Every finding on record at Westbrook Acres

Based on clinical and hospital record review, observation, resident and staff interviews, and facility policy review, the facility failed to ensure a safe transfer and ambulation with the use of a gait belt as determined necessary by the care plan during Resident #1's staff-assisted transfer and ambulation on 3/13/26 for one of three residents reviewed for falls (Resident #1). Resident #1 fell to the floor, sustained a hip fracture with 7 out of 10 pain level, and required hospitalization with surgical repair. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam. which indicated the resident had moderately impaired cognition. Per this assessment, the resident required partial/moderate assistance to walk 10 feet, and for chair/bed to chair transfer. The MDS assessment further revealed the resident used a walker and wheelchair. The MDS assessment dated [DATE] for Resident #1 documented a 3/17/26 readmission date to the facility from an acute hospital stay. Her diagnoses included a primary medical condition of a hip replacement, a fracture of unspecified part of neck of right femur (the longest, heaviest, and strongest bone in the human body, running from the hip to the knee), and a subsequent encounter with routine healing, personal history of a traumatic fracture, Alzheimer's Disease, and diabetes mellitus. The MDS identified a BIMS score of 10 out of 15. The MDS coded a functional limitation in range of motion (ROM) with impairment present on one side of the resident's body in the lower extremity, and coded the use of a walker and wheelchair. Resident #1's Pain Assessment Interview revealed she had experienced pain which occasionally limited her participation in her rehabilitation therapy and day-to-day activities. The MDS recorded the resident reported she had experienced pain and rated her pain at 6 on a 00 to 10 pain scale with 10 being the worst pain imaginable. The MDS documented the resident's medications included antipsychotic, antianxiety, antidepressant, antibiotic, opioid, and antiplatelet medications. The MDS documented the resident had received physical and occupational therapy services. The Care Plan initiated 3/12/25 for Resident #1 identified the resident at risk for falls. The Update 3/13/26 revealed, Fall in room with turning and losing balance noted shortening of right (R)/leg. The Intervention dated 3/12/25 directed staff to provide the assistance of one to two staff persons and walker with transfers and ambulation. Another Intervention dated 3/12/25 revealed, Discourage independent ambulation/transfer and educate on risk of falls/injury PRN (as needed). The undated Mini Care Plan for Resident #1, informed staff the resident required a walker and the assist of 1 to 2 staff persons with a gait belt for transfers. Per the Mini Care Plan for Resident #1, the resident was ambulatory with the assistance of 1 of 2 staff persons and a walker, or used wheelchair with foot pedals. The undated paper Cheat Sheet developed by the facility for use by new staff and temporary agency staff directed staff assisting Resident #1 to provide 1 or 2 staff persons and a gait belt when assisting the resident with transfers, and noted walker and/or a wheelchair use. Resident #1's Incident Report for Fall During Staff Assist dated 3/13/26 at 2:30 p.m. authored by Staff B, Licensed Practical Nurse (LPN) revealed the resident was ambulating back to her recliner after using the bathroom with agency staff member (Staff A, CNA). Agency staff (Staff A) yelled out of room [Resident #1] fell. Upon entering the room, resident was sitting in an upright position with back to door and legs on ground in front of resident body When writer (Staff B, LPN) asked agency CNA (Staff A, CNA) where the gait belt was, agency CNA (Staff A, CNA) said she did not use one. After Staff B, LPN assessed Resident #1 on the floor, a gait belt was placed around the resident and three staff members assisted Resident #1 to her recliner and then to her bed Resident then told writer (Staff B, LPN) this area right here hurts and the resident pointed to at her right hip area Residents rights leg appeared shorter than the left leg, however resident was unable to completely straighten her right leg. Per the Nurse's Note dated 3/13/26 at 5:25 PM, Staff B then called Resident #1's representative and arranged for Resident #1 to be transferred to the local hospital. The Nurse's Note dated 3/13/26 at 8:15 p.m. revealed the local hospital's emergency room (ER) nurse called to confirm that Resident #1 had broken her right hip. The Nurse's Note dated 3/13/26 at 9:23 p.m. revealed The ER nurse called back to inform Staff B, LPN that Resident #1 would be transferred to another hospital for the surgical repair of her hip fracture. Further review of Resident #1's Electronic Medical Record (EMR) revealed her documented Pain Level Summary was between 0-3 prior to her fall on 3/13/26. After her fall on 3/13/26 at 2:30 p.m. Resident #1's pain level was documented on her incident report at a level 7. Further review of Resident #1's 3/13/26 Incident Report documented the resident's gait imbalance as a predisposing factor and documented, Agency CNA [Staff A, CNA] transferred resident with a walker and shoes but without a gait belt. Agency staff member was educated on the importance of using a gait belt during transfers after the incident occurred. The Incident Report also documented Staff A, CNA's statement she had provided on 3/13/26, which revealed the following: We [Staff A and Resident #1] were coming from the bathroom, going to the recliner. Resident was walking fast and realized she was past her recliner. She [Resident #1] went to turn towards the recliner and turned to fast, loosing her balance while turning, she started to fall. I [Staff A, CNA] was standing behind her and as she lost her balance she began falling. I put my arm behind her and tried to ease her to the ground. She twisted so fast that the momentum of her fall was fast. Her butt hit the floor first and then she laid her head back and hit her head on the leg of the chair next to her doorway. And then I yelled for help out the door. The local hospital's emergency department (ED) report with an initial patient evaluation time of 3/13/26 at 4:17 p.m. revealed the patient (Resident #1) stated she had a fall that day, stated that while trying to turn left with her walker she fell onto her right side. She presented with right elbow pain and an abrasion over the right elbow. She endorsed right knee pain and pain on the right side of the head. She reported she was unable to walk after the fall due to the severity of her pain. Further review of the local hospital records revealed a 3/13/26 at 6:38 p.m. CT (computed tomography) scan (a non-invasive medical imaging test that combined a series of X-ray views taken from various angles with computer processing to create cross-sectional images of bones, blood vessels, and soft tissues inside the body) that documented an acute displaced fracture of the right femoral neck (break in the right thigh bone near the hip joint, where the fractured bone pieces have shifted out of alignment). The local hospital records documented on Friday, 3/13/26 at 