Every finding on record at Wesley Park Centre

Based on observation, staff interview, and policy review, the facility failed to properly store food in the kitchen, failed to discard a can of damaged applesauce, failed to wear hairnets while in the kitchen, and failed to prevent food contamination by placing a non-food soup bowl in direct contact with a resident's food. The facility reported a census of 61 residents. Findings include:On 1/25/26 at 10:03 AM, Staff A, Cook, was observed in the main kitchen without a hair net.At 10:18 AM, Staff A was observed wearing a hair net.The following items were observed in the refrigerators during the initial kitchen tour: An unlabeled, undated, bowl of green, leafy itemsAn unlabeled, undated, bowl of mixed fruit-like itemsA partially uncovered pan of bacon dated 1/24/26A partially uncovered braised pork dated 1/23/26A partially uncovered, unlabeled, and undated pan of tube-shaped meat.An undated, opened box of lettuceAn unlabeled, clear sealable bag of shredded, orange substanceAn undated, unlabeled pan of brown crust with a yellow topping The following items were observed in the freezer during the initial kitchen tour:An undated, previously accessed bag of cranberriesAn opened, clear sealable bag with 1 kielbasaAn opened, clear sealable bag of tenders The following items were observed in the dry goods storage room:An unlabeled bag of pasta-like itemsAn unlabeled bag of previously accessed, tan flakesA dented can of applesauce At 10:29 AM, Staff B, dishwasher, had a hair net cover pulled down below and behind the hairline of his beard while washing dishes. He picked up a gray bin from a black cart, placed it directly on a rack of newly washed cups, loaded it with clean dishes, and stored it on a wire storage rack.On 1/25/2026 at 3:30 PM, Staff C, dishwasher was observed washing dishes without wearing a hairnet. During continuous meal service observation, Staff D, food server, placed a piece of meatloaf on a resident's plate. She grabbed a dessert bowl with her bare hands, scooped green beans into it, and placed it on the plate directly touching the meatloaf. It was served to a resident.On 1/27/26 at 9:09 AM, the following items were observed in the refrigerators during a follow-up kitchen tour:An undated, opened box of lettuceAn unlabeled, clear, plastic tub dated 1/27 lunch which contained red, meat-like itemsAn unlabeled, clear, sealable bag with flat, brown, round, meat-like itemsA clear tub of white substance labeled mashed dated 1/26/26An opened bag of grapesAn unlabeled, clear sealable bag of shredded, orange substanceThe freezer contained an undated, previously accessed bag of cranberriesThe following items were observed in the dry goods storage room:An unlabeled bag of pasta-like itemsAn unlabeled bag of previously accessed, tan flakesAn unlabeled, undated, clear, plastic bin with semi-flat, multicolored items On 1/27/26 at 10:51 AM, Staff F, Sous Chef stated staff should have followed the facility policies.A policy titled Hair Restraint & [NAME] Guard Policy last approved 01/2026 indicated all food handlers who have direct contact with food, such as chefs, cooks, dietary aides, servers and homemakers, as well as others not mentioned here must wear hair nets, caps, or beards nets, or other reasonable forms of hair containment. They must be designed and worn effectively to keep hair from contacting exposed food, clean equipment, utensils, and unwrapped single service items. A policy titled Label & Dating Policy last approved 01/2026 indicated label and dating for prepared foods stored in refrigerators and freezers out of their original packaging will include the following on the label:Food item nameDate made/prepared or openedUse by date - reference the facility's Food Storage and Handling policyFood handler's initialsA policy titled Hand Washing & Hand Hygiene Policy last approved 08/2024 indicated hand hygiene must be performed after touching a contaminated item and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and/or the environment.

Based on observation, staff interview, and policy review, the facility failed to ensure kitchen staff were competent with dishwashing temperature checking procedures. The facility reported a census of 61 residents. Findings include:On 1/25/26 at 10:45 AM, an observation of three (3) dishwashing cycles revealed the rinse-water temperature gauge reached 171 degrees Fahrenheit (deg F) during all three observations. At 10:51 AM, Staff B, dishwasher, was asked to perform a dishwasher temperature check (procedure which uses a color-changing, temperature sensitive strip to confirm the dishwasher rinse-cycle water temperature reaches the required 180 deg F). Staff B stated he did not know how to perform the test because he never learned how to do it.At 11:03 AM, Staff B informed Staff E, dishwasher, that a dishwasher temperature check was requested. Staff E asked Staff B where the test strips were located. Staff B stated he did not know and both Staff B and Staff E searched for the strips. Staff E located the strips hanging in front of the dishwasher temperature check binder stored on the wall to the left of the dishwasher. Staff E performed a dishwasher temperature check and the strip indicated the rinse-cycle water temperature reached the required 180 deg F temperature. At 3:30 PM, Staff C, dishwasher, stated the dishwasher water temperature should reach at least 170 deg F in order to get bacteria off of the dishes but stated he never learned how to check the water temperature. When asked what staff does if the water temperature gauge registered 160 degrees, he stated he would do nothing because the water temperature would increase over time.At 3:55 PM, Staff E stated the dishwasher water temperature should be between 170-180 deg F to kill foodborne bacteria. She also stated if the water temp did not reach at least 170 deg F, she would contact maintenance to repair the dishwasher.On 1/27/26 at 2:30 PM, the Sous Chef stated staff should have sought coworker assistance to help with questions they felt they could not answer. She also stated the staff should have been trained on the process.On 1/28/26 at 10:30 AM, the facility indicated they did not have a policy directly related to dishwashing requirements.

Based on observation, clinical record review, resident and staff interviews, and policy review, the facility failed to provide appropriate treatment and services to prevent a urinary tract infection for 1 of 1 resident (#56). The facility reported a census of 61 residents. Findings include:The Minimum Data Set (MDS) Assessment for Resident #56 dated 11/20/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of coronary artery disease (disease of the heart arteries), high blood pressure, a stroke, and a urinary tract infection (UTI). It indicated he was independent with rolling from left-to-right in bed, required setup assistance with eating and oral and personal hygiene, required moderate assistance with upper body dressing and sit-to-lying and lying-to-sitting, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It also indicated he had a UTI within the previous 30 days.A laboratory report dated 11/01/25 confirmed the resident's urine specimen contained bacteria.The Progress Notes dated 11/01/25 at 1:13PM revealed the physician reviewed the laboratory results and prescribed an antibiotic for the resident's UTI.The Electronic Health Record (EHR) included a Clinical Physician's order dated 11/02/25 that directed staff to administer an antibiotic (Levofloxacin) for his UTI.The November 2025 Medication Administration Record (MAR) indicated the resident received the prescribed antibiotic for five (5) days between 11/02/25 and 11/06/25.The Care Plan with revised date 1/19/26 revealed the resident would like good peri-cares with each incontinence episode.On 1/25/26 at 2:09 PM, the resident's family member stated the resident was treated for a UTI after he was admitted to the facility.On 1/27/26 at 11:23 AM, Staff G, Certified Nurse Aide (CNA) and Staff H, CNA performed Resident #56's toileting hygiene care. During continuous observation, Staff G and Staff H performed hand hygiene with soap and water and put on gloves. Staff G assisted Resident #56 to a standing position while Staff H grabbed a hygiene wipe and wiped his right groin, grabbed another hygiene wipe and wiped his left groin, then grabbed a third hygiene wipe, wiped the resident's testicles, and used the same hygiene wipe to clean the tip of the resident's penis. She grabbed another hygiene wipe and cleaned the resident's anus. She pulled the resident's brief and pants and transferred him to his recliner.At 11:30 AM, Staff H stated she received Infection Prevention education upon hire. She confirmed the education included pericare which directed staff to clean a male resident's penis starting at the tip. She admitted that she forgot to perform the care in the correct order because she was in a hurry based on the resident's desire to sit down quickly after toileting hygiene.At 11:35 AM, Staff G stated pericare on a male resident included cleaning the penis beginning at the tip and working down the shaft.At 2:35 PM, the Director of Health Services (DHS) stated staff should have followed proper pericare procedure or should have redone it correctly.An undated document titled Provide Perineal Care/Incontinence Care directed staff to follow the following procedure for male residents;if the resident is uncircumcised, gently push back foreskin. Gently wash penis and scrotum, using a circular motion from the tip of the penis to the base. Rinse in the same manner if using washcloths. Pat dry if using washcloths, allow to air dry if using disposable wipes. If uncircumcised, gently return foreskin to its natural position. Wash the scrotum and groin area (area around penis and scrotum to the upper thighs). Rinse if using washcloths, allow to air dry if using disposable wipes.

