Every finding on record at West Point Care Center Inc

Based on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP) used during wound care and urinary catheter care as a measure to reduce the transition of multidrug resistant organisms for 1 of 1 residents (Resident #5) reviewed for infection control. The facility reported a census of 29.Findings included:Review of the Minimum Data Set (MDS) assessment for Resident #5, dated 4/19/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated a mild cognitive impairment. The assessment list of diagnoses included diabetes, arthritis and cancer. The MDS indicated Resident #5 used a urinary catheter and had a stage 3 pressure ulcer (full-thickness of skin loss exposing subcutaneous fat). The resident identified as dependent on staff for toileting, lower body dressing and transfers. Review of Clinical Physician Orders for Resident #5 revealed the following:a. Clean wound, apply skin prep to surrounding skin, cover with border gauze, change twice weekly and PRN (as needed) until healed; one time a day every Tue (Tuesday), Fri (Friday) for ulcer on coccyx and as needed if soiled. Start Date: 4/24/26.b. 16 Fr (French, indicates size of catheter) 10mL (milliliter, amount of sterile water to put in the catheter balloon to secure the device) indwelling foley catheter. c. Resident #5 did not have an order to use Enhanced Barrier Precautions during wound care or catheter care. During an observation on 5/4/26 at 9:50 AM, Resident #5 door/room noted to not have a sign to indicate the need to use EBP. Resident #5 in the room, sitting in his wheelchair with a urinary catheter attached to the chair. During an interview, Resident #5 reported staff wore gloves to empty his catheter. Resident #5 also stated he had a sore on his bottom, and the staff were putting an ointment and patch on the area. During an observation on 5/5/26 at 9:51 AM, Resident #5 laid supine (face up) in his bed. Staff A, Licensed Practical Nurse (LPN) and Staff B, Registered Nurse (RN) in the room to complete wound care. Without completing hand hygiene, donning (putting on) a gown or gloves, Staff B, RN leaned over Resident #5 to help reposition him. Staff B, then washed her hands and donned gloves. Staff A, Licensed Practical Nurse (LPN), completed hand hygiene with an alcohol-based rub, gloved and without donning a gown, and obtained a red plastic bag for soiled items. Without donning a gown, Staff B, RN, pulled down Resident #5's pants, unfasted the tabs on the incontinence brief, and assisted the resident to roll onto his right side. Staff B, RN, used a disposable measuring tape to measure an open wound located on upper middle coccyx area. Staff B, RN cleaned the wound with wound cleanser and 4 x 4 gauze, removed her gloves, washed her hands, gloved, applied Skin Prep around the wound edges and covered the wound with the foam dressing. Staff A, LPN helped to hold the resident's left hip in place while Staff B measured, cleaned and treated the wound. Staff B helped to reposition the resident, secure the incontinent brief and pull the resident's pants back into place. During an observation on 5/5/26 at 12:58 PM, during an observation, Staff C, Certified Nurse's Assistant (CNA) and Staff E, CNA, entered Resident #5's room. Resident #5 positioned in his wheelchair with a mechanical lift vest underneath him. Without donning gloves or a gown, Staff C and Staff E connected the resident's lift vest to the mechanical lift and transferred him from the wheelchair to his bed. Staff C moved the resident's catheter bag from the wheelchair frame to the bed frame. While Staff C and Staff E leaned over the resident to disconnect the lift vest from the lift their uniforms touched the resident. Staff E left the room with the mechanical lift. Staff C rolled the resident side to side while removing the mechanical lift vest. During this repositioning, Staff C's uniform rubbed up against Resident #5's arms and clothing. Staff C removed the resident's shoes and gave the resident his call light. Staff C then washed her hands, gloved, obtained a plastic bag, paper towel, graduated cylinder and alcohol swab. Without donning a gown, Staff C, CNA placed the paper towel on floor inside the plastic bag, and the graduated cylinder on the paper towel. Staff C emptied urine from the resident's catheter bag into the cylinder, cleaned the port of the catheter bag and emptied the graduated cylinder into the toilet. During an interview on 5/5/26 at 1:11 PM, Staff C, CNA, stated nursing staff placed resident's on EBP when residents had a wound or were sick. She reported doing monthly education related to infection control and had practiced donning and doffing gowns. Staff C reported when a resident was on EBP, there was a sign on the door along with personal protective equipment (PPE) supplies including gowns, gloves and masks. Staff C explained the PPE was on the outside of the resident room doors, because staff gowned up before they entered the room. During an interview on 5/5/26 at 1:12 PM, Staff A, LPN, reported the facility placed resident's on EBP along with extra precautions depending on what the resident had if they had anything infectious including MRSA (Methicillin Resistant Staphylococcus Aureus), Covid or C-Diff (Clostridioides difficile, a type of bacteria). Staff A thought staff should wear a gown and gloves when providing personal or catheter cares if the resident had a urinary catheter. During an interview on 5/5/26 at 4:03 PM, Staff B, RN, stated resident are placed on EBP when they had a catheter or wound. Staff B explained staff needed to wear gloves if they were only doing wound or catheter care. During an interview on 5/5/26 at 4:05 PM, the Director of Nursing (DON) reported it was an oversight that they missed placing Resident #5 on EBP, and staff should be wearing a gown when doing cares with the resident. Review of the facility policy, titled Enhanced Barrier Precautions, dated 9/21/25, revealed, in part, .signs will be posted on the doorway of any resident under Enhanced Barrier Precautions .All employees entering the room for the purpose of hands on resident care activities must perform the following .put on appropriately fitting gloves; don an isolation gown .additionally, if the care to be provided involves anticipated contact with bodily fluids (such as urine or blood), or is a procedure that is likely to result in contact with bodily fluid (such as tracheostomy or catheter cares), the following additional PPE must be worn: surgical face mask (or N95 as appropriate), face shield or appropriate eye protection, nitrile gloves should be considered due to elevated risk of breakage with vinyl gloves.Review of the facility policy, titled Implementation of Personal Protective Equipment in Nursing Homes to Prevent MDROs (multiple drug-resistant organisms), dated 7/26/2019, revealed, in part, residents with any of the following: wounds and/or indwelling medical devices (e.g. central line, urinary catheter, tracheostomy/ventilator) regardless of MRDO colonization status. PPE used for these situations: during high contact care activities .transferring .device care or use (urinary catheter) .wound care: any skin opening requiring a dressing.

Based on record review, staff interviews, and the facility policy, the facility failed to perform check and changes on a resident for at least 8 hours for 1 of 3 residents reviewed for incontinence cares (Resident #1). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated the resident had impairment in one upper and lower extremity. The MDS revealed Resident #1 dependent on toileting hygiene and required substantial/maximal assistance with chair/bed to chair transfer. The MDS indicated the resident was frequently incontinent of bladder. The MDS revealed medical diagnoses for hemiplegia following cerebral infarction (stroke) affecting the left non-dominant side. The Care Plan revealed a focus are revised on 10/9/24 for assistance with Activities of Daily Living (ADLs) related to history of cerebral vascular accident (CVA) (stroke) with weakness/impairment to one side of the upper and lower extremity, decreased mobility, and balance/gait impairments. The intervention revised on 2/6/24 indicated assistance of 1 staff member for toileting due to resident incontinent of bladder. The Care Plan revealed a focus area revised on 1/2/25 for bladder incontinence due to history of CVA (stroke). The intervention dated 1/2/25 indicated clean peri-area with each incontinent episode. The Nurses Note dated 11/10/25 at 12:25 PM, revealed [name redacted] has been quiet during this shift, denying any pain or discomfort. He has been observed resting in bed with his eyes closed, respirations even and unlabored. He was incontinent of bladder earlier, and peri care was provided. Bed in lowest position and call light is in reach.The Nurses Note dated 11/14/25 at 6:45 PM revealed resting easy in recliner. No sob (shortness of breath) noted. Denies needs or wants. Call light in reach.The Summary Report for Resident #1 regarding allegations of neglect (no dated indicated) revealed the following timeline of events beginning November 14, 2025 and November 15, 2025a. 3:10 PM- POC (Plan of Care) showed Resident #1 toileted and continent at this time with bladder elimination. b. 6:30 PM- Staff B, Certified Nurse Aide (CNA) notified Staff A, CNA that both residents in 28 are ready for bed.c. 6:38 PM- Resident #1 utilized call light to ask for assistance. Staff A states that he assisted Resident #1 to his recliner per his request. Staff A states Resident #1 told him to get the f**k out at this time. Staff A assisted Resident #1 roommate Resident #2 before exiting the room. d. 9:15 PM- Staff C, Registered Nurse (RN) administered medications to Resident #1 and inquired if he was ready for bed. Resident #1 declined. e. 10:00 PM- Staff D, CNA reported observing Resident #1 in his recliner at this time during shift change rounds.f. 10:30 PM- Staff E, RN stated at this time Resident #1 requested his water pitcher and bedside table to be placed closer to him.g 12:00 AM- Staff D reported observing Resident #1 in his recliner at this time during rounds. h. 12:33 AM- POC showed Resident #1 did not void at this timei. 2:00 AM- Staff D reported observing Resident #1 in his recliner at this time during rounds.j. 2:33 AM- POC shows Resident #1 did not void at this time. k. 4:00 AM- call light report showed Resident #1 utilized his call light to request assistance. l. 4:30 AM- Staff A stated Resident #1 requested to be placed in his bed at this time. Staff A stated that he told Resident #1 the time and that Resident #1 changed his mind and requested the urinal instead. Urinal was provided and Resident #1 placed his feet up in recliner. Staff A stated that urinal not emptied after use at this time due to Staff A exiting the room prior to the use of the urinal. m. 6:00 AM- Staff A reported to Staff G, CNA that Resident #1 refused bathroom and to be put in bed. Staff A reported to Staff G that Staff A was told to get out of the resident's room. n. 6:20 AM- POC showed Resident #1 incontinent at this timeo. 6:30 AM- 6:45 AM- Staff F, CNA and Staff G assisted Resident #1 and Resident #2 up for the day. Both CNAs observed Resident #1 clothes, chuck, and recliner were soiled with urine. Both CNAs observed Resident #1 wore yesterday's clothes. When Staff F inquired if staff attempted to help Resident #1 to bed or the bathroom Resident #1 stated I told him to get the hell out. Staff F inquired as to why Resident #1 would say this to the staff and he replied with he is too rough. Staff F inquired to whether anyone else came to toilet Resident #1 and he responded no.During an interview on 1/2/26 at 4:35 PM, Staff A stated Resident #1 turned on his call light around 4 AM and said Resident #1 needed to use the bathroom so Staff A gave Resident #1 his urinal. Staff A stated he did not go back into Resident #1 room and empty the urinal, but he should of checked. Staff A stated he put Resident #1 in bed around 6:30-7:00 PM and Resident #1 kicked him out of the room. Staff A stated he did not physically check Resident #1 for incontinence because Resident #1 would use the call light. Staff A stated they sometimes physically checked Resident #1 on morning rounds. Staff A stated Resident #1 wanted to go to bed at 4:00 AM and Staff A convinced him to stay in his recliner because of the time and Resident #1 agreed. Staff A asked if he told anyone Resident #1 kicked Staff A out of Resident #1 room and Staff A said no, because Staff A thought the situation was under control. Staff A confirmed he didn't go into Resident #1 room after 6:30-7:00 PM until Resident #1 put his call light on until around 4:00 AM. Staff A stated he didn't physically check Resident #1 incontinent brief because Resident #1 would voice when he needed changed. Staff A stated if he could go back, Staff A would of checked and changed Resident #1 and put Resident #1 in bed.During an interview on 1/22/26 at 8:16 AM, Resident #1 stated he didn't want Staff A in his room because Staff A was a big bag of wind and talked too much. Resident #1 stated recently they started to wake him up to check his brief. During an interview on 1/22/26 at 9:13 AM, Staff F stated she went into Resident #1 room and when she moved Resident #1 blanket, Staff F noticed Resident #1 soaked with urine. Staff F stated Resident #1 can only use the urinal when Resident #1 wore a wraparound incontinent brief (the ones with the tabs) and when Staff F changed Resident #1 he wore a pull up incontinent brief. Staff F stated because of the stroke, Resident #1 could not pull down the brief and hold the urinal at the same time. Staff F stated the recliner was soaked from top to bottom and even Resident #1 was wet with urine. Staff F stated she basically gave him a bed bath and changed Resident #1 clothing. Staff F stated she smelled urine when Staff F walked into Resident #1 room. Staff F stated Resident #1 could express his needs but sometimes Resident #1 denied needed to go to the bathroom or changed when Resident #1 did. Staff F stated, Resident #1 needed encouragement to change his brief and then Resident #1 would do it. Staff F stated if Resident #1 did refuse care from a CNA, the staff needed to try a different face to see if Resident #1 would go to bed or get changed. Staff F queried on how Resident #1 reacted when Staff F changed him and Staff F stated Resident #1 didn't seem happy and wanted out of the chair. Staff F stated she didn't ask Resident #1 a lot of questions, just got him out of the chair and cleaned up. During an interview on 1/22/26 at 9:57 AM, Staff G queried on the incident with Resident #1 and Staff G stated when shift rounds completed, Staff G did not physically check Resident #1 brief because call lights were going off and Staff G didn't go into Resident #1 room during shift rounds. Staff G stated after rounds she went into Resident #1 room to get his roommate up and could smell an ammonia smell and then Staff F came into the room to get Resident #1 up and noticed Resident #1 saturated in urine. Staff G stated Resident commented he was not checked on because Resident #1 didn't want Staff A taking care of him. Staff G stated Resident #1 wore a pull up incontinent brief and day shift were the only ones who used those with Resident #1. Staff G stated Resident #1 couldn't use the urinal when Resident #1 wore the pull up brief because he only used one hand. Staff G asked when they did shift rounds if they physically checked the residents and Staff G stated no, they would trust the staff, but now the staff always do physical checks. Staff G stated Staff A should of told the nurse or the other aide about Resident #1 kicking Staff A out of his room if Resident #1 was refusing cares. During an interview on 1/22/26 at 12:12 PM, Staff D stated Resident #1 was not a check and change at the time of the incident and Staff D did not physically check on him throughout the night of November 14th. Staff D stated she did rounds every 2 hours and would look in Resident #1 room and Resident #1 would be asleep. Staff D stated all she knew was Resident #1 refused to go to bed for Staff A. Staff D stated if residents were a one assist, staff would wake them up to check if the residents needed to use the bathroom. Staff D stated if she knew more about Resident #1 refusing Staff A, Staff D would of done a better job with checking on Resident #1 and made sure Resident #1 dry and clean. During an interview on 1/22/26 at 1:04 PM, Staff B stated Resident #1 had a habit of being incontinent and needed to be changed. Staff B stated she regularly checked Resident #1 for incontinence and Resident #1 usually incontinent between 2-4 AM rounds. Staff B stated Resident #1 sometimes would use the urinal. During an interview on 1/22/26 at 2:04 PM, Staff E, RN queried on the incident in November with Resident #1 and Staff E stated he was not aware of Staff A being kicked out of Resident #1 room by the nurse in report or other staff. During an interview on 1/22/26 at 2:23 PM, Staff C, RN queried on the incident in November with Resident #1 and Staff C stated Staff A never told Staff C about being kicked out of Resident #1 room. Staff C stated if she would of known, Staff C would of checked on Resident #1 and asked another CNA to go into Resident #1 room. During an interview on 1/22/26 at 3:13 PM, the Director of Nursing (DON) queried on her thoughts of the incident and the DON stated she wished the CNA would of passed it on the nurse that Resident #1 told the CNA to leave his room. The DON stated the resident being upset was not a reason for staff to not attempt to physically do check and changes. The Facility Rounding on Resident Policy dated 11/18/25 revealed all residents were to be rounded on approximately every 2 hours and at the end of each shift. Incontinence check, with peri-cares or toileting as necessary.

Based on observation, staff interview, and clinical record review, the facility failed to update the Care Plan for 2 of 12 residents for risk of elopement (Resident #18) and use of an antibiotic (Resident #26). The facility reported a census of 27 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 7 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident did not exhibit wandering. Review of Resident #18's Care Plan did not address wandering/elopement risk. Review of Resident #18's Elopement Evaluation dated 5/21/25 revealed the resident scored 0.0 on the assessment, indicated a score of 1 or higher indicated risk for elopement. The assessment revealed, in part, the following questions had been answered with response of no: Has the Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? Does the resident wander? Review of Resident #18's Progress Notes revealed the following: a. 1/5/25 at 9:25 PM: Resident has been refusing cares. Continues to say he is leaving and going home. Staff ensure him he is not leaving tonight as he doesn't have anyone here to pick him up. b. 2/15/2025 at 7:31 AM: Resident was confused at 1130pm. He was watching movies in the dining area. He got turned around looking for room and stated he didn't have a room here. He needed to lock up and go home. Wanted to give this nurse and aide a ride home so he could lock up and leave. Explained we were here all night to help and attempted to get resident into bathroom. He went into bathroom but would not stand to go to toilet. Stated he wasn't doing that, he just needed to go home. Told aide we would wait a little bit, answer the lights and then try again. When this writer came back a couple minutes later from another room resident was no longer in dining room. Went down hallway to find him. He was in whirlpool room attempting to stand at whirlpool with hand in back of his pants digging at soiled pants. Assisted resident back into chair and with cleaning his hands. Then brought him down to his room where aide met us to assist with getting him into bed and changed. Resident allowed us to change him and laid down in bed. He was awake the rest of night laying in bed watching tv. c. 2/19/2025 at 3:54 AM: Resident not allowing staff to get him up and changed at first rounds. Was given some time and went back and resident was swinging at staff, stating we weren't going to help him, he didn't need it and he was going home. Would not stand for staff but did allow up to put on sling for standing lift. We were able to get him changed and cleaned before laying down in bed. d. 4/1/25 at 9:37 PM: When staff was assisting resident into bed, resident kept stating that he wanted to go home. Swapped out staff members and was able to redirect resident easily. Resident does not want to go to sleep though at this time and is laying in bed watching TV. e. 4/25/25 at 11:58 PM: Pleasantly confused, states he was going to get his car and go home before supper, able to redirect to dining table and a tv show and no further asking to go home. Did refuse to go to bed but states he is comfortable in his recliner. f. 5/2/25 at 8:53 PM: States he wants to go home, that he hasn't seen his mom in 3 weeks. Redirection and reassurance given and effective. g. 5/22/25 at 10:07 PM: After resident finished his supper, attempted to open door in dining room. Stated that he was going home. Attempts to reorientate resident were not effective. Resident would continue to say that he was going home. After resident was assisted into bed, he would pull curtain to talk to staff, ask for help getting his socks and shoes on to go home, and would turn sideways in bed so his legs were hanging outside of the bed. Turned movie on TV for resident to watch but this was not effective to redirect and preoccupy. Resident fell asleep after about an hour. h. 5/24/25 at 7:43 PM: After supper, attempted to exit through front door once. Resident stated that he was going to get in his car and leave. Attempts to orientate resident not effective. Attempted to redirect by turning movie on in dining room. Resident stated that he did not want to watch a movie and wanted to go home. He is currently sitting in the dining room in wheelchair watching movie. When 3 separate staff members attempted to toilet resident, he was resistive, not standing, repeatedly saying, no, I'm not going to, and that he was going home. Resident refused snack when offered. i. 5/25/25 at 10:04 AM: Resident pleasantly confused this shift. Sitting in dining room in wheelchair. Staff asked resident to return to room so they can provide cares. Resident refused to go to room, stating I'm getting ready to go home. I have to wait here. Able to redirect resident. j. 5/25/25 at 8:15 PM: Resident pleasantly confused this shift. States several times that he is going home. Has not attempted to exit building. Currently refusing cares and is in dining room watching TV. On 5/28/25 at 11:37 AM, Staff C, Certified Nursing Assistant (CNA) queried if Resident #18 every tried to leave, responded sometimes the resident got confused, wandered, would go down other halls, and never tried to leave the facility. When queried if the resident went to the doors, Staff C responded she had never seen [Resident #18] try to open the door and leave, anything like that. When queried if the resident ever discussed anything like that, Staff C responded, Not to me, no. On 5/28/25 at 2:33 PM, Staff E, CNA queried if Resident #18 wandered, and responded sometimes in wheelchair, and further explained sometimes the resident would get confused and he would forget what hall supposed to be in. On 5/29/25 at 12:30 PM, the Assistant Director of Nursing (ADON) explained Resident #18 was getting more confused in the evenings, and acknowledged she had heard the resident say he had to go home, then he didn't want to go home. The ADON explained she hadn't heard that the resident tried to get out the doors. Per the ADON, that would be a trigger, and resident needed a [wandering alert device] on. When queried if wandering/elopement should be part of the resident's Care Plan, the ADON responded if resident was to successfully get out, yes. The ADON acknowledged if a [wandering alert device] in place, that would be care planned. 2. Review of the MDS assessment dated [DATE] revealed Resident #26 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, Resident #26 took an antibiotic. Review of Resident #26's Care Plan did not not address antibiotic use. The Nurses note dated 3/18/25 at 1:57 PM revealed, in part, New orders received from provider. Start azithromycin 500 mg (milligram) x 3 days, then maintenance dose of 250 mg on MWF (Monday, Wednesday, Friday) every week. Review of the Physician Order dated 3/24/25 revealed, Azithromycin Oral Tablet 250 MG (Azithromycin) Give 1 tablet by mouth one time a day every Mon, Wed, Fri related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. On 5/29/25 at 12:39 PM, the facility's Assistant Director of Nursing (ADON) queried if prophylactic antibiotics should be included on the Care Plan, and was unaware. Review of the Facility Policy titled Care Planning-Interdisciplinary Team, last revised 7/2018, revealed the following: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, clinical record review, and staff interview, the facility failed to instruct a resident to swish and spit after receiving a puff of a steroid inhaler for 1 of 1 residents observed for inhalation medication administration (Resident #16). The facility reported a census of 27 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed diagnosis for asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease. Review of the clinical record revealed an Physician Orders for Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (micrograms per actuation) (fluticasone-salmeterol)- 1 puff inhale orally two times a day related to emphysema, unspecified During an observation on 5/29/25 at 7:33 AM, Staff D, Certified Medication Aide (CMA) took Resident #16 Advair Diskus 250 mcg/50 mcg inhaler to the dining room table and Resident #16 inhaled one puff and did not swish or spit after inhalation. Staff D did not bring another cup over for Resident #16 to spit in or cue Resident #16 to swish and spit. Resident #16 then proceeded to take her oral medications. During an interview on 5/29/25 at 9:16 AM, Staff D queried if she had special instructions with any inhalers and she stated no, she didn't think so. Staff D stated Resident #16 was the only resident Staff D gave an inhaler and Resident #16 did it herself. Staff D asked if residents needed to swish and spit after inhaler use and Staff D stated she didn't know. During an interview on 5/29/25 at 12:48 PM, the Assistant Director of Nursing (ADON), confirmed residents needed to swish and spit after administration of the Advair inhaler. The facility policy, titled Administering Medication Policy revised December 2012 did not address use of inhaled medications. Review of a undated document titled Instructions for using Fluticasone Propionate and Salmeterol Inhaler, provided by the revealed instructions, which included rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it.