7:11 p.m. there was no orthopedic coverage over the weekend at that hospital, and Resident #1 needed to be transferred to another hospital. Later that evening at 8:38 p.m., another hospital was located that accepted the resident for the orthopedic surgery. Review of hospital records from the hospital Resident #1 transferred to documented an inpatient consultation on 3/13/26 at 9:18 p.m Records detailed Resident #1 was found to have acute displaced fracture of the right femoral neck, and was transferred to [Hospital Name Redacted] for orthopedic surgery. Further review of the hospital records revealed an Operative Note dated 3/14/26 at 10:22 a.m. during which the Physician documented that he had discussed with Resident #1 her medical findings and treatment options, including the risks, benefits, complications, and alternatives. Per the Operative Note, the resident understood and requested to proceed with hemiarthroplasty [partial joint replacement, a surgical procedure that replaces only one half of a damaged joint. Most commonly performed on the hip, it replaces the ball of the joint (the femoral head) while leaving the natural socket (acetabulum) intact). The admission Summary Note dated 3/17/26 at 1:00 p.m. revealed the resident was readmitted back to the facility. In an interview on 6/1/26 at 1:40 p.m. Resident #1 stated she had lived at the facility over a year. She recalled the fall she had on the afternoon of 3/13/26 when she used her walker, turned to quick, lost her balance and fell. She stated her pain was at a 7 or 8 at the time of the fall accident. She said she was taken to the local hospital by an ambulance and then transferred to a [City Redacted] hospital for surgery, stayed at the hospital for one week and then returned to the facility. She stated she had received therapy services at the facility when she returned. Observation on 6/2/26 at 1:03 p.m. revealed Staff D, CNA and Staff E, CNA assisted Resident #1 in her room while she was seated in her wheelchair. Staff D, CNA placed a gait belt around Resident #1's waist and Staff E, CNA placed the resident's walker in front of her. With a staff member on each side of the resident holding on to the gait belt, Resident #1 was assisted to a standing position on both of her legs. Once standing, Resident #1 used her walker and walked a few steps to her recliner with the two staff members grasping the gait belt with both of their hands. Resident #1 then turned slightly to position herself in front of her recliner and with both the staff members assistance sat down in her recliner. Staff D, CNA and Staff E, CNA were asked about the resident's transfer and walking ability and assistance required and they stated Resident #1's ability to transfer and walk had returned to the same level she had prior to her fall on 3/13/26. In an interview on 6/2/26 at 2:52 p.m., Staff F, CNA, revealed that she had worked at the facility as an agency CNA before she was hired by the facility as a CNA in November 2025. Staff F, CNA recalled that when she started working as an agency CNA at the facility, she was shown the paper Mini Care Plans her first day. Staff F, CNA was asked how the CNAs knew what interventions or assistance was needed for each resident, and she stated there was a three-ring binder at the nurses station that contained a hand-written, one-page Mini Care Plan for each resident. Staff F, CNA, stated she had not worked Friday, 3/13/26, but had worked the next day on Saturday, 3/14/26 and heard about Resident #1's fall that day. Per Staff F, there was always a gait belt on Resident #1's chair in her room.When asked regarding agency CNA staff, Staff F stated for agency CNA staff that were new to the facility, she oriented them by going over where the Mini Care Plans are located and we provide them a paper Cheat Sheet that the new agency CNA staff could carry with them to refer to when caring for the residents. She stated she had never worked with Staff A, CNA. In an interview on 6/2/26 at 3:56 p.m., Staff B, LPN, stated she had worked the second shift on 3/13/26 from 2:00 p.m. to 10:00 p.m., and that when Resident #1 had fallen she was getting the nursing report from the first shift nurse. Staff B recalled that when she entered Resident #1's room, the resident was sitting on the floor with her back against the wall and appeared razzled. Staff B stated she recalled the CNA (Staff A) in Resident #1's room was an agency staff member, but could not recall her name. Staff B stated she had asked the agency CNA (Staff A) where the gait belt was and Staff A replied that she had not used a gait belt. Staff B stated she assessed Resident #1 while the resident was on the floor and Resident #1 had stated my butt hurts. Staff B stated she and other staff moved the resident to her recliner and then to her bed. Resident #1 would not extend her right leg fully and Staff B stated she had called for an ambulance to transfer the resident to the local hospital. After the incident, Staff B recalled asking Staff A why she was not using a gait belt when she assisted Resident #1 with her transfer and ambulation (walking) and Staff B recalled seeing two gait belts in Resident #1's room at that time. Staff B stated she had said to Staff A there was no excuse not to use a gait belt, especially when ambulating a resident. Staff B explained Staff A, CNA had apologized for not using a gait belt. Staff B recalled provided education to Staff A after the incident. In an interview on 6/2/26 at 11:58 a.m. with the Director of Nursing (DON), when asked about the orientation provided for staff members working at the facility, the DON stated that no orientation checklist was completed with agency staff on their first assignment to the facility. The DON explained the facility had not done that with agency staff as the agency was responsible to send staff that were qualified to fill the positions that had been requested. The DON stated that on the first assignment of a CNA from a staffing agency to the facility, a CNA employed directly by the facility would provide a facility tour, show the new CNA where the gait belts, supplies, and Mini Care Plans for the residents were located, and provided a Cheat Sheet to the new CNA that they could carry with them to refer to during the shift. On 6/2/26 at 12:51 p.m., the DON explained after the incident on 3/13/26, she had posted a note for one month at the nurses' station that reminded staff to use gait belts and to review the resident care plan if they were unsure of that resident's transfer or ambulation status. Signatures were not collected. On 6/2/26 at 3:09 p.m., the DON stated the facility had developed the Cheat Sheets for new staff who needed something to refer to on the floor until they became comfortable with the residents' care needs. It was noted the Cheat Sheet listed the assistance level (independent, assist of 1 or 2 staff) needed for each residents' transfer, the assistive devices needed (walker, wheelchair, gait belt, type of mechanical lift), the residents' care information (glasses, dentures, hearing aids, and continence status), and products used (type and size of incontinent product, braces, compression wear, and protectors). In an interview on 6/3/2026 