Based on record and document review, staff and family interviews, the facility failed to follow Physical Therapy recommendations regarding the ambulation status for 1 of 3 residents reviewed for falls (Resident #61). Resident #61 was to be an assist of 2, on [DATE] Resident #61 was only provided an assist of 1 which resulted in a fall. Resident #61 was transferred to a tertiary hospital and diagnosed with a right femur fracture that required surgery on [DATE]. Following surgery, Resident #61 was placed in intensive care and subsequently died on [DATE]. The Death Certificate revealed manner of death: complications of femur fracture due to or as a consequence of ground level fall.The facility reported a census of 65 residents. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] for the immediacy which began on [DATE]. On [DATE], the surveyor reviewed and confirmed the prior actions taken by the facility based upon their investigation were implemented. Therefore, it was determined the IJ was lifted as of [DATE] and the scope and severity was dropped to a G On [DATE] The Director of Nursing intiated staff education to ensure all nursing staff were aware to check Kardex/Communication tab (computer) update (phone) for the correct and most up to date information before starting each shift for their assigned unit.On [DATE] a Risk Management session was conducted to review incidents, that included root cause analysis. The faciltiy conducted Quality Assurance reviews on [DATE], [DATE], and [DATE] that included communications related to resident changes, and updated Plans of Care. Findings include: Review of Admission Minimum Data Set (MDS) dated [DATE] revealed, Resident #61 was admitted from the hospital to the facility for skilled rehabilitation on [DATE] with the goal to discharge home. Diagnoses included; Hypertension, Peripheral Vascular Disease, Renal insufficiency, Paraplegia (paralysis of legs and lower body related to history of a back injury), groin abscess, lymphedema, and cellulitis of right lower leg. Resident #61's Brief Interview for Mental Status (BIMS) of 13, which indicated cognitively intact. On admission MDS indicated Resident #61's impairment to both lower extremities and needing partial/moderate assistance (helper does less than half the effort, helper lifts, holds, and supports trunk or limbs, but provides less than half the effort) for sitting to stand, transfers to and from bed or wheelchair, and walking 10 to 50 feet. Baseline Care Plan dated [DATE] revealed Resident #61 needed one person physical assist for transfers and walking with the use of a walker. Safety risk indicated Resident #61 had a fall in the past month prior to admission due to weakness while ambulating. Noted skin integrity included right groin, right inner thigh, right inner calf, right heel, and coccyx. Physical Therapy (PT) to be provided to improve functional status. Resident #61's Orders Summary revealed an order dated [DATE] for PT and Occupational Therapy (OT) to evaluate and treat. Progress note dated [DATE] at 9:54 AM stated, Resident #61 told therapy that she would not be walking with a walker, she would be using a wheelchair to walk with and then tried to tell therapy staff that she would fall if they made her use a walker and then pushed into therapy staff attempting to fall. Therapy explained that Resident #61 needs to use walker to work towards independence to go home. Resident #61 continued to attempt to fall on OT staff. Skilled evaluation note dated [DATE] at 10:27 AM revealed, Resident #61 has an unsteady gait and poor balance. Progress note dated [DATE] at 6:43 PM revealed, Resident #61 admitted post hospitalization for right leg and groin abscesses, skilled level of care (SNF LOC) to work with therapy, currently assist of 2 for ambulation with wheelchair to follow, stand pivot for transfers. Progress note dated [DATE] at 5:19 AM revealed, Resident #61 continues SNF LOC post hospitalization for leg wounds. Lung sounds clear to auscultation, shortness of breath noted with exertion. Resident up with assist of 1 and walker for toileting and moving to bed. Review of Resident #61's Care Plan initiated on [DATE] revealed, Resident #61 required assist of 2 and Front Wheel [NAME] (FWW) for transfers, required assist of 2 and FWW during ambulation in room with wheelchair to follow, and only stand pivot transfers. Progress note dated [DATE] at 7:15 AM revealed, Resident #61 was being transferred to the bathroom with assistance of CNA, gait belt, and walker. CNA reported falling with resident #61 in the bathroom. When this nurse walked into Resident#61's bathroom she was lying on the floor with legs out in front of her and her back up against the wall in the shower. Resident #61 reported that she had hit the back of her head, right lower extremity with outer rotation. Resident unable to move at initial assessment. Resident #61 had non-skid socks on. This nurse went to call the physician to get an order to send to the ER to evaluate and treat. Progress note dated [DATE] at 10:48 AM revealed, Resident #61's Representative called and said Resident broke her femur. Orthopedics had been called to see if they are going to do surgery. Facility's Discharge Summary note dated [DATE] at 1:06 PM revealed, Resident #61 had a femur fracture due to a fall and was sent to ER via ambulance. Resident #61's Representative stated Resident will be at the hospital for weeks and does not want to hold the bed. Review of Facility Provided Investigation dated [DATE], revealed the following: 1. On [DATE] Resident #61 was admitted as an assist x1 for transfers, ambulation, and toileting from hospital. Nursing review and this is acceptable as the Resident did well and reported limitations. Baseline Care Plan started upon admission after completion of assessment and review. Nursing staff in the unit made aware of status. 2. On [DATE] Incident occurred with therapy, resulting in therapy recommendation changing Resident #61 to assist x2 with no ambulation; OT reported Resident #61 was attempting to fall into her and refused to use a walker for ambulation as she wanted to use a wheelchair to walk with as she did at home. 3. On [DATE] Interdisciplinary Team (IDT) notified of incident during rounding; IDT and nursing staff discussed and determined no ambulation would hinder Resident #61's progress and would continue using Baseline Care Plan information as there were no reports of fall or incident during hospitalization . Nursing staff reported no concerns of Resident #61 attempting to fall into them. Nursing staff also reported Resident #61 requested FWW for ambulation attempts and refused to use a wheelchair while in her room. 4. On the evening of [DATE] Resident #61's status update for PT was provided to MDS nurse for Resident #61 to be assist x2 with wheelchair to follow. Therapy recommendation was developed as a result of the encounter with OT on ,d+[DATE]. Nursing staff continue to use the Baseline Care Plan based off IDT's review on [DATE]. 5. Interview on [DATE], Staff H, CNA RA (restorative aide), determined she asked her peer Staff E, CNA about Resident #61's transfer status prior to working with her. 6. Interview on [DATE], Staff E, CNA, reported status of transfer and ambulation for Resident #61 as an assist x1 with FWW and toileting as an assist x1 since admission. 7. Facility reviewed Resident #61's progress notes and Point of Care (POC) charting on [DATE] which reflected Resident #61 as an assist x1 for transfer, toileting, and ambulation. After occurrence with OT there is one progress note indicating Resident #61 was assist x2 for a short period ([DATE] at 6:43PM) next note and all following indicated assist x1 with FWW with no difficulty. 8. Therapy notes reviewed on [DATE], stated Resident #61 needed limited assistance (assist x1 with FWW) for transfer and ambulation. Facility Provided Investigation dated [DATE] stated; Upon completion of investigation, it was determined Staff H, CNA RA, was using safe transfer technique as well as fall interventions were in place at time of incident. Prior to the incident occurring there is no record of knee buckling in Resident #61's history that the facility was made aware of. Nursing staff were following the Baseline Care Plan at the time of the incident. Review of Facility's Investigation included statement by Staff H, CNA RA, on [DATE] revealed Staff H, CNA RA stated Resident #61 had said she tripped over the transition strip from the room to the bathroom, Staff H reported being clear of this transition and were halfway into the bathroom when the fall happened, making it impossible for Resident #61 to trip on the transition strip. Staff H, CNA RA also stated she spoke with the Therapy team and they advise her, Resident #61's update was that way because when working with OT Resident #61 was acting like she was going to fall several times and kept saying, I (Resident #61) cannot walk without my wheelchair as my walker or I will fall Review of PT Discharge Summary, end of care date [DATE], revealed Resident #61 was walking with aide to the bathroom and had a fall. Resident was sent to the hospital with a fractured femur. Skilled services provided included, gait training, therapeutic exercise, therapeutic activity, and balance training. Resident #61 was assist x2 with staff for gait and transfers. During an interview on [DATE] 11:39 AM, DON stated there was no documentation of the IDT meeting on [DATE] when it was determined Resident #61 would continue as an assist x1 instead of Physical Therapy's recommendation of an assist x2 with FWW and wheelchair to follow. Review of Facility's Self Report submitted on [DATE] by DON (Director of Nursing) to Iowa Department of Inspections, Appeals, and Licensing (DIAL) revealed the following: 1. Incident Summary: Timeline of Incident: On [DATE] at approximately 8:50 AM, DON was notified Resident #61 had a fall and was sent to the ED on [DATE] for evaluation. Facility staff were notified of confirmed fracture at approximately 12:00 PM and Resident #61 would be admitted to the hospital. Staff H, CNA RA, stated she was assisting Resident #61 with getting ready for the day, she went into Resident #61's room and asked if she was ready to get up for the day. Resident #61 stated she was and needed the restroom. Staff H, CNA RA, stated she grabbed the gait belt, her walker, and ensured Resident #61 had her gripper socks on. Resident #61 sat up independently on the side of the bed and waited for Staff H. Staff H, CNA RA, secured the gait belt on Resident #61 and placed the walker in front of her. Resident #61 stood without difficulty and started to ambulate to the restroom. Resident #61 entered the restroom and started to side step, Staff H, CNA RA, asked Resident #61 if she was ok. Resident #61 reported she needed to sit on the toilet. Staff H, CNA RA, reminded Resident #61 she needed to get closer to the toilet and Resident #61 fell straight down on the floor. Staff H, CNA RA, reported she had a hand on the gait belt, however it occurred quickly therefore unable to slowly lower Resident #61 to the floor. Staff H, CNA RA ensured Resident #61 was safe and as if she was okay. Resident #61 reported her right leg hurt a little. Staff H, CNA RA placed a pillow behind Resident #61's head for comfort and immediately called for the nurse. Staff I, RN responded to Resident #61's room and completed a full head to toe assessment and obtained vitals. RN's assessment revealed external rotation of the right lower extremity and noted the right lower extremity was shorter than the left. Facility Physician was notified and an order to send Resident #61 to ER was obtained. Ambulance arrived at 7:30 AM and left facility with Resident #61 at 8:00 AM. Resident #61's Representative was notified at approximately 7:26 AM. Hospital notes state: Severe osteoarthritis both hips, greater in the right. Moderately displaced impacted spiral fracture proximal right femur shaft and negative for acute intracranial process. Corrective Action Description: Facility immediately initiated investigation and additional information will follow, Facility respectfully requests to provide further information and updates as appropriate and/or it occurs. 2. Amendment Details: On [DATE] Liaison notified Facility, Resident #61 passed away on [DATE]. Suspected related to known peripheral vascular disease that resulted in multiple prolonged hospital stays prior to skilled stay at Facility. Post-surgical notes state risk of surgical repair include; bleeding, infection, nerve injury, muscle damage, malunion of fractures, nonunion of fractures, need for additional procedures. Resident #61 opted for surgery and underwent surgical repair the morning of [DATE]. Surgery went well without complications noted. Overnight Resident #61 went into A-Fib and respiratory failure resulting in ICU admission and intubation with initiation of pressor support. Family met and discussed current condition along with past several months of ongoing medical concerns and determined Resident #61 should be placed on comfort measures and extubated around 9:30 AM. Resident #61 passed around 9:40 PM on [DATE]. 3. On [DATE] at 4:06 PM Report status changed to Pending Review by DIAL. 4. On [DATE] at 2:49 PM Report status changed from Pending Review to No Investigation by DIAL. During an interview on [DATE] at 3:24 PM Staff C, LPN explained the process when Therapy determines new recommendations. Staff C, LPN revealed therapy will notify the nurses with a form that indicates the recommendations. The Nurse will then note recommended changes in Resident's #61 Electronic Health Record (EHR). The Kardex (plan of care used by CNA staff) will be updated by the nurse, when this is done a notification will show up on CNA's phones to make them aware of the changes. Therapy will give a copy of the recommendations to the MDS coordinator to update Resident' s MDS and Care Plan. During an interview on [DATE] at 1:20 PM, Staff J, Physical Therapist (PT) stated OT had done an evaluation the morning of [DATE], Resident #61 had made statements of falling, after this encounter OT recommended Resident #61 be an assist x2. Later that day Staff J, PT had evaluated Resident #61, stating she had done well functionally ambulating from her bed to the bathroom. On the way back to Resident #61's bed, she became weak and tired. Staff J, PT had to get a wheelchair and placed behind it behind Resident #61 to prevent her from falling. Due to Resident #61's low stamina, Staff J, PT recommended Resident #61 have an assist of 2 using FWW and wheelchair to follow due to the risk of fatigue and falls. During an interview on [DATE] 2:01 PM, Facility's Medical Director stated he would expect nursing staff to follow Therapy's recommendations. Facility's Medical Director also confirmed, he does sign off and approve Therapy's recommendations, If therapy recommended a Resident to be an assist x2, staff should be following these recommendations and provide the assistance of 2. Review of Resident #61's Certificate Of Death revealed, Resident #61 died on [DATE] at 9:36PM, with Manner of Death: Accident, Immediate Cause of Death: Complications of femur fracture, due to or as a consequence of: ground level fall. Review of Facility provided Ambulation Policy originated ,d+[DATE] revealed Facility's procedure is to check resident's medical records for any ambulation related order, note equipment ordered if any and check Care Plan for level of assistance with ambulation.

Based on observations, record review, resident, family and staff interview and policy review, the facility failed to accurately assess and prevent a pressure wound to 1 of 3 residents reviewed for pressure ulcers (Resident #54). The nursing staff identified a pressure wound caused by the Ankle/Foot Orthotic (AFO) splint to right foot and continued to utilize the AFO for transfers, resulting in a wound that needed a higher level of treatment. The facility reported a census of 65 residents. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] for Resident #54 revealed a diagnosis of a Stroke with aphasia (difficulty speaking) and right sided hemiplegia (paralysis), Diabetes Mellitus and end stage renal disease and received hemodialysis via the peripherally inserted central catheter (PICC) access (a long, flexible tube inserted into a vein in the arm). The Brief Interview for Mental Status (BIMS) revealed a score of 14 which suggested an intact cognition. The MDS documented that the resident was at risk for developing pressure ulcers/injuries. The MDS did not document unhealed pressure ulcers/injuries. The document titled Base line Care Plan Summary dated 11/14/24 for Resident #54 revealed current skin integrity issue as redness of coccyx, no further skin integrity issues and directed staff to encourage good nutrition and hydration in order to promote healthier skin and to follow protocols for treatment of injury. The document titled Nursing Assessment on admit for Resident #54 dated 11/14/24 revealed self-care performance for dressing required 1 person and for transfers 2 persons to physically assist with a cane mobility device. The document titled Clinical Admission with the date 11/14/24 documented the only skin concern as; redness of coccyx area. A document titled Patient Discharge and Transfer Form dated 11/14/24 identified devices to assist Resident #54 as a walker, a specialty mattress, and glasses. The orders failed to identify a prosthetic or an AFO. Therapies ordered as Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) and Dialysis. Progress note on 12/30/24 for Resident #54 revealed: 1. Skin issue #1 to right chest, port for dialysis. 2. Assistive device listed as 1/2 side rail, hemi walker and brace used for right upper extremity with transfers. 3. PT, OT, ST, the resident continues to participate in therapy as ordered. Progress note on 1/6/25 at 2:47 PM for Resident #54 revealed: 1. A new skin issue to right lateral foot, a scab in place, with redness noted to surrounding skin. 2. Appears area was related to his brace worn to right lower extremity, brace off until healed. Progress note on 1/7/25 at 2:05 PM for Resident #54 revealed: 1. New wound care orders. 2. Antibiotic ordered for 7 days. 3. Therapy aware of needing to evaluate his brace to right lower extremity. 4. Not wearing brace. The Physician Orders for Resident #54 failed to contain an order for a brace or AFO to right foot. A document titled Physical Therapy PT Evaluation & Plan of Treatment dated 11/14/24 for Resident #54 revealed: 1. Patient will demonstrate stand supported for greater than 3 - 5 minutes in order to increase participation with activities of daily living (ADL) tasks. 2. Patient will demonstrate improved functional lower extremity strength as evidenced by an improved score to 3 on the 30 second sit to stand test. 3. Patient will improve ability to safely transfer to a standing position from sitting in a chair, wheelchair or the side of the bed with supervision or touching assistance with ability to right self to maintain balance. 4. Patient will improve ability to safely transfer from lying on back to sitting on the side of the bed with no back support. 5. Patient will improve ability to safely transfer from bed to chair. 6. Patient will navigate 4 stairs with a rail to safely enter /exit home. 7. Patient will safely ambulate on level surfaces 200 feet using a hemi walker. 8. The PT evaluation failed to address or recommend an AFO to the right lower extremity, foot or ankle. A document titled Microbiology Culture Final for Resident #54 revealed: 1. The sample was collected on 1/15/25 from right foot wound. 2. A heavy growth of Methicillin Resistant Staphylococcus Aureus (MRSA). During an observation on 1/21/25 at 3:39 PM Resident #54 was in a bariatric bed with head at the top of the mattress and his feet inches away from the foot board of the bed. Resident did not have the anti-embolism socks on and had a wound to his right lateral foot the approximate size of a silver dollar. The wound was uncovered and had a small amount of drainage on the bed. During an interview on 1/21/25 at 3:39 PM Resident #54's wife stated he was admitted on [DATE] after a stroke for dialysis and therapy for strengthening. The wife stated he had a splint applied to the right foot that caused the open wound and the nursing staff continued to use the splint after finding the wound. Documents titled Skin and Wound Evaluation for Resident #54 revealed an in-house acquired pressure wound to right lateral (outside) mid-foot: 1. Date 1/15/25, measured 1.8 centimeters (cm) x 1.4 cm x (unable to measure as wound bed as it contained 50% slough (dead skin debris) and 50% eschar (black dead skin) with a light seropurulent (combination of pus and serous fluid) drainage, evidence of infection. Unknown how long the wound was present. 2. Date 1/19/25 measured 1.8 cm x 1.8 cm x not applicable (100% slough). During an interview on 1/23/24 at 11:10 AM, Staff G Physical Therapist (PT) stated Resident #54 arrived on admit wearing a right ankle foot orthotic (AFO). Staff G stated therapy staff was walking Resident #54 while he was wearing the AFO, and stated that type of AFO is usually changed to a different type of walking splint, But that takes a while. During an interview on 1/23/25 at 8:56 AM, Staff F, Licensed Practical Nurse (LPN) stated the night nurse would assist the Certified Nursing Assistant (CNA) to get Resident #54 dressed, put the anti-embolism socks and brace on, before he went to dialysis in the mornings. E-mail on 1/23/25 at 2:40 PM, The Director of Nursing wrote in regards to Resident #54 that they attempted to add additional nutritional support for the last couple of months with the wife continuing to refuse. The DON wrote, When the area was first noted, we encouraged staff to only use the brace upon transferring, once we noted the wound worsening, we did hold the brace completely. The house wound nurse assessed on 1/15/25 and notified (the provider) of the area to obtain a wound culture and start antibiotics and sent out for additional wound nurse support (local facility that specialized in geriatric care) on 1/20/25 as we believe this wound will be difficult to heal so we want as much support and guidance as we can. A document titled Wound Treatment Plan dated 1/24/25 revealed: 1. Resident #54 did wear an AFO to his foot and now had a pressure wound so they are not using the AFO. 2. Resident #54 is taking Bactrim (antibiotic) for the foot wound. 3. Skin inspection: pressure ulcer right foot that measures 2.5 cm x 1.6 cm x 0.3 depth, 20% deep tissue injury with small amount of exudate (drainage). 4. Discontinue the current treatment. Cleanse with wound cleanser and apply betadine moistened gauze to the wound bead and cover with dry gauze and secure with gauze wrap and tape daily. A policy titled Foot Care dated 1/2025 revealed: 1. Purpose was to prevent infection of the feet. 2. Wash feet well and soak approximately 10 minutes, rinse well and dry between toes. 3. Examine feet carefully for evidence of discoloration, mushy heels, breaks in skin integrity irritation or edema (swelling). 4. Toenails are to be clipped with toenail clippers straight across. 5. Note: The podiatrist or licensed nurse is to provide foot care for all diabetic residents.

