used the same phone number as the phone that was missing/stolen. The daughter noticed some text messages coming through that she did not recognize. She gave the messages to the Administrator. She stated the facility handled the phone incident really well, she believed the facility conducted a thorough investigation and let the staff member go who was believed to have taken the phone. During an interview 1/28/25 at 1:00 PM, the Administrator stated the facility made a referral to the Des Moines Police Department (DMPD), who said the family had to be the one to press charges. The family did not want to press charges. The facility offered to replace the missing cell phone, the family said they would replace the phone and did not want the facility to do this. The Administrator stated they realized the phone was missing when the family tried to Facetime the resident, this was around the first part of November, the family thought the phone was dead so they called the facility and the facility staff looked for the phone and could not find it. The family then activated another phone they had with the resident's phone number and when they did this, they noticed text messages on the phone. The facility thought it was Staff F, Certified Nursing Aide (CNA), who was using the resident's phone. Staff F did not admit to this and she did not show up for the 2nd interview they had scheduled with her. Staff F was terminated on 11/5/24. Review of the facility internal investigation report with regard to Resident #35's cell phone revealed on the night of Friday 10/25/2024, the daughter of Resident #35 messaged Staff E, Assistant Director of Nursing (ADON) to let her know that the resident's phone was dead and they were not able to facetime him like they wanted too. Staff E and other facility staff were not able to find the phone at this time. The daughter was notified and shared that she figured he lost it like he had in the past and it will come back like it has before. Staff continued to look for the phone. The daughter shared that the family decided to replace the phone because they believed that he had misplaced the phone, and it was in the facility somewhere. On Friday night 11/1/2024 the family of Resident #35 decided to activate an old phone that they had sitting at home. At this point they had turned on the new phone they saw messages from Friday the 1st that they did not know who they were from. The family then let the facility know that they believed the phone had been taken out of the facility by someone else. The facility worked with the family and received the cell phone from the family on Saturday night to be able to see if the facility knew any of the numbers that were messaged or called on the phone. A message that was received to the resident's new phone at 6:06 pm on Friday night was from Staff F stating that she was clocking out. This message was the only message sent to the phone from a staff member. The facility did call other numbers to see who they were and a lot of them were males that the facility did not have any correlation with. The facility then conducted interviews from all the staff that worked between 10/25/2024 to 11/1/2024. On 11/4/2024 when interviewing staff members the facility received the following responses, I have never seen the phone. I saw the phone a while ago but can not remember the last time. I saw the phone about 2 weeks ago sitting on the resident's mini fridge plugged in. The facility asked staff if they remember the color of the iPhone and the ones that have seen it stated that it was red. The color was verified by the family. The staff that typically work with the resident and on the fourth floor stated that they saw it approximately 2 weeks ago and on the mini fridge. The facility has been in contact with the family and let them know they believe they know who has taken the phone. The family still has stated that they will not be pressing charges but knows that it is their right to do so. The facility has also encouraged the family to change the resident's phone number so he does not receive messages from anyone who might have the old number. During a review of the text messages that came through to Resident #35's phone when the number was reactivated on 11/1/24, at 6:20 PM a text message was received on the resident's phone sent from a number stating I'm at Wayne's house. At 6:09 PM a text message was received that a Cricket update was completed. At 6:06 PM a text was received on the resident's phone number, this was a different number from the one received at 6:20 PM, it stated Clocking out. During an interview 1/29/25 at 11:12 AM, the Administrator stated the phone number that sent the message I'm at Wayne's house was a number the facility did not know or recognize. The Administrator called that number and a male answered and did not say their name, she did not recognize the voice. The Administrator called the number that sent the message to Resident #35's cell phone number on 11/1/24 at 6:06 PM that said Clocking out and a female answered, said hello. The Administrator said who she was and asked to whom she was speaking with, the female did not say, and hung up. The Administrator said she recognized the voice and thought it was Staff F, who had worked at the facility for a year. The Administrator texted that number from her personal phone on the 1st of November, saying hey is this Staff F, it's the Administrator from UP? Staff F replied back to the Administrator on the 4th of November, saying yes, this is her, what's going on? The Administrator texted Staff F back on this number that sent a text to the resident's number, asking Staff F to come into UP, they have a situation that they need her help with. Staff F replied back saying okay, I can come in a sec, let me throw some sweats on, is it bad? This was on Monday, the 4th of November. Staff F came in for an interview with the Administrator on the 4th of November. Staff F admitted the phone number that sent a text message to Resident #35's cell phone number on the 1st of November saying clocking out was her number, she said she used a texting app phone number and it generated the number that she had used to send text messages. The Administrator asked Staff F who she was texting to Resident #35's number that she was clocking out. Staff F then said she didn't text that number, she said she didn't know who it was. The Administrator watched video footage when Staff F clocked out that day and she got in her own car and left, did not see her on her phone or get into anyone's car. Staff F worked on the 1st of November, from 6:00 AM to 6:00 PM. The Administrator stated they looked through other staff phone's and did not see Resident #35's number come up anywhere on their phones. The Administrator thought Staff F took Resident #35's phone and gave it to someone she knows, because she texted that number. Staff F was asked to come back in for a second interview on the 4th of November, Staff F initially said she would come in, then she did not show up for the interview or show up for work on her next scheduled shift. Staff F was terminated on 11/5/24 due to a violation of company policy regarding not working with the facility on an investigation and a no call no show for a scheduled shift on November 5th, 2024. Resident #35 had a different roommate at the time, the roommate had a low BIMS and was not interviewable. Telephone contact was attempted with Staff F on 1/29/25 at 11:26 AM, a voice message was left and a text message was sent requesting a return call. During an interview 1/30/25 at 11:00 AM, the Administrator stated an expectation residents are free from abuse and do not have their property stolen or misappropriated. Review of the facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting, updated 7/8/24, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on observation, resident and staff interviews, record review and policy review, the facility failed to have sufficient nursing staffing to respond to resident's needs in a timely manner after a call light was activated. The facility reported a census of 76 residents. Finding include: 1. According to the Minimum Data Set (MDS) for Resident #50, dated 11/15/24, Resident #50 scored 14 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident was dependent on staff for toileting hygiene and required substantial assistance for lower body dressing. The resident's diagnoses included muscle weakness and other orthopedic conditions. During an observation 1/27/25 at 2:00 PM, upon entering the hallway, Resident #50's call light was activated above the door to the bedroom. During an observation 1/27/25 at 2:10 PM, Resident #50 was sitting on the toilet in the bathroom located in his bedroom, the call light above his door was on and activated. Resident #50 stated he pushed his call light at least 20 minutes prior and was waiting for staff to assist with toilet hygiene. Observed staff enter the resident's room at 2:10 PM and inquire what the resident needed and said they would return. Observed staff re-enter at 2:15 PM to assist the resident. During an interview 1/27/25 at 2:39 PM, Resident #50 stated he sat on the toilet for 45 minutes, he said he has his phone with him in his shirt pocket and said he pushed his light at 1:45 PM today. Resident #50 pulled his cell phone out of his shirt pocket, indicating he had this with him and it was on and working. Resident #50 stated he has sat on the toilet before for 25-30 minutes waiting for staff to help him wipe, he said he does not need assistance with transferring, he just needs assistance with wiping. He said his legs get sore from sitting on the toilet for so long. The resident stated this has happened a few times. He said they answer quickly when he pushes it while in his bed. The resident stated today when he sat for so long on the toilet he called down to the front desk to ask for someone to come up and help him. He said he has waited for 30-45 minutes for someone to come into the bathroom to assist him more than once. 2. According to the MDS for Resident #84, dated 1/21/25, Resident #84 scored 15 on the BIMS, indicating intact cognition. The resident was dependent on staff for toileting assistance and required substantial assistance for lower body dressing and chair to bed/chair transfer. The resident's diagnoses included a stroke. During an observation 1/27/25, beginning at 2:22 PM, Resident #84 was sitting sitting upright in his reclining chair with his pants partway down his legs with a brief on and visible from the open doorway to his bedroom. Resident #84 was observed sitting in this position until 2:50 PM when a staff placed a blanket over the resident's legs. The resident's call light was observed to be activated at 2:45 PM. Observation from 2:22 PM to 2:49 PM revealed no staff member entering the resident's room to assist the resident. During an interview 1/27/25 at 2:25 pm, Resident #84 stated staff was just in his room and little while ago, they needed to get another person for assistance. The resident stated he was wanting to get into his wheelchair and was a two person assist for transfers. During an interview 1/27/25 at 2:45 PM, Resident #84 stated no one came back to help him into his wheelchair so he put his call light back on, he said he has been sitting in his chair with his pants partway down waiting for assistance to get into his wheelchair since 2:00 PM. During an observation 1/27/25 at 2:56 PM, Resident #84 was still sitting upright in his reclining chair with a blanket over him, his pants were still not pulled up and he was still not transferred to his wheelchair. During an interview 1/29/25 at 2:45 PM, Staff D, Registered Nurse (RN), stated she was working on Monday, the 27th, on the 4th floor. She recalled being asked to go into Resident #84's room to assist him to pull up his pants, this was later in the afternoon, sometime around 3:00 PM or after. Staff D stated the resident was sitting upright in his reclining chair with his pants down, he said he had been waiting for staff to help him with his pants and transfer him to his wheelchair. She helped him with his pants and then had to get another staff to assist with the transfer. Staff D stated another staff asked her to help the resident because he had been sitting for at least an hour in his chair waiting to have his pants pulled up and transferred to his wheelchair. Staff D stated they normally answer call lights quickly, within 15 minutes. She said if staff need another staff to assist, they come back quickly, within a few minutes, she said they should not leave a resident for longer than 15 minutes waiting for assistance. During an interview 1/29/25 at 3:00 PM, Staff E, Assistant Director of Nursing (ADON), stated an expectation call lights are answered within 15 minutes, or sooner. If a staff responds to a call light and needs another staff to assist, they should return within a few minutes, no longer than 15 minutes. If it will take longer than just a few minutes, staff need to let the resident know and return within 15 minutes. Review of the facility Resident Council meeting minutes, dated 1/27/25, documented under Nursing, day shift slow to answer call lights. Review of the facility policy Answering the Call Light, revised March of 2021, documented the purpose of this procedure is to ensure timely responses to the resident's requests and needs.

Based on observation, family and staff interview, and policy review, the facility failed to ensure call light was within reach for 1 of 19 residents reviewed (Resident #68). The facility reported a census of 76. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #68 with a Brief Interview for Mental Status score of 13 indicating intact cognition. Diagnoses included anemia, heart failure, hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body), hip fracture with presence of an artificial hip joint, and osteoporosis. The MDS stated Resident #68 used either a walker or wheelchair and requires moderate assistance with transfers. The Admission/Readmission Narrative Bundle, Section C-Falls, dated 12/19/24, assessed Resident #68 at risk for falls with a score of 14. The Care Plan revised on 1/15/25 revealed Resident #68 has self-care deficits. Interventions included staff assistance of one for transfers and walker mobility. The Care Plan also stated Resident #68 is a fall risk. Interventions included call light within reach, removal of wheelchair pedal while in the wheelchair to avoid self-transfers, and completion of Morse Fall Assessment quarterly and as needed. During a family interview on 1/27/25 at 2:00 PM, family reported seeing the call light out of reach for Resident #68 to use. This occurred when the resident was sitting in the recliner. During an observation on 1/29/25 at 1:30 PM, Resident #68 was in their room and seen sleeping in a recliner. The call light observed laying across the bed-side table which was over 3-feet away from the resident and out of their reach. During a return visit at 2:10 PM, Resident #68 remained asleep in the recliner with the call light on the bed-side table over 3-feet away. During an interview on 1/30/25 at 10:00 AM, Staff C, Assistant Director of Nursing, reported an expectation that staff should ensure call lights are within resident's reach. The policy titled Answering the Call Light, revised March 2021, stated when a resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on observation, record review, resident interviews, staff interviews and policy review, the facility failed to assure residents were treated with respect and dignity for 2 of 3 residents reviewed (Resident #84 and #54). The facility reported a census of 76 residents. Findings include: 1. According to the Minimum Data Set (MDS) for Resident #84, dated 1/21/25, Resident #84 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. The resident was dependent on staff for toileting assistance and required substantial assistance for lower body dressing and chair to bed/chair transfer. The resident's diagnoses included a stroke. The Care Plan included Resident #84 had the potential for diversional activity due to cognitive impairment and/or physical assistance needed and the resident needed assistance to and from activities. Interventions included invite and encourage resident to attend activities and offer assistance for locomotion as indicated. The Care Plan further included the resident had a self-care deficit as evidenced by requiring assistance with Activities of Daily Living (ADLs), impaired balance during transitions requiring assistance and /or walking, incontinence. The resident required a one person staff assist with dressing/undressing and toileting and a two person staff assist with transfers with a sit to stand lift. During an observation 1/27/25 at 2:22 PM, Resident #84 was sitting upright in his reclining chair with his pants partway down his legs with a brief on. The brief was completely visible, initially it appeared the resident was sitting in his chair in his underpants. The door to his bedroom was open, his roommate was in the room, the curtain was open and the roommate was awake, the roommate could visually see the resident sitting in his chair with his pants down and the brief exposed. The resident could be observed sitting in his brief from the open doorway. The resident was observed sitting in his brief until 2:50 PM, when a staff placed blanket over his lower body. During an interview 1/27/25 at 2:25 PM, Resident #84 stated staff was just in his room, they needed to get another person for assistance and said they would return. The resident stated he was wanting to get into his wheelchair and go down to the activity that started at 2:00 PM. During an interview 1/27/25 at 2:45 PM, Resident #84 stated he turned his call light on because no one came back to help him into his wheelchair. The resident stated he has been sitting in his chair with his pants partway down waiting for assistance to get into his wheelchair since 2:00 PM. He wanted to transfer to his wheelchair to go down to the activity on the lower level. During an interview 1/27/25 at 2:50 PM, Resident #84 stated he wanted to go downstairs for the activity, which was national cupcake day and get a cupcake, he has now missed this activity. During an observation 1/27/25 at 2:56 PM, staff brought Resident #84 a cupcake wrapped in a paper towel. The resident was still sitting upright in his reclining chair with a blanket over him, his pants were still not pulled up and he was still not transferred to his wheelchair. During an interview 1/29/25 at 2:45 PM, Staff D, Registered Nurse (RN), stated she was working on Monday, the 27th, on the 4th floor. She recalled being asked to go into Resident #84's room to assist him to pull up his pants, this was later in the afternoon, sometime around 3:00 PM or after. She stated the resident was sitting upright in his reclining chair with his pants down, he said he had been waiting for staff to help him with his pants and transfer him to his wheelchair. She helped him with his pants and then had to get another staff to assist with the transfer. Staff D stated another staff asked her to help the resident because he had been sitting for at least an hour in his chair waiting to have his pants pulled up and transferred to his wheelchair. She stated for dignity she would not leave a resident sitting in his chair with his pants down. During an interview 1/29/25 at 3:00 PM, Staff E, Assistant Director of Nursing (ADON) on the 4th Floor, stated an expectation staff cover a resident and not leave a resident in their chair with their pants pulled down and the door open to their room. ADON stated an expectation staff assist the resident immediately, and not leave them in an exposed condition. The ADON stated an expectation the resident be covered for dignity purposes. The ADON stated an expectation staff assist residents to activities and accommodate resident's choices to attend activities. Review of the facility policy Quality of Life-Dignity, revision date of August 2009, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 50500 2. The Quarterly MDS dated [DATE] revealed Resident #54 with a BIMS of 15, indicating intact cognition. Diagnoses included anxiety, diabetes, and depression with severely impaired vision. The MDS stated Resident #54 requires set-up assistance at meals with maximal assistance with transfers and self-cares. The Care Plan revealed Resident #54 had a self-care deficit, was at risk for falls and had visual impairment/blindness. Interventions include set-up assistance at meals, environment free of spills and personal items within reach. Resident #54 utilized a wheelchair that staff propels. During breakfast observation on 1/28/25, the dining room was full with approximately 15 residents and 4 staff members (3 staff assisting residents to eat and 1 staff checking-in with residents throughout the meal). At 8:40 AM, Resident #54 accidentally dropped a bowl of oatmeal on the floor next to them creating a trail of oatmeal approximately 18-inches long. Staff did not immediately acknowledge or respond. At 8:48, an unknown therapy staff member picked-up the bowl, left the dining room and returned with towels to clean up. There was no interaction with the resident during this time. At 8:52 AM an unknown staff member cleaned-up the area further. The staff member did not interact with Resident #54, such as alerting to the spill/clean-up or offering another bowl of oatmeal. At 8:58 AM, when asked, Resident #54 indicated they were done with breakfast and staff began to clear off the table. At 9:08 AM staff escorted the resident back to their room. During an interview on 1/28/25 at 1:10 PM, Resident #54 indicated they were aware the oatmeal bowl fell to the floor. Resident #54 believes the bowl may have been moved accidentally and was not in its usual position. Resident #54 stated they would have liked another bowl of oatmeal if asked in a timely manner. However when staff asked if they were finished with the meal (18 minutes later), Resident #54 just wanted to return to their room. During an interview with Staff C, Assistant Director of Nursing, suspected staff overcompensated with the lack of interaction with Resident #54 as not to draw attention. Staff C would expect staff to address any food spills in a timely manner. The policy Quality of Life-Dignity, revised August 2009, stated staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before performed.

Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to provide a sanitary environment to help prevent the spread of communicable disease and infections. The facility failed to perform hand hygiene, don gloves, change gloves and use a barrier under a graduate during catheter drainage for 3 of 3 residents reviewed (Resident #51, #11 and #61). The facility reported a census of 79 residents. 1.The Minimum Data Set (MDS) assessment for Resident #51 dated 1/3/2024, included diagnoses of non-Alzheimer's dementia and obstructive uropathy (condition that blocks the flow of urine). The MDS documented the resident had an indwelling catheter (tube to drain urine from the bladder). The MDS documented a Brief Interview for Mental Status (BIMS) score of 8 completed, indicating moderate cognitive impairment for decision-making. During an observation on 3/19/24 at 2:50 PM, Staff D, Certified Nurse Aide (CNA) entered Resident #51's room, did not perform hand hygiene and applied gloves. Staff D drained the catheter bag into a graduate and placed the graduate directly on the floor, not placing a barrier under the graduate. Facility policy, Emptying a Urinary Drainage Bag revised 10/2010 instructed to place a paper towel on the floor beneath the drainage bag and position the measuring container under the drainage bag. Interview on 3/20/24 at 11:53 AM, Staff E, Assistant Director of Nursing (ADON) stated expectation is to complete hand hygiene before completing care and place a barrier between the graduate and floor. 34817 2. On 3/18/24 at 12:43 PM, observed Staff C, Environmental Services, wear gloves and push a cleaning cart onto the elevator. Staff C used her gloved hand and pushed the buttons on the wall inside the elevator. Staff C continued to wear the gloves as she rode the elevator to the next floor and then proceeded to push the cleaning cart off the elevator. 3. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had diagnoses of multiple sclerosis, cerebrovascular accident, and hemiplegia (paralysis on one side of the body). The MDS indicated the resident had incontinence, and had total dependence on staff for toileting, dressing, and personal hygiene. The Care Plan revised 1/26/24 revealed the resident had incontinence and at risk for skin impairment, urinary tract infections, and skin irritation in the peri-area. The Care Plan also indicated the resident required assistance with activities of daily living (ADL's). Staff directives included check and change the resident's brief and provide peri-care with every incontinence episode and as necessary. On 3/19/24 at 1:13 PM, observed Staff A, certified nursing assistant (CNA) and Staff B, CNA, don a pair of gloves. Staff A removed the resident's brief, then took disposable wipes and cleansed Resident #11's groin and perinea. Staff B assisted the resident to roll onto her left side. Staff A removed the brief from the resident's backside which had a large amount of stool present. Staff A took disposable wipes and cleansed between the buttocks front to back, then removed the soiled brief. Staff A changed gloves, then took additional wipes and cleansed the buttocks area again. Staff A then tucked a clean brief under the resident, rolled the resident onto her back, pulled the brief up, and attached the tabs on the brief. In an interview 3/21/24 at 11:50 AM, Staff E, Assistant Director of Nursing (ADON) reported she expected staff changed gloves in-between going from dirty to clean tasks. 4. The MDS assessment dated [DATE] revealed Resident #61 had diagnoses of dementia and mild intellectual disability. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. The MDS revealed the resident had total dependence on staff for toileting. The Care Plan revised on 9/10/22 revealed the resident had incontinence and required assistance with ADL's. The Care Plan directed staff to provide peri-care with every incontinent episode. On 3/19/24 at 1:44 PM, observed Staff A, CNA, and Staff B, CNA, use a mechanical lift and transfer Resident #61 from a wheelchair to the bed. Staff A and Staff B wore gloves during the transfer. Staff A and Staff B removed the sling under the resident, then removed the resident's pants and soiled brief. Staff A took disposable wipes and cleansed the resident's groin and penis. Staff B rolled the resident onto his left side. Staff A opened the back of the brief, which contained a moderate amount of stool. Staff A took disposable wipes and cleansed between the resident's buttocks, and then removed the soiled brief under the resident. Staff A placed a clean brief under the resident, rolled the resident onto his back, and attached the brief tabs. Staff A wore the same gloves during cares. The facility's Handwashing/Hand Hygiene policy (version 2.2) revealed an alcohol-based hand rub or soap and water used before moved from a contaminated body site to a clean body site during resident care, and after gloves removed. The facility's Personal Protective Equipment -Using Gloves policy revised 9/2010 lacked direction as to when gloves needed changed. The facility's Perinea Care policy revised 2/2018 revealed the following procedural steps: a. Wash hands. b. Put on gloves. c. Wash perinea area, wiping from front to back. d. Turn resident on side. e. Wash the rectal area. f. Remove gloves. g. Wash hands. In an interview 3/21/24 at 11:50 AM, Staff E, ADON, reported she expected staff changed gloves in-between going from dirty to clean tasks.

Based on clinical record review, staff interviews, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 5 of 5 residents reviewed who were discharged or transferred from the facility (Residents #5, #14, #23 #42, and #59). The facility reported a census of 79 residents. Findings include: 1. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #5 had an unplanned discharge to the hospital and reentered the facility on 10/16/23. The facility's Census List revealed Resident #5 hospitalized [DATE]-[DATE]. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman lacked documentation of Resident #5's discharge to the hospital on 10/11/23 as required by federal regulation. 2. Review of the MDS assessment dated [DATE] and 1/3/24 revealed Resident #23 had unplanned discharges to the hospital and reentered the facility on 10/12/23 and 1/5/24. The facility's Census List revealed Resident #23 hospitalized [DATE]-[DATE] and 1/3/24-1/5/24. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman lacked documentation of Resident #23's discharge to the hospital on 10/11/23 and 1/5/24 as required by federal regulation. 40905 3. The MDS for Resident #14 dated 1/9/24, included diagnoses of a seizure disorder and diabetes. A Brief Interview for Mental Status score of 14, indicated mild cognitive impairment. The facility Census List revealed Resident #14 admitted to the hospital 12/9/23 and returned to the facility 12/13/23. Review of the facility's Notice of Transfer Form to Long Care Term Ombudsman form for 12/2023 lacked documentation of Resident #14's transfer to the hospital. 34817 4. The MDS assessment dated [DATE] revealed Resident #42 had an unplanned discharge to the hospital and reentered the facility on 1/16/24. The Census List on the facility's computer software program used for electronic medical record documentation revealed Resident #42 hospitalized [DATE] to 1/16/24, and 2/8/24. Review of the E-interact transfer form revealed Resident #42 transferred to the hospital on 1/10/24, 2/1/24, and 2/8/24. Review of the Notice of Transfer Form to the LTC Ombudsman lacked documentation of Resident #42's discharge to the hospital on 1/10/24, 2/1/24, and 2/8/24 as required by federal regulation. 5. The MDS assessment dated [DATE] revealed Resident #59 had an unplanned discharge to the hospital and reentered the facility on 2/2/24. The Census List on the facility's computer software program used for electronic medical record documentation revealed Resident #59 hospitalized [DATE] - 2/2/24. Review of the Notice of Transfer Form to the Long Term Care (LTC) Ombudsman lacked documentation of Resident #59's discharge to the hospital on 1/27/24 as required by federal regulation. In an interview 3/20/24 at 3:15 PM, Staff E, ADON, stated the Administrator reported the resident discharges to the LTC Ombudsman. In an interview 3/21/24 at 8:45 AM, the Administrator reported the facility did not have policy for reporting to the LTC Ombudsman. The Administrator reported she sent a report to the LTC Ombudsman when residents discharged or transferred from the facility. In an interview 3/21/24 at 9:30 AM, the Administrator reported she pulled a report from the electronic software program but the report did not include some of the residents who discharged from the facility. She found another report that pulled all of the resident's discharged and/or transferred to the hospital. She planned to use this report now and in the future to provide a report to the LTC Ombudsman.

Based on observations, clinical record review, staff interview and facility policy review the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice by providing oxygen (O2) without a physician's order and not changing oxygen tubing for 1 of 1 resident (Resident #73) reviewed. The facility reported a census of 79 residents. Findings include: A Minimum Data Set, dated dated dated [DATE] for Resident #73, included diagnoses of chronic obstructive pulmonary disease and received O2 therapy. A Brief Interview for Mental Status score of 12 indicated mild cognitive impairment. On 3/18/24 at 3:06 PM, observed the resident sitting in a wheelchair with O2 on at 2.5 Liters (L) per nasal cannula (NC) and O2 tubing with no date marked on it. On 3/19/24 at 1:48 PM, observed the resident sitting in a wheelchair with O2 on at 2.5 L per NC and tubing remained without a date. Resident's Order Summary Report with active orders as of 3/19/24 lacked a physician's order for O2. The facility policy, Respiratory Therapy revised 11/2011 instructed to change the oxygen cannula and tubing every 7 days. Interview on 3/20/24 at 11:56 AM, Staff E, Assistant Director of Nursing confirmed the resident did not have a physician's order for O2 and expectation is to have an order and change the O2 tubing weekly.

Based on observations, resident and staff interview, and policy review, the facility failed to ensure a safe, clean, and homelike environment for 2 of 2 nursing units. The facility reported a census of 80 residents. Finding include: Observations on 11/14/23 starting at 1:50 PM revealed the following: a. Missing paint from door frames on rooms 305, 306, 307, 308, 309, 312, 417, 419, 420, 422, 426, 427. b. A panel covering the lower part of the door on rooms [ROOM NUMBERS] was lifted up from the surface of the door, and had a sharp edge. c. The wall in room [ROOM NUMBER] was marred and had scuffed up paint. On 11/14/23 at 2:00 PM, the exit door on the 4th floor had a motorized wheelchair parked in front of it. The motorized wheelchair was plugged into an electrical outlet near the exit door. On 11/15/23 at 1:30 PM, the wall by the resident's bed and the recliner in room [ROOM NUMBER] had missing paint and dry wall showing. The ceiling tiles by the window were discolored and had shades of brown-colored water stains. On 11/16/23 at 12:20 PM, room [ROOM NUMBER] had several holes in the wall near the TV. The wall had a golf ball sized hole with a broken cable plate and cable cords attached, and five round holes (approximately 1 centimeter). The wall by the bed had missing paint and drywall showing. The bathroom floor by the toilet had a black soiled area. At the time, the resident reported the holes in the wall had been there since he moved into the room. The resident reported he had seen mice in his room but it had been awhile ago. Observed he still had 3 mousetraps set up in his room. On 11/16/23 at 12:25 PM, room [ROOM NUMBER] had a large dried puddle of a black liquid debrided under the sink in the bathroom. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported the facility recently went through a color selection to upgrade walls and paint certain areas. During an interview 11/21/23 at 12:30 PM, the Administrator reported paint color chosen and they were working on painting areas in the facility, starting on the fourth floor. A facility's policy for Quality of Life-Homelike Environment revised 5/2017 revealed facility staff and management shall maximize the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a safe, clean, comfortable and homelike environment.

Based on clinical record review, observations, resident and staff interviews, and staff competency checklist, the facility failed to ensure a mechanical (Hoyer) lift in a safe and functional condition to safely transfer a resident for 1 of 4 residents observed during a transfer (Resident #10). The facility staff also failed to ensure a proper sized sling used for transfer of a resident in a mechanical lift for 1 of 4 residents observed for transfers (Resident #13). The facility reported a census of 80 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of dementia, sepsis, and schizophrenia. The resident had a Brief Interview for Mental Status (BIMS) of 0 out of 15, indicating severely impaired cognition. The MDS documented the resident had total dependence for transfers. The Care Plan revised 7/18/23 revealed the resident had a self-care deficit and required assistance with ADLs (activities of daily living). The staff directives included use of a Hoyer and two staff for transfers. During observation on 11/14/23 at 2:10 PM, Staff A, certified nursing assistant (CNA), and Staff B, CNA, connected a sling to an EZ way mechanical lift. Staff A raised Resident #10 up in the mechanical lift and transferred the resident from a broda chair into the bed. The resident had dark faded bruises to her right calf and shin. During the transfer, the mechanical lift was slow in raising and lowering the resident from one surface to another. Staff A stated she didn't know if the battery would last. The mechanical lift had exposed wires and what appeared to be electrical tape loosely wrapped around some of the wiring that extended toward the battery pack. During a confidential resident interview on 11/15/23 at 9:00 AM, a resident reported two staff used a Hoyer whenever they transferred her, but staff practically flipped her out of the Hoyer when they transferred her. The resident reported one of the Hoyer machines was antiquated and the facility needed to get a new one. She had hit her head on the Hoyer three times due to the unpredictable mechanics of the Hoyer. The resident reported she told staff about the Hoyer and filled out a grievance about it. She recommended they get rid of it but staff continued to use the Hoyer. The resident reported the Hoyer was not related to the CNA's who used it, but rather the functionality of the machine. During an interview 11/20/23 at 9:45 AM, Staff F, CNA, reported the facility's mechanical lifts was always broken or had something electrical wrong. The staff always had to switch out the Hoyer because they didn't work. Staff F reported the equipment had a lot of battery issues, and the battery charger didn't charge the batteries. Staff F reported one time she had to use the emergency button on the Hoyer because they got the resident up in the sling, in the air, and then the machine didn't work. She got the resident over the bed and raised the bed up, then had to use the Hoyer's emergency button to lower the resident into her bed but it wasn't that far of a drop. Staff F stated she took a CNA course in 2017 to learn how to operate a Hoyer mechanical lift but had no other training on how to use this equipment. During an interview 11/20/23 at 10:40 AM, Staff H, Registered Nurse (RN) and Unit Manager, reported she let maintenance staff know whenever equipment, such as a mechanical lift, was broken. Staff H reported a lock out tag out was placed on broken equipment if they didn't want the staff to use it. During an interview 11/20/23 at 11:00 AM, Staff G, CNA reported she let the nurse or management know whenever equipment was not working. Staff G stated she looked at the resident's care plan to know how a resident transferred, and if a device such as a Hoyer or EZ stand used. Staff G reported she had not had a Hoyer lift malfunction. Staff G reported when the battery is low, the machine is slow, and that meant the battery needed charged. During an interview 11/20/23 at 12:15 PM, the Social Worker reported no concerns or grievances reported about a Hoyer mechanical lift equipment. During an interview 11/20/23 at 1:05 PM, Staff E, Maintenance, reported he had worked at the facility for 7 months. Staff E reported he checked the TELS computer program daily to see what needed done. Staff and residents tracked him down or called and told him when something needed repaired or checked. Staff E reported he worked on some equipment such as mechanical lifts and wheelchairs, but called the company for some of this equipment depending upon warranty or contracts. Staff E reported he kept track of equipment and repairs in the computer. Staff E reported no current preventative maintenance on mechanical lift equipment, he worked on the equipment whenever staff or a resident reported an issue. The only repairs he had done on the mechanical lifts recently included cleaning out the wheels to make it easier to move the machine and fixing a battery. Staff E stated staff are supposed to charge batteries on mechanical lifts at night. During an interview 11/16/23 at 12:30 PM, Staff I, Licensed Practical Nurse (LPN), reported she let maintenance know if equipment not working. Staff I recalled over 8 months ago, one of the CNA's had to use the emergency button on a Hoyer when a resident was in it. The CNA no longer worked at the facility. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported she expected staff to let maintenance or their manager know if wires exposed or equipment not working properly. Staff P stated the batteries checked by manufacturer 4/2023 and a battery was replaced. The problem lies with staff not charging the batteries fully. The facility's grievance log dated 5/1/23 to 11/14/23 revealed no information pertaining to mechanical lift or equipment concerns. The EZ Way service manual revealed the EZ Way Smart Stand required a minimum of servicing to keep it in good working order. It is important the maintenance staff completed certain basic checks periodically to ensure on-going safety of the device. The manufacturer suggested components checked (such as all bolts tightened, pins engaged, safety tabs not missing or torn, wheels and brakes checked, check for damaged, loose, or missing parts, and a load test performed). Any detected deficiency must be rectified before equipment put back into service. The Invacare Reliant patient lift user manual revealed regular maintenance of patient lifts by qualified personnel is necessary to assure proper operation of the equipment. A facility's policy for Quality of Life-Homelike Environment revised 5/2017 revealed facility staff and management shall maximize the characteristics of the facility including a safe and comfortable environment. 2. The Admission MDS assessment dated [DATE] revealed Resident #13 had diagnoses of Parkinson's disease, seizure disorder, and intellectual disability. The MDS documented a BIMS of 9 out of 15, indicating moderately impaired cognition. The resident had dependence on staff for transfers. The Care Plan revised 11/9/23 revealed the resident had a diagnoses of Parkinson's disease and had involuntary muscle movements. The resident had a risk for falls related to neuromuscular impairment. The care plan directed staff to provide a safe environment and use a Hoyer and two staff for assistance with transfers. The care plan lacked information pertaining to the sling size to use. During observation on 11/15/23 at 1:15 PM, Staff C, CNA, and Staff D, CNA, pulled a small blue sling under Resident #13 while the resident sat in a wheelchair, and connected the sling straps to a Hoyer mechanical lift. Staff C took a remote and began to raise the resident up. Resident #13 had jerking motions in her arms and legs. Staff C told Staff D she didn't think this was going to work because the sling didn't look like it was under the resident far enough. Staff D told Staff C it's ok, she hung the straps so the straps closest to the resident were longer than the straps connected closer to the lift/ resident legs. Staff D explained to Staff C when they lifted the resident up in the sling, the resident would be in more of a reclining position rather than a sitting position and she won't slide out. Staff C stated the sling was up too high, because it was not under the resident's legs. Staff D stated the reason was because the sling was small. Staff D took the lift remote and raised the resident in the sling. Resident #13 yelled they're hurting me. Staff D reassured the resident. Resident #13 continued to holler. Staff D offered to get someone else to help the resident, but the resident said no. Staff D and Staff C transferred the resident into bed and removed the sling from under the resident. During an interview 11/20/23 at 9:45 AM, Staff F, CNA, reported she determined what sling size to use based on a resident's weight and width. Staff F reported the care plan showed how many staff to transfer a resident but did not include what size sling to use on a resident. Staff F stated she took a CNA course in 2017 to learn how to operate a Hoyer mechanical lift but had no other training on how to use this equipment. During an interview 11/20/23 at 11:00 AM, Staff G, CNA, reported she looked at the resident's care plan to know how a resident transferred, and if a device such as a Hoyer used. Staff G reported she looked at the color of the sling to determine the size of the sling. Staff G thought the resident's care plan included the size of the sling used. During an interview 11/21/23 at 10:50 AM, Staff O, Occupational Therapy, reported therapy made recommendations on how a resident transferred if they were on therapy's caseload. Therapy filled out a communication sheet with recommendations for transfers. Therapy doesn't make recommendation on the sling size to use or provide training to staff on use of equipment such as a Hoyer. During an interview 11/21/23 at 11:20 AM, Staff P, Unit Manager, reported they used the mechanical lift user guide for recommendations on what size sling to use for residents who transferred with a mechanical lift. The sling size was determined by the resident's height and weight. Staff P reported staff told in a verbal report what size sling to use on a resident. Resident council meeting notes dated 10/9/23 revealed residents requested to keep wider Hoyer slings on the 3rd and 4th floors, not just on the 3rd floor. A Hoyer Lift Competency Checklist revealed the following procedural steps: a. Check the resident's care plan for transfer instructions b. Ensure resident provided correct sling size and proper weight for device per manufacturer specifications. c. Ensure resident feels safe, comfortable, and secure with transfer. d. Position sling under the resident in a seated position. e. Tip resident forward and position sling handles facing outside and away from the resident. f. Position leg straps inside the arms of the wheelchair. The horseshoe seam reinforcing the sling should touch the seat of the chair, conforming to the resident's tailbone area. g. Pull the leg straps of the sling toward you and position them between the chair and the resident's legs. Pull the leg straps across under the resident's thighs. h. Attach the sling to the lift. Attach right and left shoulder strap to the nearest sling support hook. Attach sling support hooks away from the resident. i. Push the up button to raise the resident up. j. Transport resident to desired location, and carefully lower the resident into desired location. k. Lower the lift beam enough to allow unhooking and removal of sling straps. The Invacare Reliant patient lift user manual revealed slings are specifically designed to be used in conjunction with Invacare patient lifts. Slings designed by other manufacturer's are not to be utilized as a component of Invacare patient lift system. When the sling is connected with color-coded straps to the patient lift, the shortest of the straps MUST be at the back for support of the patient. Make sure there is sufficient head support when lifting a patient.