at 1:16 PM Staff G, Physical Therapist (PT) revealed Resident #1 had received therapy services prior to the 3/13/26 incident, from 1/19/26 to 3/13/26 three times a week. Therapy was working with Resident #1 on bed mobility, functional transfers, and ambulation for longer distances, 150-200 feet. Resident #1 was being discharged from her therapy services on 3/13/26 and Staff G stated she had met her bed mobility goal. Resident #1's functional transfer goal was to be able to transfer with stand-by assistance and clarified that meant the resident's goal was to be able to stand with staff standing beside her, but with no hands-on contact. Staff G stated she had not achieved that goal and for transfers Resident #1 was to be assisted with contact guard which she stated meant staff were to use a gait belt around the resident's waist and have their hands on that gait belt while she transferred. Resident #1's ambulation goal was not met which was for the resident to be independent walking on her own. Staff G confirmed that on 3/13/26 Resident #1's transfer and ambulation status was contact guard assist. On 6/3/26 at 1:59 p.m. Staff E, CNA, stated he had worked full time at the facility the past four years. Staff E stated he was familiar with Resident #1. He stated Resident #1 was able to walk short distances with the use of a walker while staff used a gait belt around her waist. Staff E explained he had always used a gait belt when he had assisted Resident #1 with transfers and walking and he had always seen other staff use a gait belt with Resident #1. Staff E pointed to the facility's Cheat Sheet which was in a binder at the nurses' station and to Resident #1's care information which indicated that she was a one to two staff assist with gait belt. On 6/1/26 at 4:52 p.m., the Administrator explained, in part, the following regarding the 3/13/26 incident: The Administrator revealed that the facility had not kept any Cheat Sheets from the time of the incident, but provided a current Cheat Sheet. The Administrator confirmed for Resident #1, one to two staff were needed to assist the resident with her transfers and ambulation, with staff use of a gait belt. When the Administrator was asked where the gait belts were located, she stated they were at the nurses station and in the resident rooms. On 6/3/26 at 3:17 p.m., the Administrator explained the root cause of the incident was that Staff A, CNA, had failed to use a gait belt as indicated on Resident #1's Mini Care Plan. Attempts to contact Staff A, CNA on 6/2/26 and 6/3/26 were unreturned prior to the exit of the survey. Review of the facility's Gait Belt policy reviewed on March 2011 revealed the standard directed, All employees providing direct resident care are required to utilize a gait belt whenever hand on assistance is needed for resident transfer and/or ambulation. The policy's rationale documented, In effort to ensure that residents and employees safety is protected during transfer and ambulation. The policy stated that the gait belt would be provided by the facility, was considered part of the employee's uniform, and was to remain in the facility. The policy further directed, All direct care staff are required to wear gait belt while on duty, and prior to transfer of a resident, staff member is to remove his/her gait belt and place it around the resident's waist, securing it with approximately one finger's space between the belt and the resident. The policy further directed staff to, Place any needed devices (walker, wheelchair, etc.) in proper position, and if transferring to a walker, make sure the resident is safely secured. The policy instructed staff that the gait belt be used to assist with walking a resident. It [the gait belt] can serve as a handle to grasp if the resident begins to fall. This can prevent a fall or control the resident's descent. Review of the facility Plan of Care Policy revised 2024 revealed, Plans of care, referred to a Mini Careplans, are to assure staff has the appropriate information to provide care. The policy informed staff all mini careplans were available in binders at both nurses desks.

Based on staff interview, clinical record review, and facility policy review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days unless the prescribing practitioner documented a rationale to extend medication for 1 of 5 residents reviewed for unnecessary medications (Resident #34). The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Review of the resident's diagnoses per the MDS included cancer, non-Alzheimer's dementia, Cerebrovascular Accident (CVA or stroke), anxiety disorder, and adult failure to thrive. Review of the Care Plan Focus area initiated on 12/30/25 for Resident #34's use of the psychotropic medication revealed the following: The resident used Lorazepam, related to anxiety disorder, with times of yelling out to peers/staff, insomnia, non-sensical speech, and fixation on health. The Care Plan identified the resident currently took Lorazepam 0.5 milligrams (mg) twice per day as needed. Interventions included the following, in part: a. Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness after given. Date initiated: 1/15/26. b. Abnormal Involuntary Movement Scale (AIMS) test every 6 months. Date initiated: 1/23/26. c. Consult with Hospice as needed. Date initiated: 2/03/26. d. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of Lorazepam. Date initiated: 1/15/26. e. Monitor the resident for significant adverse drug reactions with anti-anxiety medication. Date initiated: 1/15/26. Review of a Nurse's Note dated 12/30/25 at 1:40 PM revealed Resident #34 had agitation and aggression noted and new order received for 0.5 mg of Lorazepam twice a day as needed was processed. The Nurse's Note dated 2/12/26 at 11:13 AM revealed the Hospice nurse visited and the facility received a new order to increase Resident #34's Lorazepam to 0.5 mg every 4 hours as needed for increased unusual behaviors. Review of Resident #34's Medication Administration Record (MAR) dated March 2026 revealed a current order for Lorazepam (Ativan) 0.5 mg, with instructions to give 1 tablet every 4 hours as needed (order dated 2/16/26). Lorazepam 0.5 mg was given multiple times in the month for agitation, anxiety, and restlessness. Review of Resident #34's Electronic Health Record (EHR) lacked documentation of physician rationale to extend the order for Lorazepam 0.5 mg as needed for greater than 14 days. During an interview on 3/12/26 at 1:18 PM, Staff E, Licensed Practical Nurse (LPN) reported Resident #34 started the Lorazepam 0.5 mg on 12/30/25 and was increased by Hospice. Staff E stated the resident's as needed Lorazepam was minimally effective in treating Resident #34's symptoms of anxiety, restlessness, and agitation unless given early or as soon as symptoms started. On 3/12/26 at 3:30 PM, the Facility Administrator denied documentation related to physician indication to continue Resident #34's Lorazepam 0.5 mg as needed past 14 days. The facility policy titled Drug Regimen Review Policy, undated, revealed the objective of the drug regimen review policy was to try to minimize or prevent adverse consequences or to prevent residents from receiving unnecessary drugs.