Based on observation, staff interview, and clinical record review, the facility failed to ensure fall interventions were consistently implemented for 1 of 3 residents reviewed for accidents (Resident #18). The facility reported a census of 27 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 7 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Further review of the assessment revealed the resident had fallen since admit, entry, reentry, or prior assessment, and had one fall with no injury. Review of the Care Plan dated 12/17/24 revealed, I need assist with ADL's (activities of daily living) R/T (related to) history of rhabdomyolysis, requiring significant cues to stay on task and use proper form, and poor attention which places me at risk for falls/injury. The Intervention dated 5/26/25 revealed, Fall intervention 5/26/25: alarm at all times. The Physician Order dated 5/26/25 at 10:00 PM revealed, Alarm at all times every shift. On 5/28/25 at 8:01 AM, 8:10 AM, and 8:18 AM, Resident #18 observed in their wheelchair in the dining room, and an alarm box not observed to the back of the resident's wheelchair. On 5/28/25 at 8:20 AM, Staff A, Licensed Practical Nurse (LPN) queried if Resident #18 had any alarms, and responded yes, they were a recent addition. When queried when the resident was to have it on, Staff A responded at all times. Staff A queried if able to check about resident's alarm, and Staff A observed to alert Staff B, Certified Nursing Assistant (CNA). Staff B observed to go to Resident #18's room, and alarm observed present in the resident's room on the resident's bed. Staff B queried about alarm for the resident while Staff B present in Resident #18's room. Staff B explained the resident just got it a few days ago from slipping out of bed. Staff B acknowledged the resident was to have it in the wheelchair, chair, and bed. When queried Staff B got the resident ready today, Staff B acknowledged she did, and acknowledged she forgot the alarm. Staff B brought the alarm out of the resident's room. On 5/28/25 at 8:23 AM, Staff B went over to Resident #18 while Staff B held the alarm, carried the alarm back down to the resident's room, then returned with the alarm and a walker. On 5/28/25 at 9:32 AM, Staff A queried about the alarms for resident, explained the resident had one on the bed, confirmed the resident did not have the alarm in the dining room and should have. Staff A further explained it was new, and explained resident had a recent fall. On 5/29/25 at 12:29 PM, the facility's Assistant Director of Nursing (ADON) explained, in part, the alarm was on the Care Plan and was not on the ADL sheet. Per the ADON, it was on the resident's sheet now, and the ADON had talked to the CNA and let her know if had been a very recent change. When queried if the alarm should have been on the wheelchair when the resident was in the dining room, the ADON responded yes. Review of the Facility Policy titled Falls-Clinical Protocol, last revised 3/13/23, revealed the following: The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

Based on record review, interviews, and the facility policy reviewed, the facility failed to provide showers daily per physician orders for 1 of 3 residents reviewed for showers (Resident #5). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition severely impaired. The MDS revealed the resident required a substantial/maximal assistance with shower or bathe self and dependent with tub or shower transfers. The Care Plan revealed a focus area revised on 2/26/24 for assistance with ADL's (Activities of Daily Living) related to CVA (cerebral vascular accident) with right-sided weakness, and poor vision which placed the resident at risk for falls and injuries. The interventions revised on 11/8/23 revealed assistance the resident with bathing with 1 staff. The resident scheduled daily baths per family request and he refused to take them on some days. The Physician Orders revealed the following order: a. To have daily showers- every day shift- ordered 11/24/21 The POC (Plan of Care) Response History Report for February 2024 revealed the following dates Resident #35 didn't receive a shower: a. 2/3/24- marked with 97 (which indicated- not applicable) b. 2/4/24- marked with 98- (which indicated - resident refused) c. 2/8/24- marked with 98 d. 2/10/24- marked with 98 e. 2/11/24- marked with 98 f. 2/13/24- marked with 98 The facility lacked documentation the nurse notified of the refusals for the showers. The Disciplinary Warning dated 2/16/24 revealed Staff B, Certified Nurse Aide (CNA) received a warning for carelessness and poor follow through with inconsistency with cares and completing showers as scheduled. Staff B had frequent refusals with no follow up and misinformation passed on to others not to do showers on Wednesdays and weekends. The Disciplinary Warning included, part of the position included educating others and reporting refusals, and due to this carelessness, you will no longer be the shower aide. During an interview on 3/12/24 at 4:02 PM, Staff A, CNA queried on what the protocol is when a resident refused showers and she stated she needed to tell the nurse and the shower aide of the resident's refusal. During an interview on 3/12/24 at 4:13 PM, Staff B, CNA queried on who performed the showers and she stated the facility scheduled a shower aid on Monday, Tuesday, Thursday, and Friday and on Wednesday and the weekends the CNAs on the floor performed the showers. Staff B asked if residents refused and she stated yes they did and when they refused, the CNA supposed to go to the nurse and they would tell us to ask the resident again and if the resident refused a second time, the nurse talked to the resident and documented the refusal. Staff B stated she put in a note in the resident's record documenting the resident's refusal and why they refused. Staff B asked what not applicable meant in the charting for showers and she stated it meant not part of their job but showers were a part of the CNA job and they shouldn't chart not applicable. Staff B asked if Resident #5 ever refused showers and she stated yes and everytime he refused the shower, she reported it to the nurse. Staff B stated the importance of showers for the residents and they needed to report when the residents refused to the nurse. During an interview on 3/13/24 at 8:50 AM, the Assistant Director of Nursing (ADON) queried on who completed showers and she stated they scheduled a bath aide during the week except for Wednesdays and the CNAs on the floor gave showers on Wednesdays and they schedule for a CNA to come in on the weekends to give a bath to Resident #5. The ADON stated Resident #5 refused showers but his cognition failing and sometimes you just told him, he needed to take a shower. The ADON stated they looked back on Resident #5 shower log and saw his showers didn't get completed and they pulled the bath aide from showers because she documented he refused. The ADON stated the CNA knew if they got a refusal they needed to tell the nurse and the nurse supposed to go down and talk to the resident and if the resident still refused, it needed documented in the chart. The ADON asked if the refusals charted and she stated no, and the protocol been in place for awhile. The ADON stated they noticed the issue and been working to fix it. During an interview on 3/13/24 at 11:18 AM, the Director of Nursing (DON) queried on how often resident received showers and she stated twice a week unless the resident asked for it more frequently or the physician ordered the showers more frequently. The DON asked if any of the residents received showers daily and stated Resident #5. The DON asked if Resident #5 typically refused showers and she stated he typically refused showers once or twice weekly. Discussed with the DON the multiple days the chart documented resident refused his shower and she stated he typically refused once or twice and they removed the CNA who was scheduled for the bath aide and now another CNA scheduled to do them. The DON stated she felt they had a better process now and at the end of the day received a list of the residents who refused the showers. The DON asked expected to be done with this issue and she stated she would of liked them to of performed bed baths with the resident and the documentation of the refusals. The DON asked for the policy for showers and she stated the policy stated to inform the nurse but didn't address the refusal needed documented, but the nurses knew they needed to document it. The Facility Shower/Tub Bath Policy and Procedure (no date identified) revealed the following information: a. Documenting Procedure: The following information shower be recorded in the POC record. 1. Any refusal of shower or bath. b. Reporting to Supervisor 1. Notified the nurse and DON if resident refused the shower or bath.