Based on observation, policy review, and resident and staff interviews, the facility failed to ensure hot foods were held at an appetizing temperature for 1 of 1 meal observed and for 2 of 24 residents reviewed (Residents #48 and #163). The facility reported a census of 65 residents. Findings include: 1. An observation prior to the start of the lunch service on 1/22/25, Staff A [NAME] obtained the following temperatures: grilled ham and cheese sandwiches 151.6 F at 11:53 a.m. meat sauce 162.6 F at 11:56 a.m. noodles 172.6 F at 11:59 a.m. mashed potatoes 160.4 F at 11:58 a.m. pureed vegetables 132.2 at 12:01 p.m. Staff A did not heat up the pureed vegetables prior to the start of service. Staff A served the first tray at 12:10 p.m. and the last tray at 12:55 p.m. Immediately after staff served the last tray, the State Agency requested a test tray. The State Agency obtained the following temperatures with a facility provided thermometer. The Certified Dietary Manager was present during this process. grilled ham and cheese sandwiches 107.3 F at 12:57 p.m. noodles covered with meat sauce 106.6 F at 12:58 p.m. mashed potatoes 122.9 F at 12:59 p.m. After the service, no pureed vegetables remained for a temperature reading. The facility policy Food Safety, revised July 2024, stated the U.S. Department of Health and Human Services Food Code used 135 F for hot foods but directed to check state regulations as they varied. On 1/23/24 at 9:35 a.m., the Certified Dietary Manager(CDM) stated staff should maintain hot holding temperatures in a range which was appetizing and appealing and a minimum of 135 degrees. She stated (after the temperatures yesterday) the facility took corrective actions such as turning up the hot box. 44512 2. The Minimum Data set (MDS) dated [DATE] for Resident #48 revealed the Brief Interview for Mental Status (BIMS) as 12 which suggested an intact cognition. During an interview on 1/21/25 at 10:15 AM Resident #48 stated when the food was served in the dining room, it was cold. Resident #48 stated he had to ask staff on multiple occasions to warm it up before he could consume it. 3. The Minimum Data set (MDS) dated [DATE] for Resident #163 revealed the Brief Interview for Mental Status (BIMS) as 15 which suggested an intact cognition. During an interview on 1/21/25 at 10:15 AM Resident #163 stated the food was cold when served to him on a tray brought to his room multiple times and had to ask that it be warmed up.

Based on observation, policy review, and staff interview, the facility failed to ensure staff prepared food under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 65 residents. Findings include: During the initial kitchen tour on 1/21/25 at 9:46 a.m., dust particles hung from 8 of 8 fire suppression spigots. Two string-like particles of dust, approximately 2 inches in length, hung down from the spigot on the left side of the stove hood, located directly above a pot of boiling food. During a follow-up visit to the kitchen on 1/22/25 at 10:59 a.m., dust remained on the spigots of the fire suppression system. The metal surface behind the tilt skillet also contained a thick layer of dust particles. The undated facility Night [NAME] Closing List and Morning [NAME] Checklist did not include direction for staff to clean the fire suppression system spigots. The facility policy Food Safety, revised July 2024, directed staff to monitor the risk of contamination during cooking, cooling, holding, and reheating. On 1/23/24 at 9:35 a.m., the Certified Dietary Manager(CDM) stated the kitchen should be sanitized and they will work on a plan regarding the dust buildup on the spigots.

Based on observations, record review, resident and staff interviews, the facility failed to provide dignity with care by turning off the call light and leaving the room without ensuring the resident's needs were met for 1 of 6 residents reviewed for dignity (Resident #54). The facility reported a census of 65 residents. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] for Resident #54 revealed a diagnosis of a Stroke with aphasia (difficulty speaking) and right sided hemiplegia (paralysis), Diabetes Mellitus, and required the assistance of 2 for repositioning in bed. The Brief Interview for Mental Status (BIMS) score was 14 which suggested an intact cognition. The Care Plan for Resident #54 directed staff to allow adequate time to respond when communicating, and repeat if necessary or request clarification from the resident to ensure understanding and required the assistance of 2 staff for bed mobility, toileting and transfers. During an observation on 1/21/25 at 3:39 PM Resident #54 was in a Bariatric bed with his head at the top of the mattress and his feet inches away from the foot board of the bed. During an interview on 1/21/25 at 3:39 PM Resident #54 stated on Friday (1/17/25) after dinner, a young gal put him to bed. Resident #54 stated, I tried to tell her my foot was stuck in the foot board. Resident #54 stated she had left his room without adjusting him and he had turned the call light on again, and the she did not assist him when she had responded to the call light. Resident #54 stated he then called his family. During an interview on 1/21/25 at 3:39 PM, Resident #54's wife stated he called her phone 7 times on 1/17/25, first at 5:30 PM and reported the staff forgot his supper. He then called after 10:30 PM when Resident #54 told her that his feet were stuck in the foot board and the Certified Nursing Assistant (CNA) walked out on him 3 times without assisting him. The wife stated she called the facility both times and talked to Staff C Licensed Practical Nurse (LPN) who assured Resident #54's wife that it would be looked into. During an interview on 1/22/25 at 1 PM Staff D, CNA stated she had worked Friday 1/17/25 on the overnight shift. Staff D stated it was an extremely busy night and she had entered Resident #54's room a few times but was unable to understand what it was that he needed. Staff D stated Staff C, LPN did work the evening shift but did not inform her that family had called. Staff D stated Resident #54's feet was always down to the foot board, as he was a tall man. During an interview on 1/22/25 at 1:13 PM, Resident #54 stated Staff C LPN never checked on him the evening of 1/17/25. Resident #54 stated that the night shift staff ignore him and that it makes him feel worthless. During an interview on 1/22/25 at 3:10 PM, Staff C, LPN stated he had worked the evening shift on 1/17/25 and had remembered a phone call from Resident #54's wife at dinner time, but did not remember getting a call later in the evening. Staff C stated his expectation of the CNA's was to inform the nurse if a resident was in need and could not be understood. During an interview on 1/23/25 at 9:10 AM, Staff E, CNA stated she had worked at the facility for 2 years and found that a couple of CNA's on the night shift didn't have the patience to listen to the residents.

Based on observation, policy review, and staff interviews, the facility failed to ensure water temperatures at points of delivery did not exceed safe maximum temperatures for 4 of 6 resident room sinks and for 1 of 3 shower rooms. The facility reported a census of 65 residents. Findings Include: Temperature readings obtained by the State Agency on 1/22/25 revealed the following concerns: 8:15 a.m. room [ROOM NUMBER] bathroom sink 127.7 F(Fahrenheit) 8:20 a.m. room [ROOM NUMBER] bathroom sink 126.4 F 8:26 a.m. South Sunset Shower room [ROOM NUMBER].4 F 8:38 a.m. room [ROOM NUMBER] bathroom sink 125.4 F 8:42 a.m. room [ROOM NUMBER] bathroom sink 121.6 F Temperature readings obtained by Staff B Maintenance Staff on 1/22/25 revealed the following concerns: 8:49 a.m. room [ROOM NUMBER] bathroom sink 125.2 F. Staff B stated that's not good while he obtained this temperature. 8:52 a.m. room [ROOM NUMBER] bathroom sink 124.5 F. After the temperature measurements, Staff B stated water temps should be less than 120 F and stated he would adjust the mixing valve to add more cold. On 1/22/25 at 1:02 p.m., Staff B rechecked the sinks in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and the South Sunset Shower room and all temperatures measured less than 112 F. The facility policy Water Systems: Hot Water Temperature Readings, revised 9/2019, directed staff to maintain hot water temperatures at 110 degrees F in all resident areas. On 1/23/25 at 10:27 a.m., the Executive Director stated that the acceptable water temperature range was 100-120 F. The stated after the high temperatures yesterday, the facility increased the frequency of checks. She stated they would discuss the concern in their Quality Assurance(QA) meetings to decide the frequency of monitoring moving forward. Based on observations, staff interviews, and facility policy the facility failed also to ensure water temperatures at points of delivery did not exceed safe maximum temperatures for 4 of 6 resident room sinks and for 1 of 3 shower rooms. The facility reported a census of 65 residents.

Based on observations, clinical record review, staff interview, resident interview and policy review the facility failed to ensure resident call light within reach for 1 of 21 residents reviewed (Resident #22). The facility reported the census is 64. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented a Brief Interview of Mental Status (BIMS) of 8 indicating moderate cognitive impairment. The MDS documented diagnosis to include heart disease, renal disease, dementia, anxiety and stroke or transient ischemic attack. The Care Plan included intervention initiated 3/19/24 for Resident #22, documented resident often times places call light pendant in small places and unable to recall location. Resident #22 does have wall pendant in place and able to verbalize needs to staff. Care plan focus initiated 1/15/24 included, Resident #22 is at risk for falls related to dementia, hallucinations, insomnia, and possible medication side effects. Interventions included Resident #22 encouraged to sit back down if dizzy and call for assistance. Observation on 03/18/24 at 2:14 PM of Resident #22 sitting in her chair, no necklace pendant viewed, and no call light within reach. Observation on 03/20/24 at 2:10 PM of Resident #22 ambulating out of room for bingo activity, Resident #22 responded in regards to a call pendant that she does not have a necklace. In an interview on 3/20/24 at 4:00 PM Resident #22 sitting in her recliner in her room, and queried about how she would get staff help if needed. Resident #22 voiced she had a call necklace but they took it away from her. Resident #22 acknowledged having a call light on the wall above the bed, to use at night. No call light within reach while in her recliner. Observation on 03/21/24 at 10:27 AM of Resident #22 asleep in her recliner, the only call light in the room is the one attached to the wall, above the bed that is not within reach. In an interview on 03/21/24 at 11:54 AM the Director of Nursing (DON) acknowledged the expectations for call lights is to be within reach. The DON relayed there is one call light policy for the entire facility. Facility policy titled Memory Care/Support Call Light Procedure, revised 4/2022 stated: Through the admission assessment or as significant changes occur the clinical team will identify those residents who are able to understand and use the call light system appropriately. These residents will have the call signal within reach or available in their room as needed.