Based on staff interview, clinical record review and facility policy review, the facility failed to obtain consent to administer psychotropic medications taken by 1 of 5 residents reviewed for unnecessary medications (Resident #9). The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 12/23/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included Alzheimer's Disease, Cerebrovascular Accident (CVA or stroke), seizure disorder, anxiety disorder, and psychotic disorder. Resident #9 used the following high-risk medications: antipsychotic, antianxiety, antidepressant, and anticonvulsant. Review of the Care Plan initiated 3/12/25 revealed a Focus area for psychotropic medication use related to diagnoses of anxiety, dementia, frontal lobe meningioma (brain tumor), and psychotic disorder. The Care Plan indicated that Resident #9 was currently took Buspirone (medication used to treat anxiety disorders). Interventions included, in part: a. Administer meds as per physician orders. Date initiated 3/12/25.b. Abnormal Involuntary Movement Scale (AIMS) test every 6 months. Date initiated: 9/25/25. c. Consult with Pharmacy for medication review as needed. Date initiated 3/12/25. d. Gradual Dose Reduction (GDR) as per physician when deemed appropriate. Date initiated 3/12/25. e. Monitor exacerbation of mood or behavior issues or acute changes and notify physician as needed. Date initiated 3/12/25. f. Monitor for potential significant side effects antianxiety and antipsychotic medications and notify physician of abnormal as needed. Date initiated: 3/12/25. Review of Resident #9's Medication Administration Records (MAR) between the dates of March 2025 and March 2026 revealed the following psychotropic medications and dose changes for the resident's medications: 1. Buspirone (Buspar) tablet 5 milligrams (mg), with instructions to give 1 tablet by mouth three times a day for Generalized Anxiety Disorder. Date initiated: 3/03/25a. Increase in Buspirone to 10 mg, with instructions to give 1 tablet three times a day. Start date: 5/09/25.b. Decrease in Buspirone to 7.5 mg, with instructions to give half a 15 mg tablet (7.5 mg) three times a day. Start date: 12/02/25. 2. Quetiapine (Seroquel) tablet 25 mg, with instructions to give one tablet by mouth at bedtime for dementia. Date initiated: 3/03/25a. Decrease in Quetiapine to 12.5 mg at bedtime, between the dates of 4/08/25 and 4/21/25, then discontinue (stop) medication on 4/22/25. b. Restart Quetiapine 12.5 mg, with instructions to give 12.5 mg daily. Start date: 9/26/25. 3. Citalopram (Celexa) tablet 10 mg, with instructions to give one tablet by mouth daily for anxiety/depression. Date initiated: 7/31/25. a. Increase Citalopram to 20 mg, with instructions to give 20 mg by mouth daily. Start date: 9/16/25. Review of the facility provided document titled Psychotropic Medication Therapy Informed Consent Form revealed the following:1. Resident #9 signed consent on 3/03/25 to receive the antianxiety medication Buspirone 5 mg three times a day for anxiety/irritability. The medical records lacked documentation of consent obtained when dosage was increased to 10 mg three times a day on 5/09/25. 2. Resident #9 signed consent on 3/03/25 to receive the antipsychotic medication Quetiapine 25 mg daily for dementia with behavioral disturbance. The medical records lacked documentation of consent obtained following restarted Quetiapine 12.5 mg daily on 9/26/25.3. Resident #9's medical records lacked documentation of consent obtained for the antidepressant medication Citalopram 10 mg daily, ordered for depression, or consent obtained when Citalopram increased to 20 mg daily. On 3/12/25 at 2:22 PM, the Director of Nursing (DON) stated the normal process for psychotropic medication consents included obtaining consent from a resident or resident representative upon admission, after discussing potential side effects. The DON explained also was done intermittently when there were changes in medication dosage or if side effects were observed. The DON denied having documentation of psychotropic medication consents obtained for Resident #9's Citalopram started, increased Buspirone dosage, or restarted Quetiapine. Review of the facility policy titled Residents' [NAME] of Rights revised 11/2016 revealed the following per Section C. Planning and Implementing Care: The Resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. (5) The right to be informed in advance, by the physician or other practitioner, or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Based on clinical record review, staff interview and policy review the facility failed to complete a comprehensive assessment and evaluation of a resident for readmission to the facility after hospitalization for 1 of 3 residents reviewed for discharge (Resident #48). The facility reported a census of 40 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 revealed the resident admitted to the facility on [DATE]. The MDS assessment dated [DATE] for Resident #48 documented an unplanned discharge to a short term general hospital, with return not anticipated. Diagnoses included urinary tract infection over last 30 days, depression and vascular dementia.A Baseline Care plan initiated 1/9/26 documented Resident #48 admitted from the hospital with the goal to return home after therapy goals were met. Resident #48 was alert and oriented to self, and confused. The discharge goal revealed to remain at Long Term Care (LTC) setting. Resident #48 required assist of one with transfer, bathing, grooming, and locomotion on and off the unit. The resident used a walker. A Physical Therapy Evaluation and Plan of Treatment for Resident #48 beginning 1/9/26 documented the resident was referred by neurologist for skilled therapy after hospitalization for acute cystitis (bladder infection) and weakness. The resident was expected to transition to Long Term Care (LTC) after skilled therapy. Complexities included acute cystitis, legal blindness, heart disease, stroke and vascular dementia. The Transition/Discharge section of the form revealed the resident was to reside in the LTC facility.The admission Summary Note dated 1/9/26 at 12:20 PM revealed the resident admitted to the facility, was alert, and was pleasantly confused. The Nurse's Note dated 1/10/26 at 12:41 AM revealed the Resident #48 was able to make their needs known and denied pain. The Nurse's