Based on clinical record review, staff interviews, and information from the Davis's Drug Guide, the facility failed to consistently report weight loss to the physician for 1 of 1 residents (Resident #4) reviewed who was prescribed a dosage of a weight based medication. The facility reported a census of 80 residents. Findings include: The Minimum Data Set (MDS) for Resident #4, dated 5/4/22 documented diagnoses that included heat failure, hypertension (high blood pressure), ischemic cardiomyopathy (damaged heart muscle) and coronary artery disease. The Care Plan revealed a focus area of anticoagulant medication dated 2/24/22. The Care Plan directed staff to perform daily skin inspection and to monitor and report signs of anticoagulant complications. The Care Plan failed to reveal to monitor resident weight related to the weight based ordered dosage. The Medication Administration Record (MAR) for August of 2022 for Resident #4 documented the resident received 10 mg of Prasugrel, (an anti-platelet medication) with an order start date of 2/24/22. The Weight Summary section of the Electronic Health Record (EHR) of Resident #4 documented a weight of 134.6 pounds (61.18 kg) on 2/24/22. The Davis's Drug Guide documented the dosage of Prasugrel for adults who weigh equal to or greater than 60 kg (132 pounds) is 10 mg once daily and 5 mg once daily for adults who weigh under 60 kg. The Weight Summary documented the resident had a weight loss over the next several months. Her weight was monitored frequently and documented in progress notes as being discussed in weight and skin meetings and having no dietitian recommendations. The Nurse Practitioner was notified of the resident's weight changes multiple times through 5/26/22 per the progress notes. The Weight Change Note dated 6/2/22 by the Registered Dietitian documented the resident to have a stable weight of 124.7 pounds (56.68 kg) and recommended discontinuing daily weights. The note stated the resident was on diuretic medication and weight loss was expected. The Weight Summary documented the resident weighed 129.6 pounds (58.9 kg) on 5/6/22 and remained under 60 kg continuously from that point forward. On 8/1/22 the resident was down to 111.0 lbs (50.45 kg) and the EHR flagged this as an 11.1% weight loss since 7/1/22. No progress notes documented notification to the Nurse Practioner or Medical Director of the weight loss past 5/26/22. In an email from the Director of Pharmacy operations dated 11/17/23, the pharmacy stated there was no order change for the Prasugrel. The resident was on 10 mg of the medication from 2/24/22 until 8/4/22. The email stated the medication has a boxed warning for bleeding risk and one of the risk factors is a body weight of <60kg. He stated he found no documentation from the facility notifying of a weight change. In an email dated 11/21/23, the Administrator stated the facility does not have a policy regarding dosing weight based medications. She stated the facility would follow physician orders and pharmacy recommendations which are completed monthly with a full chart review. In a second email from the Director of Pharmacy dated 11/21/23, the Director stated the system does not contain updated real time information on the weight of the residents. He stated the only time the pharmacy would be aware of a weight change is if they received notice from the facility. On 11/21/23 at 8:35 am, the Registered Dietitian (RD) stated that when the resident was receiving hospice care, they stopped closely monitoring her weights. She stated the facility still weighed her but she was no longer discussed in weight meetings. She stated the normal protocol for notifying the medical provider of a weight change is for she, the RD to notify the staff nurses and they would then notify the nurse practitioner. She stated she did a dietary review on 8/2/22 noting the significant weight loss of the reticent. However, the resident passed away prior to a weight meeting to discuss the weight loss.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure residents were free of significant medication errors for 3 of 22 residents reviewed for medications(Residents #4, #5, and #11), failed to ensure residents received insulin within ordered blood sugar parameters for 1 of 4 residents reviewed for insulin administration(Resident #5), failed to ensure residents received insulin in a timely manner as ordered for 2 of 4 residents reviewed for insulin use(Residents #13 and #14), and failed to ensure a safe system of monitoring blood sugars by having night shift staff obtain blood sugars for the day shift. The following circumstances constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 85 residents. Findings include: 1. The MDS(Minimum Data Set) assessment tool, dated 5/8/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance of 1 staff for bed mobility, transfer, dressing, toilet use, and personal hygiene, and extensive assistance of 1 staff for bathing. The MDS listed the resident's BIMS(Brief Interview for Mental Status) score as 10 out of 15, indicating moderately impaired cognition. a. A 2/3/21 facility Medication Error Report stated a staff member administered another resident's medications to the resident during the morning medication pass. The facility transferred the resident to the ER and he stayed for 24 hour observation. A 2/3/21 11:06 a.m. nursing note stated Staff A CMA(Certified Medication Aide) reported she administered Resident #15's medications to Resident #5. The nurse called the physician and checked the resident's blood pressure. The nurse rechecked the blood sugar at 8:30 a.m. and it was 73/45 mm/hg(millimeters/mercury). The facility attempted to start an IV(intravenous line) and transferred the resident to the hospital. Review of Resident #15's MAR(Medication Administration Record) revealed the following morning medications(administered in error to Resident #5 on 2/3/21): [MEDICATION(S)](for high blood pressure) 10 mg(milligrams), Aspirin 81 mg, [MEDICATION(S)](an antidepressant) 30 mg, [MEDICATION(S)](controls stomach acid) 40 mg, [MEDICATION(S)](for high blood pressure) 48 mg, Garlic 10 mg, [MEDICATION(S)](for [CONDITION(S)]) 100 mcg(micrograms), [MEDICATION(S)](for allergies) 10 mg, Multivitamin, Olmesartan(for blood pressure) 40 mg, [MEDICATION(S)](for constipation) 1 packet, [MEDICATION(S)](for blood pressure) 25 mg, Vitamin C 500 mg, Vitamin D3 25 mcg, [MEDICATION(S)](for breathing) 250-50 1 puff, [MEDICATION(S)](for irritable bowel syndrome) 10 mg, [MEDICATION(S)] (for diabetes) 500 mg, [MEDICATION(S)](for ulcers) 1 gram. A 2/4/21 hospital report stated the resident admitted to the hospital for [CONDITION(S)](low blood pressure) secondary to a medication error. The note stated the incorrect medications the resident received were: [MEDICATION(S)] 500 mg, [MEDICATION(S)](used to treat asthma) 10 mg, Olmesartan 40 mg, and [MEDICATION(S)] 1 gram. The note stated the resident received 2 liters of fluid in the ER which improved his blood pressure and the hospital admitted him for observation overnight. A 2/4/21 nursing note stated the resident returned from the hospital. Resident #5's face sheet revealed the resident was a white or Caucasian male. Resident #15's face sheet revealed the resident was a black or African American female. On 3/10/21 at 9:22 a.m., Staff A CMA stated she normally worked on a different floor but the facility assigned her to pass medications on Resident #5's floor. She stated she prepared Resident #15's medications and went to the room which had Resident #15's name on the door. She stated she walked in and stated to the resident in the room I have your medication (Resident #15's name), and the resident stated ok. The resident was a male. He then stated he didn't have an inhaler. Staff A then went to sign off the medications in the EHR(Electronic Health Record) and saw that the picture was of a woman. She stated she notified the nurse of the error. Later during breakfast, the resident's blood pressure was low. She stated she had not heard in report that the resident had changed rooms. During an interview on 3/10/21 at 9:30 a.m. Staff B RN(Registered Nurse) stated the CMA informed her she made an error(with Resident #5's medications) and she assessed the resident and called the physician. She stated when she rechecked the resident's blood pressure later it was low so they sent the resident to the hospital. b. A 2/5/21 facility Medication Error Report stated staff administered insulin when a blood sugar was less than 150 mg/dl(milligrams/deciliter). Review of the February 2021 TAR(Treatment Administration Record) listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR documented on 2/5/21 staff administered the insulin and the resident's blood sugar was 106 mg/dl. The TAR also listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR documented staff administered the insulin with a blood sugar less than 150 mg/dl 27 times. A 3/3 Medication Error Report stated staff administered insulin when the resident's blood sugar was 72. The March TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated staff administered the insulin on 3/3/21 and the resident's blood sugar was 72 mg/dl. 2/4/21 Care Plan entries stated the resident had diabetes and directed staff to administer diabetes medication as ordered by the physician. 2. The MDS assessment tool, dated 2/19/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident required limited assistance of 1 staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene, and extensive assistance of 1 staff for bathing. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A Medication Error Report, dated 3/5/21, stated on 2/22/21 the physician ordered the resident's [MEDICATION(S)](a diuretic-used to rid the body of fluid) to increase to 40 mg twice daily for 3 days then resume to 40 mg daily. The February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The February 2021 TAR listed a 2/22/21 order for a daily weight x 3 days, but the facility could locate no documentation that showed staff obtained a weight on 2/23/21 and 2/24/21. An undated, untitled facility document which described the medication error related Resident #11 revealed on 3/5/21, the resident asked the medication aide why she was not getting her white pill anymore. The facility then reviewed the resident's chart and noticed a transcribing error from 2/22/21. A 2/21/21 care plan entry documented Resident #11 as on diuretic therapy due to [CONDITION(S)](swelling). 3. The MDS assessment tool, dated 1/26/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required supervision assistance of 1 staff for personal hygiene, extensive assistance of 1 staff for bed mobility, walking, dressing, and bathing, and extensive assistance of 2 staff for transfers and toilet use. The MDS listed the resident's BIMS score as 15 out of 15, indicating an intact cognitive status. A 1/21/21 hospital Medication Discharge Report listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed staff to remove the resident's PICC(Peripherally Inserted Central Catheter-a tube inserted into a vein, used for long-term intravenous antibiotics or other medications) line after the last dose of antibiotics. The January 2021 TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated the resident received the medication from 1/23/21-1/27/21. The TAR lacked documentation the resident received the medication from 1/28/21-1/31/21. The February 2021 TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR documented the resident did not receive the medication from 2/1/21-2/10/21. A 3/9/21 physician's progress note stated the resident was supposed to continue with his [MEDICATION(S)] until 2/28/21 but this was stopped on 1/28/21 per the facility staff and the facility also removed the resident's PICC line. A PICC was placed on 2/10/21 and the resident resumed his [MEDICATION(S)] for a total of 6 weeks from 2/10/21. The care plan, reviewed 2/7/21, identified the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] 4. The MDS assessment tool, dated 1/26/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required supervision assistance of 1 staff for transfers, walking, and toilet use, limited assistance of 1 staff for dressing, and extensive assistance of 1 staff for bathing. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. Care plan entries dated 1/8/21, documented the resident had diabetes and directed staff to monitor blood glucose. The March 2021 TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] a. 3/6/21 at 10:35 a.m. b. 3/7/21 at 9:46 a.m. c. 3/11/21 at 11:53 a.m. d. 3/13/21 at 10:59 a.m. e. 3/14/21 at 9:15 a.m. f. 3/21/21 at 10:10 a.m. The March 2021 TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .m The TAR documented staff gave the insulin late on the following dates and times: a. 3/4/21 at 9:54 p.m. b. 3/5/21 at 10:38 p.m. c. 3/6/21 at 9:32 p.m. d. 3/7/21 on 3/8/21 at 12:45 a.m., e. 3/10/21 at 9:54 p.m. f. 3/11/21at 11:47 p.m. g. 3/12/21 at 10:00 p.m. h. 3/13/21 at 9:18 p.m. i. 3/14/21 at 10:37 p.m. j. 3/15/21 at 9:20 p.m. k. 3/18/21 at 9:42 p.m. l. 3/20/21 at d at 9:22 p.m. 5. The MDS assessment tool, dated 1/29/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance of 1 staff for bed mobility, transfers, dressing, toilet use and personal hygiene, and required extensive assistance of 2 staff for bathing. The MDS listed the resident's BIMS score as 6 out of 15, indicating severely impaired cognition. The care plan, reviewed 2/7/21, stated the resident was insulin dependent and had the potential for hyper/hypo(high/low) blood sugars. The February 2021 TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] a. 2/13/21 at 3:03 p.m. b. 2/14/21 at 11:35 a.m. c. 2/20/21 at 4:43 p.m. d. 2/21/21 at 3:18 p.m. The February 2021 TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The February 2021 TAR listed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] a. 2/12/21 on 2/13/21 at 12:41 a.m. b. 2/14/21 at 9:51 p.m. c. 2/15/21 on 2/16/21 at 12:02 a.m. d. 2/18/21 at 11:42 p.m. e. 2/20/21 on 2/21/21 at 12:33 a.m., f. 2/21/21 at 11:13 p.m. g. 2/26/21 11:32 p.m. h. 2/27/21 on 2/28/21 at 1:04 a.m. i. 2/28/21 at 10:59 p.m. 6. An untitled facility posting, dated 3/4/21, stated effective immediately, night nurses and medication aides would no longer obtain blood sugars for the day shift nurses. The facility policy Medication and Treatment Orders, revised July 2016, stated orders for medications and treatments would be consistent with principles of safe and effective order writing. The policy stated staff should immediately record all verbal orders in the resident's chart. The facility policy, Insulin Administration, revised September 2014, stated the facility would verify the type of insulin, dosage requirements, strength, and method of administration prior to the administration of insulin to assure it corresponded with the order on the medication sheet and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy, Administering Medications, revised December 2012, stated the individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time, and right route prior to giving the medication. On 3/10/21 at 9:40 a.m., Staff C LPN(Licensed Practical Nurse) stated the night shift nurses obtained the blood sugars in the past but recently the day shift began to obtain them. With regard to Resident #11's medication error, she stated she took multiple orders from the physician over the phone. She stated she input an order to increase the resident's [MEDICATION(S)]([MEDICATION(S)]) for 3 days but forgot to put in the order to continue the maintenance dose after the resident completed the 3 days. She stated the facility now had a system to double check orders. On 3/10/21 at 10:52 a.m., Staff D LPN stated at times she worked with a medication aide who could not administer insulin. She stated the time period of 6:00 p.m. to 10:00 p.m. was busy and by the time she administered insulin, it was late, it was midnight. On 3/10/21 at 11:57 a.m., Staff E RN stated the night shift obtained blood sugars around 5:30-5:45 a.m. or close to 6:00 a.m. She stated the day nurses administered insulin when the breakfast trays arrived, usually around 7:30 a.m.