Based on clinical record review staff interview and policy review the facility failed to ensure assessments before and after outpatient hemodialysis treatments for 1 of 1 resident reviewed that required dialysis. (Resident 42) The facility reported a census 55. Residents 42's Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status of 15, which indicated an intact cognition. Diagnoses documented diabetes, kidney failure and dependence on renal dialysis. Orders dated 1/31/23 revealed Hemodialysis on Monday, Wednesday and Friday with DaVita at MercyOne Newton, or other location as needed. Assess port fistula to right arm, check for Infection daily - warm, pain, redness, swelling, discharge, temperature, tenderness Dressing - remove Band-Aids or gauze 4 hours after discharge from dialysis. Observe for clotted access and\or hematoma. Assess patency daily by feeling the access for a thrill; listen with a stethoscope for a bruit. The care plan focus area with a revision date of 7/28/22 identified a need for hemodialysis (the process of running the blood through an external machine to rid the blood of toxins) on Monday, Wednesday, Friday and as needed per physician orders. The care plan documented an intervention to Assess Bruit and Thrill of fistula each shift and report abnormalities to physician. Facility assessments titled Dialysis Preassessment Version 1 (V-1), Dialysis Preassessment Version 2 (V-2), and Pre/Post Dialysis Evaluation failed to document 6 of 13 preassessments and 4 of 13 post assessments for 30 days reviewed in January 2023. a.1/2/23 Pre and Post b.1/13/23 Pre and Post c. 1/16/23 Pre and Post d.1/18/23 Pre e. 1/20/23 Pre f. 1/25/23 Pre g. 1/30/23 Post Interview with Infection Preventionist 2/1/23 at 2:30 PM revealed the expectation for the resident to have an assessment prior to dialysis and upon return. She stated the facility had recently retired a version 1 of a pre and post assessment form. She stated a version 2 had been initiated and a Pre/Post evaluation assessment had been utilized as well. She stated it was possible that some agency nurses documented assessments in the progress notes. Interview with ADON 2/2/23 at 8:30 AM revealed the facility had not been consistently completing pre and post assessments. Interview with the DON 2/2/23 at 10:30 AM revealed she had obtained a clarification order, placed assessments on the medication administration record and clarified the assessment form to be completed in the electronic health record. Facility document dated 2/2023 titled Dialysis Process directed the facility to complete pre and post dialysis assessments on the Dialysis Evaluation in the electronic health record.

Based on policy review, record review, observation, and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed (Resident #5 & #8). The facility failed to use a gait belt when they transferred and ambulated (walked) with (Resident #8) in accordance with industry safety standards and facility policy. As a result, the resident fell and sustained a right [CONDITION(S)]. The facility also failed to ensure staff locked the brakes on Resident #5's bed. Resident #5 ambulated independently. When she sat on the bed, it moved and she fell . The facility reported a census of 61 residents. Findings include: 1. According to the Minimum Data Set (MDS) Assessment tool dated 3/25/22, Resident #8 had diagnoses that included [CONDITION(S)], multiple fractures of ribs, and [CONDITION(S)] and collapse. The MDS documented the resident scored 12 of 15 possible points, which meant the resident demonstrated moderately impaired cognitive abilities. The MDS also documented Resident #8 required limited (staff provided guided maneuvering of limbs or other non-weight bearing) assistance with transfers and ambulation. The MDS revealed the resident received an anticoagulant. The Order Summary Report dated 3/31/22 documented Resident #8 took [MEDICATION(S)] (a blood thinner) 5 mg twice a day due to a diagnosis of [CONDITION(S)]. The Care Plan dated 3/23/22 documented Resident #8 transferred from surface-to-surface with assist of one staff, a walker, and a gait belt. A Care Plan revision added 3/29/22 documented Resident #8 ambulated with assist of one staff, a gait belt, and a walker, and instructed staff to walk with the resident three times a day (to meals is easiest). An Incident Report dated 3/31/22 documented staff called Staff C, LPN, to the dining room. Resident #8 lay on the floor on his right side with his walker in front of him with blood coming from the back of his head. Resident #8 reported pain in his his right upper thigh/hip area as 10 out of 10 (0 = no pain, 10 = worst pain ever experienced). Staff placed a gait belt on the resident to move him from the floor. Resident #8 reported losing his balance, falling onto his right hip, and hitting his head. The facility sent the resident to the Emergency Department due to hitting his head and taking a blood thinner. An Operative Report dated 4/2/22 documented Resident #8 underwent a surgical procedure on 4/1/22 following the fall, which resulted in a subcapital mid-cervical femoral neck (hip) fracture. The resident underwent a hemiarthroplasty (partial hip replacement) of the right hip. An observation on 5/5/21 at 1:30 p.m. revealed Staff D, Certified Nurse Aide (CNA) and Staff E, CNA, transferring Resident #8 from his wheelchair into bed with the use of a Hoyer (full body) mechanical lift. The resident had a hip abductor cushion between his thighs and an immobilizer on his right leg from upper thigh to ankle. Observation of his right hip/thigh revealed a healed surgical incision. Resident #8 answered only yes or no questions from staff. A gait belt hung on the back of the room door. On 5/5/21 at 1:40 p.m., Staff D, CNA, reported Resident #8 had transferred and walked with assistance of 1 staff, walker, and gait belt before he broke his hip. On 5/9/22 at 4:20 p.m., Staff C, LPN, stated on 3/31/22 she had been down the hall when called to the dining room. She observed Resident #8 seated on the floor with his walker in front of him and no gait belt around his waist. Staff G, CNA, who had been taking the resident back to his room, appeared distraught and stated she had only turned away for a moment. Staff C reported she had observed bleeding from the back of Resident #8's head. Staff C and Staff F, LPN, assessed the resident: he reported no more pain than usual at that time (Resident #8 had admitted to the facility) with right hip pain. On 5/10/22 at 10:00 a.m., Staff G, CNA, verified that she did not place a gait belt on the resident prior to transferring him after supper on 3/31/22. She reported she asked the resident to stand from his dining room chair, which he did on his own with Staff G and the walker next to him. Staff G stated she took three or four steps away from the resident and then he fell . Staff G reported Resident #8 normally stood up by himself and then she would walk with him, although he could be a bit wobbly after standing. Staff G also reported Resident #8 needed assist of 1 staff, a gait belt, and his walker for transfers and walking. Staff G added she had not grabbed the gait belt from the resident's room when she brought him to the dining room and so she did not have it to use when she walked back with him. On 5/10/22 at 2:50 p.m., Staff F, LPN, reported he heard Resident #8 fall on 3/31/22. Staff F said when he arrived in the dining room, he saw Resident #8 sitting on the floor approximately 3 feet from the chair where he ate supper with his walker at his feet. Staff F reported Resident #8 did not have a gait belt around his waist and observed Staff G, CNA appeared upset as she reported she had not paid attention for a moment when the resident fell . Staff F and Staff C, LPN, assessed Resident #8: his daughter had arrived in the dining room after the fall and reported the resident had right leg pain when admitted . Staff F said Resident #8 went to the emergency room as a precaution because he had hit his head when he fell and he was on anti-coagulant therapy (blood thinners). The facility's Safe Resident/Client Transfer Procedure policy dated 04/2014, documented staff would assess Resident #8's transfer abilities when he returned to the facility and reassessed quarterly with any noted changes. The policy defined gait belt assistance - one person as the resident required supervision or contact assistance when ambulating (walking), and assistance with sitting to standing might be required. The facility's Ambulation Procedure dated 06/2016 instructed staff to check the Care Plan for specific instructions and use a gait belt per facility policy by grasping the gait belt with one hand and supporting the resident as needed with the other hand. The policy also directed: do not let go of the gait belt. On 5/10/22 at 4:30 p.m., the Director of Nursing (DON) stated she expected staff to use gait belts for transfers and ambulation as directed by the Care Plan. The DON added that after the resident's fall, the facility immediately educated Staff G, CNA, regarding gait belt use, and subsequently educated all nursing regarding transfer and ambulation policies. 2. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #5 had diagnoses that included spinal stenosis, chronic pain, and muscle weakness. The MDS also documented the resident scored 15 of 15 possible points (intact cognitive abilities) and independently walked and transferred in her room. The Care Plan dated 12/23/20 identified Resident #5 as at risk for falls due to weakness, pain, and activity intolerance. The Care Plan included a revision dated 8/9/21 that directed that Resident #5 ambulated independently in her room with her walker. An Incident Report dated 12/14/21 documented staff found Resident #5 sitting on the floor next to her bed and noted the brakes on the bed were not locked. The resident reported she had attempted to sit down on her bed and it rolled away. In an interview on 5/5/22 at 9:50 a.m., Resident #5 reported she fell on ce because someone unlocked the brakes on the bed and the bed moved when she tried to sit on it. She added that although therapy worked with her, she could ambulate independently before and after the fall. On 5/9/22 at 4:45 p.m., Staff B, Licensed Practical Nurse (LPN), stated staff summoned him to Resident #5's room when she fell by the bed. He reported found the resident sitting by the bed with the bed moved from its normal position and positioned at an angle. Staff B said the housekeeper had stripped the bed that morning, and when staff re-made the bed, they did not lock the brakes.

Based on clinical record review and resident and staff interviews, the facility failed to provide two showers/baths per week as scheduled for 1 of 3 residents reviewed (Residents #5). The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #5's Brief Interview for Mental Status (BIMS) as 15, which meant the resident demonstrated intact cognitive abilities. The MDS documented the resident required physical help with bathing. The Care Plan revised on 8/4/21 revealed Resident #5 bathed twice weekly and required staff assistance with this activity. The Point of Care (POC) Response History for Task: Activities of Daily Living (ADL) - Bathing form showed Resident #5 scheduled for baths on Tuesdays and Fridays. Review of the form revealed she preferred whirlpools, but had not received her scheduled whirlpools/baths/showers from 4/26/22 until 5/4/22. On Friday, 4/29/22, staff had documented not applicable and did not document anything for Tuesday, 5/3/22. In an interview on 5/5/22 at 9:50 a.m., Resident #5 reported she had received a whirlpool the day before: her first in eight days. She stated the facility scheduled her baths twice weekly on Tuesdays and Fridays, but when staff called in, the facility did not complete the showers. She commented that the facility tried to make them up, and althopugh some residents had their Friday showers on Saturday instead, but she did not. She added she had also waited nine days between whirlpools twice. The facility's staffing schedule for 4/29/22 documented three staff call-ins and no bath aide assigned. On 5/10/22 at 10:57 a.m., Staff A, Certified Medication Aide, reported she completed the residents' showers/baths for the facility on Mondays, Tuesdays, Thursdays, and Fridays, but if unable to complete showers on those days, she provided the missed showers on Wednesdays and Saturdays. On 5/10/22 at 4:30 p.m., The Director of Nursing stated her expectation that staff offer all residents a shower/bath twice per week. When staff call in, the last resort is to pull the bath aide. Usually a manager would come in so showers could be completed, or they were made up the following day.

Based on personnel record review, policy review and staff interview, the facility failed to document registry verification for Certified Nurse's Aides (CNA) prior to employment for 3 of 3 CNA's selected for review (Staff A, Staff B and Staff C ). The facility identified a census 57 of residents. Findings include: 1. The personnel file for Staff A, CNA, showed a hire date of 1/18/19 for employment as a CN[NAME] The personnel file contained a copy of a Single Contact License & Background Check, dated 1/9/19, which showed abuse and criminal background checks but did not include registry verification. The personnel file lacked any documentation of CNA registry verifying her eligibility to work. 2. The personnel file for Staff B, CNA, showed a hire date of 8/27/18 for employment as a CN[NAME] The personnel file contained a copy of her Direct Care Worker (DCW) card and a Single Contact License & Background Check, dated 8/7//18, which showed abuse and criminal background checks but did not include registry verification. The personnel file lacked any documentation of CNA registry verifying her eligibility to work. 3. The personnel file for Staff C, CNA, showed a hire date of 10/09/18 for employment as a CN[NAME] The personnel file contained a copy of a Single Contact License & Background Check, dated 9/26//18, which showed abuse and criminal background checks, in addition to a Department of Human Services (DHS) clearance to work dated 10/1/18, but did not include registry verification. The personnel file lacked any documentation of CNA registry verifying her eligibility to work. During an interview on 9/04/19, at 2:15 PM, the Director of People and Culture reported she looks at the CNA registry but does not print anything to verify registry verification had been completed and does not check for registry eligibility with the SING. Review of a facility policy titled Dependent Adult Abuse Reporting, revised 4/3/17, revealed in part Before new hires are permitted to work with residents . DCW (Direct Care Worker) Registry, as applicable, will be contacted regarding the prospective employee's background before permitted to work with residents . Review of the nursing schedule for the past month revealed Staff A, Staff B and Staff C have been scheduled to work on the floor. Review of the facility's current employee list, dated 9/3/19, identified Staff A as a full-time employee, Staff B as an as needed (PRN) employee and Staff C as a full-time employee.