Based on clinical record review, Incident Report review, observations, and staff interviews the facility failed to ensure a resident with severely impaired cognition remained free from burns from hot liquid when the resident was found with a cup on their lap during shift change to night shift, resulting in blisters to the left abdomen and thigh and documented pain for one of four residents reviewed for accidents (Resident #7). This resulted in an Immediate Jeopardy (IJ) to the health and safety of a resident who resided at the facility. The facility reported a census of 30 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 1/11/24 at 2:15 PM. The IJ began on 1/1/24. Facility staff removed the Immediate Jeopardy on 1/16/24 at 9:57 AM by completing the following: a. All residents were assessed via the Hot Liquids Safety Evaluation form for safety, when handling hot liquids. b. Any resident found to be at risk for inability to handle hot liquids safely will be placed on a Hot Liquids Safety list. The list will be kept in the Dietary Department and Nursing Department where all staff can visualize. This list will be updated by the Nursing Office. c. All facility staff were educated regarding the Hot Liquid Assessments, the list and where it is kept. d. Audits to be completed to assure staff compliance with the Hot Liquids Safety List will be done at every meal x 7 days, daily x 7 days, weekly x 2 months and then monthly times 2 months. e. Results of all Audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Meeting monthly for any observations and recommendations. The scope lowered from J to D at the time of the survey. Findings Include: 1. The Minimum Data Set, dated dated dated [DATE] for Resident #7 revealed the resident was rarely to never understood and required supervision or touching assistance for eating. The Care Plan dated 10/14/22, revision date 12/27/23, for Resident #7 revealed, in part, the following: a. The resident needed assist with Activities of Daily Living (ADL) related to (R/T) a cerebrovascular accident (CVA- stroke) with right sided lower extremity (LE) weakness, right sided upper extremity flaccidness which places the resident at risk for falls/injury. b. The resident not able to eat in the dining room at this time due to there being too much stimulus, causing the resident to yell out and be disruptive to others. c. The resident does eat better in own room or during the week can go into the Activity Room and eat with [Name Redacted] or [Name Redacted] there. Resident likes it in this room, and eats better and stops yelling. d. The Intervention dated 3/4/22 documented to assist the resident with eating by supervising and making sure able to eat the food on own. Sometimes need physical assistance due to having to use left hand. e. The Intervention dated 1/2/24 documented, Intervention for burn/blister: Resident will not be given any hot liquids without supervision and all trays/hot liquids will be removed from room when staff leaves room or family leaves room. Resident is to be up to dining room if possible for all meals. The Diet Order 3/14/22 documented, Mechanical soft diet, Ground meat texture. Review of the resident's Nutrition Quarterly assessment dated [DATE] revealed the following per the ability to feed self-section: feeds self with supervision and cueing, and the current mental status section revealed, severe impairment. The Incident Report dated 1/1/24 at 10:30 PM for Resident #7 documented the following Incident Description Nursing Description: Third shift Certified Nursing Assistant (CNA) alerted Staffing Nurse about areas on left abdomen and thigh. Appears to be blistered areas with redness around blisters. Cup removed from lap before transferring to bed, with what appeared to be coffee in it cold at this time. The Resident Description documented, Unable to state what happened. The Immediate Action Taken Section documented, Resident cleaned per CNA and made comfortable in bed. CNA notified this nurse also by text of issues. CNA stated nurse came down measured areas and applied cool wash cloth. The Injuries Observed at Time of Incident Section documented abdomen and left thigh. The Mental Status Section documented Resident #7 alert to person. Predisposing Physiological Factors marked included the following for the resident: Confused, drowsy, incontinent, impaired memory, recent change in cognition, and weakness/fainted. The Other Info Section of the Incident Report documented, Resident was left with supper tray in room in reach and coffee was on tray which was spilled into lap. Due to dementia and issues with coordination resident is to be supervised with meals. The Nurses Note dated 1/1/24 at 10:44 PM documented, resident was found to have blisters on lower left abdomen and left upper thigh area. two blisters present on abdomen. one blister present on upper thigh area. no complaints of (C/O) of pain at this time. Blisters maybe caused by hot food spilling on the resident. The Progress Note authored by the Assistant Director of Nursing (ADON) dated 1/2/2024 10:18 AM documented, was reported to this nurse through text on 1/1/2023 that resident was found sitting in recliner with food tray and cup on her lap. When assisted to bed CNA noted that resident had redness and blisters to left thigh and abdomen. Called nurse to room who placed cool cloth on areas and measured areas. Daughter was notified this AM along with [Name Redacted] Advanced Registered Nurse Practitioner (ARNP) and Hospice. Review of the Visit Note Report from Hospice dated 1/2/24 documented the following Chief Complaint/Problem: Patient (Pt) has burns/blister from spilling coffee on her last night. The Assessment Section documented, Pt has fluid filled vesicles on the left upper thigh and left lower abdominal quadrant. The Assessment documented, Speech is unclear. Pt can occasionally get something simple like Yes No or Out spoken, and also documented, Cognitive decline interferes with Pt's ability to express pain, rate pain, characterize pain. The Visit Note Report dated 1/2/24 documented the following wound descriptions: a. Wound #1: The resident had a left proximal thigh burn, onset date 1/1/24, documented as 5 centimeters (cm) length by 2 cm depth by 0 cm depth. The Wound Care Provided Section documented, Large blister intact with clear/yellow colored fluid. There is an area of redness surrounding. Unable to determine of area is painful or if Pt just refusing care as she is refusing all assessment. b. Wound #2: Burn to the abdominal left lower quadrant, onset date 1/1/24, documented as 5 cm by 8 cm by 0 cm. The Wound Care Provided Section documented, there are 3 separate blistered areas. Pt resistive to assessment and only able to get a rough measurement of the cluster of blisters versus each individual blister. There is redness surrounding the wound. Pt would not allow measurement of the redness. Unable to determine if the area is painful as Pt was resistive and uncooperative with assessment in general. The Narrative for the Visit Note Report dated 1/2/24, documented, in part, as needed (PRN) visit completed due to (D/T) Pt spilling coffee on herself last night causing redness and blistered areas on the left lower abdomen and left upper thigh. There is one fluid filled/intact blister on the left thigh and 3 fluid filled/intact blisters on the left lower abdomen. There are areas of redness surrounding these areas. Review of a Quality Monitoring/Performance Improvement Plan (PIP) dated 1/2/24 documented, Resident received burn from coffee. The Corrective Action Section of the form documented corrective action was needed, and revealed, in part, the following: a. A CNA from [Agency Name]-lied to [Facility Name] staff when they asked her how Resident #7 ate. She stated she ate good. In fact, it appears she did not check on her. CNA no longer able to come to facility. b. Nurse from [Agency Name]-Appears she did not check on Resident #7 in person as Resident #7 not gotten ready for bed appropriately. This nurse no longer will be allowed to work at [Facility Name]. The Physician Order dated 1/2/24 at 11:00 AM documented: cleanse left abdomen and left thigh gently with soap and water. Pat dry apply Xeroform Vaseline gauze to areas. Change daily and PRN. Check every shift to make sure dressing is in place to burn/blister. One time a day for wound healing discontinue (DC) when healed and as needed for wound healing and every shift for wound healing. Check to make sure Xeroform is in place. Review of the resident's Treatment Administration Record (TAR) dated January 2024 revealed treatment initiated 1/2/24. The Nurses Note dated 1/2/24 at 6:48 AM documented: Skin sheet done on resident for blisters on upper left thigh and lower left abdomen. Multiple blisters noted on abdomen. Blisters are fluid filled with redness noted around the blister. Skin was warm to the touch and it was noted that the blisters were uncomfortable/painful for resident. ADON/skin nurse notified. Hospice called and notified of burns to skin. The Notes Section of the Incident Report dated 1/2/24 documented the following: a. Resident will not be given any hot liquids without supervision and all trays/hot liquids will be removed from room when staff leaves room or family leaves room. Resident is to be up to dining room if possible for all meals. b. Have spoken to CNA'S and Nurses personally and had them sign regarding not leaving before they do a physical round (eye balling) each resident even the ones that they are not directly responsible for to see if anything needs done. c. [Staff G, CNA] the CNA from staffing will not be allowed back into the facility due to her lying to a staff CNA about resident eating fine and no issues. (resident was not fed by CNA and tray was left in room) d. It was reported that Resident #7 spilled her ice water on her that was in a sippy cup. Her gown was completely wet and the linens all had to be changed. Staff is being educated to of course not give hot or warm fluids at all and visually check on Resident #7 every two hours at minimum. e. Dietary Aide stated coffee was served to Resident's room tray in a lidded cup. Cook states at approximately 7:10 pm while passing evening (HS) Snacks she did not witness any coffee cup on Resident's lap but that she wasn't looking for it. Food tray was not on her lap at that time, nor did resident show any signs of discomfort or pain, Dietary staff have been instructed not to serve Resident any hot beverages and that Resident will no longer be a room tray but will be seated in the dining room with assistance with eating. The Nurses Note dated 1/4/24 at 5:24 AM documented, in part, dressing completed to left lower abdomen and left upper thigh. 2 large clear fluid filled blisters present to abdomen wound. Areas cleansed, dried, applied Xeroform gauze et covered per orders. Facial grimacing noted during dressing change, resident continued to push this nurse's hands away while applying the dressings. The Note dated 1/9/24 on the Incident Report documented, Summary: Staff did not know how Resident #7 even got coffee on her super tray until all staff input made it clear Resident #7 nods her head yes to most everything. The CNA that took her supper ticket to the kitchen did not know this information. This is why no temporary staff will be on any halls by themselves until oriented a minimum of 8 hours. All residents have had an evaluation for hot liquids done, the list of residents that should not get hot liquids in their rooms or without 1:1 supervision will be kept in the kitchen and the Care Plans updated. Resident #7 will no longer receive hot liquids even with 1:1 due to pouring ice water on her head even while her daughter was sitting next to her. The Alert Note dated 1/9/24 at 10:39 AM documented, Skin Note: Blister to left thigh is scabbed as this is where she has peeled the skin off of. Area is 6 cm across by 4.5 cm. Area was cleansed and new dressing applied no signs/symptoms (S/S) of pain with this. Left abdomen has one boomerang shaped area measures 6 cm by 5 cm and 5 cm by 3 cm with epithelial tissue present as she did not peel skin off of this, no S/S of infection. Smaller 2 cm by 1 cm area to inner left abdomen. No S/S of infection to any areas. No complaints of (C/O) pain with cleansing or treatment change. On 1/10/24 at 1:14 PM, Staff F, Registered Nurse (RN) explained eating assistance required for Resident #7 depended on the day, and some days the resident was fine and able to do herself. Staff F explained the resident often refused help. Per Staff F, they offered more than one person to assist, the resident ate in the dining room, and ate in her room if her daughters at the facility. Staff F explained she did not let the resident stay in her room because Staff F liked to watch her. The Nurses Note dated 1/10/24 at 2:25 PM documented, Resident remains on Hospice [Company Name Redacted] cares. No noted behaviors this shift. See Nursing Note about eating. Blisters are open and draining. Blister on thigh is red with slough. On 1/10/24 at 3:15 PM, interview with Staff D, CNA revealed the following: Per Staff D, Resident #7 usually ate on her own really, did not use utensils, and used her fingers. Staff D explained if the resident ate in her room someone always supposed to be in to help and the resident no longer got coffee unless someone assisted. Staff D explained need to cue the resident if the resident falling asleep, and further explained the resident ate with her fingers pretty good. Per Staff D, if Resident #7 was too weak sometimes, then the resident did not want to get up. Per Staff D if the resident did not have energy, they would go in and feed Resident #7. Staff D explained for the most part the resident did really good. The Nurses Note dated 1/10/24 at 8:49 PM documented, no noted behaviors, blisters on wound on thigh is red around the boarder with white slough on the center of the wounds. Wound on stomach is red around the board no noted slough. Ate supper with assistance from staff. On 1/11/24 at 8:45 AM, the ADON explained the Night Shift Nurse had been a staffing nurse, and the ADON received a call from the Night Shift Aide on behalf of Staff I, Licensed Practical Nurse (LPN), Staffing Nurse. The ADON explained they (ADON) filled out the incident report. Per the ADON, Staff G, staffing CNA worked with Resident #7 that night. The ADON explained she received a call from a facility CNA (3rd shift), Staff J, CNA. On 1/11/24 at 8:50 AM, observation revealed Resident #7 in their room in their recliner chair. Observation of wound care to the resident's thigh conducted with Staff H, Hospice Registered Nurse (RN). An area observed to the left thigh with yellow wound bed and redness around wound bed. Staff H explained the following about the area to the resident's left thigh: The last time Staff H saw the area, skin was covering, and now it was yellow with red around. Per Staff H, the area was much worse than when she last saw it. Per Staff H, the resident picked at the blister. Staff H explained she would call the doctor about an antibiotic cream. Staff H explained the area had to hurt, and acknowledged it came from coffee. Review of the Visit Note Report from dated 1/11/24 revealed the following wound description for Wound #1: The resident's left proximal thigh wound: The measurement section documented 6 cm by 4.5 cm by 0.2 cm, depth description noted full thick, with scant purulent drainage. The Narrative Section of the Visit Note Report documented, in part, Performed her wound dressing change on her thigh. It does appear infected, reached out to [Name Redacted] Nurse Practitioner (NP) for orders, awaiting her return call with new orders. Wounds on abdomen do not appear infected at this time. On 1/11/24 at 11:57 AM, interview conducted with Staff J, CNA, who explained the following about the incident: Staff J explained she worked nights, did not remember the incident date, and came in on nights at approximately 9:45 PM with another staff member (Staff K, CNA). Staff J explained the nurse for her shift was a Staffing Nurse, and explained on second shift a Staffing Nurse and Staffing Aide present when she came in. Per Staff J, the Staffing Aide (on the shift prior) had never worked at the building before, and had been in charge of South Hall where Resident #7 resided. Staff J explained the other two staff who worked with the Staffing Aide were facility staff. Staff J explained the Staffing Aide floated and helped. Staff J explained in getting report from the Staffing CNA, the Staffing CNA said she had never been in the facility before and was not able to tell Staff J much. Staff J explained when Staff J got to the facility a couple people were up in the dining room, and Staff K went ahead and started walking the halls. Staff J further explained Staff K said there were a lot of people up, and Staff J explained at that point it was easier to let the Staffing CNA go. Staff J and Staff K started a round, and offered to see if anybody wanted to go to bed. Staff J explained since the Staffing CNA had been on the South hall, they went ahead and started the round on South hall right after 10:00 PM. Staff J explained Resident #7 was the first person they addressed on the South hall. Per Staff J, she and Staff K went in and Resident #7 was still in the recliner, which Staff J explained had never happened as the resident was always in bed when she got to the facility. Staff J explained Resident #7's blanket was peeled back, underneath the resident wore blue snap pants, and there was a puddle around the resident's pants, dark, brown, and dried. Staff J explained it was like the second shift aides had not touched the resident since first shift put the resident in the recliner before they left. Per Staff J, the resident was so soaked her brief had seeped through. Staff J explained the resident's tray was on top of her on her lap. Per Staff J, the resident was known for that to pull things down on her. Staff J explained the resident was Care Planned to have a soda on the side of the bed and would pick it up and dump on herself. Per Staff J, the resident was not safe to have hot liquids in her room. When queried how this information was communicated prior to the incident, Staff J responded common sense, and if spilling soda pop on her, then wouldn't put coffee. Per Staff J, if Staffing (Agency) staff were not shown, then they did not know, and the facility had more Staffing (Agency Staff) in the facility than regular people. Staff J explained the resident had regular dishes, the tray itself was still on the nightstand, the only thing on the tray was the tray and plate, and everything else was in her lap (cups/bowl). Staff J explained maybe the brown ring in her lap could have been coffee, and she and the other staff member thought urine because the resident was soaked through the back. Per Staff J, she and Staff K took everything off the resident's lap and set it on the nightstand, used the Hoyer (mechanical lift) to get the resident to the bed, cleaned the resident up, took the resident's pants down, and realized the resident had started to blister on the left bottom part of the resident's abdomen and one spot on her top part of her thigh. Staff J explained it was all red all around and yellow/bubbly. Staff J explained when she and Staff K started rounding she told the Staffing Nurse to keep an eye on the hall as they were going to be busy for a while. Staff K explained the Staffing Nurse was down taking care of another resident, she waited for the nurse for a few minutes, the nurse looked at Resident #7, and said yeah it has to be a burn for sure. Staff J explained the resident was given a bed bath, cleaned up, the nurse came in and did measurements, and hourly checks were done after that. On 1/11/24 at 3:27 PM interview conducted with Staff I, Licensed Practical Nurse (LPN), who explained they worked the day after the incident, came in at 10 PM (on 1/2/24) to 6 AM (on 1/3/24). Per Staff I, she came in on her shift, received report, and was told there were blisters on the Resident #7's left leg and left side of her lower abdomen. Staff I explained she knew they were from a hot liquid. When queried about symptoms of pain for the resident, Staff I said yes, and explained just applying the dressing around the area the resident flinched and was very cautious. Staff I explained she could tell it was painful. Per Staff I, prior to the incident that resident had to have the special cups with sippy type device to hold onto it, and explained the resident did sit at the assisted table on a regular basis. Staff I explained sometimes the resident wanted your help and also very independent wanted to do herself. Staff I explained assistance was more supervisory. The Physician Order for Resident #7 dated 1/12/24 documented, Cefadroxil Oral Suspension Reconstituted 250 MG/5 ML (milligram/milliliter) with instruction to give 5 ml by mouth every 12 hours for infection for 7 Days. On 1/16/23 at 912 AM, Staff F, Registered Nurse (RN) explained Resident #7 started on antibiotic for the thigh area, as worried about infection as the resident liked to pick at it. On 1/16/24 at 1:28 PM, Staff N, LPN acknowledged she did work 1/1/24 (date of incident). Staff N explained she got to the facility at 8 PM to 6 AM, explained she had worked for the facility as a CNA, and came in at 8 PM for training. Staff N explained when the overnight staff came in at 10:00 PM or 10:30 PM, the aides came in and said it looked like spilt food all over the resident. Staff N explained getting the resident laid down, and had blisters to the lower left abdomen and left upper thigh. Per Staff N, a cool washcloth applied, and she call the ADON to let her know. Staff N further explained Resident #7 sat in the recliner, and staff called her in to see food spilt all over. Per Staff N, the blisters were noticed once got the resident into the bed. Staff N was unable to recall the names of the aides. When queried if the resident spoke, Staff N explained the resident did not really talk to her. Staff N explained she asked the resident if in pain, and the resident shook her head no. On 1/16/24 at 1:33 PM when queried if she worked the night of the incident, Staff O, Medication Aide/CNA explained she thought so, and later clarified she did. Per Staff O, she did not normally go down that hall (where Resident #7 resided) and did meds on two other halls. Staff O explained she knew there was a Staffing CNA that night who had passed the trays on the hall where Resident #7 resided. Per Staff O, she saw the CNA take the cart, and didn't see the staff member actually pass the trays. Staff O explained she knew the resident had been getting room trays or eating down with family in her room and before the incident she was not aware of the resident spilling drinks on herself. On 1/16/24 at 2:48 PM, Staff P, CNA explained she worked 4 PM to 8 PM on the date of incident (1/1/24). Per Staff P, an agency staff was working the hallway and it was the agency staff's first time at the facility. Staff P explained the agency staff passed trays, and had Resident #7 and another resident eating in their rooms. Per Staff P, after dinner she had seen the staff member coming towards the kitchen with a tray, which made Staff P think of Resident #7 as the resident did not always eat in her room and if Resident #7 was not hungry she would not eat it. Staff P explained it made Staff P ask the Agency Staff, and the Agency Staff reported Resident #7 ate everything. Staff P explained she was very busy before 8:00 PM, had four residents up, and passed on that she had not helped the Agency Staff member with Resident #7 or another resident yet, and explained those residents required assistance of Hoyer transfer. Staff P explained she did not come back down to check herself, and took the Agency Staff member's word for it when the staff said the resident ate everything. When queried if Resident #7 could eat in their room by themselves prior to the incident, Staff P responded yes, and further explained sometimes with medication the resident got sleepy, and when she ate in her room Staff P would wake her up and let her know food was there. Per Staff P, prior to the incident, the resident drank a lot of coffee, at least for dinner, and for the most part ate in the dining room. On 1/22/24 at 12:53 PM, when queried if the facility had a way to assess residents for hot liquids prior to the incident, the Interim Director of Nursing (DON) explained not that she was aware of. When queried if the resident was known to dump fluids on herself prior to the incident, the Interim DON responded no, and as long as the Interim DON had been at the facility the resident would drink cans of soda in her room, and would not dump that on herself. When queried where the resident ate, the Interim DON explained since she started at the facility the resident almost always ate in the dining room. Per the Interim DON the resident used to feed herself, and over the last six months the resident slowly started to not want to eat, and the resident needed cueing. Per the Interim DON, sometimes the resident would let you scoop food on her spoon for her, and wanted you to leave it. When queried how often CNA's and nurses rounded on the resident, the Interim DON explained normally the resident should be ok for every 2 hours. Per the Interim DON, they had not seen the resident drink hot liquids, and usually at night the resident drank water or soda, and when she would work days saw her drink orange juice or water in the morning. On 1/22/24 at 4:25 PM, the Interim DON provided an undated form titled Hot Liquids Safety Evaluation, and explained to be included with the plan of correction. The form documented, Directions to be completed at time of admission, readmission or change in condition: (1) Evaluate for the presence of risk factors for spills and burns from hot liquids. (2) Place a check mark for each risk factor in space provided for that evaluation date. (3) Initial and sign the evaluation. (4) Review evaluation during care team meeting to determine appropriate interventions to prevent spills and burns. (5) Record date intervention was initiated, notes and date it was discontinued (if applicable).