-8:00 a.m. She stated the night shift reported the blood sugars to the day shift nurses and the day shift nurses input them into the electronic record. On 3/10/21 at 2:36 p.m., the 3rd floor ADON(Assistant Director of Nursing) stated if the nurse followed the 7 Rights of medication administration, the error with Resident #5 would not have happened. She stated staff should change door name signs at the time a resident changed rooms. On 3/10/21 at 3:11 p.m., Staff F LPN stated until recently, the day shift utilized the blood sugars the night shift obtained to administer the resident's insulin. She stated the night shift reported the blood sugars to the day shift and the day shift input them into the electronic record. She didn't know for sure but thought this recently changed because a resident received insulin when his blood sugar was too low. She stated when she was the only nurse with a med aide, there were times when residents had already eaten breakfast when she gave insulin. On 3/11/21 at 10:05 a.m., Staff G LPN stated in the past, the night shift nurses obtained the blood sugars and the day shift utilized those blood sugars. She stated on the day of the error she was involved in with Resident #5, the insulin parameters on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated there were times when nurses did not give insulin until after breakfast. On 3/11/21 at 10:47 a.m., Staff B RN stated when the night shift obtained the blood sugars, they wrote them on a piece of paper and gave them to the day shift. She stated the day shift nurses then utilized those blood sugars to give the day shift insulin. On 3/11/21 at 11:39 a.m. the DON(Director of Nursing) stated she was not aware the night shift obtained the blood sugars and stated staff should obtain blood sugars closer to the time of insulin administration. She stated they couldn't utilize blood sugars obtained 3 hours earlier. She stated if an order directed nurses to hold insulin for blood sugars under 150 mg/dl, they should hold the insulin. On 3/11/21 at approximately 12:00 p.m., the 3rd floor ADON stated she was not aware the night shift was obtaining blood sugars for sliding scale insulin and stated the person administering the insulin should obtain the blood sugar. On 3/11/21 at 12:22 p.m., the Administrator stated if the nurse looked at the picture in the electronic chart and followed the rights of medication administration, the mistake with Resident #5 should not have happened. She stated staff should not take blood sugars until after 7:30 a.m. and stated she was not aware the night shift obtained the blood sugars. On 3/24/21 at 12:53 P.M., the DON stated a staff member entered Resident #4's [MEDICATION(S)] order incorrectly and this was the reason the facility stopped it in error. She stated the resident's PICC line was discontinued and he went about a week without his [MEDICATION(S)]. She stated they then restarted it and he just completed it. She stated she had done education with staff regarding this. The facility was notified an Immediate Jeopardy (IJ) had been identified on 3/11/21. After the facility submitted additional information, it was identified the IJ had been removed on 3/5/21 after the investigation began, but prior to the Department representative's exit. The IJ was lowered in scope and severity from a K to an E when the facility took the following actions: 1. All nurses and agency staff have been educated regarding the policy and procedures for following physician orders. Any staff that the facility was unable to reach were educated prior to working with resident. Education included proper transcription of orders, administering insulin, obtaining blood sugars as ordered, and the 7 rights of medication administration (right patient, right drug, right dose, right time, right route, right reason and right documentation). 2. The facility immediately implemented a double check system that required the nurse that administered the insulin to verify the 7 rights of medication administration with either another nurse or a Certified Medication Aide. 3. The facility immediately implemented a system that ensured the Director of Nursing would review any new medication orders and accompanying progress notes to ensure accuracy prior to the daily morning quality assurance meeting. 4. On 3/4/21, the Director of Nursing and the Assistant Director of Nursing audited all blood sugars and insulins for accuracy in transcription and administration. 5. The facility implemented medication audits two times weekly for four weeks, then one time weekly for four weeks, and then as needed according to quality assurance committee recommendations

Based on clinical record review, facility policy review and staff and primary care provider interviews, the facility failed to ensure two residents (#2 and #8) did not receive facility-acquired pressure ulcers. In addition, Resident #8 did not receive assessment and measurement of an ulcer when it was first discovered. The facility identified a census of 89 current residents and five residents were reviewed for pressure ulcer prevention and care. Findings include: The MDS (Minimum Data Set) assessment tool 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. 1. According to the MDS dated [DATE], Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented Resident #2 possessed severely impaired cognitive skills for daily decision-making. The MDS documented he had one unhealed pressure ulcer and the risk of developing further pressure ulcers. Staff documented his pressure ulcer as unstageable. Resident #2's Care Plan, initiated on 8/6/20, documented he had impaired skin integrity related to incontinence, the inability to reposition himself, diabetes and peripheral vascular disease. The Care Plan documented his wounds were being followed by an ARNP (Advanced Registered Nurse Practitioner). The resident's clinical record showed Wound Treatment Plans documented by the Wound ARNP throughout 2020. During a phone interview on 11/2/20 at 11:15 AM, the resident's Wound ARNP stated that in 3/20, when Resident #2 had his second toe removed, the first time she saw him afterwards, his dressing was tight. When they removed the dressing, new open areas appeared. The ARNP did not know if facility staff or hospital staff put the dressing on too tight. Also, with the open areas she saw in March, the open areas were located where the straps of a Prevalon (supportive) boot fell . She thought the straps of the boot could have caused the open areas. The ARNP tried to get the Prevalon boot discontinued but it kept re-appearing. Review of the Treatment Administration Record of 3/20 revealed staff changed Resident #2's right foot dressing and covered the dressing with an ACE wrap every shift from 3/4 to 3/10/20. The Wound Treatment Plan Note dated 3/4/20 documented Resident #2 underwent amputation of the second digit of his right foot at the hospital and just returned to the facility. The resident's surgeon managed the surgical site. The Wound Treatment Plan note dated 3/11/20 documented several new areas of purple discoloration to the right foot that lined up with the straps on the Prevalon boot. The plan note documented the new areas were located as follows: a. Lateral right foot, unstageable pressure ulcer, measuring 9.5 cm (centimeters) by 2.7 cm by 0.1, described as 5% stable eschar and 95% deep tissue injury. b. Dorsal right foot, unstageable pressure ulcer, measuring 4.6 cm by 4.2 cm by 0.1 cm (3 linear areas. c. Right foot hallus, PIP (proximal interphalangeal) joint, unstageable pressure ulcer, measuring 2 by 2 by 0.1 cm. The note documented that all new deep tissue injury areas appeared to be secondary to the Prevalon boot. The distribution is linear and line up with straps of the boot. The ARNP ordered to discontinue the Prevalon boots. The Wound Treatment Plan note dated 3/18/20 documented Resident #2 continued to require wound consultation. An Ankle Brachial Index test with arterial study completed the previous week showed some restriction in arterial blood flow and her wound inspection identified the etiology of his right foot ulcers as primarily related to pressure with a secondary cause as arterial. The Wound Treatment Plan notes dated The Wound Treatment Plan note dated 3/25/20, 4/8/20 and 6/17/20 documented Resident #2 wore Prevalon boots during the ARNP's wound care visits. She documented removal of the boots from the resident's room on 4/8/20. The Wound Treatment Plan notes revealed the ARNP continued to see and treat Resident #2's wounds weekly with the most recent note dated 11/4/20. During interview on 11/5/20 at 2:15, when asked the reason for placement of the Prevalon boot following it's order to be discontinued, the 4th floor Unit Manager (UM) stated stated that one night nurse kept putting the boot back on. The UM stated she talked to the staff member (Staff F) and told her of the resident's new open areas. Then the UM saw Resident #2 wear the boot again. The UM made a sign for the resident's room and talked to Staff F again when she saw the resident wearing the Prevalon boot; Staff F told the UM she forgot. The UM stated she finally removed the boot from the room and hid it. During a phone interview on 11/16/20 at 7:48 am, Staff F, RN (Registered Nurse) recalled that Resident #2's Prevalon boot did cause skin issues, but orders for it's use went back and forth. Staff F did not recall any conversations with the UM regarding the Prevalon boot. During an email dated 11/10/20 at 8:58 am, Resident #2's surgeon wrote that his only concern with the resident's wounds was that a dressing may have been applied too tightly causing development of wounds. Otherwise, the wound care had been appropriate. The clinical protocol for Pressure Ulcers/Skin Breakdown, revised 4/18, instructed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers and the physician would help identify causal or predisposing factors towards breakdown, clarify status of relevant medical issues and order pertinent wound treatments. The facility provided an Independent Contractor Agreement for the Wound Care ARNP interviewed above to provide wound care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #8 entered the facility on 8/18/20, according to the Minimum Data Set (MDS) assessment of 8/22/20. The MDS documented he had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded he had moderate cognitive and memory impairment, as evidenced by a BIMS score of eight. Resident #8 required the assistance of one staff to move in bed, transfer, walk in his room, use the toilet and complete personal hygiene. The assessment identified a risk for pressure ulcer development and current moisture associated skin damage, with pressure relief to his bed and chair, application of creams and a turning schedule. Resident #8's hospital Discharge Summary dated 8/18/20 documented he entered the hospital on 8/11/20 after a prolonged stay in the lobby of his apartment building. Resident #8 informed hospital staff he went to the lobby in his electric wheelchair on 8/10/20 to watch the rain. The apartment had a power outage and the elevator did not work, so he could not return to his second floor apartment. After an overnight stay in the lobby, Resident #8 experienced incontinence and emergency medical services brought him to the hospital. The resident's Care Plan dated 8/18/20 identified his risk for impaired skin integrity and instructed staff to encourage him to frequently shift his weight, evaluate his skin integrity, to monitor for moisture and apply a barrier product as needed. The 8/20 Treatment Administration Record (TAR) recorded staff applied [MEDICATION(S)] paste to the resident's buttocks twice a day. His first documented skin assessment dated [DATE] at 3 pm documented he had intact skin. A Progress Note dated 8/25/20 at 4:36 am documented Resident #8 had a superficial open area on his right buttock. The nurse, Staff G RN, cleansed the wound, patted it dry and applied his treatment: [MEDICATION(S)] paste according to the 8/20 Treatment Administration Record (TAR). The TAR also documented twice a day skin checks beginning 8/18/20. A Progress Note dated 8/28/20 at 12:33 pm documented Resident #8 had an unstageable area to his coccyx and the former wound nurse (author, Staff H, RN) was not notified. Staff H recorded an air mattress on order and starting the resident on weekly rounds. The note did not contain measurement or other description or assessment of the unstageable area. A Progress Note dated 9/9/20 at 9:45 am documented the Wound care ARNP as unable to see Resident #8 as the paperwork and signed consent had not been received. The resident discharged from the facility on 9/9/20. The resident's Care Plan contained no updated interventions following development of the open area on 8/18/20, the superficial area on 8/25/20 and unstageable area on 8/28/20. A Weekly Wound Assessment form dated 9/2/20 at 1:30 pm and authored by Staff H documented Resident #8 had an unstageable pressure wound to and a his coccyx that measured 10 cm in length and 13.8 cm in width, with a 0.1 unstageable depth, described as eschar. Staff documented the goal to keep the wound from opening and heal while closed, keep him off his back, encourage him to get out of bed and order of a pressure relief mattress. The assessment form documented notification to the resident's provider. Resident #8's TAR of 8/20 documented staff staff placed Duoderm (a protective dressing) to his coccyx and the TAR of 9/20 documented removal on 9/1/20. A Verbal physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20 TAR documented the order as discontinued on 9/2/20. Duoderm at 8:32 am (a provider order could not be found for application). A Verbal physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20 TAR documented staff implemented the dressing change on 9/3/20 at 8 am. On 9/2/20, the TAR recorded placement of a pressure relieving mattress on the resident's bed and directed to reposition Resident #8 side to side every two hours, to not position him on his back and to encourage him to get out of bed twice during the day (the MDS of 8/22/20 recorded Resident #8 received a turning schedule since on or before that date). During a phone interview on 11/4/20 Staff H stated with regards to her Progress note of 8/28/20, she learned of Resident #8's coccyx wound on that date; it was black and started fairly small. Regarding assessment of wounds and Wound clinic referrals, Staff H stated she learned about resident wounds from any staff and thought the shower aide told her about his. Staff H then measured the wound, obtained treatment orders, and made a referral to the wound clinic. She remembered the Third Floor Unit Manager told her she would refer Resident #8 to the Wound clinic sometime between 9/2/20 and 9/9/20, but thought the 9/2/20 referral may have been missed. During a telephone interview on 11/5/20 at 7:40 am, Staff G stated she did not remember Resident #8 specifically but if she discovered an open area, she would pass the information to the oncoming shift, leave a note in the doctor's box to be seen and send a facsimile for treatment orders. If Staff H was not scheduled, she'd tell her in person. Staff G concluded that she would not have assessed the resident's wound upon discovery; Staff H assessed resident wounds then. On 11/5/20 at 11:47 pm, the Third floor Unit Manager stated after the 8/25/20 discovery of an open area, Resident #8 should have been added to hot charting related to the wound. Facility expectations include an assessment of a wound when it is first discovered. The Unit Manager denied referring Resident #8 to the Wound Clinic and referral would have come from the Staff H. The resident's air mattress overlay was placed on 8/26 (Progress Notes documented the air mattress ordered on 8/28/20 and the 9/20 TAR documented placement on 9/2/20). The Unit Manager provided shift-to-shift report sheets documenting an open area to Resident #8's buttocks beginning 8/25/20 and a pressure sore to his bottom beginning 8/29/20. During interview on 11/5/20 at 12:30 pm, the Director of Nursing (DON) stated that upon discovery of a wound, staff are expected to notify the wound nurse and the physician for treatment orders. The DON would have expected wound measurements on 8/25 and 8/28/20. She did not think Resident #8 had a complicated wound on 8/25/20, so a Wound clinic referral would not have been done. By 9/2/20, Resident #8's wound appeared more complicated and should have been referred to the Wound clinic. The DON conducted resident wound assessments at present, Staff H left facility employment on 9/10/20.