Note dated 1/10/26 at 12:55 PM revealed the resident required reminders to use call light and to not transfer independently. The Nurse's Note dated 1/10/26 at 3:58 PM revealed the resident's family visited, and the resident rested in a chair. The Nurse's Note dated 1/11/26 at 2:33 AM revealed Resident #48 rested quietly in bed, voiced no complaints, and was able to make their needs known. The Nurse's Note dated 1/11/26 at 9:50 AM revealed the resident required assist of one with cares and required cues and reminders from staff. The Nurse's Note dated 1/12/26 at 4:45 AM documented Resident #48 refused to get up to bathroom, and stated, I dont get up at night. Per the Nurse's Note, incontinence care was provided, and the resident was pleasant and cooperative.The Nurse's Note dated 1/12/26 at 8:00 AM revealed the resident was slightly non-compliant with morning cares and dressing, with assist of two (staff) used. The Nurse's Note further revealed the resident yelled in the main dining room that she did not belong [at facility] and insisted on going home right now. The resident mimicked staff, yelled at staff, and tried to kick and swing at staff. The resident attempted to push their chair into other residents, refused to eat breakfast, and was noncompliant with therapies. The Nurse's Note further revealed the resident was placed in her room and was offered to sit in her recliner. The resident refused, and yelled to get her out of here right now. The resident was left alone to calm, and was checked on frequently from the doorway. The Nurse's Note later in the day at 10:00 AM revealed the resident said no thank you to the offer of her recliner.The Nurse's Note dated 1/12/26 at 1:27 PM revealed the resident had a new order to obtain a urinalysis. Per the Nurse's Note dated 1/13/26 at 1:30 AM, the resident's urine specimen was obtained. The Nurse's Note dated 1/13/26 at 7:45 AM revealed the resident refused medication and spit them out two attempts. The resident demanded to go back to their room.The Nurse's Note dated 1/13/26 at 8:10 AM revealed the resident was observed in their room in their wheelchair with the wheelchair tipped backwards. The handle bars of the wheelchair prevented the resident's head from being on the floor. The Nurse's Note dated 1/13/26 at 8:45 AM revealed the resident wanted to leave, staff tried to talk with her, and the nurse instructed to go ahead and have 911 paged. The Nurse's Note dated 1/13/26 at 9:15 AM revealed notification to the resident's family that facility was sending resident to the hospital for acute behavior changes, and that the facility and would be discharging the resident that day. Per the Nurse's Note, the facility was unable to accommodate a female admission in memory care at that time. A Discharge Summary form for Resident #48 for admission on [DATE] and discharge on [DATE] revealed the resident was discharged related to inappropriate behaviors, and no beds in the memory care unit for a female. Per the form, the resident was discharged to [redacted name] hospital. The Additional Comments section of the form revealed the resident had increased agitation and aggression towards staff, and tossed trays of food. It further revealed the resident refused care, hit, scratched, put their feet on dining room tables, and yelled. The Additional Comments section further noted the resident made unsafe choices as tried to get up and ambulate. The resident was sent to check for acute causes of mental status change. The Additional Comments section further revealed no memory care beds were available for females, and unable to readmit. A Physical Therapy (PT) Discharge Summary for dates of service 1/9/26 to 1/12/26 revealed Resident #48's discharge location was unknown. Per the PT Discharge Summary, the resident was discharged unexpectantly due to noncompliance and insistence on leaving the facility.An Emergency Involuntary Discharge letter dated 1/13/26, signed by the Administrator, was faxed to the hospital. The Emergency Involuntary Discharge letter documented the facility sought to discharge the resident from the facility because her discharge was mandated to protect the health, safety, or well-being of other residents and staff. The Emergency Involuntary Discharge letter revealed Resident #48 was being discharged to [hospital name redacted] Emergency Department (ED) on 1/13/26. On 3/10/26 at 1:48 PM the hospital Social Worker (SW) explained the nursing facility relayed would not accept Resident #48 back to the facility. The SW relayed during hospitalization that Resident #48 did not have such agitation as reported, and further relayed resident was sassy and not trusting. Per the Hospital SW, it would subside and the resident took medication as ordered. The SW relayed the hospital did have to keep the resident longer than required related to obstacles of finding another facility. Resident #48 was treated for respiratory infection and did release to another nursing facility. On 3/12/26 at 10:40 AM the Director of Nursing (DON) revealed Resident #48 admitted from the hospital to the facility, and no behaviors reported. The first few days, the resident ate in her room. The resident did agreed to come to the dining room then yelled, and said didn't belong, take me home. The resident refused the meal. The next day, agreed again to go to the dining room, and became very angry and belligerent. Staff tried change of environment to the memory care unit for increased one to one. The DON recalled on Resident #48's last day at the facility that Staff A, Licensed Practical Nurse (LPN), the DON and the Administrator attempted to calm the resident who stood up and held on the nurse's counter. The resident would not follow direction, held onto staff, did not believe hit staff and did not hit another resident. The DON relayed Resident #48 was very difficult, aggressive, threw her food tray while in her room, and was unwitnessed. The DON reported the Administrator decided to send Resident #48 to the hospital and discharged resident from the facility. On 3/12/26 at 11:00 AM Staff A relayed knew Resident #48 worked with therapy, and recalled a day at breakfast that Resident #48 was upset, agitated, and unable to console. The resident had abruptly stood up from the wheelchair, tried to get her (resident) to sit, would not, and hung on to staff. Per Staff A, got the gait belt on with difficulty, and