Based on Facility Reported Incident (FRI) review, observations, staff interviews, and facility policy review, the facility failed to protect the residents' right to be free from mental abuse and verbal abuse by a staff member for three of six residents reviewed for abuse (Resident #30, #84, and #134), resulting in a resident report of the employee being mean to them, resident display of negative reactions including being irate and displaying increased behaviors around the employee, and staff report of the employee taunting a resident. The facility reported a census of 30 residents. Findings Include: Review of a Self-Report Reporting Information for an Incident which occurred 10/9/23 at 10:00 AM, documented the following per the Incident Summary: A staff member wrote a statement stating Staff B, Certified Nursing Assistant (CNA) on 2nd sift talks badly to the residents. She stated that residents have told her to get out of their room. The statement reports Resident #4 was told she could take herself to the bathroom and she is not helpless. Resident #4 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Staff B told Resident #30 she wasn't going to help her if she was going to keep acting crazy. Resident #30 has a BIMS of 6 out of 15 and is very confused. The statement reports that Resident # 13 was told he was lazy and could do more for himself. Resident #13 was then reported to say Staff B didn't like him at another facility and she still didn't like him now. Resident #13's BIMS is 14 out of 15. At this time, we do not know when any of these things were said. We assume it was in their rooms. Review of the Summary of Investigation of Incident section dated 10/11/23 documented, in part, the following: At this time [Facility Name Redacted] has completed its investigation of the allegation of verbal abuse/personal degradation. While the residents that have a BIMS of 10 or above, report there is no problem with Staff B, CNA, staff report Staff B has said things to our confused/dementia residents that could be considered shameful, degrading, and possibly causing humiliation or harm to their personal dignity. Review of a Situation, Background, Assessment, Request (SBAR) form to the Nurse Practitioner (NP) dated 10/13/23 documented, Allegation of verbal abuse was reported to us + (and) reported to State-CNA made faces + comments to some residents about you could do more for yourself, you are lazy, if you fall, then one less person I have to care for. The SBAR included four resident names, Resident #1, Resident #4, Resident #13, and Resident #30, with notation the first three residents denied anything and the fourth had dementia. Review of the clinical records for Resident #1, Resident #4, Resident #13, Resident #30, and Resident #134 revealed the following residents had intact cognition per their BIMS scores present on the Minimum Data Set (MDS) assessment, as indicated below: 1. The MDS assessment dated [DATE] revealed Resident #1 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 2. The MDS assessment dated [DATE] revealed Resident #4 scored 14 out of 15 on a BIMS exam, which indicated intact cognition. 3. The MDS assessment dated [DATE] revealed Resident #13 scored 14 out of 15 on a BIMS exam, which indicated intact cognition. The following residents had severely impaired cognition per their BIMS scores present on the MDS assessment, as indicated below: 4. The MDS assessment dated [DATE] revealed Resident #30 scored 6 out of 15 on a BIMS exam, which indicated severely impaired cognition. 5. The MDS assessment dated [DATE] revealed Resident #134 scored 3 out of 15 on a BIMS exam, which indicated severe cognitive impairment. On 1/17/24 at 2:24 PM, Resident #134 observed in their room in a recliner chair. Review of Medical Diagnoses for Resident #134 revealed a diagnosis of anxiety disorder. When queried, Resident #134 unable to state the name of where they currently were. Interview with staff at time of survey revealed Resident #84's described reaction to Staff B. Resident #84 was not included in FRI documentation. The BIMS information for Resident #84 included the following: 6. The MDS Assessment for Resident #84 dated 10/6/23 revealed the resident scored 00 out of 15 on a BIMS exam, which indicated severely impaired cognition. Review of medical diagnoses for Resident #84 revealed the resident had a diagnosis of dementia without behavioral disturbance. Review of a statement by Staff C, CNA, dated 10/9/23 at 10:45 AM, documented, I [Staff C] seen [First Name matching that of Staff B, CNA talk badly to the residents, she goes in their rooms with poor ethic she will refuse to help those she doesn't like, I've seen and heard residents say she's mean she's evil, I heard residents tell her to get out of their room. Staff B told Resident #4 she's not helpless she could take herself to bathroom. Staff B told Resident #30 she wasn't going to help her if she was going to keep acting crazy. Staff B would refuse to help Resident #1 more than once I would have to go answer Resident #1's call light cause she wouldn't [Staff B] and would talk bad to Resident #13 saying he was lazy and he could do more for himself I heard Resident #13 say to Staff B, you didn't like me at [another facility name redacted] and you still don't like me here. Review of a statement by Staff D, CNA, dated 10/11/23 documented, I, [Staff D], have witnessed Staff B verbally abusive + Taunt residents at [Facility Name]. It's mostly with residents with memory issues. Their demeanor changes when she enters the room + they start to have behaviors. Another CNA + I had to go into Resident #30's room to get her up because she would not for Staff B. Resident #30 said Staff B was hateful + mean to her + we calmed her. Staff D noticed Staff B peaking though the curtain taunting her with faces. I have heard the same resident who was experiencing pain say she was going to throw herself out of her chair + kill herself + Staff B told her to go ahead and do it then, less work for us, etc. Resident #134 said how mean Staff B is to her. Staff D had been in the room when Staff B said things back mocking their pain + confusion. Staff B walks into rooms with sour faces, a bad attitude, + is just mean to some residents. Especially the residents who react to her negative energy. Staff D cannot remember every word said but, Staff B should not take care of the elderly who have memory loss, who are confused or scared she mocks them, she is not supportive + she is mean to them. Review of a statement by Staff E, Registered Nurse (RN), documented, had noted Staff B making negative sarcastic comments to residents over the past week. Staff E had also overheard a couple residents making a comment along the lines of you just don't like me. Staff B had made negative statements about residents to me and within earshot of me that certain residents get on her nerves and she does not like caring for them. On Friday night 10/6/23, several CNA's were sitting discussing similar situations they have encountered with Staff B in the recent past 1-2 weeks. On 1/10/24 at 3:04 PM Staff D, CNA queried about her statement and Staff B. Staff D explained she really enjoyed working with Staff B, then started noticing Staff B was kind of talking with the residents with memory disabilities kind of mean. Per Staff D, she heard the employee had been turned in. Staff D explained she provided a statement about Staff B's treating a few of the residents, clarified as two residents, and Staff D explained she needed to go and take care of residents because they did not want Staff B near them. Staff D provided the first names of the two residents, Resident #30 and Resident #134. Staff D explained she looked back and Staff B was poking through the curtain mocking a resident (Resident #30), and didn't care for that, and Staff B's negative energy rubbed off on residents and something had to be said. Staff D explained she needed to go in and do cares because Resident #30 did not want Staff B, would not listen to her and be around her. Per Staff D, with Resident #134, right when the resident was having a really hard time and said something like, Oh, I'm just going to fall or something, Staff B said just go ahead. Per Staff D, she knew Staff B would never let someone actually fall, and didn't know if Staff B said it loud enough for resident to hear, but think the employee did so (loud enough to hear). When queried about reporting, Staff D explained she just wasn't sure, thought this was not Staff B, and explained she had worked with Staff B prior. Staff D explained when they were approached by a staff, Staff D realized it was an actual problem, and explained now when it happened they would not think the staff was just going through something rough and would notify right away. Staff D explained she was approached by the Director of Nursing (DON). Staff D explained this occurred with just people with memory problems and nobody who was actually alert. When queried about the residents' reaction, Staff D explained when Staff B was in the room they would get immediately irritated, and further explained it probably did not just happen when Staff D was at the facility, and probably happened often. On 1/11/24 at 12:11 PM, during an interview with Staff J, CNA, about concerns with staff treatment to residents, Staff J explained there was one lady who was let go. Staff J explained she wouldn't want her taking care of people. Staff J provided a first name of that matching Staff B, and last name starting with the same letter as Staff B's name. Per Staff J, she believed the employee was accused of abuse, and explained she believed it was valid. Per Staff J, the employee was very vulgar, straight to the point, very blunt, and was like children talking to her. Staff J explained she was the one that took report from the employee the night the allegation was made. Staff J explained there was a resident down [redacted] hall, Resident #21, who had a [Brand Name camera device with monitoring display screen] in their room. Per Staff J, the [Camera Device] can hear (described as like a baby monitor). Staff J explained if right outside the room giving report you could hear, and there was a resident across the hall from Resident #21, later identified by first name of Resident #30, who was louder, and Staff B said, quit that fake crying. Per Staff J, she heard it directly, Staff B left, and the nurse working with Staff J asked if Staff B was like that a lot. Staff J explained the other part of the camera was at the Nurse's Station so when giving report the staff member probably heard Staff B telling resident she was faking. Staff J explained Staff B was trying to finish report, Resident #30 was hollering and crying, and Staff B made the comment. When queried if she thought residents could hear the comment, Staff J responded they were all in bed. Per Staff J, she had worked with Staff B in the past and that seemed to be her normal. Per Staff J the above described happened, Staff J was off for a few days, Staff J came back, and heard the staff member had been reported. On 1/16/24 at 12:21 PM, a display screen with an image was observed at the Nursing Station. When queried whose device it was, Staff L, Restorative Aide explained for Resident #21. Observation of Resident #21's resident room revealed a camera device on the wall. On 1/16/24 at 12:45 PM, Staff M, Licensed Practical Nurse (LPN) explained she worked night shift, 10:00 PM to 6:00 AM. When queried about concerning statements by staff to resident, Staff M denied knowing of any. When queried if a resident had a camera device, Staff M explained Resident #21. When queried if the device had audio, Staff M responded yes, and it had the option to turn audio off. When queried if she ever heard anything concerning though the camera device, Staff M denied hearing anything. On 1/17/24 at 9:53 AM, interview conducted with Staff Q, CNA. When queried about staff to resident treatment concerns, Staff Q explained not for staff at the facility now. Per Staff Q there was one lady, matching first name of Staff B, that she worked with one day. Staff Q explained she did not like how Staff B spoke to residents, and Staff Q thought Staff B was too burnt out and got frustrated with the residents. Per Staff Q, Staff B wasn't yelling at residents, and Staff Q explained she did not say anything to anyone else, and didn't think it was a form of abuse. Per Staff Q, Staff B was very stern speaking, and described the employee as fed up and over it. Staff Q was not able to remember anything said to the residents. When queried if the facility had spoken to her about staff to resident concerns, Staff Q explained they had for a different situation (involving a different allegation type). When queried if directed towards certain residents or more widespread, Staff Q responded with everybody. Staff Q explained mainly what she remembered the residents met Staff B's energy and gave it right back. When queried how Staff B responded, Staff Q explained she knew Staff B argued with a couple of residents and they would argue right back with her. When queried as to specific residents, Staff Q responded she did not think at the facility any more. On 1/17/23 at 2:55 PM, when queried about treatment from staff to residents, Staff E, former employee, explained a staff would make offhand comments towards resident in the hall or their tone of voice was a little rough. Staff E explained she noticed the employee's tone of voice, and figured it was kind of her personality as the employee would be that way to other staff. Staff E explained they never heard anything she needed to report. Staff E explained when they heard discussion by CNAs, then it needed to be reported. Staff E explained it boiled down to one CNA. Staff E queried if this would be the same situation described in her statement, included with FRI documentation, and acknowledged yes. Per Staff E, the employee would not give a simple response when a resident would ask for something. Staff E further explained with a regular exchange for the resident, the employee would throw in something extra and put an edge on it. When queried about resident response, Staff E explained some of them seemed to not be really comfortable around her. Per Staff E, none of the residents refused to let the employee care for them that Staff E could recall. Staff E explained it was on a midnight shift when she overheard conversation from CNAs, and she felt like someone needed to report it as it was openly talked about in front of Staff E. Staff E further explained the discussion was around how a CNA from second shift spoke to residents when doing walking rounds per her recollection. Per Staff E, the discussion surrounded on how they did not think how the employee was talking was right. On 1/17/24 at 4:14 PM, during an interview with Staff R, CNA explained Staff B used to agitate the [h*ll] out of every single resident she would go into. Per Staff R, she would follow Staff B and would take report from Staff B, and multiple residents were agitated to high [NAME] and she needed to calm them down almost every day. Staff R explained there was one resident who was at the facility for four days, Resident #84, who would be irate, throwing things at Staff B. Per Staff R, Resident #84 had dementia, and she would assist in getting the resident settled down and then the resident was fine for the rest of the night. Staff R explained Staff B had a very short temper, very short attention span, and if did not do what she wanted, she was going to yell at them. Staff R further explained the following about Resident #30: Per Staff R, Resident #21 had a [brand name device like baby monitor], and the volume of the monitor would be kept up at night in case the resident started talking. Staff R explained the volume of the monitor was turned up when she got to the facility. Per Staff R, she turned it up and heard Staff B in the hallway mocking Resident #30 because Resident #30 used to have behaviors and scream. Staff R explained they heard Staff B yelling back at the resident in the hallway, heard through Resident #21's monitor. Staff R explained the following example: Resident #30 would yell she wanted out of there and wanted to go home, and Staff B in a mocking tone did it back, not to the resident's face, but in the hallway. Staff R explained she could hear it on Resident #21's monitor. When queried if she thought Resident #30 could hear Staff B, Staff R responded no as the resident was pretty hard of hearing, but she still didn't like it and was not appropriate. Staff R explained she knew Resident #4 had said the staff member was short with her, and Resident #4 said Staff B had a real short attention span, got short with her, and made her hurry. Per Staff R, it was irritating when the same few people were always upset. On 1/18/24 at 4:21 PM when queried about findings, the facility Administrator explained their intuition was that something was not right. The Administrator explained she thought Staff B thought she was joking, but it came off harsh. The Administrator explained she had not seen Staff B treat a resident wrong, and she could not remember which CNA told her of Staff B and the curtain peeking incident, and she did not know why Staff B did that. The Facility Policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 revealed, in part, all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation. 47336 During an interview on 1/18/24 at 3:05 PM, the ADON (Assistant Director of Nursing) queried on Staff B, CNA behavior towards staff and she stated she knew Staff B for a long time and from other facilities. She stated she didn't know about any allegations until the Administrator told her and she thought Staff B was stressed and joked with the residents. She stated she didn't know what was said but if Staff B was joking around she needed to know her audience before doing it.

Based on Facility Reported Incident (FRI) review, staff interviews, and facility policy review the facility failed to ensure allegations of mental abuse and verbal abuse from a staff member to residents was reported to the State Agency within required regulatory timeframe for five of six residents reviewed for abuse included as part of a Facility Reported Incident and/or included in staff statements as part of the FRI (Resident #1, #4, #13, #30, and #134). The facility reported a census of 30 residents. Findings Include: Review of a Self-Report Reporting Information for an Incident which occurred 10/9/23 at 10:00 AM, documented the following per the Incident Summary: A staff member wrote a statement stating Staff B, Certified Nursing Assistant (CNA) on 2nd sift talks badly to the residents. She stated that residents have told her to get out of their room. The statement reports Resident #4 was told she could take herself to the bathroom and she is not helpless. Resident #4 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Staff B told Resident #30 she wasn't going to help her if she was going to keep acting crazy. Resident #30 has a BIMS of 6 out of 15 and is very confused. The statement reports that Resident #13 was told he was lazy and could do more for himself. Resident #13 was then reported to say Staff B didn't like him at another facility and she still didn't like him now. Resident #13's BIMS is 14 out of 15. At this time, we do not know when any of these things were said. We assume it was in their rooms. Review of a statement by Staff E, Registered Nurse (RN), documented, had noted Staff B making negative sarcastic comments to residents over the past week. Staff E had also overheard a couple residents making a comment along the lines of you just don't like me. Staff B had made negative statements about residents to me and within earshot of me that certain residents get on her nerves and she does not like caring for them. On Friday night 10/6/23, several CNA's were sitting discussing similar situations they have encountered with Staff B in the recent past 1-2 weeks. Review of the Summary of Investigation of Incident section dated 10/11/23 documented, in part, the following: At this time [Facility Name Redacted] has completed its investigation of the allegation of verbal abuse/personal degradation. While the residents that have a BIMS of 10 or above, report there is no problem with Staff B, (CNA), staff report Staff B has said things to our confused/dementia residents that could be considered shameful, degrading, and possibly causing humiliation or harm to their personal dignity .Also, at this time staff is being educated starting today regarding the need to report verbal abuse immediately to the Director of Nursing (DON) and or the Administration instead of waiting a day or two to do so. When asking the staff members why they did not report sooner. They stated they were fairly new here and thought maybe it was just her way. It was not until they got together and started talking that they knew they needed to report this. On 1/17/23 at 2:55 PM, when queried about treatment from staff to residents, Staff E, Registered Nurse (RN), explained a staff would make offhand comments towards resident in the hall or their tone of voice was a little rough. Staff E explained she noticed the employee's tone of voice, and figured it was kind of her personality as the employee would be that way to other staff. Staff E explained they never heard anything they needed to report. Staff E explained when they heard discussion by CNAs, then it needed to be reported. Staff E explained it boiled down to one CNA. Staff E queried if this would be the same situation described in her statement as part of the facility reported incident, and acknowledged yes. Per Staff E, the employee would not give a simple response when a resident would ask for something, and with a regular exchange for the resident, the employee would throw in something extra and put an edge on it. When queried about resident response, Staff E explained some residents seemed to not be real comfortable around her. Per Staff E, none of the residents refused to let the employee care for them that Staff E could recall. Staff E further explained it was on a midnight shift when she overheard conversation from CNAs, and she felt like someone needed to report it as it was openly talked about in front of her. Per Staff E, the discussion was around how a CNA from second shift spoke to residents when doing walking rounds is what she remembered them talking about. Per Staff E, they were all discussing how they did not think how the employee was talking was right. On 1/18/24 at 4:16 PM when queried how the incident was reported to her, the Administrator explained an anonymous note was left on her desk. The Administrator acknowledged coordination with the DON to start asking questions, and that is when statements started coming in on 10/9 (2023). When queried who had left the note, the Administrator responded she heard it was a CNA and heard it was a nurse, she did not know. The Administrator responded it should have been reported to her and the State Agency. When queried about expectations for staff, the Administrator explained she would expect for them to call her as soon as saw something or heard something, explained she always told staff 2 hours she knew with injury, and minimum of 24 hours. When queried if this occurred in this instance, the Administrator responded, no, it did not. Per the Administrator, when she asked staff, the response was they were new, did not want to make any trouble, and wanted to talk about it. The Administrator further explained from what she understood, they had talked about it for more than one day. The Facility Policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 revealed the following per the Reporting section: All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of Resident Abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made.

Based on Facility Reported Incident (FRI) review, clinical record review, staff interviews, and facility policy review, the facility failed to conduct a thorough investigation following allegations of mistreatment, mental abuse, and verbal abuse from a staff member to residents for six of six residents reviewed for abuse, four of which were named in a Facility Reported Incident (FRI) (Resident #1, #4, #13, and #30), one additional resident referenced in a staff statement included in the FRI documentation (Resident #134), and for one additional resident identified by staff upon interview (Resident #84). The facility reported a census of 30 residents. Findings Include: Review of a Self-Report Reporting Information for an Incident which occurred 10/9/23 at 10:00 AM, documented the following per the Incident Summary: A staff member wrote a statement stating Staff B, Certified Nursing Assistant (CNA) on 2nd sift talks badly to the residents. She stated that residents have told her to get out of their room. The statement reports Resident #4 was told she could take herself to the bathroom and she is not helpless. Resident #4 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Staff B told Resident #30 she wasn't going to help her if she was going to keep acting crazy. Resident #30 has a BIMS of 6 out of 15 and is very confused. The statement reports that Resident # 13 was told he was lazy and could do more for himself. Resident #13 was then reported to say Staff B didn't like him at another facility and she still didn't like him now. Resident #13's BIMS is 14 out of 15. At this time, we do not know when any of these things were said. We assume it was in their rooms. Per the Resident Section of the Self-Report, the names of Resident #1, Resident #4, Resident #13, and Resident #30 were listed. The residents listed in this section of the report had the following Brief Interview for Mental Status (BIMS) scores: 1. Per the Minimum Data Set (MDS) dated [DATE], Resident #1 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. 2. Per the MDS dated [DATE], Resident #4 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. 3. Per the MDS dated [DATE], Resident #13 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. 4. Per the MDS dated [DATE], Resident #30 scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Review of a Situation, Background, Assessment, Request (SBAR) form to the Nurse Practitioner (NP) dated 10/13/23 documented, Allegation of verbal abuse was reported to us + (and) reported to State-CNA (Certified Nursing Assistant) made faces + comments to some residents about you could do more for yourself, you are lazy, if you fall one less person I have to care for. The SBAR included four resident names, Resident #4, Resident #1, Resident #13, and Resident #30, with notation the first three residents denied anything and the fourth had dementia. Review of a staff statement included as part of the FRI included information for Resident #134. Resident #134 was not included in the list of resident names included in the Resident Section of the Self-Report form. The BIMS for Resident #134 included the following: 5. Per the Minimum Data Set (MDS) dated [DATE], Resident #134 scored 3 out of fifteen on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Interview with staff at time of survey revealed Resident #84's described reaction to Staff B. Resident #84 was not included in the FRI, and was not referenced in witness statements by staff provided with the FRI. The BIMS information for Resident #84 included the following: 6. The MDS assessment for Resident #84 dated 10/6/23 revealed the resident scored 00 out of 15 on a BIMS exam, which indicated severely impaired cognition. Review of medical diagnoses for Resident #84 revealed the resident had a diagnosis of dementia without behavioral disturbance. Interviews conducted during the time of survey with Staff J, CNA, Staff Q, CNA, and Staff R, CNA revealed the following additional information including specific alleged incidents with residents, staff, and Staff B: On 1/11/24 at 12:11 PM during an interview with Staff J, CNA, about concerns with staff treatment to residents, Staff J explained there was one lady who was let go. Staff J explained she wouldn't want her taking care of people. Staff J provided a first name of that matching Staff B, and last name starting with the same letter as Staff B's name. Per Staff J, she believed the employee was accused of abuse, and explained she believed it was valid. Per Staff J, the employee was very vulgar, straight to the point, very blunt, and was like children talking to her. Staff J explained she was the one that took report from the employee the night the allegation was made. Staff J explained there was a resident down [redacted] hall, Resident #21, who had a [Brand Name camera device with monitoring display screen] in their room. Per Staff J, the [Camera Device] can hear (described as like a baby monitor). Staff J explained if right outside the room giving report you could hear, and there was a resident across the hall from Resident #21, later identified by first name of Resident #30, who was louder, and Staff B said, quit that fake crying. Per Staff J, she (Staff J) heard it directly, and when she came up, Staff B left, the nurse working with her asked if Staff B was like that a lot. Staff J explained the other part of the camera was at the Nurse's Station so when giving report the staff member probably heard Staff B telling resident she was faking. Staff J explained Staff B was trying to finish report, Resident #30 was hollering and crying, and Staff B made the comment. When queried if she thought residents could hear the comment, Staff J responded they were all in bed. Per Staff J, she had worked with Staff B in the past and that seemed to be Staff B's normal. Staff J explained that happened, then Staff J was off for a few days, came back, and heard the staff member had been reported. On 1/16/24 at 12:21 PM, a display screen with image was observed at the nursing station. When queried whose device it was, Staff L, Restorative Aide explained for Resident #21. Observation of Resident #21's resident room revealed a camera device on the wall. On 1/17/24 at 9:53 AM, interview conducted with Staff Q, CNA. When queried about staff to resident treatment concerns, Staff Q explained not for staff at the facility now. Staff Q explained there was one lady, matching first name of Staff B, that she worked with one day. Staff Q explained she did not like how Staff B spoke to residents, and Staff Q thought Staff B was too burnt out and got frustrated with the residents. Per Staff Q, Staff B wasn't yelling at residents, and Staff Q explained she did not say anything to anyone else and didn't think it was a form of abuse. Per Staff Q, Staff B was very stern speaking, and described the employee as fed up and over it. Staff Q was not able to remember anything said to the residents. When queried if the facility had spoken to her about staff to resident concerns, Staff Q explained they had for a different situation (different allegation type than this incident). When queried if the behavior was directed towards certain residents or more widespread, Staff Q responded with everybody. Staff Q explained mainly what she remembered the residents met Staff B's energy and gave it right back. When queried how Staff B responded, Staff Q explained she knew Staff B argued with a couple of residents and they would argue right back with her. When queried as to specific residents, Staff Q responded she did not think at the facility any more. On 1/17/24 at 4:14 PM during an interview with Staff R, CNA explained Staff B used to agitate the [h*ll] out of every single resident she would go into. Per Staff R, she would follow Staff B and would take report from Staff B, and multiple residents were agitated to high [NAME] and she needed to calm them down almost every day. Staff R explained there was one resident who was at the facility for four days, Resident #84, who would be irate, throwing things at Staff B. Per Staff R, Resident #84 had dementia, and she would assist in getting the resident settled down and the resident was fine for the resident of the night. Staff R explained Staff B had a very short temper, very short attention span, and if did not do what she wanted, she was going to yell at them. The Facility Reported Incident (FRI) did not include Resident #84. Staff R further explained there was a resident, Resident #30. Staff R explained Resident #21 had a [brand name device like a baby monitor], and the volume of the monitor would be kept up at night in case the resident started talking. Staff R explained the volume of the monitor was turned up when she got to the facility. Per Staff R, she turned the volume up and heard Staff B in the hallway mocking Resident #30 because Resident #30 used to have behaviors and scream. Staff R explained they heard Staff B yelling back at the resident in the hallway, heard through Resident #21's monitor and mocking. Staff R explained the following example: Resident #30 would yell she wanted out of there and wanted to go home, and Staff B in a mocking tone did it back, not to the resident's face, but in the hallway. Staff R explained she could hear it on Resident #21's monitor. When queried if she thought Resident #30 could hear Staff B, Staff R responded no as the resident was pretty hard of hearing, but she still didn't like it and was not appropriate. Staff R explained she knew Resident #4 had said the staff member was short with her, and Resident #4 said Staff B had a real short attention span, got short with her, and made her hurry. Staff R explained she always told the nurse of the situations which occurred, most of the time she let them know hey, this just happened and I got the resident calmed down. Staff R explained the specific phrasing she believed she used to communicate about Staff B. Per Staff R, it was irritating when the same few people were always upset, and she knew she told. Staff R explained she knew Staff M, Licensed Practical Nurse (LPN) had been present when she said something. Staff R explained she would report to a nurse. When queried if she was asked by the facility about the situation similar to current interview, Staff R said no. On interview, two staff referenced the monitor in Resident #21's room, one who reported what they heard on the monitor by Staff B, and another who alleged she was asked about Staff B by a nurse who heard via the monitor. The Facility Reported Incident did not reference Resident #21 or the monitor. On 1/18/24 at 4:16 PM when queried how the incident was reported to her, the Administrator explained an anonymous note was left on her desk. The Administrator acknowledged coordination with the Director of Nursing (DON) to start asking questions, and that is when statements started coming in on 10/9 (2023). When queried who had left the note, the Administrator responded she heard it was a CNA and heard it was a nurse, she did not know. On 1/18/24 at 4:27 PM, the Administrator explained residents with confusion would not be able to vocalize being treated wrongly unless there were outbursts, increased fighting back, or resisting cares, and explained she had not heard that anything had been extraordinarily off with the residents who had dementia. The Facility Policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 revealed the following: The Administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident.