Based on record review, observations and staff interviews the facility failed to follow appropriate infection control practices during Gastrectomy ([DEVICE]) medication administration for 1 of 1 residents observed. (#34) The facility reported a census of 57. Findings include: 1. The Minimum Data Set Assessment (MDS), dated [DATE], revealed Resident #34's [DIAGNOSES REDACTED]. It further shown the resident's cognition to be severely impaired. Resident #34's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During on observation on 9/04/19 at 3:59 p.m., Staff D, Licensed Practical Nurse, (LPN), prepared Resident #34's medication for administration. Staff D dropped a [MEDICATION NAME] tablet onto the top of the medication cart as it was punched out of the packaging. Staff D then used 2 new medication cups to scoop the tablet off of the cart, put in into a medication cup and crushed the tablet. Staff D took the med cup to the resident's room and placed the med cup on the bedside table. Staff D went to the resident's bathroom and washed their hands. An unmarked plastic graduate cylinder and a syringe sat on the bathroom sink next to the hot water faucet. A graduate labeled 'urine 9/4/19' sat on a trash bag on a shelf on the back of toilet. Staff D turned on the hot water with an ungloved hand and filled the unmarked graduate with tap water from the sink. Staff D then placed the syringe into graduate. Staff D filled the med cup with 30 ml's water from the graduate and sat the med cup on the bedside table. Staff D drew up 30 ml's water into the syringe and replaced the syringe into the graduate. Staff D placed a towel under the resident's [DEVICE] and disconnected the tubing from the [DEVICE]. Staff D next used the syringe and flushed the [DEVICE] with H2O. Staff D then poured the dissolved med into the syringe which remained attached to [DEVICE]. Staff D drew up another 30 ml's H2O from graduate and flushed the [DEVICE]. Staff D connected the [DEVICE] to the feeding pump and turned the pump on. Staff D took the graduate and syringe to the bathroom, removed gloves, rinsed the graduate and syringe, sat them on the sink next to the hot water faucet and washed their hands with soap and water. Staff D returned to med cart to sign the med book. Staff D failed to maintain infection control practices when the medication was dropped on the med cart. Staff D also stored the unlabeled graduate and syringe without a protective covering on the bathroom sink. During an interview on 9/04/19 at 4:15 p.m., Staff D, LPN, revealed the graduate and syringe were replaced every 24 hours on night shift. Staff D further reported the graduate and syringe were stored on the bathroom sink uncovered, and noted the graduate not dated, but stated it should be. Staff D also explained when a medication is dropped on the med cart, Nursing Staff utilize a spoon to pick it up and use the med as long as they hadn't touched it. During an interview on 9/04/19 at 4:20 p.m., the Director of Nursing (DON) revealed there was not a designated area to store Resident #34's graduate and syringe. The DON further explained the graduate and syringe should be changed daily, dated and stored on a clean surface and should not be on the sink uncovered. The DON stated if a medication is dropped on the med cart it should be discarded and a new medication used. During an interview on 9/04/19 at 5:00 p.m., the DON reported the facility did not have a written policy regarding dropped meds. The DON further stated, the top of a med cart should be cleaned before and after each med pass.

Based on clinical record review and staff interview, the facility failed to follow physician orders [REDACTED]. (Resident #59) The facility census was 59 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #59 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. A facsimile dated 5/25/18, indicated a clarification order regarding the [MEDICATION NAME] 7.5 mg. Was it to be as needed twice daily or twice daily. The physician circled the twice daily as needed and returned it to the facility on [DATE] and was noted by staff. During interview on 6/14/18 at 8:51 a.m., the Director of Nursing (DON) stated the [MEDICATION NAME] 7.5 mg was ordered twice daily as needed from the hospital discharge orders, but when the order was transcribed on to a facsimile order form to the physician it indicated twice daily scheduled. The pharmacy sent a clarification order on 5/26/18 and the physician response directed staff to use as needed. The DON verified the most current Physician order [REDACTED]. The DON verified the MAR indicated [REDACTED].

Based on observation, clinical record review, resident council meet review, resident and staff interview, the facility failed to ensure staff answered resident call lights in a timely manner in order to meet the needs of three residents observed. (Resident #3 ). The facility census was 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene needs. During interview on 4/6/18 at 11:35 a.m., the resident indicated his call light was on as long as 1/2 hour as he used the clock on the wall or his watch to time it. 2. Resident Council Meeting minutes dated 2/13/18 & 1/11/18 indicated the wait times for the call lights was a while at times. On 12/7/17, a resident stated there was times he/she gave up on assistance because of the call light wait time. 3. During interview on 4/19/18, Staff A, Certified Nurse Aide, CNA confirmed staff was not always able to answer call lights within 15 minutes especially when very busy. During interview on 4/5/18 at 3:40 p.m., Staff B, CNA confirmed staff was not always able to answer call lights within 15 minutes and a previous resident even called the facility with a cell phone for assistance. 4. An observation of the facility call light computer system monitor on 4/25/18 at 1:38 p.m., revealed the following: a. room [ROOM NUMBER] bed B call light on at 1:06:43 p.m. and off at 1:41 p.m. b. room [ROOM NUMBER] bed B call light on at 1:15:32 p.m. and off at 1:40 p.m.

Based on clinical record review, observation, group interview and resident and staff interviews, the facility failed to provide adequate staff to care for the resident's needs. The facility reported a census of 61 residents. Findings include: 1. During the group interview on 4/11/17 at 3:00 p.m. 2 of the 4 residents stated the facility did not provide enough staff to take care of all the residents. During the group interview 2 of 4 residents stated the lack of staff disrupted their daily routines such as assistance to the bathroom. 2. The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident had moderately impaired cognitive level. The MDS documented the resident required extensive assistance of 2 staff for transfers, bed mobility, hygiene, and toileting. The MDS indicated the resident used a wheelchair for mobility and required extensive assistance of 1 staff for locomotion around the unit. The MDS documented the resident had bowel and bladder incontinence. In an interview on 4/13/17 at 10:00 a.m., Resident #11 reported he/she waited 40 minutes for staff to answer the call light and to provide assistance. The resident reported he/she wore a wrist watch and had a clock on the wall to track the amount of time it took for staff to respond. The resident reported he/she had an accident in pants while waited for staff to come. This had upset him/her and had made him/her feel like a 2 year old. The resident reported the longer response times happened all of the time, no specific day or time of day. The resident attributed longer response times occurred because the facility didn't have enough help. The resident also stated he/she sat in the dining room at least 30 minutes before staff took him/her to room. 3. The MDS dated [DATE] documented Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS score of 6 out of 15, which indicated the resident had severely impaired cognition. The MDS documented the resident required extensive assist of 1 staff for transfers, ambulation, and toileting. Observations on 4/11/17, included the following: At 9:00 a.m., Resident #3 sat in a wheelchair in the sunroom and colored. The resident told Staff A, Certified Medication Assistant (CMA), he/she had to go to the bathroom. Staff A told the resident she had to pass two other resident's pills and then she and a CNA would take her to the bathroom. Staff A walked from the Sunroom down the hall. At 9:15 a.m., the resident yelled, I have to go to the bathroom. At 9:29 a.m., the resident self propelled wheelchair slowly down the hall. At 9:34 a.m., the resident wheeled self in wheelchair into a room near the end of the hallway. At 9:40 a.m., Staff K, CNA, and Staff A, CMA, walked another resident down the hall to a room across the hall from Resident #3's room. At 9:45 a.m., Staff K walked by Resident #3's door and told the resident she would be back to assist her. At 9:52 a.m., Resident #3 observed patting leg with his/her hand. The leg catheter bag bulged with urine, and had been secured to the resident's left upper leg with a mesh stockinette dressing over the bag. At 9:57 a.m., Staff K and Staff A entered the resident's room and took the resident to the bathroom.

Based on clinical record review and observation, the facility failed to follow proper gloving and handwashing technique, and use a barrier when administered eye medications to prevent the spread of microorganisms for 5 of 8 residents observed (Resident #5, #9, #11, #14, & #16) ). The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 staff members for toilet use including incontinence care. The MDS documented the resident as frequently incontinent of bowel and bladder. The clinical record revealed a culture of a urinalysis dated 5/8/16 that indicated a urinary tract infection. The clinical record revealed a culture of a urinalysis dated 8/18/16 that indicated a urinary tract infection. During observation on 4/11/17 at 8:00 a.m. Staff E, Certified Nurse Aide (CNA), assisted the resident to the toilet. Staff E removed soiled disposable brief without gloves and placed it in the trash container. Without washing hands, Staff E put on gloves and assisted the resident to brush the resident's teeth. Staff E assisted the resident to wash his/her hands and face. Without changing gloves, Staff E assisted the resident to stand. Staff E used a disposable wipe to cleanse the resident's anal area then used another wipe to cleanse through the resident's legs from the backside. Staff E assisted the resident to stand by grasping the resident's hands. Staff E pulled the resident's brief and pants. Staff E assisted the resident to the wheelchair. At 8:22 a.m. Staff E removed her gloves and washed her hands. Review of the Infection Control Manual, dated 2014, revealed the following: a. Non-sterile gloves worn to prevent contamination of employee's hands when provided treatment or services to the resident and when cleansed contaminated surfaces. b. Hand hygiene performed after gloves removed. Gloves do not replace hand hygiene. c. Disposable gloves replaced when contaminated, torn, punctured, or when barrier compromised. 2. The MDS dated [DATE] documented Resident #14 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 staff for toilet use including incontinence care. The MDS documented the resident as frequently incontinent of bowel and bladder. The clinical record revealed a urinalysis dated 11/20/16 that indicated a urinary tract infection. The clinical record revealed a culture of a urinalysis dated 1/24/17 that indicated a urinary tract infection. The clinical record revealed a culture of a urinalysis dated 3/12/17 that indicated a urinary tract infection During observation on 4/13/17 at 9:26 a.m. Staff C, CNA, and Staff D, CNA, provided toileting assistance. Staff C and Staff D placed the resident on the toilet where the resident had a bowel movement. Staff C and Staff D used the mechanical lift to place the resident in a standing position. Staff D used a disposable wipe to cleanse the resident's hip, buttocks and anal area in a swiping motion without changing the surface of the disposable wipe. Staff D did not change gloves and cleansed the resident's front groin areas. Staff D did not change the surface of the wipe. 3. The physician's orders [REDACTED]. The Medication Administration Record dated 4/2017, indicated the resident received Refresh eye drops on 4/11/17, at noon. During observation on 4/11/17 at 11:39 a.m., Staff D, Certified Medication Assistant (CMA), removed the lid on the medication bottle and placed the lid on an overbed table in the resident's room. Staff D spread the resident's upper and lower eyelid apart, and administered an eye drop to each eye. Staff D picked the lid up off the overbed table and placed the lid on the medication bottle. Staff D didn't cover the overbed table or use a barrier to place the eye medication lid or supplies on, and didn't disinfect the overbed table before or after use. An undated procedure titled, Eye Drop Administration Procedure, revealed 7. Remove cap from eye drop container and place on a clean barrier. 4. The physician's orders [REDACTED]. The Medication Administration Record dated 4/2017, revealed artificial tears to both eyes administered in the morning on 4/11/17. During observation on 4/11/17 at 7:12 a.m., Staff A, CMA, removed Resident #16's eye medication bottle from the medication box and placed the medication box on top of the laundry hamper lid in the shower room. Staff A donned a pair of gloves, then removed the medication bottle from the box, unscrewed the lid on the medication bottle and placed the lid down on the lid of the laundry hamper. Staff A proceeded to administer the eye drops to the resident and used a tissue to wipe the resident's cheek. Staff A took the lid of the medication bottle off of the laundry hamper lid and screwed the lid on the eye medication bottle. 5. The MDS assessment dated [DATE], recorded Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 staff for hygiene, dressing, and toileting. The MDS documented the resident had bowel and bladder incontinence. The Care Plan dated 2/12/16 and updated on 3/9/17, indicated the resident had frequent urinary incontinence. The care plan directed staff to check the resident's brief at least every 2 hours, toilet the resident, and provide incontinence care as needed. A culture report on 3/16/17, revealed the resident had MRSA (Methicillin resistant staph Aureus - a bacteria) in the urine and penile drainage. A culture report on 1/2/17, revealed the resident had Pseudomonas (a bacteria) in the urine. Observation on 4/12/17, at 2:17 p.m., revealed Staff N, CNA (Certified Nursing Assistant) and Staff K, CNA, used a mechanical lift and transferred the resident into bed. Staff N donned a pair of gloves after she had washed hands, but Staff K stayed by the resident's bed. Staff N tore the incontinence brief on the resident's right side, and Staff K tore the incontinence brief on the resident's left side. Staff K and Staff N rolled the resident and placed a bedpan under the resident's bottom. At 2:25 p.m., Staff N removed the bedpan, and Staff K rolled the resident onto his/her back. Staff N took a disposable cloth and cleansed the penis, threw the disposable cloth in the bathroom, and washed her hands. Staff N and Staff K rolled the resident side to side and donned a clean brief. In an interview on 4/12/17, at 2:45 p.m., Staff N, CNA, confirmed the resident had a wet brief when she removed it. In an interview 4/13/17, at 2:45 p.m., Staff O, Licensed Practical Nurse (LPN), reported gloves should be worn whenever had potential contact with body fluids, during pericare, and when gloves soiled. In the Infection Control Manual, dated 2014, revealed gloves worn when hands likely came in contact with blood, body fluids, or other potentially infectious material. 6. The MDS assessment dated [DATE], recorded Resident #10 had [DIAGNOSES REDACTED]. The MDS documented the resident had short and long term memory impairment, and moderately impaired decision making skills. The MDS documented the resident required extensive assistance of 2 staff for toileting and personal hygiene. The Care Plan dated 11/21/16, indicated the resident had impaired ability to perform activities of daily living or self cares, and no longer had the capability to do much for self. The care plan directed staff to toilet the resident and assist to wash hand before and after meals. During observation on 4/12/17, at 4:25 p.m., Staff L, CNA, and Staff M, CNA, ambulated Resident #10 to the bathroom. At 4:34 p.m., Staff L and Staff M stood the resident by the toilet. As Staff L provided pericare and cleansed between the resident's buttocks, the resident reached his/her right hand toward the buttocks. Staff L requested Staff M to hold the resident's right hand because the resident had reached toward the buttocks. Staff L continued to cleanse between the buttocks until no stool visible on the disposable cloth. Staff L removed gloves and pulled the resident's brief and pants up. At 4:38 p.m., Staff L ambulated the resident from the bathroom to the dining room. The resident sat down in a chair in the dining room. Staff didn't wash the resident's hands after toileted the resident. The Infection Control Manual, dated 2014, revealed hand-washing performed to prevent or minimize the spread of infection.