finally got resident to sit and took back to room. Per Staff A, Resident #48 grabbed staff, did not hit, and just hung on to the nurse's station and the nurses. Staff A agreed sometimes would see similar behaviors with an infection, and thought staff attempted to rule that out. Staff A relayed was able to get Resident #48 to her room to calm her, and attempted with different staff to calm. The Administrator tried to calm than decided to just send her out. On 3/12/26 at 11:10 AM, Staff B, CNA relayed when Resident #48 arrived, the resident was friendly and compliant. Then, within a few days, would yell out. Staff B explained knew the resident was confused, and the resident talked about leaving. Staff B, relayed the day Resident #48 left, she was fine in the morning. The resident was taken to the dining room, got angry, yelled, and kicked at the table. Interview with Staff B revealed the resident did not strike at residents or staff just the table. The resident was loud so took her back to her room to avoid a resident to resident interaction. Per Staff B, made sure she had her food tray, her call light, and left her to calm. Maintenance staff viewed Resident #48 in room and (the resident) had tipped the wheelchair backwards, and she (resident) had flung her tray of food everywhere. The Nurses came to assess, brought the resident to the nurse's station, could not calm her, and resident was sent out to the hospital shortly after. On 3/12/26 at 11:20 AM, Staff C, CNA relayed Resident #48 got dressed for staff, and had no aggression until she came to the dining room. Per Staff C, the resident was aggressive, explained as not towards others, and the resident wanted to leave. Resident #48 pushed at the chairs and table, said didn't belong here, and was loud and disruptive. Other residents were about to eat. Per Staff C, tried to calm (resident)at the table, would not listen to any staff. Resident #48 was taken back to her room with room tray and access to call light. Per Staff C, shortly after was called to the room because resident had thrown ice in the hall, and the tray and food were on the floor. Resident #48 was brought back to dining room, felt calmed a little bit, then was sent to the hospital. On 3/12/26 at 11:32 AM, Staff D, Registered Nurse (RN) relayed first time they met Resident #48 was the day she left. On that morning the resident sat on bedside, and agreed to vitals except refused the blood pressure. Staff D further explained the also refused the standard COVID test for new residents. Per Staff D, let her be, and was aware got a urine sample and had tried to get blood. Staff D explained had wondered if (resident) had a UTI with the confusion. At 7:45 AM Resident #48 was at the breakfast table, agreed to take medications, then spit them out. Resident #48 said someone bumped their foot, not seen that, resident was flexible, and put her leg up on the dining room table. The resident got mad, and demanded (go) back to room. Staff D explained resident was taken back, given a tray of food, and call light. Staff D relayed at 8:10 AM the maintenance staff summoned nurses because Resident #48 tipped the chair over. Food and drink were everywhere, and couldn't say if she (resident) threw the food tray or bumped it over. Per Staff D, tried to assess the resident, and the resident swatted at Staff D. The resident struck out and wanted to be left alone, wouldn't let anyone assess. The resident knew her name, and was confused and wanted her husband who passed. Resident #48 was brought up front for the DON to sit with her. The Administrator and the DON and Nurse, Staff A were there and got a gait belt because resident wanted to walk, which made her more agitated, and was taken back to resident's room. The Administrator directed a nurse to call 911 to send her out because she was so agitated, and had a standing orders to send out. The paramedic came and resident in agreement to a ride. Per Staff D, it was communicated did not have urinalysis results back. Staff D confirmed the facility did have residents with dementia throughout the facility as well as in the memory care unit, and sometimes residents waited in the regular halls and moved back to the unit with availability. On 3/12/26 at 12:25 PM the Administrator relayed felt could not accommodate Resident #48, and felt needed the memory care unit. The Administrator explained the facility did not have an open bed, and due to the behaviors, could not have Resident #48 return. The Administrator acknowledged did not reassess after Resident #48 was sent to the hospital. The Administrator explained the Physician was notified after the resident was transferred. The Facility Assessment updated 2/20/26 documented the facility did accept residents with or that may develop complex care and management. This included residents with psychiatric, mood disorders with common diagnoses of impaired cognition, metal disorders, and behaviors that needed interventions. The Facility Assessment further revealed the average or range of residents with mental health/behavioral health needs equaled 21. Per the assessment, on occasion the facility had residents that required temporary one on one supervision, and at those times, had increased staffing to accommodate.

Based on time card review, schedule review, and staff interview, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. The facility reported a census of 44 residents. Finding include: Review of all Nursing Schedules from 7/1/2024 thru 9/30/2024 and Time Card Punches from 7/1/2024 thru 8/18/2024 revealed the facility failed to staff an RN for 8 consecutive hours on the following dates: 7/6/24, 7/7/24, 8/4/24, 8/17/24, and 8/18/24. During an interview on 3/5/25 at 2:47 PM, the Administrator revealed the facility uses an accounting company to submit all Payroll Based Journal staffing data. The accounting company emailed the Administrator a report reflecting the staffing data submitted. A Review of the Payroll Based Journal Quarterly Analysis from the accounting company for the period of 7/1/2024 to 9/30/2024 submitted documented the total number of days with no RN coverage for the quarter to be 5 days. The identified dates are 7/6/2024, 7/7/2024, 8/4/2024, 8/17/2024 and 8/18/2024. On 3/6/25 at 10:50 AM, the administrator acknowledged there were no RN's working in the facility for 8 consecutive hours on the identified dates.