Based on review of the Centers For Medicare & Medicaid Services (CMS)-2567 reports for the Surveys conducted at the facility, staff interviews, and facility Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current Recertification and Complaint Survey previously identified during Surveys completed in the last seventeen months. The facility reported a census of 30 residents. Findings Include: Review of the facility's CMS-2567 form from a Complaint Survey which occurred 8/8/22 to 8/12/22 revealed the facility received a no actual harm level citation for freedom of abuse, reporting of alleged violations of abuse, and investigating/preventing/and correcting alleged violation of abuse. The facility also received a no actual harm level for labeling and storing of medications. The facility's current Recertification Survey, entrance date 1/8/23, resulted in repeat citations for freedom from abuse, timely reporting for alleged abuse, investigating/preventing/and correcting alleged abuse, and proper storage of medications. During an interview on 1/22/24 at 3:55 PM, the Administrator queried on the expectation of not repeating the same citations and she stated she would meet with the Director of Nursing (DON) and the Department Heads and talk with their employees and see what their fears are with reporting and find out what we need to do to get reports done in a timely manner. The Administrator stated she would get more involved in the investigations and she stated the expectation for the medication carts was to keep them locked at all times and they would conduct audits on the carts staying locked as an example The Facility Quality Assurance and Performance Improvement (QAPI) Program reviewed on January 2023 revealed the following information: a. Develop, implement and maintain an effective, comprehensive, data-driven QAPI program for services provided at the facility, focusing on indicators of outcomes of care and quality of life. b. provide a working framework for excellence in quality monitoring processes, identification of opportunities for improvement, implementing action steps to correct and/or improve measures, evaluates outcomes and demonstrates sustained compliance/outcomes.

Based on personnel record review,Facility Assessment review, staff interviews, and facility policy review, the facility failed to conduct annual training on Quality Assurance and Performance Improvement (QAPI)) for all staff reviewed for QAPI training. The facility reported a census of 30 residents. Findings Include: The training competencies for 2023 reviewed for staff showed the training competencies lacked documentation for the facility staff completing QAPI training for the year of 2023. During an interview on 1/18/24 at 11:26 AM, the Administrator queried to supply the training competencies documentation for QAPI training and she reviewed her files and then stated they didn't schedule it. She then stated it should of been completed in December of last year. She stated her goal was to include everyone in QAPI and she spoke to all the new hires about QAPI when they were hired. During an interview on 1/22/24 at 4:10 PM, the Administrator stated she looked and found the last QAPI training conducted in the fall of 2022. The Facility Assessment Tool for 2024 revealed the following information for Staff Training/Education and Competencies: a. Describe the staff training/education and competencies necessary to provide the level and types of support and care needed for your resident population. 1. QAPI fundamentals, and the needed team involvement using Performance Improvement teams. 2024 goal would be open meeting to more staff and residents The Facility Quality Assurance and Performance Improvement Program (QAPI) Policy last reviewed on 1/23/23 documented the following information: a. Identified and scheduled mandatory education and/or skills training needed included elements and goals of the facility's QAPI program. b. Establish a staff competencies and annual education/competency calendar.

Based on clinical record review, staff interviews and facility policy review, the facility failed to notify the Physician after the resident expressed thoughts of self harm for 1 of 1 residents reviewed for change of condition (Resident #21). The facility reported a census of 30 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS documented the resident had medical diagnoses including Non-Alzheimer's dementia, and depression. The MDS revealed the resident took antipsychotic, antidepressant, and antianxiety medications. The Care Plan documented a Focus Area dated 3/1/23 for a mood problem related to cognitive decline, and inability to safely return to her home. The interventions dated 3/1/23 directed the staff as follows: a. Assist the resident, family, and caregivers to identify strengths and positive coping skills and reinforce them. b. Monitor/record/report mood patterns with signs and symptoms of depression, anxiety, sad mood as needed to the Medical Doctor (MD) as per the facility behavior monitoring protocols. The Electronic Medical Record (EMR) revealed the following diagnoses: a. Major depressive disorder, single episode, unspecified. b. Unspecified depression. c. Unspecified dementia, unspecified severity, with other behavioral disturbance. The Physician Orders revealed the following orders: a. Ordered on 10/10/23 and discontinued on 10/17/23- Clonazepam oral tablet disintegrating 0.25 milligram (mg) - give 1 tablet by mouth one time a day every other day for anxiety for 7 days. b. Ordered on 8/21/23 and discontinued on 12/21/23- Sertraline HCl (hydrochloride) oral tablet 25 mg- give 1 tablet by mouth one time a day. c. Ordered on 2/17/23 and discontinued on 11/13/23 Risperidone oral tablet 0.25 mg- give 0.5 mg by mouth one time a day. The Progress Note dated 8/23/23 at 8:55 PM, revealed after resident in bed staff heard her crying. Certified Nurse Assistant (CNA) stated when she talked with the resident, the resident stated, I just want my children here and for us all to die together so I can be with them. 1:1 placed with resident and resident calmed down and checked by nurse and resident asleep. The facility lacked documentation the family or the doctor notified of the residents thoughts/behaviors. The Progress Note dated 10/14/23 at 3:16 PM, revealed the resident stated to another resident that if I had a gun, I'd shoot myself. This nurse went and talked with resident. The resident stated that she really didn't want to kill herself, she just felt useless. Resident kept requesting to go to see her mother, who was ill. This nurse put 1 on 1 supervision with the resident, then went and got the basket of clothing protectors and asked for resident's help folding them. This nurse called family to let them know and see if one of them could visit with the resident. Resident folded the clothing protectors in the basket and then smiled at this nurse and stated that made her, feel happier. Another resident joined her in folding some of the clothing protectors. This nurse went back to laundry and pulled a load out of the dryer and gave them to both residents. Both sat there and folded them chatting with each other. The facility lacked documentation of notification to the doctor of the residents thoughts of harm. During an interview on 1/17/24 at 11:26 AM, Staff F, Registered Nurse (RN) queried on the situation when the resident made comments about wanting to shoot herself and Staff F stated she believed they spoke to the Physician. Staff F asked if the Physician notified, would it be documented and she stated yes. During an interview on 1/17/23 at 3:46 PM, Staff T, RN queried what she done when residents expressed thoughts of harm and she stated she asked a few more questions such as did they have a plan and why did they think that way and then she would talk to the Assistant Director of Nursing (ADON) and let the Physician know. During an interview on 1/18/24 at 1:15 PM, the ADON queried on Resident #21's behaviors and she stated she knew about a time when the resident said something about a gun and she stated they called the family. The ADON asked if the Physician needed notified and she stated yes they should. The ADON queried about another time the resident spoke of wanting her family with her so they could all die together and the ADON confirmed the Physician should of been notified. During an interview on 1/22/24 at 12:44 PM, the Interim Director of Nursing (DON) queried on her expectations when a resident made comments of self harm and she stated it would depend on the resident and if they were capable of following through and look at the situation and she would look at urinary symptoms, look to see if resident started new medication or had family visits and let the doctor know of the situation. The Facility Resident Change of Condition Physician Notifications Policy dated 1/22/18 revealed the following information: a. The attending Physician or Physician On-Call notified with changes in a resident's condition or health status. 1. Significant change in mental or psychosocial status. 2. Other conditions as deemed necessary. b. Document time of call, Physician or Nurse Practitioner or other person spoke to, reason for call and results or orders received.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to update a Care Plan when a resident started a diuretic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #19). The facility reported a census of 30 residents. Findings Include: The MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #19 scored a 5 of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed the resident received a diuretic. The Care Plan lacked documentation for a Focus Area and interventions for Resident #19's diuretic medication. The Electronic Medical Record (EMR) revealed the following medical diagnoses: a. Heart failure, unspecified. b. Unspecified systolic (congestive) heart failure. c. Chronic kidney disease, Stage 3 unspecified. d. Hypertensive chronic kidney disease with Stage 1 through Stage 4 chronic kidney disease, or unspecified chronic kidney disease. The Physician Orders documented the following medication orders: a. Ordered 11/10/23- Bumetanide oral tablet 1 milligram (mg)- Give 1.5 mg by mouth one time a day. During an observation on 1/8/24 at 1:44 PM, Resident #19 sat in her Geri chair in high semi-Fowlers position and the Certified Nurse Aide (CNA) escorted her from the dining room. Alarm in place on the arm of her Geri chair. During an interview on 1/18/24 at 1:28 PM, the Assistant Director of Nursing (ADON) stated they all worked on the Care Plans. The ADON queried if Resident #30 on a diuretic, and if the diuretic needed documented on the Care Plan and she stated the facility usually didn't put diuretics on the Care Plan. She stated they Care Planned blood thinners, antipsychotics, and antidepressants. During an interview on 1/22/24 at 12:35 PM, the Interim Director of Nursing (DON) queried on the expectation of a diuretic addressed on the Care Plan and she stated she didn't think they Care Planned the diuretic. She stated they Care Planned antipsychotics, anticoagulants, and antianxiety medications but didn't think they Care Planned the diuretics. The undated Facility MDS/Care Plan Review Policy didn't address the need for medications to be addressed on the Care Plan. The undated Facility MDS/Care Plan Review Policy revealed the focus areas, goals, or interventions on the Care Plan were good to review for assistance with what to document on.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to recheck a blood pressure, notify the doctor, and document a follow up Progress Note after a elevated blood pressure reading of 190/88 with a stomachache and back pain for 1 of 2 residents reviewed for closed records (Resident #30). The facility reported a census of 30 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed diagnoses of hypertension and non-Alzheimer's dementia. The Electronic Medical Record (EMR) revealed a diagnosis of hypertension. The Physician Orders documented the following medication: a. Ordered 10/31/23- metoprolol tartrate oral tablet 25 milligrams (mg) - give 1 tablet by mouth two times a day The Skilled Evaluation Progress Note dated 11/26/23 at 8:07 PM, revealed the following vitals: a. Temperature 97.7. b. Blood Pressure (BP) 123/64. c. Pulse 74 beats per minute (bpm). d. Respirations 16 breaths per minute. e. Pulse Oximetry (O2) 96%. The Progress Note dated 11/26/23 at 9:09 PM, documented Resident #30 complained of stomachache and back pain. As needed (PRN) Tylenol administered and gave warm blankets wrapped around stomach and back. Temperature 97.4, pulse 74 bpm and regular, respirations 20 breaths per minute, BP 190/88 laying position, left arm. While resident laid down stated I'm going to be sick and gagged with only spit coming out. Also passed a large amount of gas at that same time. The resident got up into recliner so that she sat in upright position if she vomited. After a few minutes she stated she wanted to get into bed again. Encouraged her to sit up but replied I'm not that sick. Assisted back to bed into comfortable position on her side, with wastebasket at bedside and fresh warm blanket. The facility lacked documentation for a recheck of the elevated blood pressure, notification to the doctor of blood pressure and symptoms, and a follow up Progress Note for resident's symptoms or if the Tylenol effective for pain relief. During an interview on 1/17/24 at 11:23 AM, Staff F, Registered Nurse (RN) queried what she'd do when a resident had a high blood pressure reading and she stated she waited a little bit and then rechecked the blood pressure and if the reading still showed the blood pressure elevated she contacted the provider. She stated she'd let the oncoming nurse know of the elevated blood pressure. Staff F confirmed when she took a blood pressure reading, she documented the reading in the chart. She stated the system now had alerts to inform the nurses if they needed to chart on a resident and the interventions that completed. During an interview on 1/17/24 at 3:46 PM, Staff T, RN queried if she remembered the last time she cared for Resident #30 and she stated yes. She stated Resident #30 had a stomach ache and had a huge bowel movement and went to sleep and then she checked on her throughout the shift. Staff T asked about the elevated blood pressure she documented and she stated she didn't remember the blood pressure and if the resident had an elevated blood pressure reading she rechecked it manually. Staff T stated sometimes Resident #30 hard to get vitals assessed. Staff T stated she normally documented when she rechecked the blood pressure. She stated if the blood pressure elevated she would probably call the on-call. Staff T stated she might of called the on-call but didn't know and it would be documented. During an interview on 1/18/24 at 1:38 PM, the Assistant Director of Nursing (ADON) queried on Resident #30 elevated blood pressure and she stated she would have called the family and rechecked the blood pressure. During an interview on 1/22/24 at 12:39 PM, the Interim Director of Nursing (DON) queried on Resident #30's elevated blood pressure and the expectation of nurses evaluating elevated blood pressure and the DON explained the nurse should re-take the blood pressure and document another Progress Note and if the blood pressure continued to be high notify the Physician. She stated if a wrist blood pressure cuff used, the nurse would recheck the blood pressure manually. She stated she took care of the resident that evening and the resident commented about a stomach ache and then had a bowel movement and the Interim DON stated she checked on her during and at the end of her shift. The undated Facility Resident Vital Parameters Policy revealed the following information: a. Upon admission admitting nurse requested parameters for vital sings. b. Nurse put parameters into weights and vitals tab on EMR. c. When vitals taken, they needed documented in weights and vitals tab which prompted the nurse of vital signs out of parameter. d. Nurse needed to recheck vital signs that were out of parameters and notify the Physician. e. Documentation of the time of the call, what Physician the nurse spoke with, and what vitals were out of parameter and any new orders received. The Facility Resident Change of Condition Physician Notifications Policy dated 1/22/18 revealed the following information: a. The attending Physician or Physician On-Call notified with changes in a resident's condition or health status: 1. Change in vital signs. 2. Pain (new or unmanaged). b. Document time of call, Physician or Nurse Practitioner or other person spoken to, reason for call and results or orders received.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure a medication cart remained locked when staff not present for one of two medication carts. The facility reported a census of 30 residents. Findings Include: On 1/8/24 at 10:45 AM, observation of a medication cart present outside of room [ROOM NUMBER] of the facility revealed the cart unlocked, drawer of cart able to be opened without a key, and medication cards inside the cart. Staff were not observed to be present with the medication cart at time of observation. On 1/8/24 at 11:14 AM, observation of a medication cart in the same location of the facility revealed although the main lock for the medication cart depressed, the second drawer on the right side of the cart unlocked with the drawer slightly opened. Medication card visible inside of the drawer. On 1/8/24 at 11:18 AM, when queried if the drawer was the narcotic drawer, Staff A, Licensed Practical Nurse (LPN) confirmed. Staff A questioned how the main lock of the cart locked while the drawer was unlocked. On 1/22/24 at 12:50 PM when queried when medication carts should be locked, the Interim Director of Nursing (DON) responded any time the Nursing Staff are not standing there taking something out. The Interim DON also explained the Pharmacy was contacted who provided the carts, and it was explained the main lock could be locked with the narcotic drawer unlocked. The Facility Policy titled Storage of Medication revised 4/07 documented at point #7: a. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on clinical record review and staff interviews, the facility failed to ensure a residents medical needs were provided in accordance with professional standards of care for 1 of 4 residents reviewed. (Resident #5) The facility reported census is 34. Findings include: According to a Minimum Data Set (MDS) with a reference date of 8/3/22, Resident #5 had a Brief Mental Status (BIMS) score of 10 which indicated a moderately impaired cognitive status. Resident #5 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #5's diagnosis included congestive heart failure, coronary artery disease and seizure disorder. The Admission Record documented that Resident#5 had diagnoses including kidney stones, and cancerous tumor of the prostate. The Admission Record revealed that the resident had been admitted from a hospital on 7/28/23. A Progress Note dated 8/19/23 at 3:07 p.m. documented that the resident had amber colored urine, and the resident refused a lot of his meals. In an interview on 5/4/23 at 1:00 p.m. Assistant Director of Nursing (ADON), stated when residents have an appointment outside of the facility, they coordinate with family to ensure transportation for the resident. The ADON stated if family is not able to transport the resident, they would contact their transportation provider, which is wheelchair accessible. The ADON was questioned regarding progress notes she wrote on 8/26/22 at 8:59 p.m. in which she indicated Resident #5's condition was worsening, 8/27/22 at 9:58 p.m. in which Resident #5 continued to decline and on 8/28/22 at 12:06 a.m. Resident #5 had a blood pressure of 104/52 and a temperature of 96.5 and whether the physician was notified of Resident #5's decline. The ADON stated the physician and nurse practitioner were both aware. (no indication in the progress notes of an assessment or physician notification) In an interview on 5/4/23 at 1:07 p.m. Staff E, MDS coordinator, stated when residents need transportation to get to appointments, she or other nurses will help facilitate the transportation. Staff E stated they only have one provider which is wheelchair accessible. Staff E questioned regarding a progress note dated 8/11/22 at 2:31 p.m. in which Resident #5 had a pre-op appointment in Iowa City on 8/12/22 and planned stent removal on 8/16/22. Staff E stated Resident #5 was unable to sit or stand for long periods of time and their transportation provider would not be suitable for a long trip. The progress note indicated Staff E contacted the urology department and they were to call back in the morning. Staff E stated there was no follow up the next day and Resident #5 missed his pre-op appointment. A progress note dated 8/16/22 at 3:34 p.m. indicated Staff E spoke with the urology department at a closer facility about removing Resident #5's stent there. Staff E stated she was planning on making arrangements but Resident #5's family was talking about leaving against medical advice (AMA). Resident #5 did not leave. Staff E indicated she did not follow up with making arrangements including transportation to have Resident #5's stent removed. Staff E reviewed the progress note dated 8/26/22 at 1:16 p.m. Staff E stated on that date she had made an appointment to have the Resident #5's stent removed on 9/8/22 and the spouse was to contact Care Transport to transport Resident #5 by stretcher to the hospital. Staff E stated on 8/30/22 the spouse called and stated she was not able to get transportation set up. The spouse reportedly contacted the urology department who instructed her to have the resident sent by ambulance to the hospital. Resident #5 was sent by ambulance to the hospital. In an interview on 5/4/23 at 1:15 p.m. Staff H, Registered Nurse, was questioned about a progress note dated 8/25/22 at 1:16 p.m. in which Resident #5's spouse indicated Resident #5's hematuria was not normal for him. Staff H wrote she educated the spouse about hematuria and it being normal with stents. Staff H was asked if she saw the hematuria the spouse was referring to. Staff H stated she had. There was no note describing the observation or assessment of the resident's reported abnormal hematuria. Staff H was questioned about a progress note dated 8/31/22 at 6:44 a.m. Staff H stated that morning she had spoken to the Intensive Care Unit (ICU) nurse. The nurse stated Resident #5 was admitted related to sepsis and that the issues could have been avoided had the facility followed up with his urology appointments regarding his stents. Staff H stated it was the families responsibility to coordinate appointments and transportation. The ICU nurse stated Resident #5 had a catheter put in, blood pressure medications to address his hypotension, intravenous fluids and antibiotics.