Based on observation and staff interview, the facility failed to label and date items in the walk in freezer and failed to apply hair restraints in the food preparation area. The facility reported a census of 61 residents. Findings include: During initial dietary tour on 4/10/17 at 9:28 a.m. the walk in freezer contained the following items unlabeled and undated: Open package of bread dough Open package of fish or chicken patties Open package of tenderloin or country fried steak Open package of fish patties Open package of chicken patties Open package of pepperoni During an interview on 4/10/17 at 9:47 a.m. Staff H,dietary cook, could not clearly state identify the items. Staff H discarded the open packages. During observation on 4/10/17 at 9:34 a.m. Staff I, representative from vendor, walked through the food preparation area without a hair net. During observation on 4/10/17 at 4:05 p.m. Staff F, dietary aide, and Staff G,dietary aide, stood in the kitchen in the food preparation area without a hair net. During observation on 4/11/17 at 9:04 a.m. the dietary manager stood in the food preparation area without a hair net. During an interview on 4/13/17 at 2:00 p.m. the dietary manager stated he expected all dietary staff to wear a hair net upon entrance to the kitchen.

Based on record review, staff interviews, and review of the manufacturer ' s recommendations, the facility failed to ensure Resident #1 received adequate supervision to protect against hazards from self. The resident used an alarm system to alert staff when the resident attempted to self- transfer without assistance. The staff were aware the resident would manipulate the alarm and the alarm would be deactivated and not sound. The facility did not have a system in place to check and change batteries in the alarms in order to be activated and sound. The sample consisted of 4 residents and the facility reported a census of 57 residents. Finding include: 1. Resident #1 had a MDS (Minimum data set) assessment with a reference date of 05/18/15. Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS (Brief Interview for Mental Status) score of 9 out of 15. A score of 9 identified the resident with moderately impaired cognition. The MDS identified Resident #1 required extensive assistance of one staff members to physically assist with transfers, bed mobility, ambulation, toilet use, dressing and for personal hygiene. The MDS documented the resident normally used mobility devices of a walker and wheelchair for mobility and reflected the resident balance during transitions and walking not steady but able to stabilize with staff assistance. The MDS documented the resident had one fall with no injury since the prior assessment being completed. The Care Plan dated 05/29/15, identified the resident at risk for falls as evidence by fall risk assessment. The Care Plan listed interventions that directed staff to do the following: Staff are to remind the resident to use the call light for assistance. Staff are to use a gait belt when transferring the resident. Pressure alarm on when I am in the bed or chair to help remind me to call for assistance and to alert staff resident is trying to get up on own. Staff are to monitor for changes in my balance and report declines to my doctor. Staff are to assist the resident to apply non slip footwear prior to any transfer or ambulation. Staff are to keep my bed in low position, due to resident sliding out of bed in the past. Staff are to keep my room and the halls I walk in well-lit and free of clutter. Staff are to anticipate the resident's needs. Turn off resident's TV at bedtime and make sure remote control is within resident's reach. If resident falls and hit their head, the resident's doctor request staff to send to the emergency room due to medication taken for seizure (Pradaxa). The Care Plan lacked interventions for placing the resident's alarm box for safety of the resident with known behaviors of reaching for alarm boxes, turning alarm boxes off, and taking alarm off. Review of the Fall Risk assessment dated [DATE], reflected the resident had a score of 13. A score of 10 and above identified the resident as high risk for falls. Review of the facility's Incident report dated 7/5/15 at 7:30 a.m. identified the resident as found on the floor of the room lying on left side by the doorway. The resident responsive, but continued to close eyes during the assessment. Resident denied pain at the time. Resident's pressure alarm in recliner and not sounding. Resident appeared relaxed or lethargic, not anxious. Resident confused due to unable to recall time or place. Resident assessed and sent to the hospital ER (emergency room ) to be further evaluated per physician orders [REDACTED]. Unknown at this time if resident sustained [REDACTED]. The fall was unwitnessed. The Nurse's Notes, dated 7/5/15 at 7:30 a.m. reflected the staff found the resident lying on left side on floor of room with back to door and no pressure alarm sounding; resident previously seen on alarm prior to fall. Resident seen by staff 10 minutes prior to fall sitting in recliner resting. An assessment identified the resident denied pain, resident closes eyes during the assessment, resident denies pain, resident closes eyes during assessment and the resident has a history of seizures. Resident assisted by staff to the wheel chair and pillows were used to support the resident from leaning in the wheelchair. The resident ' s physician notified and orders received to send the resident to the emergency room for further evaluation. Resident taken to the ER via the wheelchair. Review of the facility Incident Report dated 5/6/15 at 1:30 am, reflected the staff found the resident sitting on the bathroom floor of the room, with back towards door of bathroom, alarm on bed not sounding. The resident denied hitting head and stated he/she crawled. The nurse assessed the resident and noted no injury. Two staff assisted the resident up and neurological checks were implemented. The assessment identified the resident as oriented to person and confused intermittently, unsteady gait. The resident had forgotten to use a walker when attempting to toilet self. The facility added interventions to perform 30 minute checks for 24 hours. The Nurse's Notes dated 5/6/15 at 1:30 am, reflected the Certified Nurse Aide (CNA) called the resident into the room. The note reflected the staff found the resident sitting, with legs stretched out in front of him/her, on bathroom floor with back towards the bathroom door. The resident stated he/she crawled out of bed and over to the bathroom cause she/he needed to use the toilet. The resident assessed and no injury noted. Resident assisted up by staff, resident had no complaints of pain, resident assisted to the bathroom and then back to bed. The resident denied hitting head, neurological checks initiated. The resident ' s bed had been in low position with alarm in place on the bed but not sounding prior to fall. The resident ' s physician notified of resident being found on the floor in the bathroom, physician ordered not to send to emergency room at this time unless change in condition is noted of resident and to continue to do routine neurological checks. Review of the facility's Screening Forms dated 5/27/15 revealed the physical therapy comments of no change of resident bed mobility, transfers, gait, and skin. The resident crawled out of low bed and staff found the resident on hands and knees. The nurse identified no injurie and the resident removes alarms. The form identified the resident as on a restorative program and is non-compliant with the exercise program. There were no therapy evaluation recommended. Review of Consultation dated 7/5/15 from the hospital, revealed Resident #1 underwent a fall at the facility and was evaluated and found to have a femoral neck fracture on the left. The resident was transferred to another hospital for more definitive care. Review of Operative Report dated 7/8/15, revealed Resident #1 preoperative Diagnosis: [REDACTED]. The resident had a surgical repair of the left hip on 7/8/15. Review of the Nurse's Notes dated 7/11/15 at 1:00 p.m., revealed Resident #1 returned to the facility from the hospital. The staff noted the resident to have intact staples to left lateral thigh surgical site and a Band-Aid to the forehead for a skin tear. Review of the Manufactures User Instructions for Standard Bed and Chair Fall Monitoring System (pressure alarm), not dated, included use instructions of: To test the monitoring system before each use and inspect the pads and monitor to make sure they are not damaged. Be certain that protocols direct staff to log the 45-day, 90-day, 180-day, and 1 year 'Date Put in Use' date on the blank provided on the pad itself AND in the resident's chart. If the pad is used on more than one resident, the original Date Put In Use date must be transferred from chart to chart. On 7/22/15 at 11:40 p.m. observation with the Director of Nursing (DON) present, identified Resident #1 ' s alarm pad to be dated as 5/7/15. The alarm box and alarm batteries lacked any date. The resident's chart lacked the information of the alarm date information in the clinical record or on the resident ' s Care Plan. The DON stated this is the same alarm system that had been in place prior to the resident's fall and staff continue to use this alarm after the fall. On 7/22/15 at 11:20 a.m., 1:15 p.m. and 7/23/15 at 8:20 am the Director of Nursing (DON) was interviewed and stated the staff check alarms as they transfer the resident and the alarm will sound when the resident sits on the pad and they know it is working. The DON stated Resident #1's alarm was found to be working after the fall and staff assumed the resident had turned it off. The DON stated the alarm box had been placed on the resident's table by recliner along with remote control of the television and call light prior to fall. The resident did not activate the call light prior to the fall. The DON stated there is no procedure/policy/system in place for checking the alarm system and having staff sign out that the complete alarm system is in working order and good condition. The DON stated the staff change the alarm batteries when the battery light comes on, located on the alarm box. The facility did not date or have a regular schedule of changing batteries of the alarm boxes, just when the light comes on. The DON stated the resident is known to fiddle with things and always kept the alarm box on the table at the recliner side or recliner pocket. The DON stated the facility have been using this type of alarm for at least a year but unsure of the date. On 7/22/15 at noon, Staff C, Licensed Practical Nurse (LPN), was interviewed and stated she worked the morning of 7/5/15 and assigned to Resident #1. Staff C stated she did not see the resident prior to the fall that morning. Staff C stated she was summoned to the resident room by a staff member and informed the resident to be on the floor. Staff C stated when she entered the resident's room, the resident laid on left side on the floor with head at doorway of the room door and back towards wall. The walker was located at the end of the bed. Staff C stated no alarm sounded. Staff C stated she assessed the resident and noted the resident's appearance appeared very relaxed, resident not with it (confused), not like the resident's normal behavior, but like his/her behavior when resident has had a seizure activity. Resident easy to awaken but could not speak but did ask where he/she was at. Staff C stated she assessed the resident and identified no injury present. Staff C stated there was a standing order and in Care Plan, that the resident should be sent to the hospital for an unwitnessed fall due to the resident having a history of seizures. Staff C stated she and a couple other staff members got the resident to a sitting position then to a standing position and transferred her to the wheelchair. Staff C stated she instructed the staff member to transfer the resident to the ER is across the street and the facility has an underground tunnel to the hospital. Staff C stated the resident never made any complaints of pain or indicated having pain prior to going to the ER. Staff C stated pillows had to be placed in the sides of the wheel chair to give the resident support as the resident leaning and very sleepy. Staff C stated staff reported to him/her that the resident complained of back pain during transfer from wheelchair to the hospital bed. Staff C stated she received a call later that the resident had a left hip fracture. Staff C stated that she and Staff D, Certified Nurse Aide, tested the resident's alarm after the fall and it was working. Staff C stated the resident has a history of messing with the alarm box and she tries to keep the alarm box and the alarm cord out of sight of resident; the alarm cord is not very long. On 7/22/15 at 2:00 p.m. Staff B, Certified Nurse Aide (CNA) was interviewed and stated she worked day shift on 7/5/15 and was assigned to the hall where Resident #1's lived. Staff B stated she along with Staff D, CNA, went into the resident's room and assisted the resident with toileting and morning cares around 6:30 a.m. and dressed the resident including socks and shoes. Staff B stated Staff D assisted the resident to his/her recliner in the room as it was too early to go to the dining room for breakfast. Staff B stated they also assisted the resident's roommate with getting up out of bed and doing morning cares. Staff B stated he/she and Staff D then went to another resident ' s room, right across the hall from Resident #1, to assist the resident with getting up and doing morning cares. Staff B stated they were in the room for about 15 minutes and walked out into the hall and that is when they saw Resident #1 lying on the floor by the door of the room with walker in upright position by resident's head. Staff D summoned for the Nurse. Staff B stated no alarm sounded and they heard no alarm sound while in other resident's room. Staff B stated the Nurse assessed the resident, and then sat the resident up in a sitting position and then to a standing position and transferred into the wheelchair and the Nurse sent the resident to the emergency room via wheel chair. Staff B stated the resident was not saying anything and staff found that to be odd. The resident appeared more confused after fall then before, alert and leaning in the wheelchair. On 7/23/15 at 10:20 a.m. with Staff D, Certified Nurse Aide (CNA) was interviewed and stated she along with Staff B, CNA, went into Resident #1's room around 6:30 a.m. due to resident's roommate yelling out. Staff D stated she did cares on the roommate and got her up and dressed for breakfast. Staff D stated that Resident #1 requested at that time to get up out of bed. Staff D stated she assisted the resident to the bathroom and to the toilet with gait belt and walker. Staff D stated the resident is one assist with cares and ambulation at that time. Staff D stated morning cares completed, resident dressed, including shoes and socks and assisted to his/her recliner in the room. Staff D stated prior to the resident sitting in the recliner, she had moved the alarm from the bed to the recliner and when the resident sat on the alarm pad it beeped indicating it to be working. Staff D stated she clipped the alarm box to the outside of the recliner pocket, gave the resident her call light and TV remote and walker to the left side of resident. Staff D stated the resident keeps her recliner remote in the recliner pocket and is able to reach it and use it. Staff D stated the resident is a walk to dine for meals and it had been too early for breakfast. Staff D stated it takes about 15 to 20 minutes to do morning cares with the resident and after she went across the hall to a resident room with Staff B. Staff D stated they did morning cares on that resident that takes about 15 minutes to do; and heard no alarm sounding while doing cares. Staff D stated she and Staff B walked out of the resident's room and saw Resident #1 lying on the floor by the room doorway, no alarm sounding and resident not yelling out. Staff D summoned the nurse. Staff D stated the resident words were slurred, like when the resident has had a seizure, resident denied pain, and resident limp and lethargic. Staff D stated prior to the fall, the resident seemed normal. Staff D stated the nurse assessed the resident and then staff assisted the resident to a sitting position, then to standing position and then into the wheelchair. Staff D stated Staff E, CNA, had come down the hall to the resident's room and the nurse asked Staff E to take the resident to the emergency room . Staff D stated she checked the alarm after the resident's fall and it worked. Staff D stated seeing the alarm box placed in different areas by staff and staff put a cover (incontinent pad) over the alarm pad so the resident did not see it and mess with it. Staff D stated at times the alarm would bother the resident and she would become agitated. Staff D stated the facility had no system in place for checking the alarm system. Staff D stated the staff check the alarm as they use it. On 7/23/15 at 11:00 am Staff A, Certified Nurse Aide and Certified Restorative Aide was interviewed. Staff A stated she has purchased the alarms and supplies for the past two years. Staff A stated she dates the alarms when they are delivered to the facility, not when put into use, the batteries are not dated. Staff A stated Resident's #1 alarm box is the older model the facility used at one time and unsure when it initially put in use. Staff A stated the facility had no check system for alarms and staff check the alarms when used. Staff A stated the resident could and did use remote control for television and call light. Staff A stated the resident would fidget with the alarm box if seen. Staff A stated she would put the alarm box out of sight of the resident to prevent her/him from messing with it. Staff A stated she heard the resident would turn the alarm box off and get up on own. Staff A stated on the morning of 7/5/15 she went to get the resident to walk to breakfast since the resident is assigned to the walk to dine program. Staff A stated when she got to the resident's room, the nurse was checking the resident on the floor. Staff A stated after the nurse assessed the resident, she and two other CNA's assisted the resident up and transferred the resident to the wheelchair and the resident never said anything about pain at this time. On 7/23/15, Staff E, Certified Nurse Aide (CNA) was interviewed and stated she went to Resident #1's room and saw the resident lying on the floor. The nurse was checking the resident and no alarm sounding prior or when Staff E arrived at the resident's room. Staff E stated after the nurse assessed the resident, she and two other CNA's got the resident up and transferred to the wheelchair. The nurse stated she would be sending the resident over to the ER. Staff E stated the resident voiced no complaints of pain with the transfer. Staff A stated the nurse instructed her to take the resident over to the ER via wheelchair. Staff E stated in the ER she and a nurse transferred the resident from the wheelchair to the hospital bed when the resident started voicing her/his lower back and leg hurt. Staff E stated he/she returned to the facility and reported to the nurse that the resident complained of pain during the transfer at the hospital. Staff E stated the resident has a history of playing with the alarm box and pulls on the alarm cord to get to the alarm box. Staff E stated she attempts to hide the alarm box and cord from the resident. Staff E stated she has caught the resident up on her own in the room with no alarm sounding and it could be seen that the alarm box had been messed with.