Based on review of the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the quarter of July 1, 2024 - September 30, 2024, facility staffing reports, and staff interviews the facility failed to submit accurate staffing reports for the PBJ Staffing Data Report. The facility reported a census of 44 residents. Findings include: The PBJ Staffing Data Report with a run date of 2/26/25 triggered for excessively low weekend staffing (submitted weekend staffing data is excessively low). A review of the schedules for the months of July 2024, August 2024, and September 2024 revealed nursing shifts covered by facility employee and outside staffing agencies. During an interview on 3/5/24 at 2:47 PM, the Administrator revealed the facility utilized an outside accounting company to submit the PBJ staffing data. The Administrator acknowledged data provided to the accounting company comes from the Administrator and a corporate administrative assistant. The Administrator revealed prior to the accounting company submitting the data, a preliminary report had been provided to the facility. The Administrator had the opportunity to review the report for any discrepancies and correct any discrepancies identified. On 3/6/25 at 10:14 AM the Administrator acknowledged the submitted report did not accurately reflect the facility staffing for quarter 4. The Staffing Data Submission Payroll Based Journal website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission), provides information on how data is collected and who to contact for questions. The deadlines for reporting staffing data are: Fiscal Quarter Reporting Period Due Date 1 October 1- December 31 February 14 2 January 1 - March 31 May 15 3 April 1 - June 30 August 14 4 July 1 - September 31 November 14 Users are strongly encouraged to take additional steps after uploading their data to ensure a successful submission. Therefore, the following verbiage appears upon uploading data to reflect the recommended next steps: 1. Check the My Submissions page. This feature will show the status of the zip file. 2. Check CASPER for a system generated PBJ Final File Validation Report (FFVR) within 24 hours. If no FFVR appears, run a PBJ Submitter Final File Validation Report to check your file for errors. 3. Run the PBJ 1702D (by Employer) or 1703D (by Job Type) Reports to verify the quarterly PBJ data reflects your records. 4. For additional assistance contact the Quality Improvement and Evaluation System (QIES) Help desk at iqies@cms.hhs.gov.

Based on clinical record review, policy review, and staff interview the facility failed to follow the Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Schedule for pneumococcal vaccination for 1 of 5 residents sampled (Resident #31). Findings include: Resident #31 Electronic Healthcare Record (EHR) Census documented admission to the facility on [DATE]. Resident #31 EHR Immunization Record showed Resident #31 received the pneumococcal polysaccharide (PPSV) 23 vaccination on 11/01/21 at the age of 53. A review of the EHR Progress Notes, Miscellaneous documentation and paper medical chart lacked documentation of receiving a pneumococcal conjugate (PCV) 15, 20 or 21 vaccination. A Pneumococcal Vaccine Informed Consent Form signed by Resident #31's family member on 10/25/22 documented consent for the facility to administer a Pneumococcal Conjugate (PCV) 20 vaccination. The CDC 2025 Adult Immunization Schedule for Pneumococcal Vaccination for adults age 50 or over directed when PPSV23 is the only pneumococcal vaccination received, then one dose of PCV15, PCV20, or PCV21 should be offered at least 1 year after the last PPSV23 dose. On 3/05/25 at 4:10 PM the facility provided a undated document titled Pneumococcal Vaccination for Patients 50 to less than [AGE] years of age that had a circle in the category of PCV 13 (at any age) and PPSV23 at less than [AGE] years of age indicating Resident #31 required a PCV in five years from the last pneumococcal vaccination. The Document for PPSV 23 only (at any age) had the recommendation for PCV 20 or PCV 21 to be administered at 1 year or greater after the PPSV 23 vaccination. Interview on 3/06/25 at 7:40 AM with the MDS Coordinator reported she had received the Pneumococcal Vaccination Document from the pharmacy. The pharmacy reported Resident #31 was not due for a PCV vaccination until 2026. She did not know the year or information the recommendation was based on. Interview on 3/06/35 at 7:43 AM the Director of Nursing (DON) reported the facility didn't know if Resident #31 had received the PCV 13 vaccination prior to admission to the facility. Resident #31 admitted from a nursing home in another state and they had asked the family, but the family didn't know her vaccination status. On 3/06/25 at 10:35 AM the Assistant Director of Nursing (ADON) reported they were checking on the resident's pneumococcal status with the prior nursing home which is out of state and hadn't heard anything back yet. During an interview on 3/06/25 at 10:55 AM the ADON reported she reviews the Immunization Registry Information System (the IRIS system is a computerized tracking system of immunizations for adults who are seen in a variety of public and private health care provider sites throughout the state of Iowa), and hospital EHR records for any vaccinations that may have been done at a physicians visit. She had not been aware of the 2025 CDC pneumococcal (vaccination) schedule changes and the facility just ordered the updated consent forms today. She further stated all residents are to be offered the pneumococcal vaccinations. If a resident admits and doesn't have a record of updated pneumococcal vaccinations, they would address that. On 3/06/25 at 11:15 AM the DON voiced she expects the CDC to be followed regarding pneumococcal vaccinations. During an interview on 3/06/25 at 11:40 AM the Administrator voiced if a resident's vaccination status is unknown, then they need to proceed to ensure the correct vaccinations are offered. The Pneumococcal Policy, undated, provided by the facility directed a pneumococcal vaccination and education would be offered on admission, regardless if long or short term stay resident following the current recommendations by the CDC or the Iowa Department of Public Health. The Procedure further outlined as appropriate, residents will be offered the opportunity to receive a one-time dose of vaccine for pneumococcal pneumonia after the age of 65; or per the recommendations by the CDC or Iowa Department of Public Health. Each time the facility offers immunizations they will provide the education regarding the benefits and potential side effects of the immunizations to the resident/legal guardian, whether or not the resident elects to receive the immunization.