Based on staff interviews and document and policy review, the facility failed to update its facility-wide assessment annually as required to determine resources necessary to competently care for residents. The failure had the potential to affect the 31 residents residing in the facility. Findings include: A review of a Policy and Procedure Subject: Facility Assessment, dated 09/01/2019, revealed, The facility assessment is completed at the facility level by the Administrator and Leadership Team with input from the Medical Director annually and as as [sic] necessary when plans include a change that would require substantial modification to any part of the assessment. During the entrance conference on 08/08/2022 at 9:43 AM, the Administrator was asked to provide a copy of the latest facility assessment. The assessment was provided to survey staff that day. A review of the facility's Assessment Tool showed the facility assessment was last updated starting on 01/15/2021 and reviewed with the Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAA/QAPI) committee on 02/17/2021. During an interview on 08/10/2022 at 8:13 AM, the Administrator stated the copy of the facility assessment provided was the most updated document. During an interview on 08/12/2022 at 8:32 AM, the Administrator stated the facility began updating the facility assessment in February of 2022, noting the update started just prior to an outbreak of COVID-19 and, due to the outbreak, finishing the update was put off and was not completed.

Based on interviews and record review, the facility failed to ensure advance directives were completed and signed by appropriate persons for five (Residents #13, #78, #11, #10, and #6) of 17 residents reviewed for advance directives. The facility identified a census of 31 current residents. Findings include: An interview with the Administrator on [DATE] at 8:13 AM revealed the facility did not have a policy for advance directives. 1. Review of an Admission Record revealed Resident #13 had a code status of Do Not Resuscitate [DNR]. Review of a quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of a care plan, dated as revised [DATE], revealed the resident requested no cardiopulmonary resuscitation (CPR) to be initiated and to allow a natural death. Review of a No Code Authorization form revealed Resident #13 requested no heroic measures or life-saving treatment, including CPR, be used in the event of a medical emergency. Resident #13 signed the form on [DATE], and the physician signed the form on [DATE]. Review of an Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a sticky note dated [DATE] on the chart, with a message to get the physician to sign the form. According to the instructions on the IPOST form, the form must be signed to be valid. During an interview on [DATE] at 8:34 AM, Resident #13 stated that upon admission, he/she told staff let me go when the time came. During an interview on [DATE] at 11:33 AM, the Nurse Practitioner stated if a Physician, Physician's Assistant, or Nurse Practitioner did not sign the IPOST form, it was not a valid order. 2. Review of an Admission Record for Resident #78 revealed the Advanced Directive portion of the form was blank. Review of a discharge MDS, dated [DATE], revealed Resident #78 had a BIMS score of 12, indicating the resident had moderately impaired cognition. Review of a care plan, dated as revised [DATE], revealed Resident #78/legal representative chose no CPR and to allow a natural death if the resident had no pulse or respirations. Review of a No Code Authorization form revealed Resident #78's family member signed the form on [DATE] requesting that no heroic measures or life-saving treatment, including CPR, be used in the event of a medical emergency. However, the space designated for the attending physician's signature was blank and the attending physician had not signed the form. 3. Review of an Admission Record revealed Resident #11's code status was DNR. Review of Resident #11's annual MDS assessment, dated [DATE], revealed the resident had a BIMS score of 6, indicating severely impaired cognition. Review of a care plan, dated as revised [DATE], revealed Resident #11/legal representative chose to have no cardiopulmonary (CPR) resuscitation and to allow natural death if there was no pulse or respirations. Review of a No Code Authorization form signed by the resident on [DATE] and by the physician on [DATE] revealed no heroic measures and life-saving treatment, including CPR, were to be provided in the event of a medical emergency. Review of the resident's IPOST form, signed and dated by a provider on [DATE], revealed staff should not attempt to resuscitate the resident. The form revealed medical decision-making was directed by the Durable Power of Attorney for Health Care. In the space for Patient/Resident/Legal Surrogate for Health Care Signature as identified above (mandatory), the name of a person was listed with a notation which indicated per phone, dated [DATE]. There was no documented signature from the Durable Power of Attorney and no signature by a person who witnessed the phone request. During an interview on [DATE] at 3:24 PM, the Administrator stated if verbal consent was obtained over the phone, a signature should be obtained immediately. 4. Review of an Admission Record revealed the facility admitted Resident #10 on [DATE]. The resident's code status, per the record, was full code (meaning CPR was to be performed if the resident had no pulse or respirations). Review of a significant change MDS assessment, dated [DATE], revealed Resident #10 had moderately impaired cognitive skills for daily decision making per a staff assessment of mental status. Review of a care plan, dated [DATE], revealed Resident #10's code status was no code per the resident's choice, or the choice of the resident's legal representative. Interventions included that if no pulse/no respirations were present, staff were not to initiate CPR and were to allow a natural death. Review of an Order Summary Report revealed Resident #10 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's IPOST revealed their Durable Power of Attorney for Health Care signed the form on [DATE], requesting DNR status. The form was not signed by a Physician, Advanced Registered Nurse Practitioner, or Physician Assistant. According to the form, the IPOST must be signed by a Physician, Advanced Registered Nurse Practitioner, or Physician Assistant to be valid. 5. Review of an Admission Record revealed Resident #6's code status was full code (cardiopulmonary resuscitation was to be performed if the resident had no pulse or respirations). Review of an annual MDS assessment, dated [DATE], revealed Resident #6 had a BIMS score of 15, indicating the resident was cognitively intact. Review of a care plan, dated as revised [DATE], revealed Resident #6's code status was to be no code per the resident's choice or the choice of his/her legal representative. Interventions included that if the resident had no pulse/respirations, staff were not to initiate CPR and were to allow a natural death. Review of an Order Summary Report revealed Resident #6 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a No Code Authorization form signed by Resident #6's responsible party on [DATE] revealed the form was not signed or dated by the attending physician. During an interview on [DATE] at 2:14 PM, Certified Medication Aide (CMA)/Certified Nurse Aide (CNA) Staff E stated he knew what a resident's code status was by looking at their care plan. Staff E stated he did not have anything to do with getting an IPOST signed by the physician. During an interview on [DATE] at 2:20 PM, Registered Nurse (RN) Staff F, stated she knew the code status of a resident by looking at the front of their chart. She stated it was also coded on the resident's door frame. She stated a flower on the door frame indicated the resident was a full code, and a butterfly indicated the resident was a DNR. Staff F stated the Business Office Manager (BOM) completed the IPOST forms with the residents when the admission paperwork was completed. The Assistant Director of Nursing (ADON) or the MDS nurse then faxed the form to the physician for signature. According to Staff F, the IPOST form should be signed within a week. After reviewing Resident #6's IPOST form, Staff F stated it was incomplete because it did not have the physician's signature. She stated if Resident #6 were to code (stop breathing/have no pulse) that day, staff would have to provide CPR because the DNR order had not been signed by the physician. During an interview on [DATE] at 6:03 PM, Business Office Manager (BOM) Staff B stated a resident or his/her responsible party signed for the resident to be DNR status or full code status upon admission. She then faxed the form to the physician for a signature and put the form on the front of the resident's chart while awaiting a signature. She stated once the nurse received the signed copy, the nurse replaced the faxed copy with the signed copy on the chart. The BOM stated the facility used the code status provided by the hospital until the code status documentation was completed. Staff B stated the person in charge of IPOST forms retired last year, and since that time, all staff had been attempting to get the forms completed. During an interview on [DATE] at 2:37 PM, the Assistant Director of Nursing (ADON) stated staff could look in the computer system to find a resident's code status, and there was also a posting at the nurse's station of all residents who required a full code. She stated she was not sure who was responsible for ensuring IPOST forms were completed. She stated the form required a physician's signature and should be obtained within 24 hours of the IPOST being filled out. She stated the forms should also be reviewed yearly or with any significant change. The ADON stated she was not aware that residents' IPOST forms were not being signed by the physician. During an interview on [DATE] at 3:24 PM, the Administrator stated if DNR paperwork was not in the front of the chart, then it was being sent to the physician for a signature and had not been returned. She stated it was her expectation that IPOST forms be signed and returned the same day or the next day. During an interview on [DATE] at 12:05 PM, the Medical Director stated it was not best practice to have an unsigned or improperly signed advance directive. The Medical Director stated the facility should follow up with the appropriate physician to get the form signed in a timely manner.

Based on clinical record review, facility document review, resident and staff interviews, and facility policy review, the facility failed to ensure 6 (Residents #22, #16, #13, #15, #78, and #11) of 7 residents reviewed for abuse were free from staff-to-resident abuse. On 07/06/2021, Resident #16 reported physical abuse perpetrated by Certified Nursing Assistant (CNA) Staff Q. During the facility's investigation of Resident #16's allegation, three additional residents (#11, #78, and #13) reported Staff Q had abused them. Additionally, on 07/28/2021, Residents #11 and #22 reported that CNA Staff O had abused them, and during the facility's investigation, a staff member reported that CNA Staff P had abused Resident #15. The facility identified a census of 31 current residents. Findings include: Review of a facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revised 04/05/2017, revealed, All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy also indicated, Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement procedures that prohibit abuse, neglect, exploitation and misappropriation of resident property. Additionally, the policy revealed, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. 1. Review of a facility investigation revealed on 07/06/2021, Registered Nurse (RN) Staff R reported to the Administrator that Certified Nursing Assistant (CNA) Staff Q was rough and slammed Resident #16 against a wall and hid the resident's call light during the night of 07/02/2021. According to the report, Staff Q was suspended pending investigation on 07/06/2021 at 8:00 AM. Further review of the facility's investigation revealed while obtaining staff statements regarding possible abuse, three other residents voiced allegations against Staff Q. Resident #11 stated Staff Q pushed him/her up against the wall while placing the resident on a bedpan. Resident #11 stated Staff Q told him/her that the resident complained too much. Resident #78 stated that Staff Q was mean and rough but did not provide details. Resident #78 told therapy staff that Staff Q rolled the resident into the wall while giving the resident a bedpan and that Staff Q was mad at Resident #78 for being wet (incontinent of urine). In addition, Resident #13 stated that Staff Q rolled the resident into the wall while placing the resident on a bedpan and would leave the resident on the bedpan too long. 1.a) A review of Resident #16's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #16 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS further indicated Resident #16 required extensive assistance of two staff for bed mobility, transfer, dressing, toileting, and personal hygiene. A review of Resident #16's care plan, dated as initiated on 02/10/2021, revealed the resident needed assistance with activities of daily living (ADLs) due to weakness, decreased mobility, and balance/gait impairments, which placed Resident #16 at risk for falls/injury. During an interview on 08/11/2022 at 9:26 AM, Resident #16 stated there had been an issue with a CNA who had been rude and rough while providing care, but the CNA no longer worked for the facility, and it was no longer an issue. Continued review of the facility's investigation for 07/06/2021, revealed CNA Staff V reported that during shift change on 07/06/2021, Staff Q told her that Resident #16 had asked to get out of bed. Staff Q refused to assist the resident out of bed because the resident had pushed back on the staff while providing care. Staff V's statement revealed Resident #16 later was yelling for help and when she went into the resident's room, the resident stated, Thank God you're here. Resident #16 stated Staff Q shoved the resident against the wall and took the resident's call light away because the resident called Staff Q a fat [expletive]. According to the report, Staff V reported the incident to a nurse immediately. Further review of the facility's investigation revealed RN Staff R reported that on 07/05/2021 at 6:00 AM, an unnamed coworker told Staff R that Resident #16 feared Staff Q and that Staff Q was mean. Staff R told the coworker that it would be reported and documented that the concern was reported on 07/06/2021 at 7:45 AM. The incident summary on the Facility Reported Incident indicated Staff R did not report the allegation immediately to the Administrator on 07/05/2022 because she and her husband had plans, and her husband was upset that she had to work. Further review of staff statements revealed CNA Staff U reported that on 07/05/2021, Resident #16 stated that Staff Q must have been in a bad mood because she refused to get the resident out of bed. Review of former Licensed Practical Nurse (LPN) Staff T's witness statement, dated 07/06/2021, revealed Resident #16 reported that Staff Q had rolled the resident into the wall and hurt the resident's arm. Further review of the facility's investigation revealed on 07/16/2021, Staff W, a CNA, reported that during the month of June, she overheard Resident #16 saying that Staff Q was rough and hurt the resident by shoving the resident too hard when rolling the resident in bed and slamming the resident around. During an interview on 08/12/2022 at 2:13 PM, Staff Q stated Resident #16 required assistance to turn and with incontinence care. Staff Q stated the CNA would move the resident's bed out to be able to get beside the wall and roll the resident using the incontinence pad. Due to the resident's size, the resident would not help and sometimes would work against staff. Staff Q stated that Resident #16 had told her to [Expletive] off so Staff Q would get the nurse to help. Staff Q stated the resident never stated that she had shoved the resident against the wall. 1.b) A review of Resident #13's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #13's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident required extensive to total assistance from two or more people for bed mobility, transfer, and toilet use. A review of Resident #13's care plan, dated as initiated on 03/08/2019 and revised on 02/18/2022, revealed the resident required assistance with activities of daily living due to a left below-knee amputation, weakness, and unsteady balance. During an interview on 08/11/2022 at 9:35 AM, Resident #13 stated Staff Q, who had worked at night, was rough with the resident, and when the resident asked to get off the bedpan, Staff Q would leave and come back later. Resident #13 stated it was very uncomfortable and painful to have to remain on the bedpan for a long time. Resident #13 stated that Staff Q had not worked in a long time. Resident #13 stated he/she reported the incident to the former Director of Nursing (DON). Continued review of staff witness statements revealed CNA Staff T reported that Resident #13, as well as other residents, had complained about Staff Q being rough. Review of CNA Staff W's statement dated 07/16/2021, revealed during the month of June 2021, she overheard Resident #13 stating that Staff Q was too rough and left the resident on the bedpan even after the resident turned on the call light. Review of former RN Staff X's statement dated 07/07/2021 revealed that, at one time, Staff Q was not allowed to provide care for Resident #13 due to complaints that Staff Q was rough with the resident. As time went on, Staff X thought the matter had been resolved because the DON had spoken to Staff Q and allowed Staff Q to provide care for the resident again. 1.c) A review of Resident #78's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #78's discharge MDS, dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS indicated Resident #78 required limited assistance with bed mobility, transfer, and toilet use. According to the MDS, the facility discharged the resident on 07/21/2021. A review of Resident #78's care plan, dated as initiated 05/25/2021, revealed the resident required assistance with ADLs related to deconditioning, weakness, [CONDITION(S)], history of falls, and a chronic wound to the right heel. According to the care plan, Resident #78 laid in a fetal position with his/her legs curled up and had difficulty straightening them due to pain. A review of Licensed Practical Nurse (LPN) Staff AA's witness statement dated 07/06/2021, revealed she recalled therapy staff reporting an incident with Resident #78 during a stand-up meeting on 06/23/2021. According to therapy, Resident #78 complained about Staff Q rolling the resident into a wall and that Staff Q was upset with the resident the previous night because the resident was wet from an incontinence episode. Review of CNA Staff Y's witness statement dated 07/06/2021, revealed Resident #78 told her that Staff Q was rough and mean to the resident. 1.d) A review of Resident #11's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #11's annual MDS assessment, dated 06/10/2022, indicated the resident had a BIMS score of 6, indicating severe cognitive impairment. The MDS indicated Resident #11 required extensive assistance of one or two people with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident #11's care plan, dated as revised 07/01/2021, indicated the resident came to live at the facility due to needing assistance with care following a fall at home. The resident had a fracture around an artificial hip joint. The resident also had chronic arthritis and was only able to partially bear weight on the left lower extremity. The care plan indicated Resident #11 needed assistance with activities of daily living due to weakness and a history of falls. Continued review of the facility's investigation initiated on 07/06/2021 revealed former CNA Staff Y had heard Resident #11 state that Staff Q was being mean to the resident and rolled the resident against the wall. Continued review of the facility's investigation revealed former CNA Staff Z's statement dated 07/06/2021 indicated Resident #11 complained that Staff Q was being rough and mean to the resident. Review of CNA Staff K's statement dated 07/07/2021, revealed that a couple of months ago, Resident #11 reported Staff Q was rough with the resident at night. Resident #11 stated the CNA had pushed the resident, and the resident's knees hit the wall. Resident #11 told Staff K that it appeared Staff Q did not like the resident. According to the statement, Staff K indicated she reported the incident but could not remember who she told. A review of CNA Staff W's statement dated 07/06/2022 revealed she heard Resident #11 tell day shift CNAs that Staff Q slammed the resident into the wall when turning the resident and that Staff Q left the resident on the bedpan for hours. A review of LPN Staff AA's witness statement dated 07/06/202, revealed Resident #11 told her about Staff Q being rough with care, and Staff AA recalled an intervention had previously been implemented for Staff Q to only provide care for the resident if a second staff member was with the resident. 2. A review of a facility investigation revealed on 07/28/2021, Resident #11 and Resident #22 alleged that CNA Staff O was being mean and rude. Resident #11 stated Staff O pushed the resident into a wall while providing care. Resident #22 stated Staff O was being overly rough with the resident's bad leg. Further review of the facility investigation revealed a statement from CNA Staff J, who reported that CNA Staff P went through the facility cursing in resident's rooms and did not complete resident care. Staff J reported she also saw Staff P push Resident #15 into a quarter side rail, causing the resident's face and hand to get shoved into the rail and the hand to get caught. Staff J stated Staff P would not stop shoving until Staff J told Staff P to stop. According to the facility's investigation, Staff O and Staff P were not to return to the facility. 2. a) A review of Resident #11's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #11's annual MDS, dated [DATE], revealed the resident had a BIMS score of 6. The MDS indicated Resident #11 required extensive assistance of one or two people for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident #11's care plan indicated the resident came to live at the facility due to needing assistance with care following a fall at home. The resident had a fracture around an artificial hip and was receiving traction while hospitalized . The resident also had chronic arthritis and was only able to partially weight bear on the left lower extremity. The care plan indicated Resident #11 also needed assistance with activities of daily living due to weakness and a history of falls. According to the facility's investigation on 07/28/2021, Resident #11 stated a slender girl with dark glasses shoved the resident into a wall. According to the facility's investigation, Resident #11 described Staff O. 2.b) A review of Resident #22's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #22's annual MDS, dated [DATE], revealed the resident had a BIMS of 14, indicating the resident's cognition was intact. Further review of the MDS revealed Resident #22 required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. A review of Resident #22's care plan dated as initiated 02/28/2020 and revised 01/06/2022, indicated the resident required assistance with activities of daily living due to weakness, pain, and a history of falling. Continued review of the facility's investigation revealed on 07/29/2021, Resident #22 told former CNA Staff S that Staff O had been overly rough with the resident's bad leg. The investigation indicated a family member also called on 08/03/2021 to report that Resident #22 had alleged a staff member was rough with the resident and twisted the resident's leg. The family stated Resident #22 expected to be treated with respect and kindness. According to the investigation, the Administrator informed the family member that the staff involved with the incident would not be returning to the facility. During an interview on 08/11/2022 at 9:10 AM, Resident #22 stated staff had been rough, and the resident did not like it; however, the resident could not remember which staff members were rough. During an interview on 08/10/2022 at 5:37 PM, Staff O revealed she worked at the facility on a 2:00 PM to 10:00 PM shift approximately one year ago. She stated there were only three staff, including her and CNA Staff P, working that shift and they did everything they were supposed to do. Staff O stated the agency she worked for later called her and stated she could not go back to the facility because three residents reported she was mean and rough. Staff O stated she did not know what happened because she was very aware how to care for the elderly and no one ever questioned her about the allegations. 2. c) A review of Resident #15's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 received hospice care due to a terminal illness. A review of Resident #15's quarterly MDS, dated [DATE], indicated Resident #15 was cognitively intact, per a BIMS of 14. According to the MDS, Resident #15 required extensive to total assistance of two or more people for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident #15's care plan, dated 08/06/2022, indicated the resident was dependent on staff for activities for daily living related to weakness, end of life care, knee pain, [CONDITION(S)], [CONDITION(S)], obesity, and incontinence. Further review of the facility's investigation dated 07/28/2021 revealed CNA Staff J provided a witness statement which indicated she came to work at approximately 5:35 PM on 07/28/2021 and witnessed Staff P being rude and harsh to residents, using a harsh tone. The statement also indicated Staff P was cursing quite a lot throughout the night and while in resident rooms. According to Staff J's statement, Staff P was also rough with Resident #15. When Staff P rolled the resident to provide care, the resident got his/her hand and face caught on the side rail. Resident #15 stated something to Staff P about being hurt, but it was not until Staff J stated that the resident was being squished that Staff P stopped rolling the resident. On 08/10/2022 at 5:35 PM and at 5:55 PM, the surveyor's attempts to contact Staff P were unsuccessful. During an interview on 08/12/2022 at 3:33 PM, the Administrator stated that Staff O and Staff P were agency staff who had an attitude. The Administrator revealed when there was an abuse allegation, she obtained staff and resident statements and made sure the resident was okay and safe. The Administrator stated she suspended any staff allegedly involved in the allegation until the investigation was completed. The Administrator stated she sent the information to the state agency for them to investigate and waited for the state to determine if abuse was substantiated. She stated she did not do anything further with the investigations.