Based on clinical record review, observation, resident, staff and primary care provider interviews and review of staff training records and job descriptions, facility staff failed to provide a safe transfer for one of five residents reviewed for nursing supervision (Resident #3). The facility identified a census of 89 current residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had diagnoses that included anxiety, [CONDITION(S)], [CONDITION(S)], lack of coordination, right knee pain and [CONDITION(S)]. The assessment documented she had intact memory and cognitive skills, as evidenced by a brief interview for mental status score of 14. Resident #3 required the assistance of two staff during transfers and did not walk. She did not experience pain during the assessment period and had a scheduled pain medication regimen. Resident #3's Care Plan, updated 7/30/20, identified Resident #3 as nonambulatory. The Care Plan instructed staff to transfer her with the assistance of two, using a 3 XL full body Hoyer sling, not the criss-cross style sling. The Care Plan also identified she had extensive chronic pain instructed to provide her medications as ordered. The Order Summary Report dated 11/17/20 recorded Resident #3 received oxycodone 5 milligrams (mg) three times a day for chronic pain and [MEDICATION(S)] 400 mg three times a day for polyneuropathy, both medications beginning 2/29/20 . The Fall Report dated 9/27/20 at 8:31 am documented Staff A, LPN (Licensed Practical Nurse) was summoned to Resident #3's room and observed the resident sitting on the floor with a CNA (certified nursing assistant) holding her in a sitting position. Staff A documented Resident #3's leg as internally rotated. While waiting for a return call from the resident's physician, Staff A interviewed the CNA's and learned the resident fell out of the sling to the floor as the leg straps of the lift sling were not crossed between the resident's thighs. When asked by Staff A of any pain, the resident was unable to give a definite description. Staff A documented after receiving orders for portable X-Ray, she assisted the CNA's to transfer Resident #3 from the floor to bed using the Hoyer lift and during the transfer, she taught the staff to properly position and secure the sling during a Hoyer transfer. Staff A noted Resident #3's ROM (range of motion) as in defined limits and she moved all extremities. The X-Rays of Resident #3's right hip with pelvis on 9/27/20 revealed the impression as limited by body habitus with artifact (degraded imagery) on the right hip films. The X-Ray contained no evidence of a displaced fracture, no joint dislocation and her pubic rami appear intact. Review of the resident's Progress Notes dated 9/27 - 10/6/20 revealed continued assessment following the fall. On 10/5/20 at 1:23 am documented Resident #3 complained of right knee pain and the area appeared swollen. Staff noted no increased warmth or discoloration, the resident reported the knee as painful to touch and she could not move it due to the pain. Resident #3 denied bumping the knee or any other trauma to the area. Staff sent a fax to her physician to report the change. An X-Ray of Resident #3's right knee on 10/6/20 revealed a comminuted distal femoral fracture with fracture lines extended over a length of 10 cm (centimeters), surrounding soft tissue swelling and [CONDITION(S)] changes about the knee. The facility reported the incident to the Department of Inspections and Appeals on 10/6/20 and it's investigation documented Staff B and Staff C, Hospitality Aides as present during Resident #3's fall on 9/27/20. A Major Injury Determination Form signed by the resident's primary care provider on 10/7/20 documented Resident #3 did not sustain a major injury and would return to her previous functional status. During interview on 10/26/20 at 1:30 pm, Resident #3 stated that on 9/27/20, staff moved her with a lift. One staff put her in a sling and another staff cranked it up. They told her not to move during the transfer. Resident #3 stated she held on to the lift, told the staff she felt herself slipping, who then told her she would not fall. Resident #3 felt like she was falling and then did, landing on her hip. She experienced pain but could not state specifically where, and her leg went behind her. Resident #3 stated she would not have any other fall or incidents that could have caused injury. During interview at the facility on 10/26/20 at 2:41 pm, Staff A stated on 9/27/20, staff got Resident #3 up with a Hoyer lift. As Staff A passed medications, one of the staff reported Resident #3 fell . When Staff A entered the room, one of the staff held the resident's head and the resident sat on her right knee. Staff A observed the side straps of the sling were not criss-crossed and did a demonstration with both staff right after the fall. Staff A stated that both staff were new and said they did not know the straps needed to be crossed. During a phone interview on 10/26/20 at 4 pm, Staff B stated on 9/27/20, she moved to a new floor (4th) and did not know Resident #3 well. Staff B got a medium [CONDITION(S)] sling and recalled telling Staff A the sling looked wrong, who asked her to do what's needed to get the resident up. Staff B stated she was pretty new. Staff B and Staff C transferred the resident. Staff B stated she held sling and kept close to the resident during the transfer. Staff C moved, bumped the lift and Resident #3 fell . Staff B stated she slowed the resident's fall. feet first towards the floor and the resident's leg folded under her. Staff B stated she learned later the sling straps should have been criss-crossed and also where other lifts slings are stored. Staff B stated she worked eight hours a day since mid August, using a Hoyer lift at least seven times a day. Staff B stated her trainer taught Hoyer transfers using a full lift sling and she had never worked with an [CONDITION(S)] Hoyer sling prior to 9/27/20. During a phone interview on 10/26/20 at 6:36 pm, Staff C remembered 9/27/20 as a busy day. Staff C stated Staff B went to get the Hoyer sling and they worked together to place the sling under the resident, get her up and move her. Staff C stated the resident's wheelchair needed to be moved to seat the resident, so she had to turn it. As she turned the resident's wheelchair, Resident #3 slipped out of the sling. When the resident slipped, Staff B held on to the resident's sling to guide it to the wheelchair but Resident #3 never made it to the wheelchair. The resident landed with her legs bent under her buttocks. Staff C stated she had just completed training, had watched Hoyer lift transfers and she worked the lift controls. She did not remember Staff B mention concerns with the lift sling. Staff C stated she did not think either she or Staff B knew there was a difference between the types of lift slings. During additional interview on 10/27/20 at 1:10 pm, Staff A stated she did not remember talking with Staff B about any concerns with the appearance of the sling on 9/27/20. Staff B's CNA Orientation Checklist dated 9/5/20 revealed she oriented to her position on 9/5 and 9/6/20 with the assistance of Staff D, CNA. Staff C's CNA Orientation Checklist dated 9/14/20 revealed she oriented to her position on 9/14/20 with the assistance of Staff E, CNA. Both checklists documented the staff received training on the use of Hoyer lifts. During a phone interview on 11/5/20 at 3:30 pm, Staff D stated when she trained new staff on Hoyer lift use, she had new staff observe the first couple of days so they can see how it is done. The next two days, she had the new staff run the lift while she supervised. Staff D stated she oriented new staff only on the full body lift sling. Staff D stated she had never seen or used an [CONDITION(S)] sling and did not know the facility had them. Staff D also stated she used the CNA Orientation Checklist to orient new staff and had not received further training instruction from nursing staff. During a phone interview on 11/9/20 at 11:50 am, Staff E stated when she oriented new staff, she normally ran the lift with another experienced aide while new staff watched. When they were both comfortable, she would have the new staff work the lift with her. Staff E normally used a full body lift sling to orient, but would use an [CONDITION(S)] sling if a resident required one. Staff E used the CNA Orientation Checklist to train from. On 10/28/20 at 10:12 am, tour with the 3rd floor Unit Manager revealed two Hoyer lift slings stored in the third floor linen room, 16 lift slings stored in the facility laundry room and six lift slings stored in the fourth floor linen room. All sizes were available for resident use. On 10/29/20 at 12:10 pm, the Administrator stated the job description for a Hospitality Aide would be the same as the job description for a CNA. The undated Position Description for the facility's CNA's documented one essential function of the job would be to assist with lifting, positioning and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc., in keeping with specific resident safety needs. On 11/10/20 at 1:40 pm, the Director of Nursing (DON) stated that CNA's who train new staff use the CNA Orientation Checklist as a guide and they would validate the training CNAs had the skills to train others, like for transfers and incontinence care. During phone interview on 11/16/20 at 10:30 am, Resident #3's Advanced Registered Nurse Practitioner (ARNP) stated it's not uncommon to have no fracture seen on portable X-Rays only to have a fracture seen on hospital films and that happens all the time. The ARNP stated Resident #3 had no other diagnoses she knew of that contributed to the fracture and it was possible her routine pain medications masked her pain.

Based on observations, staff interviews, and record review, the facility failed to implement CMS and CDC recommended infection control practices in order to control and prevent the potential spread of COVID-19 amongst residents and staff. The facility allowed staff to work and provide care to residents after reporting signs and symptoms of COVID-19, and subsequently tested positive for COVID-19. Furthermore, the facility failed to ensure staff that provided care to residents, and working in COVID-19 positive resident areas or presumed positive resident care areas wore appropriate personal protective equipment (PPE). The facility staff cared for residents which tested positive for COVID-19, and then assisted with the care of other residents in the facility. The facility reported they had an outbreak of COVID-19, a total of 55 residents that tested positive for COVID-19, and 10 residents that died of COVID-19. Additionally, the facility failed to ensure all staff were thoroughly screened before they began their scheduled shifts. These findings constituted an immediate jeopardy (IJ) to resident health and safety. The facility reported a census of 80 residents. Findings include: 1. Review of The American Health Care Association (AHCA) COVID-19: Screening Checklist dated [DATE], identified Staff A, Certified Nurses Aid (CNA), with a headache; on the Prevent COVID-19 screening logs dated [DATE] Staff A reported a new cough; [DATE] and [DATE] with shortness of breath; [DATE] with both a cough and shortness of breath, on [DATE] the form contained documentation that revealed Staff A had a cough and headache, and her last day of work on [DATE] listed symptoms of a cough, shortness of breath, and a headache. Staff A reported a positive COVID-19 test on [DATE]. Review of the Employee Time sheet documented Staff A worked 31.59 overtime hours during the pay period week [DATE] through [DATE], for a total of 71.59 hours. Staff A was allowed to work [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] prior to receiving a positive COVID-19 test on [DATE] at 8:55 a.m. During an interview on [DATE] at 11:15 a.m., Staff B, Assistant Director of Nursing (ADON) reported the Director of Nursing (DON) checked the Prevent COVID-19 screening tool a couple times per shift and if staff answered yes to any questions she asked them about it but they explained it away. During an interview on [DATE] at 10:05 a.m., Staff A reported when she arrived on the floor during a typical work day she washed hands, and checked her own temperature, if she could find a thermometer. She reported she had signs and symptoms of shortness of breath, headache, and occasional diarrhea. She reported the charge nurse was aware of her symptoms as she was being checked up on due to working so many extra shifts, she was not sent home on any day she worked. During an interview on [DATE] at 2:05 p.m., the DON reported she tried to follow up with staff when they marked yes on the screening tool. When staff had a number of yes's she would ask them if it was a normal symptom for them. The AHCA (American Healthcare Association) COVID-19 Screening Checklist for Visitors and Staff directed all individuals entering the building must be asked the following questions: (1.) Has the individual washed their hands or used alcohol-based hand rub (ABHR) upon entry? (2.) Ask if they have any of the following respiratory symptoms: cough, shortness of breath, fever, headache, chills, muscle pain - if yes to any, restrict them from entering the building. (3.) (a.) Staff to check temperature and document results, if a fever present, restrict from entering the building. (b.) Ask if they have worked in a facilities or locations with recognized COVID-19? If yes, ask if they worked with a person with confirmed COVID-19? If yes, require them to wear PPE, including mask, gloves, gown before any contact with residents and proceed to step 4. (4.) Allow entry to building and remind the individual to: wash their hands or use ABHR throughout their time in the building. Staff, when there are cases in the facility, implement universal use of facemask for all Health Care Providers (HCP) while in the facility. Consider having HCP wear all recommended PPE (gown, gloves, eye protection, N95 respirator, or if not available, a facemask) for the care of all residents, regardless of presence of symptoms. 2. Review of The Prevent COVID-19 screening logs and AHCA COVID-19: Screening Checklists dated [DATE] through [DATE], revealed the facility lacked documentation from Staff E, Admissions. Staff E worked in the facility during this time. Review of the Employee Time sheet documented Staff E worked [DATE], [DATE], [DATE], and [DATE]. The Employee Time Sheet recorded Staff E clocked-out on [DATE] at 1 p.m. During an interview on [DATE] at 9:24 a.m., Staff E reported he became ill on [DATE] with fever, chills, dizziness, and body aches. He was off the weekend and returned after the Memorial Day holiday on [DATE] upon which he was tested for COVID-19 after work. Staff E stated he received notification that he was COVID-19 positive on [DATE] at 10:02 a.m. 3. Review of the Healthcare Services Group Employee Work Schedule from [DATE] through [DATE], the Prevent COVID-19 screening logs, and the AHCA COVID-19: Screening Checklist dated [DATE] through [DATE], identified the following Staff G, H, I, J,K, L, M, and N, employees from the housekeeping department, failed to adequately complete the Prevent COVID-19 screening logs from [DATE] through [DATE] (378 shifts), 17 screening tools were completed accurately by Staff G, H, I, J,K, L, M, and N, throughout this time period. Staff G, H, I, J, K, L, M, and N were allowed to work in the facility from [DATE] through [DATE]. 4. Review of the Employee Time sheet revealed Staff T, CNA, worked 32.67 hours of overtime during pay periods pay periods [DATE] through [DATE]. Further review of her time sheet revealed from [DATE] through [DATE] she worked 14 hours of overtime. Staff T worked the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 8:33 a.m., Staff T reported that pay periods [DATE] through [DATE], and [DATE] through [DATE], she would bring gowns from home because there was not enough in the facility. She also revealed that she would put plastic bags on her feet as shoe covers, sometimes there were not any gloves. Staff T reported she was notified by the DON on [DATE] at 4:43 p.m. that she tested positive for COVID-19. 5. Observations revealed the following: a. On [DATE] at 8:55 a.m., Staff H, Housekeeper, wore only a mask as PPE; she reported that she knew she needed either a face shield or goggles but the facility did not have any available. b. On [DATE] at 8:55 a.m., Staff I, Housekeeper, worked in the staff designated Clean Room on the 4th floor wearing mask and face shield PPE but failed to wear gown, hair covering, gloves and foot covers. During an interview on [DATE] at 9:55 a.m., Staff H reported she enters the facility through the back entrance and does not don any PPE until she arrives on 2nd floor where her PPE is stored. Staff H reported that she has been wearing the same mask for over 3 months and face shield over 1 month. She reported that she had not had her temperature checked or had not completed The Prevent COVID-19 screening log or AHCA COVID-19: Screening Checklist in approximately 2 months. She reported that no one on the 3rd floor is in isolation. During an interview on [DATE] at 9:15 a.m., Staff L, Housekeeping Manager, reported that she enters the back entrance with her mask and goggles on, walks to the main entrance of the building and completes The Prevent COVID-19 screening tool or AHCA COVID-19: Screening Checklist. Staff L reported she had followed the honor system and had not audited staff completion of the tool but stated they had been told to do so, so she believed they had. Review of The American Health Care Association (AHCA), COVID-19 Screening Checklist for Visitors and Staff revealed all individuals entering the building must be asked the following questions: (1.) Has the individual washed their hands or used alcohol-based hand rub (ABHR) on entry? (2.) Do they have any of the following respiratory symptoms: cough, shortness of breath, fever, headache, chills, muscle pain-if yes, to any restrict them from entering the building. (3.) (a.) Staff to check temperature and document results, if a fever present, restrict from entering the building. (b.) Ask if they have worked in a facilities or locations with recognized COVID-19? If yes, ask if they worked with a person with confirmed COVID-19? If yes, require them to wear PPE, including mask, gloves, gown before any contact with residents and proceed to step 4. (4.) Allow entry to building and remind the individual to: wash their hands or use ABHR throughout their time in the building. Staff, when there are cases in the facility, implement universal use of facemask for all Health Care Providers (HCP) while in the facility. Consider having HCP wear all recommended PPE (gown, gloves, eye protection, N95 respirator, or if not available, a facemask) for the care of all residents, regardless of presence of symptoms. 6. Observation revealed on [DATE] at 9:06 a.m. Staff O (CNA) wore only a face mask for PPE. She reported that she did not have her face shield with her today. 7. Observation on [DATE] at 9:10 a.m., on the 3rd floor in the hallway outside room [ROOM NUMBER] revealed soiled trash stacked on floor consisting of boxes, dirty gloves, an old basin, emitting a foul odor. 8. Observation on [DATE] at 9:12 a.m., revealed Staff P, Registered Nurse (RN), in hallway of the 3rd floor outside room [ROOM NUMBER] wearing a mask for PPE with her eye goggles sitting on top of her head. During an interview on [DATE] at 10:40 a.m., Resident #7 reported nursing staff educated her to stay in her room, wash her hands, and wear a mask when in hallway. The resident reported the facility did not provide hand sanitizer but sometimes staff wash their hands upon entering my room. 9. Review of the notification to families by the facility titled, University Park Nursing and Rehabilitation Family Update, completed via telephone logs indicate communication was done between [DATE] through [DATE], on [DATE], [DATE], [DATE] and [DATE] with the facility unable to provide documentation of telephone notification logs on [DATE], [DATE], [DATE], [DATE] and [DATE]. Notification to Families by the facility completed in the form of a letter were completed on [DATE], [DATE], [DATE], and [DATE] with the facility unable to provide documentation of notification in the form of letter on [DATE], [DATE], and [DATE]. During an interview [DATE] at 3 p.m., Staff Q, reported that Family Notification of COVID-19 updates are done weekly by telephone and bi-weekly by letter, as of [DATE] all updates will be available to families on Face Book. Staff Q verbalized that the facility follows Iowa Department of Public Health (IDPH) policy for admissions. 