Based on observation, record review, and interviews with residents and staff, the facility failed to plan for and direct nursing services to ensure six (6) of ten (10) residents received adequate supervision against hazards. Resident #1 sustained a fall that resulted in a compression fracture when he/she removed his/her gown with the alarm attached. Eight facility staff reported Resident #1 normally removed his/her alarm/clothing with the alarm attached. The care plan for Resident #1 and another resident (Resident #6) lacked any modification to address their ability to remove alarms. The facility failed to provide adequate supervision when they left residents on the Chronic Confusion and Dementing Illness (CCDI) unit without staff for 15-20 minutes. The facility failed to ensure care plan interventions intended to prevent falls and or injury were implemented for Residents #11, #8, and Resident #14; or that Resident # 15's environment remained free of potential hazards. The facility reported a census was fifty-eight (58) residents. Findings include: 1. Resident #1 admitted to the facility on [DATE]. Hospital transfer orders, dated 9/5/11 to the facility identified the resident as a fall risk with [DIAGNOSES REDACTED]. A Minimum Data Set assessment with an observation end date of 10/21/11 assessed Resident #1 with impaired short term memory and poor decision making skills. The resident required limited assistance of staff with bed mobility, transfers, ambulation, toileting and bathing. A "balance during transitions and walking test" identified the resident as not steady but able to stabilize without human assistance with moving from seated to standing position, walking, moving on and off the toilet and surface to surface transfers. The resident was not steady and required human assistance to stabilize self with turning around and facing the opposite direction while walking. The resident had functional limitations in range of motion of upper and lower extremities. The resident utilized a walker and wheelchair. The resident had [DIAGNOSES REDACTED]. The MDS identified one fall with major injury since admission. The resident measured 62 inches tall and weighed 116 pounds. A physical therapy (PT) discharge summary dated 10/13/11 identified the resident's prognosis as "Excellent with consistent staff support" and identified the resident transfers and ambulates with care giver assistance. A resident incident report dated 10/21/11 at 3:30 a.m. stated Staff R answered the resident's call light and found Resident #1 kneeling beside his/her bed with head on bed. The alarm had been attached to the resident ' s night gown. Prior to the fall, the resident removed the night gown and the alarm did not activate. The resident sustained [REDACTED].) by 1.1 cm. and the other measured 0.9 cm. The Director of Nursing (DON) documented in an e-mail to the surveyor dated 10/21/11, Resident #1 attempted to get out of bed on 10/21/11 at 3:30 a.m.. The resident turned the call light on. The DON identified the resident as alert and oriented but forgetful with a history of falls. The resident also used a night light. The resident removed his/her gown with the alarm attached before getting out of bed. The resident received treatment for [REDACTED]. The pain continued with movement so staff sent the resident to the emergency room (ER) for evaluation. The resident was diagnosed with [REDACTED]. According to a call light log, Resident #1 turned the call light on at 3:07 a.m. and staff did not answer until 13.6 minutes elapsed. Staff Interviews: Staff working the night of the incident: On 10/31/11 at 4:40 a.m. Staff R stated she was on another hallway when she heard Resident #1's call light sound. Staff R stated as soon as she finished her tasks on the other hall she answered Resident #1's call light. She estimated the time that it took her to get there as 4 minutes. She walked in the resident's room and the resident did not have his/her gown on. The gown contained the alarm. Staff R stated she observed the resident with his/her knees on floor and top half of body on the bed. Staff O (charge nurse) arrived and assisted the resident to the walker. The resident started dry heaving and Staff R left to wash her hands. Staff R stated Resident #1 did not like using the call light and would often remove the alarm or take clothes off with the alarm clipped to so it would not sound. On 10/31/11 at 6:04 a.m., Staff S stated she was working the night of the incident but was on the closed CCDI (Chronic Confusion and Dementing Illness) unit. She stated at one point in the night Staff O came in and directed her to come out of the unit to assist with the two residents that fell . Staff S stated no one was in the CCDI for 15 to 20 minutes. She stated she and Staff R left the floor and transported one of the residents to the ER. Staff S stated she knew Resident #1 to take the alarm off in the past. On 10/31/11 at 6:30 a.m., Staff O stated Resident #1 fell staff was doing 3 a.m. rounds on another hall. Staff R called her to Resident #1's room and as she assessed Resident #1. Staff O stated Resident #1's alarm did not sound because the resident removed his/her gown that staff attached the alarm to. She also stated staff rushes when short staffed and this is how Resident #14 got skin tears. Other staff: On 10/31/11 at 10:40 a.m., Staff N (nurse aide) stated Resident #1 would remove the alarm from clothing several times per day. The resident would also take off clothing with the alarm on so it would not sound. Staff N told nurses about it. On 11/1/11 at 12 p.m. Staff E (nurse aide) stated Resident #1 has removed clothing with alarm attached so it would not sound prior to the 10/21/11 incident. The resident did not like to wait for help and after 2 to 5 minutes the resident would remove clothing with alarm attached or remove the alarm and get up and go on own. Staff E reported this to the charge nurse. On 11/1/11 at 1:17 p.m., Staff D (nurse aide) stated she saw the resident remove nightgown with alarm attached so it didn't sound and the resident removed the alarm itself a lot. Staff D reported this to the charge nurse. On 11/1/11 at 2:10 p.m., Staff C (nurse aide) stated she saw the resident try to take his/her top off so the alarm would not sound and one night, the resident removed his/her sweatshirt with the alarm attached. The resident stated he/she did not want to bother staff with the alarm sounding. Staff C informed the charge nurses of this information. On 11/1/11 at 2:38 p.m., Staff B (charge nurse) stated she observed Resident #1 in bed with clothes off with alarm still attached to clothes. She stated she passed this information on in report and encouraged the resident to keep clothes on because the resident needed to keep alarm on. The resident continued to remove clothes and/or the alarm clip. The care plan, dated 9/25/11, identified the resident with a problem of potential for falls and injury related to poor safety awareness due to prior CVA (stroke). The care plan directed staff to ensure personal alarm is on to promote safety and prevent falls. The care plan failed to contain any alteration in intervention related to staff awareness of resident removing the alarm and removing clothing with alarm attached. A resident incident report, dated 10/18/11 at 7:45 p.m. stated the resident complained of his/her leg hurting. Staff then noticed the leg bleeding. Assessment showed a 7.5 cm. by 6.5 cm. hematoma with a 0.7 cm. skin tear. The resident, dependent on staff for transfers, sustained the injuries to his/her legs on 10/18/11 and the care plan did not contain interventions to protect the resident's legs from injury. 2. A Minimum Data Set (MDS) with assessment reference date of 9/15/11 assessed Resident #6 with impaired long and short term memory and severely impaired cognitive skills for daily decision making skills. The resident required extensive assistance of staff (weight bearing support) with bed mobility, transfers ambulation, dressing, toileting, personal hygiene and bathing. The assessment showed the resident not stead, and only able to stabilize with human assistance when moving from seated to standing position; when walking; when turning around; and when moving on and off the toilet. The MDS identified functional limitations in range of motion in upper and lower extremities. The resident had [DIAGNOSES REDACTED]. The resident had a fall with injury since prior assessment. Nurses notes, dated 4/12/11 at 8:30 a.m., identified that the resident often removes alarm when in bed. On 5/22/11 at 12:30 a.m., nurse ' s notes documented staff found the resident on the blue mat next to the bed with head near door hinge. Assessment showed a 3 cm. abrasion to the forehead with a small amount of bleeding. A resident incident report dated 5/22/11 at 12:30 a.m. stated the resident removed the alarm. A resident incident report dated 8/18/11 at 6 p.m. stated the resident attempted to get up from a dining room chair and then fell on his/her left side hitting left temple. Assessment showed a 1 cm. skin tear above the left eyebrow. In the area that identified if the alarm sounded staff documented, "N/A". A care plan dated 6/23/11 directed staff to "utilize pull apart alarm for safety". The care plan did not contain a change/alteration in intervention regarding the resident's ability to remove alarm per self. Observation showed on 11/1/11 at 12:50 p.m., the resident up in a wheelchair in the core area with no alarm in place. At 1:05 p.m., the surveyor questioned Staff K if the resident should have an alarm. Staff checked the resident and then got the resident's alarm. At 4:55 p.m. on the same date the resident sat in the dining room with no alarm on the wheelchair. Staff I (charge nurse) verified the resident did not have an alarm in place and directed a nurse aide to get one and apply it. 3. A Minimum Data Set (MDS) with assessment reference date of 7/14/11 assessed Resident #11 with impaired long and short term memory and decision making skills. The MDS identified the resident required extensive assistance with bed mobility, transfers, dressing, toileting and bathing. The resident required limited staff assistance with ambulation. The resident had [DIAGNOSES REDACTED]. The resident had 3 falls since the previous MDS. One fall was with injury. A resident incident report, dated 5/8/11 at 7:25 p.m. stated staff heard a noise and found the resident sitting on the bathroom floor. The resident did not sustain injury. The report identified the motion sensor was not turned on and therefore did not sound. A resident incident report dated 6/29/11 at 2:15 p.m. documented the resident was in the bathroom and got up on his/her own. Staff found the resident seated on the floor. The report identified staff left the resident alone in the bathroom. The resident did not sustain injury. A resident incident report dated 9/17/11 at 1:35 p.m. stated staff found the resident on the bathroom floor with head against the wall. Assessment showed a red raised area to the left side of the head measuring 3 cm. by 4.5 cm. skin ears to the left elbow measuring 2 cm. and a bruise between the index and little fingers of the left hand. The resident attempted to get up from the toilet unassisted after staff left the resident unattended. Care plans dated 4/21/11 identified the resident used an alarm at all times and the care plan contained an addendum dated 7/2/11 "do not leave unattended on toilet". The 7/21/11 care plan directed staff not to leave resident unattended on toilet. On 10/31/11 at 10:25 a.m. Staff P (nurse aide) stated when a resident uses an alarm staff does not leave residents unattended in the bathroom. 