Based on observation, record review, and interview, the facility failed to adequately supervise a cognitively impaired resident who eloped for 1 of 4 sampled (Resident #1). A facility staff heard the front door alarm sound, responded and allowed Resident #1 to exit the facility without supervision. The other staff had no knowledge that the resident exited the facility. A community member from a town 10 miles away alerted the staff Resident #1 was sitting on the front porch of Resident #1's home. The facility identified 4 residents as independently mobile and cognitively impaired. The facility reported a census of 29. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The resident required limited assistance of 1 staff for bed mobility, transfers, walking, dressing, toilet use, personal hygiene, and bathing. The resident had a Brief Interview for Mental Status score of 5 indicating severely impaired cognition. The Care plan entry dated 7/23/20 revealed the resident independent with mobility but required assistance with activities of daily living due to Alzheimer's dementia and delusional disorder The Nurses Notes dated 7/27/20 at 12:30 a.m., stated the resident walked out in the hallway. The Nurses Notes dated 8/6/20 at 12:14 a.m., revealed on 8/5/20 at 10:30 p.m. Resident #1's neighbor called and stated the resident was at the resident's house in Fort Madison approximately 10 miles from the facility. The staff verified the resident was not in the building and drove to the resident's home to pick her up. The resident arrived back at the facility at 11:30 p.m. The Nurses Notes dated 8/6/20 at 2:54 a.m. revealed since the resident returned to the facility a staff member sat outside the resident's room. The updated Care plan entry dated 8/6/20 revealed the resident had an elopement risk due to a history of attempts to leave the facility and directed staff to monitor the resident's location every 30 minutes, check wander guard placement every shift, and carry out one on one with the resident while in isolation. During an observation/interview on 8/12/20 at 12:00 p.m., the resident sat in her room with her suitcases near her. The resident voiced a desire to go home. During an interview on 8/12/20 at 10:20 a.m., Staff A (Housekeeper) stated between 8:00 p.m. and 10:00 p.m. she heard the front door alarm. She stated she silenced the alarm and allowed Resident #1 out the door. Staff A thought the resident was a visitor. During an interview on 8/12/20 at 10:58 a.m., Staff C (Nurse Aide) stated she was the last staff to see the resident before she left the building. Staff C saw the resident at 8:30 p.m. in the bathroom while she was taking care of another resident in an adjoining room. During an interview on 8/12/20 at 2:15 p.m., Staff B (Registered Nurse) stated on 8/5/20 at around 10:15 p.m., Resident #1's neighbor (from the community) called and stated the resident was at the resident's home in Ft Madison. The resident was on the porch. Staff B confirmed the resident was not at the facility and began to follow the elopement protocol. During an interview on 8/12/20 at 11:37 a.m., the Director of Nurses (DON) stated she was in the building the night of 8/5/20 for an employee meeting. She stated around 10:00 p.m. Staff B informed her the resident was in another town (Fort Madison). They confirmed the resident was not in the building. She and Nurse Aide drove to Fort Madison, picked the resident up, and brought her back to the facility. During an interview on 8/12/20 at 12:00 p.m., Resident #1 was unable to recall how she got to her home when she left the facility. During an interview on 8/12/20 at 2:00 p.m., the DON stated upon initial admission, the family informed the facility one of their concerns for the resident was safety which required placement in the facility. During an interview on 8/13/20 at 9:17 a.m., the Administrator stated if a staff member was unfamiliar with a person who was leaving the building, they should check with the charge nurse. During an interview on 8/17/20 at 11:50 a.m., the Administrator stated the facility did not conduct elopement drills in the last year. The undated facility policy Door or Personal Alarm Policy directed staff to visually check to see who set off the alarm and if it was a resident, assist them back inside. A Resident List Report dated 8/12/20 identified 4 residents in the facility as cognitively impaired and independently mobile. On 8/13/20 at 11:45 a.m. the State Agency informed the facility of the Immediate Jeopardy. The facility abated the Immediate Jeopardy on 8/12/20 by conducting assessments of all residents to identify residents at risk, updating policy and procedure for visitors exiting the facility, a plan to educate newly hired staff on procedure for signing out visitors, staff education on updated policy, a plan to conduct weekly audits to ensure staff retention to educational materials, and a plan to conduct behavior audits. After the corrective actions the scope and severity lowered from J to D.

Based on record review, observations, and interview the facility failed to provide adequate assessment and intervene to treat pain for 2 of 3 sampled (Residents #15 and #23). The facility reported a census of 29. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had [DIAGNOSES REDACTED]. Resident #15 had no cognitive impairments. The MDS dated [DATE] documented Resident #15 required extensive assistance of 1 staff for bed mobility, transfers, dressing, toilet use, and bathing. The MDS revealed Resident #15 had mild pain frequently. The Care Plan revealed Resident #15 had chronic pain related to arthritis, gout, and [MEDICAL CONDITION] in legs. The Care Plan directed staff to administer pain medications as ordered, apply topical pain relieving agents as ordered, apply morning dose prior to getting out of bed in the morning, attempt alternative methods of pain relief other than medication such as massage and warm packs, consult multidisciplinary team members to address pain, monitor for side effects of [MEDICATION NAME], increase mobility with nursing to decrease reports of pain, and pain scale twice a day and as needed to monitor pain symptoms. The Fax dated 2/25/19 revealed the staff informed Resident #15's physician of his painful feet that hindered therapy. The Fax dated 2/27/19 revealed the staff informed the physician Resident #15 had continued with 3 plus pedal [MEDICAL CONDITION] and staff applied [MEDICATION NAME] cream three times a day that provided some relief. The physician added [MEDICATION NAME] 5 milligrams by mouth for 7 days, recheck basic metabolic panel and then decide if Gapentin needs increased. The Physical Therapy discharge summary dated 3/22/19 revealed Resident #15 only ambulated short distances due to pain. The (MONTH) 2019 Medication Administration Record [REDACTED] a. [MEDICATION NAME] (Tylenol) 650 milligrams (mg) 1 tablet by mouth three times a day. b. [MEDICATION NAME] (nerve pain medication) 100 mg by mouth three times a day. c. [MEDICATION NAME] Cream 4% (topical pain medication) topically three times a day. d. Bio freeze Gel 4% (topical pain medication) topically every 8 hours as needed. During an observation on 5/1/19 at 8:51 a.m., Staff C (Nurse Aide) assisted Resident #15 to stand up from the wheelchair. Resident #15 grimaced and reported his feet hurt so bad. Resident #15 continued to grimace and struggled to walk to the bed only a few steps away. Resident #15 reported his medications were not helping lately. During an observation and interview on 5/1/19 at 11:00 a.m., Resident #15 sat in his wheelchair and reported his feet still hurt. The (MONTH) 2019 MAR indicated [REDACTED]. On 5/1/19, Resident #15 had a pain level of 0 on the day shift. At 12:50 p.m., Resident #15 received Bio freeze gel. During an interview on 5/1/19 at 8:00 a.m., the Therapy Program Director reported Resident #15 struggled with therapy due to uncontrolled pain. The Therapy Program Director reported the staff discussed a pain clinic referral. The Therapy Program Director reported Resident #15 received a narcotic pain medication that helped Resident #15's pain but the provider discontinued the medication. During an interview on 5/1/19 at 1:00 p.m., Staff D (Restorative Aide) stated Resident #15 had pain around 9:45 a.m. to 10:00 a.m. and refused to participate in restorative exercises due to the pain in his legs. The clinical record lacked documentation of a pain assessment and intervention for Resident #15's pain. 2. The MDS assessment dated [DATE] revealed Resident #23 had [DIAGNOSES REDACTED]. Resident #23 had severe cognitive impairments. The MDS dated [DATE] documented Resident #23 required extensive assistance of 1 staff for bed mobility, dressing, personal hygiene, and bathing. The MDS documented Resident #23 had no pain. The clinical record lacked documentation of a pain assessment and intervention for Resident #23's pain. The Care Plan revealed Resident #23 had a history of [REDACTED]. A 3/11/19 provider's progress note revealed nursing staff reported no concerns. A 4/9/19 provider's progress note revealed nursing staff reported no concerns. The (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED] a. [MEDICATION NAME] (Tylenol) 325 mg 2 tablets by mouth two times a day. b. [MEDICATION NAME] (non-narcotic pain medication) 200 mg 1 tablet by mouth as needed two times a day. c. Warm compress to right shoulder four times a day as needed. d. Bio freeze Gel 4% topically three times a day. During an observation on 4/30/19 at 7:12 a.m., revealed Staff B (Nurse Aide) assisted Resident #23 to walk to the bathroom. Resident #23 stated, my shoulder hurts so bad and moaned. Staff A (Licensed Practical NLPN walked into the room and Staff B stated to Staff A that the resident's shoulder hurt. Observation on 4/30/19 at 7:51 a.m., revealed Resident #23 sat at the dining room table and stated, this arm hurts so bad. Observation and interview on 5/1/19 at 8:51 a.m., revealed Resident #23 reported her arm hurts like the dickens. The (MONTH) 2019 MAR indicated [REDACTED]. On 4/30/19, Resident #23 had a pain level of 0 on the day shift. The (MONTH) 2019 MAR indicated [REDACTED]. On 5/1/19, Resident #23 had a pain level of 0 on the day shift. During an interview on 5/1/19 at 12:26 p.m., Staff A (Licensed Practical Nurse) stated Resident #15's provider discontinued the narcotic pain medication and he needed something stronger. Staff A reported the facility and the family asked the doctor for something stronger. Staff A reported Resident #15 had the [MEDICATION NAME] increased in the last year. Staff A reported the staff did not report to her that Resident #15 complained of pain on 5/1/19. Staff A reported Resident #23 complained of her shoulder hurting every morning but the doctor would not give her anything more for the pain. Staff A stated the facility sent the doctor faxes regarding this. Staff A stated Resident #23 continued to complain of pain. During an interview on 5/1/19 at 1:43 p.m., the Director of Nurses (DON) stated an expectation of staff to inform the charge nurse if a resident expressed pain. The DON reported an expectation of the charge nurse to complete an assessment and then check the MAR for any medications, hot packs, cold packs, [MEDICATION NAME], or transcutaneous electrical nerve stimulation unit. The DON reported the staff needed to contact the physician if the attempted pain interventions not effective. The DON stated nursing should communicate any complaints of pain residents have made to the provider when they come to the facility to see the residents. Regarding Resident #15, she stated the resident did have an order for [REDACTED].#23, she stated a warm blanket often would make her feel better and stated staff should speak with the provider and have the resident evaluated again and she should not have to live out the rest of her life in pain. The clinical record lacked documentation of a pain assessment and intervention for Resident #23's pain. The clinical record lacked documentation of communication Resident #23's physician regarding pain from 2/2/19 to 5/2/19. The Resident Examination and Assessment policy revised 7/2018 stated the purpose was to assess for any special situation regarding the resident's care including pain. The policy directed staff to report worsening pain to the physician.

Based on observation, record review, resident, family and staff interviews, the facility failed to prevent contractures to Resident #27's left hand and fingers. The sample consisted of 12 residents and the facility reported a census of 28 residents. Findings include: Resident #27 had a MDS (Minimum Data Set) assessment with a reference date of 2/19/17. The MDS identified the resident had Diagnoses: [REDACTED]. The MDS identified the resident to be cognitively intact with a BIMS (brief interview for mental status) score of 12 out of 15. A score of 12 identified the resident to be moderately cognitively impaired. The MDS identified the resident as totally dependent on staff for most activities of daily living and had impairment to one side of both the arm and leg. The Care Plan with a goal target date of 3/18/18 identified a problem of self-care deficit as evidenced by [DIAGNOSES REDACTED]. The Care Plan interventions included and directed the staff to: The resident will actively participate in restorative (no documentation of frequency and type), Encourage the resident to keep her provided left armrest on the wheelchair, No documentation to address the contracture of fingers to her left arm On 01/10/18 at 01:03 p.m. the resident and spouse reported the following: The resident stated she received bicycle therapy at the facility 3 times a week, no exercises here to get me strong enough to stand, but they do this for me at the hospital where I go 2 times a week. The resident stated she could not open up her left hand all the way. An observation at that time identified contractures to all the fingers on the left hand. The resident's spouse reported the following: They (spouse and resident) were told that Medicare ran out and we were private pay. Therapy just stopped. All they (facility) had her do was use the bicycle. We want her to walk, stand and to be able to go home. The spouse stated the doctor informed there was no reason she should not be able to stand and walk with a walker. On 1/17/18 6:35 a.m. Staff F, restorative aide/CMA was observed performing range of motion exercises to the resident's left arm and to the left hand. Staff F had the resident straighten out her fingers. The resident could not achieve extension to the left hand fingers due to pain and then the resident requested pain medication. On 1/17/18 at 06:46 a.m. the resident was observed to do 10 repetitions of leg lifts to both legs, bending at the knee. The resident then marched in place while sitting in the wheelchair and unable to lift the left foot as much as the right foot. Staff F then locked the resident's wheelchair, held the resident's hands and asked her to lean forward then back for 10 repetitions. On 1/17/18 at 06:48 a.m. Staff F unlocked the resident's wheelchair and pushed the resident in front of the omnicycle which the resident pedaled for a full 15 minutes before returning to her room. A review of the hospital discharge summary dated 4/13/17 identified the resident had no contractures to the left hand. A review of the admission Nurse's Note dated 4/13/17 at 1:14 p.m. indicated the resident had no contractures or skeletal deformities at this time. A review of the Nurse's Notes from 9/5/17 through 1/18/18 identified only one entry that addressed the resident's left hand on 1/11/16 at 10:11 a.m. - resting hand splint to left hand/wrist for proper hand position to prevent flexion contracture. The documentation identified no documentation of a contracture to the fingers on the resident's left hand. The Director of Nursing (DON) entries in the resident's record revealed the following: On 9/21/17 at 1:17 p.m., 10/18/17 at 1:00 p.m., 11/8/17 at 11:26 a.m., and 12/21/17 at 11:29 a.m. each entry had the following documentation under restorative program note: Met with restorative aide today and the resident participated in the current restorative program without complaints, no concerns at this time with limitations. Will continue current plan of care and proceed with referrals and make modifications as needed. On 1/12/18 at 3:00 p.m. met with restorative aide today and resident is participating in the current restorative program without complaints, no concerns at this time with limitations. The resident also goes to outpatient therapy at the local hospital 1-2 times per week. Will continue current plan of care and proceed with referrals and make modifications as needed. A review of the occupational therapy evaluation and plan of treatment for [REDACTED]. A review of the physical therapy discharge summary with dates of service from 4/13/17 to 7/27/17 revealed the interventions provided: therapeutic activities: transfer training to increase functional task performance, training in rolling, scooting, bridging to facilitate bed mobility and bed mobility activities to increase functional skills. The reason for discharge: highest practical level achieved. A review of the occupational therapy discharge summary with dates of service from 8/22/17 to 9/11/17 revealed the interventions provided: therapeutic activities: gross motor coordination, crossing midline to facilitate independence in functional skill performance, weight shifting to improve safety with unsupported sit/stand, static balance activities during sitting, dynamic balance activities during sitting, placement of objects out of reach to increase dynamic skill performance, range of motion techniques to increase functional task performance, analysis/training in cueing hierarchy to increase strength. Discharge recommendations: functional maintenance program/restorative nursing program and 24 hour care. A review of the hospital outpatient rehabilitation services center dated 12/21/17 had documentation of the following: Reason for referral: resident reports she had a total knee replacement in January 2017, had several [MEDICAL CONDITION] and a [MEDICAL CONDITION] following that surgery, has not had any therapy for the past 4 months at the nursing home and has goals to be able to start transferring again, possibly ambulate and dress herself. Objective: left hand has some flexion contractures in all digits except thumb. Short term goals: Will be able to demonstrate fair to good tolerance working on static and dynamic sitting balance in preparation for increasing independence with activities of daily living including that of dressing supine or sitting Will demonstrate good tolerance for custom resting hand orthotic to assist with decreasing flexion contractures on left hand/digits to allow for eventual increase use of the left hand A review of the patient visit information dated 12/8/17 by the neurologist revealed the resident had spastic [MEDICAL CONDITION] (paralysis on one side) affecting the left non-dominant side and had orders for physical therapy and occupational therapy for lower strengthening three times a week for 4 weeks and upper extremity ROM (Range of Motion) and strengthening 2-3 times a week for 4 weeks A review of the restorative care documentation on the survey report v2 revealed the following: November 2017 had no documentation of restorative care given from 11/24/17 through 11/30/17, December 2017 had documentation that restorative care provided only 2 days during the week of 12/10/17 through 12/17/17 and during 12/18/17 through 12/24/17 On 1/16/18 at 2:00 p.m., Staff F, restorative aide, was interviewed and stated the resident was getting ready to leave for the day to receive therapy at the hospital as per the family's request. On 1/17/18 at 2:00 p.m., Staff B, CNA reported she could not recall when the resident began restorative care and the resident did not usually use the left hand as the resident could not straighten out those fingers. On 1/17/18 at 02:23 a.m., Staff C, CNA reported when she first worked at the facility, she thought the resident had a contracture to the left hand which he/she should wear a brace to the left hand all the time. The resident is to have the left hand strapped to the armrest of the wheelchair when he/she goes to therapy. Staff C reported she has not seen the resident able to straighten out the fingers to her left hand as it is really difficult for her. On 1/17/18 at 2:30 p.m., Staff D, RN was interviewed and stated since she began working at the facility (date unknown), the resident's left hand had always been contracted and the resident unable to fully straighten out the fingers to the left hand. Staff D stated 2 to 3 weeks ago, therapy placed a splint to her left hand. Staff D could not recall what was done for restorative care. The resident went to the hospital for therapy per the family's choice perhaps because they did not think our program was aggressive enough. During an interview on 1/17/18 at 7:35 a.m., Staff F, restorative aide/CMA reported the resident had the contracture to the left hand upon admission to the facility which restorative care included trying to straighten out the fingers to the left hand. She reported she worked with the resident 5 days a week as long as the resident is in the facility. On 1/17/18 at 11:27 a.m. the physical therapy program coordinator/PTA, reported a physical therapist had oversight over the program and came to the facility twice a week. When the resident was admitted to the facility in April 2017, physical therapy worked with her from April through July without contractures during that time frame. After discharge from the program in July, we began to notice tightness in her left hand. We picked her up again for therapy in August under Part B. The resident was discharged from Part B from occupational therapy in September 2017 as there was no contracture, just tightness. The goal was to discharge from therapy and work with restorative program - complete passive ROM (to perform joint range of motion for a person) LUE (left upper extremities), hand focus on straightening fingers completely. Restorative care was provided from September 2017 to present. She then reviewed the outpatient note on 12/21/17 and addressed the resident's contracture and verified this was the initial evaluation. During an interview on 1/18/18 at 8:24 a.m., the physical therapist with oversight over the facility program reported physical therapy primarily worked on the resident's legs and occupational therapy worked on the resident's arms. When asked what her expectation would be to prevent contractures from occurring, she reported she would expect a restorative program in place where the resident should be seen at least 5 times a week. During an interview on 1/17/18 08:51 a.m., the Director of Nursing, (DON) reported the Care Plan should be updated by the MDS coordinator, but currently the facility is in the process of training a new person for that position. The DON reported she would expect a new contracture to be updated on the Care Plan.