10. Observation [DATE] at 12:40 p.m., revealed of one yellow isolation gown with face shield hanging on wall of 3rd floor between room of 305 and 307. During an interview on the 3rd floor on [DATE] at 11:15 a.m., with Staff B, reported there was not any residents with isolation precautions on the 3rd floor and all isolation patients were on the 4th floor as they all are positive for COVID-19. Staff B, said everyone is quarantined in a private room for 14 days, and not placed in isolation as there is no reason to be in isolation because all residents have a negative COVID-19 test result. Staff B stated the facility does not accept positive COVID-19 admissions. During an interview [DATE] at 12:00 pm with Staff B, and observation of resident rooms, Staff B reported the following residents were not in isolation or quarantine and no one on 3rd floor is in isolation: residents #3 with a readmission date of [DATE], #7 with admission date of [DATE], #8 with admission date of [DATE], #9 with admission date of [DATE], and #10 with admission date of [DATE]. During an interview [DATE] at 9:35 a.m. with Staff AA, CNA, reported she does not know what type of isolation residents are in, they wear whatever PPE is outside of the residents room. She added they would know they type of isolation the residents require only if they were told. During an interview on [DATE] at 9:15 a.m., Staff AA, reported every new admit has to be quarantined for 14 days. During an interview on [DATE] at 9:35 a.m., Staff X, CNA, reported that they never know who is in isolation and they wear whatever PPE is outside the resident door. Staff X said they do not know what precautions to use, stating you don't know if a resident is in isolation or quarantined unless you are told, so you put on everything. When asked, Staff X reported that nobody reviewed the screening tools and staff did not notify anyone if they marked yes. During an interview on [DATE] at 12:40 p.m., Staff DD, CNA, reported she did not know what happened if she answered yes to a question on the Prevent COVID-19 screening log. She stated she knew when a resident is in isolation because there will be gowns and bins outside their door, but no signage indicating what PPE is required. During an interview on [DATE], Staff FF, Medical Records, reported there would usually be a cart or magnet on door if the resident was in isolation, but she would usually ask staff. Staff FF reported she had not had her skills validated on the donning and doffing checklist. During an interview on [DATE] at 2:25 p.m., Staff EE, CNA, reported she usually worked on the 4th floor and upon arrival to the facility she clocked-in, put on her mask and gloves, and checked her temperature by herself or with a nurse. Staff EE said the PPE she used was gloves and mask as that is all she was provided. She stated she was not provided gowns, shoe covers, or a face shield. Staff EE reported she was not checked off on donning and doffing PPE. Upon review of IDPH Interim Guidance for New Admissions or Return of Residents to Long-term Care Facilities, IDPH recommends that all new admissions or returning residents, no matter the source, test result, or COVID-19 status, be isolated for a minimum of the first 14 days of their stay. Upon review of Personal Protective Equipment (PPE) Competency Validation Donning and Doffing Standard Precautions and Transmission Based Precautions, the facility provided documentation for both Staff EE and Staff FF that the employees were both deemed competent with residents in Standard Precautions, Contact [MEDICATION NAME] Precautions, Droplet Precautions, and Airborne Precautions. Staff EE had date of completion [DATE] and Staff FF had a completion date of [DATE]. During an interview with Staff S, Dietary Manager, he reported dietary staff enter through the back entrance then he checks their temperature and completes the Prevent COVID-19 screening tool, and then they don masks. He stated they are to wear face shields when they leave the kitchen and go upstairs. He reported he does perform audits to ensure staff wear the correct PPE, but did not log this information. He stated the evening staff are screened and complete the Prevent COVID-19 screening tool at the main entrance desk. On [DATE] the screening tool for [DATE] revealed the facility was unable to provide screening log documentation from three evening kitchen employees indicating they completed the screening process: Staff CC, II, and JJ. 11. Observation [DATE] at 8:00 a.m., revealed a Dietary Aide on 3rd floor wore no PPE other than a face mask. When asked, she reported that she thought her eye glasses were good enough and protective eyewear was not needed. During an interview on [DATE] at 1 p.m., Staff U, Licensed Practical Nurse (LPN), reported she entered the facility that entered via the back door, donned don a mask, went to her assigned floor, took her own temperature, and then completed the Prevent COVID-19 screening tool or AHCA COVID-19: Screening Checklists. When asked, she estimated approximately half of the staff did not consistently complete the Prevent COVID-19 screening tool. Staff U reported she also did not complete the tool several times and did not receive any follow up. Staff U reported she had a cough and an occasional fever when she worked and Assistant Nursing Director rechecked her temperature. She stated even if staff had signs or symptoms of COVID-19 they were not sent home because the facility was short staffed. She reported on [DATE] she began to not feel well and on [DATE] she tested positive for COVID-19 and had shortness of breath. Staff U was allowed to work [DATE], [DATE], [DATE], and [DATE]. During an interview with 3rd floor RN Staff Won [DATE] at 9:08 a.m., she reported at one point the facility ran out of hand sanitizer and now the DON makes it for them by mixing sanitizer and aloe, although she is uncertain of the alcohol percentage. Staff W said she brings her own hand sanitizer from home. 12. Review of the Employee Time Sheet Report documented Staff D, CNA worked on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. Review of the COVID-19 screening log identified Staff D had no AHCA screening checklist or employee screening log completed ,[DATE], ,[DATE], or [DATE]. Staff D had a COVID-19 test performed on [DATE], and received COVID-19 test result on [DATE], which revealed COVID-19 detected. Staff D worked [DATE] until 2:00 p.m. The Worker's Compensation claim revealed a date of injury [DATE] and listed COVID-19 as the nature of injury. During an interview on [DATE] at 10:25 a.m., Staff D reported she had a migraine headache and nausea during the week of [DATE] but continued to work. Staff D reported the facility had performed a COVID-19 test twice during the time while she worked and was told if she didn't hear anything that her test result was negative. Staff D stated she decided to get a COVID-19 test through the Test Iowa site when she continued to feel terrible and had no relief from her headache. Staff D reported she had marked on the screening log when she had symptoms and had told her manager but she was not sent home when she had those symptoms. Staff D reported visitors had screened whenever they came to the facility but staff screening had not been consistently performed. Staff D reported when she arrived for her work shift, she often times did not have her temperature taken because with a thermometer was unavailable or not working. Staff D reported at times she took her own temperature but then couldn't find the clipboard with the screening logs to record her temperature or document any symptoms. Staff D confirmed nobody took her temperature before she left the facility at the end of her shift. Staff D reported her COVID-19 test on [DATE] through Test Iowa was positive. On [DATE] at 10:25 a.m., Staff D reported she didn't know which residents were positive for COVID-19, but he cared for all residents as if they were on isolation. Staff D reported she had found out one resident (Resident #6) on the 4th floor had tested negative for COVID-19 but she didn't know and wore an isolation gown in his room. On [DATE] at 9:45 a.m., the DON provided the surveyors the screening checklists the facility used for staff and visitors. The DON reported the screening logs and checklists contained all of the records they had since they started the screenings March, 2020. At 11:38 a.m., the DON confirmed she had created a spreadsheet with employee names, COVID-19 test dates, and COVID-19 test results, but only the most recent test results were on the spreadsheet. The DON confirmed she sent the information to the IDPH every other week. During an interview [DATE] at 10:55 a.m., the Human Resource (HR) /Payroll Director reported employee COVID-19 test results sent to the DON. Whenever an employee had a COVID-19 test at Test Iowa, the test results were sent directly to the employee. The employee then provided her a copy of the results and she submitted the information to workman's compensation. During an interview [DATE] at 10:55 a.m., the HR Director reported Staff D provided her COVID-19 test results from Test Iowa on [DATE]. At 11:35 a.m., the HR Director reported the facility started screening staff the week prior to the surveyors entering the facility. If staff had tested positive but had no symptoms they were told by the Medical Director they could return to work. 13. Review of the AHCA COVID-19 screening checklist identified Staff F, CNA, revealed only a temperature documented on the screening form on ,[DATE] and [DATE]. Review of the Employee Time Sheet Report documented Staff F worked on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. Review of the Worker's Compensation form revealed Staff F had an injury date [DATE] at 9:00 a.m., and documented COVID-19 as the nature of injury. The Employee Time Sheet Report recorded Staff F worked [DATE] 6:15 am- 2:15 p.m. During an interview [DATE] at 9:25 a.m., Staff F reported she normally worked on the 4th floor. Staff F reported she took her temperature when she arrived on the unit to work, then she donned a mask and a face shield. Staff F reported she had contact with another staff person who had tested positive on [DATE] for COVID-19. Staff F reported she had a cough and chest pressure on [DATE]. Staff F scheduled an appointment to have a COVID test with Test Iowa on [DATE], and received her COVID test results on [DATE], which indicated she tested positive for COVID-19. At that time, she told Staff V, ADON, she had tested positive for COVID-19 and then told Staff V she needed to go home. Staff F reported she had told several staff, including her charge nurse and Staff V she didn't feel right while working on [DATE] but continued to work until she received the COVID-19 test results. Staff F reported the Administrative staff were more worried if a staff member had an elevated temperature, then if they had respiratory symptoms or other symptoms, such as chest pressure or cough. During an interview [DATE] at 10:55 a.m., the Human Resource/Payroll Director reported Staff F provided her COVID-19 test results from Test Iowa on [DATE]. 14. Review of the employee timesheet report revealed Staff KK worked ,[DATE] through [DATE]. Review of the AHCA and COVID-19 screening logs revealed Staff KK had no screening performed or temperature checked ,[DATE] - [DATE]. During an interview [DATE] at 11:15 a.m., Staff KK / CNA reported when she arrived to work, she went to the 4th floor unit, and needed a temperature check, but often times had no thermometer available or the nurse was not available to check her temperature. Staff KK reported sometimes she had her temperature checked during the shift. Staff KK reported she developed a cough and wheezing [DATE]. Staff KK thought it was related to her asthma. Staff KK stated she told the nurse on duty she couldn't breathe. The nurse administered a nebulizer breathing treatment. Staff KK stated she tried to go home but the on-call nurse wouldn't let her leave until they found a replacement first. Later that day, when her shift ended, a friend took her to the Emergency Department. The ED staff told her she needed to quarantine. Two days later, Staff KK received a call from the hospital her COVID-19 test was positive. Staff KK then contacted HR to advise of her positive COVID-19 results. Observations revealed the following: a. On [DATE] at 7:50 a.m. a sign by the front entrance directed all employees must enter at the back door of the facility by the parking lot. At 7:57 a.m., Staff C, therapy, walked across the employee parking lot toward the back door. Staff C entered a code on a keypad lock, opened the back door, and walked through the back corridor past the kitchen, time clock, elevators, and business office. Staff C had no mask, face shield, or goggles on. Staff C had no temperature or screening completed. At the time, the surveyor inquired about screening. Staff C shook his head no. b. At 8:04 a.m., Staff II, Administrative Staff, took the surveyor to the front lobby area after the surveyor inquired about screening and wore no mask, goggles, or face shield on. Staff II reported no thermometer in the area and asked Staff BB/Restorative Aide where the thermometer went. Staff BB said she had no idea where the thermometer was located so she searched the area and did not find a thermometer. At 8:07 a.m., Staff II and Staff BB contacted Staff GG, CNA, and reported no thermometer. Staff GG left the area and at 8:10 a.m., Staff V, RN/ADON, brought a thermometer to the front lobby. Staff II, Staff BB, Staff GG did not wear a mask, goggles, or face shield and Staff BB reported she had not had time to put a mask or goggles on. Staff GG confirmed they had COVID-19 cases in the building. At the time, the clipboard at the front entrance contained screening logs for [DATE] and [DATE] with one name listed, the screening log dated [DATE] had five names listed, and no log found for date of [DATE]. c. At 12:10 p.m., Staff BB, sat by a table in the front lobby wearing a facemask and goggles. d. On [DATE] at 7:33 a.m., a sign on the front door directed everyone must check their temperature before they entered or left the facility. Two binders with screening logs for staff/visitors sat on a table in the front lobby. One binder labeled in and one binder labeled out. The screening logs included a temperature check and yes/no questions about symptoms for staff/visitors to mark. e. On [DATE] at 8:50 a.m., Staff Z, CNA, stood by the nurse's station on the 4th floor wearing a mask with her goggles perched upon the top of her head. Staff Z reported all residents on the 4th floor had COVID-19 except one. She stated whenever she came to work, she entered through the back door entrance, clocked in, went to the 4th floor, and had her temperature checked. f. On [DATE] at 8:55 a.m., Staff I, housekeeper, stood in room [ROOM NUMBER] with the door open into the COVID-19 hallway wearing a face shield, glasses, and mask only. g. On [DATE] at 9:02 a.m., Staff D, CNA, stood in the North hallway by a resident's room. Staff D wore a blue gown, hair covering, face shield, and mask, but had no shoe covers on. Staff D reported all residents that resided on the North Hall had COVID-19 except Resident #6, so that resident had plastic covering the doorway. h. On [DATE] at 9:07 a.m., the 4th floor East Hallway soiled utility room contained several bags of soiled linens and trash piled on the floor and in a large cart in the soiled utility room with all resident room doors open to the hallway. i. On [DATE] at 10:10 a.m., Staff Y, CNA, removed her gown, unzipped the plastic barrier to room [ROOM NUMBER] (the resident inside had been Covid-19 negative), opened the resident's door and entered the room. At 10:11 a.m., Staff Y exited the room, closed the door, zipped the plastic barrier, removed her shoe covers, sanitized her hands, and donned a gown. Staff Y wore a mask, goggles, and hair covering on, but did not change out her mask or hair covering, or disinfect her goggles. j. On [DATE] at 9:35 a.m., Staff JJ, CMA, stood by the 4th floor nurse's station wearing an N95 mask. Staff JJ wore glasses, but no face shield or goggles. k. On [DATE] at 9:46 a.m., Staff V, RN/ADON, wore a mask with goggles perched on top of her head. l. On [DATE] at 8:40 a.m., observation of the 4th floor designated COVID-19 unit revealed the following: (1). The North Hall had a mini-station set up between two plastic zippered walls. White and blue gowns hung on hooks, and a spray bottle of Virex, a box of gloves, and sugar packets and creamers sat on top of a cart. Resident room doors excepting room [ROOM NUMBER] were open on the North Hall corridor past the zippered plastic wall. room [ROOM NUMBER]'s door had plastic over the doorway, and room [ROOM NUMBER] was designated for staff. The room had a medication cart parked by the wall and shoe covering, hair covering, and hand sanitizer in the room. (2). The East Hall had plastic walls with the zipper unzipped on the outside (by the nurse's station) and the interior plastic wall leading into the COVID-19 hallway, with airflow into the hall and nurse's station by the elevator. Several residents' room doors on the East Hall were found open. During an interview [DATE] at 9:50 a.m., Staff Z, CNA, reported when there was nobody on the first floor to take a temperature, she went to the 4th floor nurse's unit. If no staff were at the nurse's station to check her temperature, she checked her own and recorded it on the clipboard. Staff Z reported all residents on the 4th floor had tested positive for COVID-19 except Resident #6, and Resident #6's room had plastic taped over the door. Staff Z stated she removed her gown before she entered the residents' room but left her mask and goggles on. During an interview [DATE] at 11:05 a.m., Staff Y, CNA, reported when she arrived to the unit, the nurse sometimes took her temperature or staff checked each other's temperature. Staff Y stated she often had to hunt down a thermometer due to no thermometer in the area. Staff Y reported they sometimes only checked their temperature and wrote the reading on a piece of paper because they didn't have any screening forms available, but if she had symptoms of illness, she contacted the on-call manager. Staff Y said the on-call manager had told her to come into work and get assessed after she arrived at work. Staff Y reported she had tested for COVID-19; the test done on [DATE] came back inconclusive, so she had another test run on [DATE], which was negative. During an interview [DATE] at 11:20 a.m., Staff V, RN/ADON, reported she expected staff had temperature checked and a screening questionnaire completed when they arrived at the nurse's station. If a staff person reported symptoms such as muscle aches or a headache, she asked if symptoms were new. Staff V reported she looked at the screening logs every shift. Staff V reported she expected staff to wear an N95 mask, goggles, or face shield while in the building. Whenever staff worked within the COVID-19 hallways on the 4th floor, she expected staff to wear an N95 mask, goggles, gown, gloves, hair covering, and shoe covers. During an interview [DATE] at 1:20 p.m., Staff M, housekeeper, reported she had her temperature checked by one of the other housekeepers but had no screening questions about her symptoms completed. Staff M reported the nurse or CNA told her which residents were in isolation and they tell her what she needed to wear before she entered the resident's room. During an interview [DATE] at 5:30 p.m., Staff LL, CMA reported he checked his own temperature and recorded the reading on the clipboard when he arrived to work on the 4th floor. He then donned a mask, goggles, gown, and shoe coverings. Staff LL stated staff in report told him which residents were are on isolation, and they had also had the same residents listed on a clipboard. During an interview [DATE] at 3:05 p.m., Staff HH, RN/Infection Preventionist, reported the nurse told staff which residents were on isolation and specified the PPE required before they entered the resident's room or cared for the resident. Staff HH reported they had signs placed on the door by the resident's room to designate the resident as in isolation but she had not been able to monitor or know what staff had done on other units. Staff HH reported she got pulled to work the floor last fall when they had staffing needs and hadn't done anything with the infection control program since that time. Staff HH reported the DON relayed information to staff about COVID-19 and PPE use. When asked, she said (TRUNCATED)