4. A Minimum Data Set, with observation end date of 8/26/11 assessed Resident # 8 with a brief interview for mental status score of 13 (no impairment) The resident required extensive assistance of staff for bed mobility, transfers, ambulation, dressing, toileting and bathing. The resident required limited staff assistance with eating and personal hygiene. The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury since the prior assessment. A safety risk data collection form dated 10/12/11 identified the resident's last fall as 8/13/11. The form identified the resident used a "pull apart" alarm and low bed due to weakness and decline in decision making skills. The form stated that sometimes the resident will take the alarm apart. A pathway health services comprehensive evaluation of skin risk factors, dated 10/13/11 identified the resident with several healing skin tears. Skin is very prone to tearing particularly the left arm and hand due to paralysis. Currently has a skin tear to left arm and hand and one to the right arm. All are covered with steri strips. Review of resident incident reports: a.) Skin tear on head 7/6/11 noted at 3:45 p.m. Staff observed a skin tear to the top of the resident's head measuring 2 centimeters (cm.) by 1.25 cm. The resident identified he/she thought they received the skin injury in the shower that morning from bumping. Nurse instructed nurse aides to use increased caution with resident during positioning, cares and transfers. b.) Skin tears to left arm on 7/27/11: While in shower, staff noticed 2 skin tear areas on the resident's left arm possibly from rubbing on rails of shower. The first area measured 1 cm. by .5 cm. and the second area measured 0.5 cm. by 0.5 cm. Nurse instructed staff to remind resident of placement of left arm. According to the incident report staff implemented arm sleeves for protection. c.) Fall 8/13/11 at 4 p.m. staff found the resident on the floor after resident activated call light. Staff found resident laying at the foot of his/her bed. The resident stated he/she fell to the left knee and then down to the ground and bumped head. No obvious injury observed. The resident removed the personal alarm before ambulating. Nurse instructed staff to place alarm where resident cannot remove it. d.) Skin tear to left hand 9/26/11 at 8:45 p.m. the resident received a skin tear to the left hand measuring 0.5 cm. by 0.5 cm. when staff dressed resident in gown. Nurse instructed staff to use caution with transfers and positioning. e.) Skin tear to left arm 10/1/11 at 9:10 p.m. resident received skin tear on left arm measuring 0.6 cm. when staff put resident to bed. The resident indicated his/her watch caught the skin. Nurse directed staff to keep arm sleeve in place on left arm for protection and keep watch over arm sleeve. f.) Skin tear to left arm 10/2/11 at 7:30 a.m. staff observed a skin tear measuring 1 cm. on the left forearm when getting the resident ready for breakfast. Nurse directed staff to be aware of affected arm and use caution with positioning and transfers and make sure arm sleeves are in place. g.) Skin tear to left arm 10/2/11 at 9 a.m. staff observed a 1.5 cm. skin tear on the resident's left mid forearm while at the breakfast table. Nurse instructed staff to monitor resident's arm position and placement to prevent injury to affected arm. h.) Skin tear left arm 10/5/11 at 6:35 p.m. staff saw blood on the resident's shirt and when investigated, staff found a 0.2 cm. skin tear on the resident's left arm. The resident's arm sleeve slipped down when the resident stood up. Nurse directed staff to place gerisleeves on left arm in the morning and off at bedtime. According to the pathway health services comprehensive evaluation of skin risk factors dated 10/13/11 identified a skin tear to the right arm. There was no incident report for a skin tear to the right arm. i.)Fall 10/19/11 at 4 p.m. Resident fell from chair when trying to get some water. Staff found the resident face down on the floor. The resident sustained [REDACTED]. The incident report did not identify the alarm sounded when the fall occurred, as they assisted another resident next door they heard yelling which drew them to the room. Nurse instructed staff to ensure alarm in place when resident is in room. The facility disciplined staff following the incident for not applying alarm. j.) Skin tear left arm 10/21/11 noted at 10:30 p.m. When staff undressed resident they noted a 3 cm. by 2 cm. skin tear to the left arm. Staff identified a need for longer geri sleeves. Nurses notes identified the following incidents: Fall 10/24/11 at 5:10 p.m. Resident reached to get hearing aid from the floor and fell from recliner. Resident hit head no redness or bumps noted. Staff assisted resident back into recliner and personal alarm placed on resident. On 11/2/11 the Director of Nursing documented in an e-mail to the surveyor, that the alarm did sound when this fall occurred. Skin tear 10/30/11 at 7:30 a.m. staff observed a 2 cm. skin tear. A resident incident report identified the resident fell on [DATE] at 12:15 p.m. Staff found resident lying on right side on floor of dining room with wheelchair tipped over. The resident sustained [REDACTED]. laceration to top of head, 1 cm. laceration to right cheekbone, open area between thumb and index finger. Staff sent the resident to ER for head lacerations immediately following the incident. Staff placed the resident in assisted dining room following the incident. The alarm did not sound as it remained attached to resident when the resident and wheelchair tipped to floor. The resident returned from the ER at 4:35 p.m. Staff measured the laceration to the top of the resident's head as 8.2 cm. long by 5 cm. wide. The laceration above the right eye measured 2.8 cm. A skin tear below the right eye measured 2.5 cm. wide by 1.2 cm. long with a purple hematoma surrounding the laceration. A 1.5 cm. long by 1.5 cm. wide open area to the bridge of the nose and a triangular skin tear to the left hand. At 11:30 p.m. the resident had periods of apnea and periods of nonresponsiveness. The facility notified the physician and the resident transported to the ER. The resident returned at 11:45 p.m. ER reports dated 10/30/11 identified the resident received a tetanus injection. The report identified the resident with a concussion/head injury and stitches to remove in 7 to 10 days. A physician order [REDACTED]. A hospice nursing note dated 10/31/11 at 2:15 p.m. documented the resident received staples to right side of forehead after sustaining an unwitnessed fall. On 11/1/11 at 6:37 p.m. the Director of Nursing stated the resident ate in the main dining room where residents eat that feed selves independently and it is not closely supervised like the assisted dining. Following the incident, Resident #8 will eat in the assisted dining. A care plan dated 7/18/11 identified the resident with a potential for impaired skin integrity and self care deficit related to left sided weakness. The resident was at risk for falls and potential injury related to paresis and decreased coordination due to CVA (stroke) and left sided weakness. The care plan directed staff to ensure alarm is in place, gerisleeve to left arm and be aware of placement of left arm at all times to prevent injury The resident care card available to CNAs directed staff to apply the alarm in recliner, bed and wheelchair. Observation showed, on 10/31/11 at 7:18 a.m., the resident in bed with alarm clipped to right sleeve. The resident's entire upper portion of head was bandaged and observation showed a large puffed bruise to the right cheek bone area. The resident had steristrips to the left and right forearms and between the index finger and thumb. The resident complained of a headache and feeling dizzy. The resident stated he/she fell when reaching to pick up a napkin from the floor. Observation showed, on 11/1/11 at 11:53 a.m., the resident seated in a wheelchair in the assisted dining room with no alarm on. Observation showed, on the same date at 3:30 p.m., the resident in bed without an alarm in place. The surveyor questioned the DON if the resident should have one. At 4:38 p.m. observation showed the resident in bed with an alarm on. The resident's family, present at the bedside stated staff just applied it. At 4:40 p.m., Staff C (nurse aide) confirmed she was directed to apply an alarm and just placed it. At 4:55 p.m. staff brought the resident to the assisted dining area without an alarm in place. Staff I (charge nurse) verified no alarm in place and sent a nurse aide to get the alarm and apply it. 5. During the incident in which Resident #1 fell at 3:30 a.m. on 10/21/11, three nurse aides and one nurse worked. The charge nurse Staff O took Staff S (nurse aide) out of the closed CCDI unit, leaving no one in the CCDI to monitor it. On 10/31/11 at 6:30 a.m., Staff O stated she "opened the doors" to the unit after Staff S left. No staff was on the CCDI for approximately 20 minutes. Staff O checked on the CCDI every 10 minutes until Staff S could return. Staff O stated she checked in the unit 2 times during that time. Staff O reported no falls or accidents occurred during this time. On 11/1/11 at 4:10 p.m. observation showed all exit doors had a keypad device except the front door to the outside. Staff F stated, at that time, the front door is not alarmed with a keypad at night. None of the residents in the CCDI use wanderguard because they are in a closed unit. Therefore, any resident from the CCDI that was capable could have left through the front double doors to the outside. On 11/1/11 at 4:50 p.m. Staff T and Staff U identified 8 ambulatory residents in the CCDI. 5 of the 8 are able to ambulate distances placing them at risk for elopement during the time the CCDI doors were open. 6. On 10/31/11 at 6:30 a.m. Staff O reported Resident #14 received skin tears due to staff having to hurry with cares during the night. A resident care sheet dated 10/15/11 directed staff to transfer Resident #14 with 2 staff. The care record identified the resident as alert and oriented times 3. Resident Incident Reports identified the following: 10/17/11 at 5:15 a.m. the resident sustained [REDACTED]. Arm bumped on wheelchair arm rest. 10/20/11 at 1 a.m. the resident sustained [REDACTED]. skin tear to the left upper arm when staff transferred the resident from bed to wheelchair after the resident's arm hit the wheelchair arm rest. 10/22/11 at 12:40 a.m. the resident sustained [REDACTED]. skin tear to the right upper arm when staff transferred the resident from wheelchair to bed. After the 3 rd incident, resident incident reports identified the facility padded the arms of the wheelchair. On 10/31/11 at 11:30 a.m., the resident stated he/she got skin tears from transfers on and off the commode. The resident stated they could use more help at night because it takes 2 to transfer the resident and sometimes staff only uses 1 for transfers. On 11/2/11 at 10:24 p.m. Staff O stated 2 staff transferred the resident when the skin injuries occurred and staff also used a gait belt. Review of Resident #14's record identified the resident admitted to the facility on [DATE]. 7. A Minimum Data Set (MDS) with observation end date of 9/29/11 assessed Resident #15 with a brief interview for mental status (BIMS) score of 13 (no impairment). The resident required extensive staff assistance with bed mobility, transfers, ambulation, dressing and bathing. During interview, on 10/31/11 at 8:55 a.m., the resident stated awhile back he/she was in the therapy room to ride the bike and some things fell off a shelf and hit him/her on top of the head. The resident pointed to a discolored area on the top of his/her head and stated, "I think they are all healed now". The surveyor viewed the resident's record and could not find information concerning the incident. On 11/1/11 at 2:45 p.m. Staff A (restorative aide) confirmed the incident did occur. She stated the resident sat by the sink to use the stationary bike and someone reached up to get a timer and one fell on the resident's head. Staff A guessed the incident took place over the summer. She stated she did not report the incident to anyone so there would not be an incident report. She did not report it because she did not see any marks or breaking of skin. Observation showed, on 11/1/11 at 3:10 p.m., four timers stored on top of a paper towel dispenser by the sink. At that time Staff V (restorative aide) stated the timers have always been stored there.