Based on observation, record review and staff interviews, the facility failed to adequately assess and provide timely interventions when a wound showed a change in condition (Resident #4). The sample consisted of 3 residents and the facility reported a census of 29 residents. Findings include: 1. The MDS (Minimum Data Set) assessment, with a reference date of 10/26/16, identified Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance of 1 staff for dressing and eating, extensive assistance of 2 staff for bed mobility, totally depended on 1 staff for personal hygiene, and totally depended upon 2 staff members for toilet use and bathing. The MDS listed the resident as at risk for the development of pressure ulcers but did not indicate the resident had any current skin conditions. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 3. A score of 3 identified the resident with severely impaired cognition. During an observation on 11/22/16 at 7:00 a.m., Staff F LPN (Licensed Practical Nurse) measured a black area surrounded by a yellow perimeter on the tip of the resident's left great toe as 1.5 cm(centimeters) x (by) 1.3 cm. The tissue surrounding the area had a red appearance. Staff F measured a dark, discolored area on the resident's left second toe as 0.4 cm x 0.4 cm. During an observation on 11/22/16 at 7:40 a.m., Staff G CNA(Certified Nursing Assistant) assisted the resident with cares as the resident sat in his/her wheelchair with a boot on his/her left foot and his/her feet resting on the wheelchair foot pedals. As Staff G walked by the resident, it appeared she bumped the resident's left foot and the resident cried out. Staff G asked Did I get ya? and the resident nodded his/her head yes. During an observation on 11/22/16 at 8:10 a.m., Staff G CNA wheeled the resident up to the dining room table. The resident's left great toe was in contact with a cushion located under the feet of the resident sitting across from him/her. The toe remained in contact with the cushion until the surveyor notified the DON (Director of Nursing) at 8:18 a.m. and she repositioned the resident's feet. A skin assessment sheet listed measurements for a skin area on the left great toe on the following dates(the sheet did not indicate the unit of measurement): 9/21/16 0.1 x 0.2 9/27/16 0.1 x 0.2 10/4/16 0.1 x 0.2 10/11/16 0.1 x 0.3 10/18/16 0.1 x 0.2 10/25/16 0.1 x 0.1 11/1/16 0.1 x 0.1 11/8/16 0.5 x 0.4 11/15/16 0.8 x 0.7 11/22/16 1.5 x 1.3 A skin assessment sheet listed measurements for a skin area on the left second toe on the following dates(the sheet did not indicate the unit of measurement): 9/21/16 0.4 x 0.4 9/27/16 0.6 x 0.5 10/4/16 0.5 x 0.4 10/11/16 0.5 x 0.5 10/18/16 0.5 x 0.5 10/25/16 0.5 x 0.4 11/1/16 0.4 x 0.4 11/8/16 0.3 x 0.2 11/15/16 0.4 x 0.2 11/22/16 0.4 x 0.4 A 9/21/16 facsimile notified the primary care physician of the great and second toe skin areas. The physician ordered [MEDICATION NAME] (an antibiotic) 100 mg (milligrams) twice per day for 10 days. A 9/27/16 8:22 a.m. Progress note indicated the area on the left second toe not improved, measured 0.6 cm x 0.5 cm, scabbed and painful to the touch and the area to the left great toe also remained reddened and painful, with a darkened spot measuring 0.1 cm x 0.2 cm. The note stated the primary care physician had not given a treatment order but the antibiotic was discontinued. A podiatrist's note dated 11/2/16 indicated the resident had a Stage II pressure ulcer measuring 0.4 x 0.5 x 0.1 cm on the left second toe. The note indicated the ulcer was selectively debrided (the process of removing damaged tissue) with instructions to staff. An 11/2/16 podiatrist's order directed staff to apply antibiotic ointment to the left great and second toes, wash with soap and water, Band-Aid daily. The order directed staff to ensure the seam of the anti-embolism hose (hose worn to prevent blood clot complications) was not rubbing and instructed staff to contact the office in 2 weeks (11/16/16) if the wound did not heal. A 11/8/16 6:37 a.m. Progress Note indicated the areas to the toes measured 0.5 cm x 0.4 cm (left great) and 0.3 cm x 0.2 cm (left second). Areas left open to air because of maceration due to the area becoming macerated (softened skin due to moisture). A 11/12/16 2:07 p.m. Progress Note indicated the left great toe remained scabbed and the toe red and painful to the touch. The resident stated he/she does have pain in the toe but refused pain medication. A 11/17/16 9:36 a.m., Progress Note indicated the left great and second toes were painful to the touch and the open areas were not improving. The great toe was swollen and red and the resident was unable to wear a shoe on the left foot. The facility faxed the primary care physician and awaited a reply. A 11/17/16 facsimile sheet, sent to the primary care physician, indicated the podiatrist saw the resident on 11/2/16, filed areas on the left great and second toe and ordered TAO (Triple Antibiotic Ointment). The sheet ordered the staff to apply every day for 2 weeks. The note indicated the areas were not improving and the left great toe was swollen and very red and painful at touch. The fax requested the physician respond to the fax today. A 11/19/16 4:42 a.m. Progress Note indicated the resident's daughter was present and staff discussed the areas to the great and second toes. The areas showed no improvement in measurements and were painful to the touch. The top of the foot area was reddened with [MEDICAL CONDITION] (swelling). Staff performed an Epsom salt foot soak per the daughter's request and faxed the physician with the above information. The note identified the facility inquired if the physician had a suggestion for protecting the top of the foot from rubbing the wheelchair pedals, as the foot protectors in place offered no protection to the affected areas. A 11/19/16 facsimile sheet, sent to the primary care physician, indicated the resident's family member would like to try an Epsom salt soak to both feet and the resident's anti-embolism hose were affecting the left foot and worsening the condition, the top of the left foot appeared red with an increase in [MEDICAL CONDITION]. The note requested a discontinuation of the anti-embolism hose and the facility resent the 11/17/16 fax that the area had not changed in condition since the facility sent the prior fax. The resident complained of pain and the left foot was very tender. The note inquired if there were any suggestions related to protecting the top of the toes as heel protectors did not protect this area. A primary care physician telephone order, written at the bottom of the same sheet and dated 11/20/16, indicated no to Epsom salt and listed an order for [REDACTED]. A 11/19/16 2:06 p.m. Progress Note indicated the toes remained reddened and sore and staff placed foot in heel protectors to attempt to protect from falling under the wheelchair pedal. A 11/20/16 9:46 a.m., Progress Note indicated the staff attempted an Epsom salt foot soak per the daughter's request and the resident did not tolerate the foot soak well. A 11/20/16 6:45 p.m. primary care physician telephone order listed the following orders: 1. Discontinue anti-embolism hose. Start [MEDICATION NAME] (a type of hose used for tissue support) on in am, off at bedtime. Change weekly on shower day. 2. [MEDICATION NAME] 100 mg twice per day for 14 days. 3. Refer to the podiatrist for evaluation and treatment. A 11/20/16 facility fax sheet, sent to the podiatrist, indicated the top of the resident's left great toe had increased signs and symptoms of infection along with the tip of the second toe. It indicated the resident's primary care physician started [MEDICATION NAME] 100 mg twice a day for 14 days. The sheet stated the area had a questionable area that may be necrotic (dead) and suggested it be debrided and cultured and requested the podiatrist come to the facility as soon as possible due to the difficulty of transferring the resident. A 11/22/16 8:50 a.m. note on the bottom of the same sheet indicated the facility called the (podiatrist's) office for an update and the nurse stated unable to come to the facility or make the resident an appointment in the office at this time, still discussing options with the podiatrist and would call back later today with an answer. Another note on the bottom of the same sheet, dated 11/23/16 indicated the facility sent the resident to the emergency roiagnom on [DATE] and the physician admitted the resident to the hospital for intravenous antibiotics. A 11/21/16 1:34 p.m. Progress Note indicated the great toe as bright red with swelling present. A 11/22/16 11:10 a.m. Progress Note indicated the left great toe with red encompassing the entire toe, necrotic area on distal portion of toe with odor, open area noted to inferior(underside) portion of left great toe, measurements obtained earlier this date. Second toe appeared macerated and had open area on distal portion of toe. The facility obtained a verbal order by the primary care physician to have the resident transported to the emergency room . A 11/22/16 emergency room note identified the resident had [MEDICAL CONDITION] (a skin infection) and an abscess (a confined pocket of pus that collected in tissues) of the foot and did not require admission but did require intravenous antibiotics and daily Santyl (an ointment used to break down dead skin) dressing changes. The note indicated the resident had an unstageable pressure ulcer to the left great toe with eschar and slough (dead tissue). A 11/23/16 6:12 a.m. Progress Note indicated the resident admitted to the hospital. The facility lacked any telephone follow up to the primary care physician between the time the facility sent the 11/17/16 facsimile, identifying the areas not improving and the time the facility received the 11/20/16 6:45 p.m. primary care physician telephone orders. The facility lacked any documentation prior to 11/20/16 of podiatrist notification of the wound condition or the worsening and increase in size of the wound. Following the 11/20/16 fax, the facility lacked documentation of any follow-up actions to the podiatrist until 11/22/16. A 8/1/16 Braden Scale for predicting pressure sore risks listed the resident's score as 14, indicating moderate risk. A Care Plan entry, dated 5/3/13 indicated the resident had the potential for pressure ulcer development related to reduced mobility and had a goal of intact skin, free of redness, blisters or discoloration by/through the review date. A 5/11/16 entry directed staff to carry out skin treatments per doctor's orders. The facility Pressure Ulcer Treatment policy, revised October 2013, directed staff to notify the physician if the wound did not improve in 2-3 weeks. During an interview following the wound measurement observation on 11/22/16 at 7:00 a.m., Staff F stated the wound looked worse than what it looked like 2 days ago. She stated the facility sent faxes to the podiatrist but the she hadn't heard back. She stated she would follow up. During an interview on 11/22/16 at 3:00 p.m., the DON stated the facility sent the resident to the emergency room and he/she had a bad infection. She stated the resident needed intravenous antibiotics twice per day. She stated when she was at the facility on 11/18/16 for the facility's Thanksgiving celebration she was horrified because the toes were not getting better. The DON stated the facility should have been monitoring the toe more closely and frequently and there should have been more faxes sent and someone should have called the physician to follow up. She stated she didn't think the toe should have gotten that bad and the resident should have been sent to the emergency room if there were not responses from the faxes. She stated more specific descriptions of the wound should have been sent to the physician and that she felt terrible about it. During a telephone interview on 11/22/16 at 3:58 p.m., the resident's podiatrist stated during a visit on 11/2/16, the resident had a small, stable ulcer and she had no concerns of infection at that time. She ordered daily dressing changes with a soap and water cleanse and triple antibiotic ointment. She wrote an order requesting the facility contact her in 2 weeks if the wound did not improve. This was last Wednesday (11/16/16). She did not hear anything and assumed the wound was ok. The first notification she received was a fax on 11/21/16 stating the facility contacted the primary care physician over the weekend who requested the podiatrist evaluate the resident. The podiatrist stated she wanted the facility to contact her last week and it bothers her this was not carried out.

Based on clinical record review, policy review and staff interview, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of three residents sampled for review (Resident #1). The facility reported a census of 29 residents. Findings include: A quarterly MDS ( Minimum Data Set) dated [DATE] identified Resident #1 ' s BIMS (Brief interview for Mental Status) scored 3 out of 15 that indicated severely impaired cognitive function related to daily decision making skills. The MDS identified Resident #1, required extensive assistance of one staff member for bed mobility, dressing and personal hygiene. Resident #1 required extensive assistance of two staff members for transfers, walking in the room or corridor and toilet use. The MDS indicated Resident #1 as unsteady with balance but with the ability to stabilize self without staff assistance. Resident #1utilized a walker and/or wheelchair for mobility. The MDS documented Resident #1's [DIAGNOSES REDACTED]. The MDS listed Resident #1 experienced a history of two of more falls that resulted in no injury. The care plan dated [DATE] identified to staff that Resident #1 required assistance with activities of daily living due to past history of [MEDICAL CONDITION] (stroke) that placed Resident #1 at risk for falls/injury. The care plan instructed staff to provide assistance of one staff member using a gait belt and wheeled walker to ambulate to the toilet and about facility. The care plan instructed staff Resident #1 had impaired cognition and impaired thought processes related to past [MEDICAL CONDITION] and required cues, reorientation and staff supervision. Provide consistent caregivers as often as possible to decrease confusion. An incident report dated [DATE] at 6:55 p.m. indicated Resident #1 was found on the floor after attempting to independently transfer to bed from an unlocked wheelchair. The staff members are instructed to keep Resident #1 in the dining room until staff can toilet, dress for bed and transfer him/her into bed. An Incident report dated [DATE] at 4:50 p.m. indicated Resident #1 stood up after using the toilet, pulled up pants, staff member held onto the gait belt when Resident #1 lost his/her balance and fell against the bathroom wall. Staff member lowered Resident #1to the floor. The intervention included ambulating Resident #1 only one way to meals and take back to the bedroom in a wheelchair, and assist out of wheelchair when back in his/her bedroom. An incident report dated [DATE] at 6:45 p.m. indicated the staff member assisted Resident #1 out of the wheelchair to stand and asked him/her to briefly stand independently. The staff member released Resident #1's gait belt and turned away from Resident #1 to get clothing from a closet, when she turned back Resident #1was observed falling. Resident #1 ' s fall to the floor resulted in a hematoma to the right temporal area and a right occipital area laceration to the head. The interventions instructed staff members not to release the gait belt of any resident that required assistance. The emergency room report dated [DATE] at 7:45 p.m. noted Resident #1 was walking with a facility staff member when he/she fell striking the right side of his/her head and face. The report indicated Resident #1 received a hematoma with a superficial two inch long laceration to the right lateral skull. The Hospital History and Physical dated [DATE] at 6:40 a.m. noted Resident #1 was walking with a staff member at the facility when he/she fell striking the right side of his/ her head and right side of the face that resulted in a hematoma with laceration in the right parietal scalp area and a black right eye. Evaluation disclosed a minimally displaced right parietal scalp area fracture and right subdural hematoma. Family decided on conservative and comfort cares. A State of Iowa Death Certificate dated [DATE] indicated Resident #1 expired on [DATE] at 3:05 a.m. with the immediate cause of death related to a subdural hematoma that resulted from a fall. The facility gait belt policy dated [DATE] instructed that staff should maintain a firm grip (hands up) on the gait belt during the entire position change and turn and while the resident safely sits. Interview on [DATE] at 9:35 a.m. Staff A CNA, stated Resident #1 was transferred to his/her room in the wheelchair from the dining room. Staff A stated she placed gait belt around Resident #1's waist and assisted him/her to stand, holding onto the gait belt. Staff A pulled a walker in front of Resident #1 as he/she stood in the doorway of the bedroom. Staff A stated she moved to the right side of Resident #1 and walked him/her about four steps into the bedroom. Staff A stated she asked Resident #1 to stand independently as Staff A removed, clothing from the closet. Staff A stated Resident #1 held onto the walker. Staff A stated she turned towards the closet not realizing Resident #1started to walk forward independently. Staff A commented she heard Resident #1 make a noise, turned back and observed Resident #1 starting to fall. Staff A stated she put her arms out to catch Resident #1 but he/she fell through Staff A ' s arms. Staff A stated she had never had a problem with Resident #1 not following directions prior to the fall. Staff A stated Physical Therapy was working with Resident #1 so she felt Resident #1 could stand independently for a minute. Staff A stated she knew better and there was no excuse for her not holding onto Resident #1 ' s gait belt. Staff A stated she never let Resident #1 stand independently prior to the fall or witnessed Resident #1 standing independently unless with therapy. Interview on [DATE] at 9:25 a.m. Staff B CNA stated she did not know if Resident #1 was able to follow directions but she would not allow a resident requiring staff assistance and a gait belt to stand by themselves. Interview on [DATE] at 11:50 a.m. Staff E CNA stated Resident #1 required a gait belt and assistance of one staff member and walker. Staff E stated Resident #1 was able to follow simple commands and stand still if asked. Staff E stated she would not allow Resident #1 to stand alone with the walker unless she held onto the gait belt. Staff E stated recently Resident #1's knees had started to buckle when getting up or down. Interview on [DATE] at 2;05 P.M. Staff J RN (Registered Nurse) stated Resident #1 was helped to stand after the supper meal, but leaned more so Staff A placed Resident #1 in a wheelchair and propelled to his/her bedroom. Staff J RN stated Staff A told her the room closet door was open so she left Resident #1 to stand alone while getting his/her clothing from the closet. Staff J stated Staff A commented Resident #1 began to walk independently and started to fall. Staff J stated that Staff A informed her that Staff A attempted to catch Resident #1 but he/she fell between Staff A ' s arms. Staff A told Staff J she heard Resident #1's head hit the floor and his/her glasses flew across the room. Staff J stated when she and Staff L, LPN (Licensed Practical Nurse) arrived to the room Resident #1 was having [MEDICAL CONDITION] activity, was unresponsive and having snoring like respirations. Staff J stated Resident #1's body was flaccid the pupils fixed and dilated. Staff J stated Staff L LPN called 911 and requested a CNA bring an ice pack to the room. Staff J stated she palpated Resident #1's head and identified a couple lacerations, one on the back of the head behind Resident #1's right ear and the other on the temporal area. Staff J stated approximately 2 minutes after the fall Resident #1 began to respond, moaning when his/her head was palpated, and about 3 minutes after responded to verbal cues. Staff J stated Resident #1 was transferred out of the facility to the local emergency room around 7:30 p.m. Staff J stated she notified the family after Resident #1 left the facility. Staff J stated Resident #1 returned to the facility a couple of days later on Hospice care and then passed away a couple of days after that. Staff J stated Resident #1 failed to have any verbal response after readmission to the facility. Interview on [DATE] at 3:30 p.m. Staff L, LPN stated she and Staff L responded to a report of Resident #1 ' s fall. Staff L stated upon entering Resident #1 ' s room, she observed Staff J on the floor beside Resident #1 and he/she had blood around the head area. Staff L stated she called 911 from the nurse ' s station. Staff L stated she returned to Resident #1 ' s room and assisted Staff J with the assessments of Resident #1 prior to the emergency room transfer.