Based on clinical record review, staff interviews, facility policy reviews and observation, the facility failed to provide adequate supervision for one of four sampled residents in order to prevent an unplanned exit (elopement) from the facility (Resident #1). The facility reported a census of 109 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11; a BIMS score of 11 indicated moderate cognitive and memory impairment. The MDS documented her [DIAGNOSES REDACTED]. The MDS revealed the resident as independent with transfers and ambulation with the use of a walker. The assessment documented Resident #1 did not display behavioral symptoms or acute mental status changes during the assessment period. A Preadmission Screening and Resident review (PASRR) dated [DATE] identified additional [DIAGNOSES REDACTED]. The PASRR documented hospitalization s of [DATE] to [DATE], [DATE] to [DATE] and [DATE] to-[DATE] with an admitting [DIAGNOSES REDACTED]. The PASRR also recommended that due to suicidal ideation and three psychiatric hospitalization s since (MONTH) (YEAR), Resident #1 would benefit from the development of a crisis intervention/safety plan to reduce her risk of self-harm. Departmental notes dated [DATE] at 1:25 p.m. by the facility's social worker documented Resident #1 told another resident she was going to sneak out of the facility, walk to the river and jump and kill herself. Notes dated [DATE] at 11:07 a.m. documented the resident continued to have behavioral issues at times and had anxiety and impulsiveness which were manageable at the facility. Departmental notes dated [DATE] at 3:10 p.m. documented the resident's dementia was getting worse and her behaviors tended to worsen at night. Staff continued to do regular checks on her room for suicidal precautions due to a history of suicide attempts and battling depression. Departmental notes dated [DATE] at 2:55 p.m. documented Resident #1 refused her medications and told staff to leave her alone and let her die. The facility's social worker met with the resident and redirected her to take her medications. Departmental notes dated [DATE] at 10:55 p.m. documented at approximately 8:35 p.m. facility staff received a phone call from a hospital emergency room (ER) staff, who reported the resident had arrived in the ER at 8:20 p.m. Nursing staff tried to speak with hospital personnel but they had already hung up. Staff alerted the nurse on-call and reported a call had been received from the ER reporting the resident was at the ER. The nurse on-call directed staff to call the ER. Staff spoke to ER staff who reported the resident arrived in the ER approximately at 8:20 a.m. The resident's coat was wet and covered with snow. Facility staff asked ER staff to check the resident for a wander-guard bracelet on the resident. Hospital staff reported the wander-guard bracelet could not be found. Hospital staff reported the resident didn't tell them how she got there. The resident had reported her feet hurt and she felt suicidal after thinking about her daughter that died [AGE] years earlier. Departmental notes dated [DATE] at 10:58 p.m. documented staff revealed camera footage which showed the resident arrived on the main floor, pushing her four wheeled walker at 6:10 p.m. The resident removed her sweater and winter coat from underneath her walker seat, put both sweater and coat on and placed the walker away from the exit door. Resident #1 pushed the red button to disable the alarm and exited through the front door at 6:11 p.m. The resident's Wander-Guard (WG, a safety alert device) was on the walker per the care plan, but the resident left the walker at a distance far enough away the WG did not sound. Departmental notes dated [DATE] at 1:31 p.m. documented facility staff received a call from hospital staff reporting the resident wouldn't be admitted and would be discharged back to the facility. The resident's power of attorney (POA) returned a call to the facility and voiced concern about the facility's ability to keep the resident safe and didn't feel 15 minute checks an appropriate safety measure. Departmental notes dated [DATE] at 8:59 p.m. recorded a late entry that Resident #1 returned at 11:30 a.m. Notes documented the resident reported hospital discharge papers had not been sent. Staff completed an assessment which revealed no injuries. Staff placed a WG bracelet to the resident's right wrist and initiated 15 minute safety checks. A review of the 15 minutes check sheets revealed completion beginning [DATE] at 11:30 a.m. through [DATE] at 11:30 a.m. Departmental notes dated [DATE] at 2:58 p.m. documented Staff A, a social worker, started looking for placement on locked units and today found placement in a locked unit. The writer noted attempts made in the past had been unsuccessful related to the resident being too high functioning. The facility had gone to court several times with attempts to get her court-committed for psych care and appropriate placement due to poor decision making although Resident #1 does well on the BIMS. The incident of last weekend ([DATE]), when she left the building, the resident's cognition allowed her to figure out how to leave without setting the alarm off. She knew to wear a coat and where she was walking to. Contributing to her exiting the facility included her POA telling the resident she would visit and then not coming to the facility. The resident responded negatively to these situations. In an interview the resident acknowledged she did not tell staff she would be leaving. Hospital ER records dated [DATE] at 8:23 p.m. documented hospital security found Resident #1 by the river. She planned to jump in the river to kill herself. Hospital ER records with a print date of [DATE] at 8:41 p.m. documented the resident reported being suicidal and planned to jump off a bridge. The resident stated she is sad because she did not want to live at the facility. The resident also thought of the death of her daughter [AGE] years ago. The resident stated she walked to the hospital from the facility. The resident's Care plan, with a problem onset revision date of [DATE], identified a crisis intervention/safety plan to reduce risk of harm to self or others related to threats of suicide, aggression toward others and non-compliance with her care plan. Interventions directed staff to report withdrawn behaviors and self-isolation, provide 1:1 interaction as needed to discuss her needs or provide emotional support if needed or to redirect behaviors. Initiate 15 minute checks as needed for suicidal thoughts, ideations or threats to harm self, shorten call light in bathroom, remove shower bar, lengthy call light removed from room, remove shoe laces and seek a court committal for psychiatric treatment if resident exhibits signs of instability/suicidal/homicidal ideation. A physician's orders [REDACTED]. The Care plan also identified a problem with the onset date of [DATE] that identified a risk for falls. Interventions directed the use an assistive device (walker) and to keep the walker within reach of the resident. A problem with the onset date of [DATE] identified self-care deficit potential related to mental difficulties, cognitive loss and [MEDICAL CONDITION] disorder. Interventions included placement of a WG due to a history of elopement attempts. The resident refused to wear the device on her person so staff placed the device on the walker. Interventions directed staff to check placement of the WG and complete safety checks at each shift. Clinical record review revealed a court order dated [DATE] at 9:42 a.m. ordering the resident for continued out-patient commitment. In this document the court, having received and reviewed a physician's report finding the resident to be seriously mentally impaired. The resident suffered from mental illness, lacked judgmental capacity by the fact she was likely to physically injure herself or others if allowed to remain at liberty without treatment. The resident was unable to satisfy her needs for nourishment, clothing, essential medical care, or shelter and likely would suffer physical injury, physical debilitation, or death. Medication Administrator Records (MARs) for [DATE] - [DATE] recorded the following medications administered to Resident #1: [MEDICATION NAME] ER 150 milligrams (mg) - one tablet daily for major [MEDICAL CONDITION], [MEDICATION NAME] Sodium ER 1000 mg - 2 tablets at bedtime for major [MEDICAL CONDITION] recurrent severe without psychotic features, [MEDICATION NAME] 30 mg - 1 tablet at bedtime, Trazadone 50 mg - 1 tablet at night for major [MEDICAL CONDITION], recurrent severe without psychiatric features. A review of MARs for this period revealed the listed medications were administered as prescribed. A facility document titled Wandering, Unsafe Resident with a revision date of ,[DATE] revealed the policy statement stated the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for a resident who is at risk of elopement. Implementation interpretation directed staff to identify residents who are at risk for harm because of unsafe wandering, including elopement. Staff will assess at-risk individuals for potential correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions directed staff to maintain safety, such as a detailed monitoring plan. The facility completed Elopement/Wandering Risk Data Set assessments for Resident #1 on [DATE] [DATE], [DATE], [DATE] and [DATE]. Each risk assessment documented she had poor safety/environmental awareness, impulsive behaviors and the risk for elopement and placement of a WG pendent. A facility documented titled Elopement Policy (no date) defines elopement as: When a resident who is cognitively, physically, mentally, emotionally and or chemically impaired; wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility unsupervised, unnoticed, and or prior to their scheduled discharge. Should an elopement occur: 1. If a WG sounds or you come up upon a missing resident IMMEDIATELY check the entire area and this includes around the perimeter of the building. The WanderGuard (WG) Blue Tag information from the manufacturer documented the WG tag and controller issues an alarm and can lock a monitored door so an at-risk resident wearing the device cannot leave through the door. The resident typically wore the WG Blue Tag on the wrist like a bracelet. Additional information provided by the facility's WG representative on [DATE] at 10:04 a.m. instructed that a WG tag could be placed on a wheelchair but placement should be on a non-metal part of the wheelchair as touching metal could interfere with the WG signal. The email did not contain direction on tag placement on a resident's walker. Treatment administration records (TARs) for January, 2019 documented when staff verified placement and function of the wander-guard pendent. Staff were required to check placement and function of the device 4 times daily; 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. TARs for the period of [DATE] revealed staff had documented placement and function check of the wander-guard pendent at 8:00 a.m., 12:00 p.m. at 4:00 p.m. and no entry for 8:00 p.m. The Administration Record with a subtitle of (e-Tar), which documented the actual time of staff records in the TAR's showed the above entries (8:00 a.m. 12:00 p.m. and 4:00 p.m.) were made on [DATE] at 9:54 p.m. and not at the specified times identified on the TARs. These entries were made after Resident #1 left the facility and was in the hospital ER. Entries made [DATE] - [DATE] revealed at least 18 additional entries where staff did not check placement and function within the times documented on the TAR's. A written statement dated [DATE] by Staff C, a certified nursing assistant (CNA) noted she started looking for Resident #1 at 7:40 p.m. She began by looking for the resident in her room but she was not there. Staff C went to the 3rd floor to look for her and asked another resident and friend of Resident #1 if she had seen the resident during the smoke break at 7:00 p.m. The resident reported she had not seen Resident #1. Staff C told Staff G, a licensed practical nurse (LPN) the resident wasn't in her room. Staff C then took the elevator to the 4th floor and upon arrival another CNA reported hospital staff had called and reported the resident was at the hospital. In a written document dated [DATE], Staff A, the facility's social worker interviewed the resident. Resident #1 reported she felt down the weekend of [DATE] and admitted she hadn't told facility staff when she decided to leave or how depressed she was feeling. The resident stated when she got down downstairs (the evening of [DATE]) she purposely parked her walker in a place where the WG alarm wouldn't sound. She pulled out her winter coat, walked to the front door, pushed the red button, de-activated the door alarm and walked out of the facility. She reported she then planned to walk to the river but decided not to and went to the hospital instead. During an interview on [DATE] at 11:30 a.m. Staff A, reported the resident had no recent history of exit seeking or elopement. The resident is high functioning and independent with most cares. She didn't show any signs of or stated thoughts of suicide. Her care plan had problem areas identified related to a history of depression along with interventions. On [DATE] at 11:30 a.m. Staff B CNA reported she had seen the resident attempt to elope from the facility the summer of (YEAR); staff intervened before the resident left the facility. The evening of [DATE] shortly after 6:00 p.m. she noted the resident left her room. She had finished dinner in her room and walked by the nurse's station. The resident acted pleasant and talkative. The resident usually went downstairs to wait for the smoke break. She made no comments about wanting to leave (Note - the facility's smoking room is inside the facility and located on the 1st floor). During an interview on [DATE] at 11:42 a.m. Staff C reported she worked at the facility for [AGE] years. On [DATE] she worked 2:00 p.m. -10:00 p.m. She reported she usually saw the resident in her room except for smoke breaks and Resident #1 would usually go a little early and wait until that time. (Facility records recorded smoke breaks are scheduled at 9:00 a.m., 1:00 p.m., 3:00 p.m. and 7:00 p.m.). Staff C reported the evening of [DATE] the resident appeared in good spirits and didn't tell anyone she wanted to leave. Staff C confirmed the original time (7:40 p.m.) she began to look for the resident. On [DATE] at 11:56 a.m. Staff D, CNA reported the resident isolated herself in her room. The resident came out for smoke breaks and would go downstairs and wait for the break to begin. On [DATE] the resident sounded like she was in good spirits. The resident didn't express any feelings of sadness and no attempts had been made to leave the facility. On [DATE] at 12:54 p.m., the Director of Nursing (DON) reported the resident removed her WG wrist bracelet sometime in (MONTH) (YEAR); she didn't recall why the resident had refused it. The resident agreed to have a WG bracelet placed on her walker. Wander-guard pendent placement and functionality checks were completed four times daily. The WG system, with one location at the facility's front door, is checked four times weekly along with entrance/exit door for all four floors and all exit doors leading outside. During an interview on [DATE] at 1:25 p.m. Staff F, Registered Nurse (RN) and 4th floor nurse manager reported Resident #1 would often stay in her room, in bed, for most of the day. She would come out early for smoke breaks and wait for smoke break to begin. She recalled the resident attempted to elope in (MONTH) (YEAR) but was not certain of the date. During an interview on [DATE] at 1:00 p.m. Staff F reported the resident had been identified as an elopement risk because the resident didn't want to be at the facility. The resident's power of attorney (a friend) usually picked her up on Saturdays. The friend didn't come to the facility that day and the resident had been planning to see her that day. A document signed by and submitted by the Administrator (without a date) with a heading of Smoke room review at 8:00 p.m. smoke break documented Staff H and Staff I did not see Resident #1 in the smoke room on [DATE]. A review of staff schedule for [DATE] listed both Staff H and Staff I working 2:00 p.m. - 10:00 p.m. On [DATE] at 3:47 p.m. Staff H CNA reported she wasn't certain she worked the evening of [DATE]. She stated staff didn't keep records of what residents attended smoke breaks. During an interview on [DATE] at 3:54 p.m. Staff I CNA reported she worked the evening of [DATE] and did attend the smoke break at 7:00 p.m. She reported Resident #1 didn't smoke at the smoke break at 7:00 p.m. She recalled hearing the resident was at a local hospital that evening but no one had asked her to look for the resident earlier that evening. During a second interview on [DATE] at 1:25 p.m. Staff A, reported she completed a number of elopement assessments (cited above titled Elopement/Wandering Risk Data). Each elopement assessment indicated Resident #1 as at risk for elopement because she had made verbal threats to leave the facility. Staff A reported she had documented some but not all of the threats she had made. She reported she had documented these threats in departmental notes. Staff A reported she believed the resident had been court committed to ICF level of care. During an interview on [DATE] at 3:10 p.m. Staff F stated checking placement and function of the wander-guard pendent ensures the device is present and functional at the times specified on the TARs. This process also assures the resident's presence at the facility. Staff have one hour before and after the specified time noted in the TARs to visually check placement and function of the wander-guard pendent and resident safety. During an interview on [DATE] at 3:25 p.m. the DON confirmed staff were to check placement and functional testing of the wander-guard at the assigned times identified in the TAR's. Additional record review and observations revealed the following: On [DATE] the facility provided a list of residents identified as at risk for elopement. This list identified 15 residents at risk of elopement. Of the 15 residents identified, Residents #1, # 3 and # 4 were identified as residents who wandered and had increased risk of elopement. An observation on [DATE] at 3:10 p.m. revealed Resident #3 lying in bed and he appeared to be sleeping. The resident's wheelchair sat adjacent to his bed with a WG bracelet strap adhered on the back of the wheelchair on a top metal cross-bar which ran horizontal from side to side. An observation on [DATE] at 11:10 a.m. revealed Resident #3's WG bracelet remained in the same position as on [DATE]. An observation on [DATE] at 12:15 p.m. revealed Resident #3's WG bracelet securely fastened to center of the top metal cross bar to a piece of foam placed over the cross bar. An observation on [DATE] at 2:20 p.m. revealed Resident #4 sitting in her wheelchair. The resident's WG bracelet had been placed on the right side of a lower metal cross-bar, loosely dangling from the bracelet strap. An observation on [DATE] at 11:10 a.m. revealed Resident #4's WG bracelet had not changed position from the previous observation. An observation on [DATE] at 11:33 a.m. noted Resident #4's WG bracelet had not changed from where it had been placed earlier. However, a piece of clear tape had been placed on the inside of the bracelet strap. The incident detailed above resulted in an Immediate Jeopardy situation for residents of the facility. The facility abated the immediate jeopardy situation on [DATE] through a combination of efforts that included: a. Re-assessment of residents for elopement potential; b. Review of the elopement book (protocol and pictures of at risk residents); c. Staff re-education on elopement procedures; d. Direct observation of Resident #1, with subsequent transfer to a locked memory unit; e. Audit of the facility's WG system and door alarm checks; f. Continued elopement drills; g. Resident care plan review and updates, h. Placement of WG tags as instructed by the manufacturer.

Based on observation, clinical record review and staff interviews, the facility failed to assess a resident after each fall in order to identify adverse symptoms for 1 of 7 residents reviewed (Resident #1). The facility reported a census of 99 residents. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 3/5/14 which identified the resident had a severe cognitive impairment and experienced [MEDICAL CONDITION], inattention and disorganized thinking. The MDS reported the resident required extensive assistance of two staff to transfer from one surface to another. The MDS identified the resident had [DIAGNOSES REDACTED]. On 3/7/14, the Care Plan identified Resident #1 at risk for injury related to falls and the resident needed assistance with transfers. It directed staff to provide a low bed with a floor matt next to the bed, non-skid socks/shoes, ambulate with assistance when having signs and symptoms of agitation, stand/pivot transfer with the assistance of two staff and provide periodic medication reviews. In the Departmental Notes dated 4/4/14 at 3:55 a.m., Staff J RN (Registered Nurse), documented Resident #1 had increased agitation/combative behaviors, scratching the aides while attempting to assist the resident to bed. The resident crawled out of bed onto the floor and also broke the CNA's (Certified Nurse's Aide) headset. The resident finally laid back in bed at this time. The notes did not include documentation that Staff J assessed the resident after finding him/her on the floor. The facility could not provide an incident report dated 4/4/14 upon request. In the Departmental Notes dated 4/13/14 (Sunday) at 1:52 a.m., Staff J documented Resident #1 had increased anxiety, crawled out of the low bed to the floor and had no injury at the time. The resident rested on the mattress on the floor. The notes failed to include documentation that Staff J assessed the resident after finding him/her on the floor. The facility could not provide an incident report dated 4/13/14 upon request. The Departmental Notes dated 4/14/14 (Monday) at 3:36 a.m. written by Staff J, documented the resident yelled out when turned per the CNA's report. Staff were unsure if Resident #1 felt pain since the resident was always combative with cares. Staff J checked the resident ' s vital signs, but the note documented no further assessment as to possible pain or injury. The Departmental Notes dated 4/15/14 (Tuesday) at 2:21 p.m. documented that with ADLs (Activity Daily Living) cares, Resident #1 moaned and displayed facial grimacing. The resident yelled out and guarded his/her right hip with a transfer from the bed to the chair. Staff contacted the Advanced Registered Nurse Practitioner (ARNP) who ordered bilateral hip x-rays due to pain and a history of falls. At 5:18 p.m., the notes documented the ARNP requested an orthopedic consult. The orthopedic physician identified the resident had a right [MEDICAL CONDITION]. On 6/3/14 at 10:15 a.m. the ARNP was interviewed and stated she arrived at the facility on 4/15/14 and was told by Staff L that the resident screamed out in pain when staff got the resident up for the day. The ARNP barely moved the resident and the resident screamed in pain. The ARNP ordered a portable x-ray. The x-ray report dated 4/15/14 revealed Resident #1 had a right [MEDICAL CONDITION]: acute intertrochanteric fracture with avulsion of the lesser trochanter (hip). The x-ray revealed no displacement (of the femoral head from the acetabulum). The hospital History and Physical report dated 4/15/14 revealed Resident #1 had a right [MEDICAL CONDITION]. The Operative Report dated 4/16/14 documented the resident received an open reduction of the right [MEDICAL CONDITION] on that date. The facility Departmental Notes dated 4/25/14 documented the resident returned to the facility at 3 p.m. During an interview on 6/3/2014 at 2:00 p.m. the DON (Director of Nursing) reported Resident #1 had falls on 3/17, 3/19, 3/30, 3/31, 4/4 and 4/13/14. The facility had no incident reports for the falls of 4/4/14 and 4/13/14. Staff J did not realize the resident had a fall when he/she moved from the low bed to the floor while unattended and During an interview on 6/3/14 at 3 p.m., Staff J stated one night (4/13/14) the aides reported they found Resident #1 sitting on the floor by the doorway. Staff rolled the resident onto a bath blanket and they placed the resident on the mattress positioned on the floor. The resident fell asleep and had no complaints of pain the remainder of the shift. Staff J did not complete incident reports when the resident crawled out of their low bed. During an interview on 6/3/14 at 11:00 a.m., Staff M, LPN (Licensed Practical Nurse), Unit Manager reported the facility had no incident reports dated 4/4 and 4/13/14 when staff found Resident #1 out of bed. During an interview on 6/3/14 at approximately 3:10 p.m., Staff G, CNA reported she worked the night shift on 4/12 - 4/13/14. Staff G stated she sat at the nurse's station and heard Resident #1's voice and witnessed the resident seated on the floor in the doorway. Staff J assisted the aides to roll the resident onto a sheet and carry him/her to the mattress on the floor. The resident complained of their leg hurting and said "mama, my leg hurts". Staff G stated Staff J did not assess the resident after they found him/her on the floor. During an interview on 6/3/14 at 12:08 p.m., Staff L (registered nurse) reported working 4/14 and 4/15/14 from 6:00 a.m. until 6:00 p.m. On Monday, 4/14/14 the resident had no signs or symptoms of pain. On Tuesday, 4/15/14 the certified nursing assistants reported the resident complained of right leg pain when they transferred the resident from the bed to the wheel chair. Staff L notified the nurse practitioner.

Based on record review, observations, review of facility policy and staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazards from self and the environment and the health service supervisor failed to direct the nursing care so each residents needs are met as planned with the application of safety alarms as planned and the transfer of a resident with a mechanical lift in a safe manner. (Resident #3 and Resident #9). The sample consisted of 5 residents and the facility reported a census of 98 residents. Findings include: 1. Resident #9 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 10/24/12, which identified the following [DIAGNOSES REDACTED]. The resident scored 11 out of 15 on the Brief Interview for Mental Status, indicative of some short and long term memory impairment and minimal to moderate impairment of cognitive function related to daily decision making skills. The MDS coded Resident #9 as required extensive staff assistance for bed mobility, dressing, personal hygiene, bathing and as totally dependent with transfers and toileting needs. The MDS coded the resident frequently incontinent of bladder and occasionally incontinent of bowel function. The MDS coded the resident sustained [REDACTED]. The resident care plan, reviewed on 11/7/12, identified the resident with a [DIAGNOSES REDACTED]. The care plan interventions directed staff to encourage safety awareness, give medications as ordered, and educate as needed. The care plan also noted an intervention, dated 8/16/12, for the staff to transfer the resident using the Hoyer lift and 2 person assist but therapy to continue to work with the resident and the EZ stand lift. An intervention, dated 8/22/12, indicated the Hoyer lift discontinued, to transfer in the EZ stand but may use the Hoyer lift as needed for fatigue. The care plan identified the resident with chronic conditions with decreased safety awareness and unrealistic expectations related to choreic (involuntary jerking and twitching movements) and personal limitations. The care plan identified on 10/29/12 the resident slipped out of the Hoyer lift during transfer. The care plan interventions noted the resident sent to the emergency room for evaluation with X-rays and a CT scan performed all within normal limits. The staff involved received immediate disciplinary action and the facility conducted an in-service regarding proper use of the Hoyer lift. A fall risk assessment, completed on 10/24/12, scored the resident with a composite score of 14 (a score of 7 - 14 indicated a moderate risk resident and care plan is indicated.) A Resident Incident Report dated 10/29/12 at 2:10 p.m. documented staff heard loud screaming and as entered the resident's room, staff around the resident as the resident found lying on the floor with a CNA holding the resident's head due to bleeding from the back of the head. A witness statement completed by Staff R, CNA (Certified Nursing Assistant), indicated as he/she entered the resident's room and saw the resident already connected to the Hoyer lift. Staff R stood on the other side of the bed as Staff S began to lift the resident up out of the wheelchair. Staff R documented on the statement that as Staff S lifted the resident, she noticed the resident leaning out of the side of the sling so she proceeded toward the lift as the resident fell . Staff R stated she grabbed the resident's legs as Staff S held onto the resident's head and removed the resident from the sling. Staff R documented at that time staff entered the room and observed the resident lying on the pedals of the lift. A witness statement completed by Staff S, CNA, indicated she was in the resident's room with the resident in the Hoyer lift and transferring from the wheelchair to the bed. Staff S documented she noticed the resident leaning far over to the left so Staff S tried to grab the resident and the chair as staff R remained positioned on the other side of the bed. Staff S documented she yelled for Staff R to assist the resident but Staff S couldn't support the resident's weight alone and the resident went down hitting head on the right leg of the lift. Staff D, LPN, entered the room and began an assessment of the resident's condition. The physician gave an order for [REDACTED]. The Resident Transfer Form dated 10/29/12 indicated the resident went to an area hospital. The reason for the transfer: Resident fell out of Hoyer, bleeding from head, nauseated, alert but tired. While at the hospital, the resident had a CT (computed tomography) of the head and cervical spine and an X-ray of the thoracic spine which identified no injury or destructive lesions. A physician Encounter Form, dated 11/13/12, indicated the resident dropped from the Hoyer lift and now expressed anxiety with regards to using the Hoyer lift and getting out of bed. The progress note identified the physician increased the resident's Valium (medication used to promote relaxation) the week prior due to anxiety and this seemed to be effective. The physician also noted the resident had depression and restarted Lexapro (Medication used for the treatment of [REDACTED]." The December MAR (Medication Administration Record) continued to show the resident received Lexapro 10 mg every evening and Valium (generic name Diazepam) 5 mg (milligrams) twice daily. An observation made on 12/3/12 at 4:15 p.m., revealed Staff I, CNA, and Staff J, CNA, properly connected the resident to the Hoyer lift and transferred the resident from the wheelchair into the bed according to the facility policy. The resident did not exhibit any signs of anxiety or distress during the transfer. An observation made on 12/4/12 at 8:05 a.m., revealed Staff G, CNA, and Staff H, CNA, properly connected the resident to the Hoyer lift and safely transferred the resident from the bed into the wheelchair. Again the resident did not verbalize or exhibit any signs of increased anxiety or fear as the staff performed the actual transfer. An interview conducted on 12/4/12 at 4:45 p.m., with the DON (Director Of Nursing) regarding the fall on 10/29/12 revealed the DON not employed at this facility when the incident occurred. The DON stated from what she knew of the situation, 2 CNAs did not connect the Hoyer sling correctly to the lift and during transit the resident fell out of the sling and hit the head on the base of the lift requiring some sutures to the head. The DON explained the 2 CNAs involved in the incident received immediate disciplinary action and an immediate in service conducted with the staff reviewed the correct way to transfer residents using lifts. An interview conducted on 12/5/12 at 8:50 a.m., with Staff A, RN (Registered Nurse), revealed she worked the day shift on 10/29/12 when this incident occurred. Staff A stated Staff C removed the Hoyer lift from the resident's room and directed staff to leave the lift as it was with the sling still attached. Staff A stated she entered the resident's room and observed the resident lying on the floor with the head facing the room doorway. Staff A stated another nurse tended to the resident due to bleeding from the head. Staff A stated she assisted Staff C to remove the wheelchair from under the resident as the resident remained partially in it. Staff A explained Staff R, CNA, and Staff S, CNA, had been in the process of transferring the resident from the wheelchair to the bed. Staff A stated the upper sling supporting the resident's head, neck, and upper torso, had not been connected using the same color loop on both sides. She explained the loop on the left side lowered the resident more than on the right side causing the resident to lean to the left. She stated the loops supporting the lower torso and legs matched in color and length. Staff A stated as the 2 CNAs began to raise the resident out of the wheelchair, the resident slid out of the sling on the left side and struck the head on the lift base. Staff A explained one of the CNAs was on the other side of the bed and couldn't get to the resident quickly enough when the CNA operating the lift realized the resident was in trouble. Staff A stated the resident remained alert following the fall but was taken to a local hospital for evaluation and treatment and returned to the facility later that day. Staff A stated both of the CNAs involved in the incident appeared quite upset after the incident. Staff A explained following the incident, the resident expressed anxiety to transfer in the lift but stated the resident exhibited anxiety in general prior to the incident. Staff A stated the physician made some medication adjustments to decrease the anxiety and now the resident appeared calm and unaffected during Hoyer lift transfers. Staff A stated all staff are trained on the use of mechanical lifts during orientation. She explained in the Accunurse documentation system, staff are provided with the information for each resident as to how they are transferred and how much assist is required. Staff A stated 2 staff need to be present at all times when using the Hoyer lift, 1 to run the machine, and the other to be with the resident and guide the resident seated in the sling to safety. Staff A stated the CNAs doing the transfer needed to communicate the color of loop used and to check all connections prior to initiating the actual lift. Staff A stated she conducted monthly transfer audits. On 12/5/12 at 9:35 a.m. Staff C. LPN (Licensed Practical Nurse) was interviewed and revealed she worked the day shift on 10/29/12. Staff C recalled the incident occurred at or close to shift change. She stated she heard yelling so she entered the resident's room and observed the resident on the floor with a CNA holding the resident's head in her lap. Staff C stated she noted bleeding and found the resident sustained [REDACTED]. Staff C stated 2 CNAs (Staff R and Staff S) were in the process of transferring the resident from the wheelchair to the bed when the incident occurred. Staff C stated the wheelchair tipped over and 1/2 of the resident's body remained in the wheelchair while the other half landed on the floor partially in the sling. Staff C stated she and the oncoming nurse assessed the resident who later transferred to the hospital for evaluation. Staff C stated during the transfer, Staff R and Staff S didn't attach the sling correctly to the lift causing the resident to lean to one side and resulted in the resident sliding out of the sling. Staff C stated both CNAs appeared quite upset after the incident. Staff C stated staff needed to know how to properly connect the sling to the lift and needed to check all connections and colors of the loops prior to moving the resident. Staff C explained during a lift transfer 2 staff needed to be present at all times, 1 to operate the lift and the other to guide the resident in the sling. Staff C stated immediately after the incident the 2 CNAs received education on the use of the lift. Staff C stated upon the resident's return to the facility he/she exhibited increased anxiety related to the use of the Hoyer lift. Staff C stated she often offered reassurance and acted as a 3rd person during the transfers to decrease the resident's fear of falling again. Staff C stated the physician ordered an antianxiety medication because the resident began expressing not wanting to get up out of bed. Staff C stated the resident currently seemed to be doing much better with the transfers and did not appear afraid or anxious as Staff C stated the resident understood the fall to be an isolated incident. On 12/6/12 at 8:30 a.m., Resident #9 was interviewed and stated she/he expressed fear and increased anxiety after the incident and related to anticipate transfers in the Hoyer lift. The resident stated the physician increased some medication and the staff offered additional reassurance, so gradually the anxiety decreased and the resident stated he/she no longer feared transfers in the lift. The facility policy/procedure titled Mechanical Lift Protocol (not dated) with no date of origin under step 9. Directed staff to " Connect the straps on the sling hooks on lift - Step 10. Once straps are secure, slowly lift the resident from the surface, ensuring the straps are secure. Utilize one staff member to operate the lift controls and protect the resident while the second staff members guides the resident onto the next surface." Step 14. Directed " Staff members are responsible to seek additional guidance in performance of this task as needed from administrative staff, report any concerns in regards to equipment malfunction or repair, and any other concerns as needed." 2. Resident #3 had an MDS with a reference date of 10 /24/12 which identified [DIAGNOSES REDACTED]. The resident ' s Care Plan, updated on 5/21/12 directed staff to provide a pressure alarm to the wheel chair and bed. On 8/2/12 the Care Plan indicated the addition of a floor mat alarm. On 9/10/12 the Care Plan had an addition for staff to place the resident in a broad chair for safety. Observation on 12/4/12 at 11:40 a.m., revealed Staff L, CNA and Staff M, CNA transferred the resident from the bed to the broda chair. The resident did not have a pressure alarm on the chair or bed. On 12/5/12 at 9:00 a.m. observation revealed the resident in bed and no pressure alarm in place. Observation on 12/6/12 at 8:00 a.m., revealed Staff E, CNA pushed the resident from the nursing desk to the table in the dining room at a distance greater than 23 foot. On 12/6/2012 at 12:00 p.m., Staff Q, RN (Registered Nurse) was interviewed and stated the staff were new, but concurred she should have been oriented to the resident needs.

Based on observation, clinical record review and interviews, the facility failed to plan for and direct nursing services to ensure Resident #2 received adequate supervision against hazard and failed to supervise care plan directives to meet his/her safety needs. The facility reported a census of 103 residents with four residents reviewed. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had short and long term memory deficits, required extensive staff assistance with his/her activities of daily living and had a fall since admission. A Fall Risk assessment dated [DATE] documented the resident had a moderate risk for falls. A Care Plan dated 5/10/12 documented the resident at a high risk for injury related to dementia. The care plan approaches included the following: a. Keep the call light in reach of the resident at all times. b. Keep bed wheels in locked position. c. PSA alarms to bed and chair A Resident Incident Report dated 5/4/12 at 3:15 a.m., documented a Certified Nursing Assistant (CNA) heard a loud noise and observed the resident on the floor. The CNA had been down the hall and was responding to the resident's alarm when she heard the loud noise. The resident had a hematoma above his/her left eye with a Y shaped laceration that had been bleeding. Additional bruising and swelling were noted to Resident #2's right hand on his/her 4th and 5th digits (fingers); and swelling to his/her chin and an abrasion to his/her left knee. The Skin Conditions (observations) forms dated 5/4/12 documented Resident #2's had a laceration to his/her left eyebrow measuring 10.0 x 5.0 cm on his/her left side of their face down to his/her chin. The nurse treated the bleeding area with steri-strips and the bleeding stopped. The steri strips remained until 5/11/12 and the form noted the area healed with a date listed as 5/15/12. The Skin Conditions (observation) forms dated 5/4/12 documented Resident #2 had dark a blue/purple ecchy area to his/her right hand including the 4th and 5th digits. The Portable X-ray information dated 5/4/12 documented no fractures to the resident's facial bones or right hand. The report documented the resident had pain and a 1.5 cm density over the forth metacarpal base. The Care Plan dated 5/10/12 identified on 5/4/12, staff had been discipline due to the resident's bed not being in the low position During a telephone interview 7/12/12 at 8:45 a.m., Staff A, Registered Nurse, confirmed the resident's bed had not been in the lowest position at the time of the fall. During an interview 7/12/12 at 10:45 a.m., the Director of Nursing confirmed the staff had been educated on the requirement to keep the resident's bed in the lowest position. Review of the facilities communication book, revealed an entry dated 5/4/12 that documented any resident in a hi-lo bed had been in it for a reason and the bed needed to have been in the low position. During an interview with Staff G on 7/11/12 at 2:25 p.m., she responded to the resident's alarm sounded. Staff G stated after the resident had been assessed, he/she stated his/her eye hurt. An observation 7/10/12 at 11:10 a.m., revealed the resident had been positioned in bed while the bed had not been in a low position. The surveyor noted the fall mat on the floor beside the bed on and functional as noted by the flashing light. The DON was asked by the surveyor to accompany her to Resident #2's room. The DON used the (bed) controls to move the resident's bed to the lowest position and the floor mat alarmed when the bed was in the lowest position. The DON confirmed on 7/10/12 at approximately 11:12 a.m., the resident's bed had not been in low position when she utilized the electrical bed controls and lowered the resident's bed. After the resident fell on [DATE], the resident's care plan directed staff to keep the resident's bed in the low position. The observation on 7/10/12 with the DON showed when the bed was lowered, the fall mat alarmed. The facility sent in documentation dated 7/18/12 acknowledging that when the resident's bed was positioned in the low position, the floor mat would alarm.