Based on document review, policy review, and staff interview, the facility failed to utilize a grievance form to address missing resident items for 1 of 2 residents sampled (Resident #40). The facility reported a census of 44 residents. Findings include: Resident #40's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS documented Resident #40 with adequate vision and hearing and able to understand others and be understood. The 1/23/25 Resident Council Meeting Note detailed Resident #40 missing a Black Iowa Select hooded sweatshirt. The 2/11/25 Resident Council Meeting Note documented Resident #40 continued to be missing a Black hooded Iowa Select sweatshirt. During an interview on 3/4/25 at 1:41 PM the Administrator reported they review for lost items during the Resident Council Meetings, then work with laundry to go through all residents' closets to search for the missing items. She reported Resident #40 sweatshirt had not been found, but Resident #40 has a family member that does take some items home. She reported they had not followed up with the family as they didn't think anyone would want to steal a sweatshirt. On 3/05/25 at 2:05 PM the Administrator responded she had called the family and they could not recall if the sweatshirt had been brought in. They searched the donated clothes, closets, and everywhere and were unable to find it, but Resident #40 is pretty sure she had it at the facility. The Administrator reported they would start using the grievance policy and forms to address any missing laundry items. During an interview on 3/06/25 at 7:45 AM Staff B Licensed Practical Nurse (LPN) recalled Resident #40 had worn a black hooded sweatshirt and reported it missing a few months ago back in January (2025). She had not seen the resident wearing the sweatshirt in a few months. She reported Resident #40 had the black hooded sweatshirt at the facility. On 3/06/25 at 9:05 AM Resident #40 reported she is still missing the black hooded sweatshirt. It was black with white writing Iowa Select Farms on the front. She had been told by laundry that they had searched every closet. She reported her family does not swap her clothing in and out and no one in the family could wear the sweatshirt. The sweatshirt was not in poor repair or stained. Resident #40 further stated the facility really couldn't replace the items because it was a gift she had been given and it meant something to her. On 3/06/25 at 9:15 PM the Laundry Supervisor reported they did not have a grievance form made out for the loss of Resident #40 sweatshirt. She reported they looked all over the facility for the sweatshirt and it was not found. Staff C, housekeeping stated the resident goes out of the facility a lot and she told the resident that she (resident) may have to search the car or see if the sweatshirt had been left somewhere on one of her outings as they had searched everywhere for it. During an interview on 3/06/25 at 9:25 AM the Administrator reported the facility is so small and up to this point they had always found missing items, so there was no need to have a paper trail on anything. She acknowledged the facility had not completed a grievance form or done any more follow-up after they couldn't locate the missing item. She reported she had talked with Resident #40 right before this interview and the resident said the items could not be replaced as it was a gift unless she wanted to replace it with a facility logo sweatshirt. On 3/06/25 at 10:52 AM the Assistant Director of Nursing (ADON)/Admission Nurse reviewed Resident #40 electronic chat and her paper medical chart. She verbalized she could not find the resident's inventory (belongings) sheet. The 2021 Grievance Policy specified that completed forms could be slid under the office door of the Administrator for anonymity, or could be given to any staff member to be directed to the Administrator. The Administrator would review the Concern Form and forward it to the appropriate department head with a time frame for completion. The completed Concern Form (including response) would be filed in the Administrative Office and kept for no less than one year. No more than 10 business days would pass between the initiation of the form and the return of the completed form, unless there was documented communication with the involved parties. The Policy further specified all complaints will be addressed whether it is through the formal written procedure or merely verbalized complaints.

Based on clinical record review and staff interview the facility failed to inform the Long-Term Care (LTC) Ombudsman office of a resident hospitalized for 2 of 2 residents reviewed (Resident #4 and Resident #46). The facility reported a census of 44 residents. Findings include: 1. Resident #4 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. The MDS listed diagnoses of non-traumatic brain dysfunction (damage to the brain by internal factors), diabetes mellitus, and Non-Alzheimer's Dementia. A review of the Electronic Health Record Census Detail page for Resident #4 revealed Resident #4 had been hospitalized from 12/24/2025 to 12/27/2025 and from 1/31/2025 to 2/6/2025. A Progress Note dated 12/24/2024 a 10:44 PM, documented the hospital called to inform the facility that Resident #4 had been admitted . On 12/27/24 at 3:44 the Progress Notes revealed Resident #4 had been readmitted to the facility. A Progress Note dated 1/31/2025 at 10:40 AM documented Resident #4 had been transferred to the hospital. A Progress Note dated 2/6/2025 at 4:50 PM revealed Resident #4 had been readmitted to the skilled nursing facility. A review of the Notice of Transfer Form to Long Term Care Ombudsman dated December 2024 and January 2025 lacked documentation the LTC Ombudsman Office had been notified of Resident #4 transfers to the hospital. The Notice of Transfer Form for December contained notification of resident transfers from 12/5/24 to 12/29/24. The Notice of Transfer Form for January contained notification of resident transfers from 1/2/25 to 1/30/25. During an interview on 3/4/2025 at 3:38 PM, the Administrator acknowledged Staff A, Assistant Director of Nursing (ADON)/Admission Nurse had been responsible for sending the notifications to the LTC Ombudsman. The Administrator acknowledged notifications to the LTC Ombudsman had not been completed for any hospitalized residents. On 3/6/2024 at 10:46 AM, Staff A, ADON/Admission Nurse acknowledged she failed to submit the required notification to the LTC Ombudsman for all hospitalized residents. The facility failed to provide a policy for the required notification to the LTC Ombudsman for resident transfers and discharges. 42133 2. Resident #46 MDS dated [DATE] showed a BIMS score of 3 out of 15 indicating severe cognitive loss. The MDS listed diagnoses of cancer, urinary tract infection in the past 30 days, Non-Alzheimer's Dementia, and other fracture. A Review of Resident #46 Electronic Medical Record Census documented Resident #46 out to the hospital on 2/21/25 and returned to the facility on [DATE]. A 2/21/25 5:30 PM Progress Note documented the local ambulance arrived at 5:30 PM and transported Resident #46 to a local hospital emergency department. A 2/25/25 Admission Summary Progress Note documented Resident #46 returned to the facility. Review of the February 2025 Notice of Transfer Form to the LTC Ombudsman Form lacked documentation the LTC Ombudsman Office had been notified of Resident #46 transfer to the hospital. The Notice of Transfer Form contained notification of resident transfers from 2/4/25 to 2/26/25.

Based on clinical record review, Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 User's Manual, Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Vaccination Schedule, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the health status of 1 of 5 residents reviewed for pneumococcal immunizations (Resident #31). The facility identified a census of 44 residents. Findings include: Resident #31 Electronic Health Record (HER) Census documented admission to the facility on [DATE]. Resident #31 EHR Immunization Record showed Resident #31 received the pneumococcal polysaccharide (PPSV)23 vaccination on 11/01/21 at the age of 53. The Immunization Record lacked documentation of any other Pneumococcal Vaccination received by the resident. The CDC 2025 Adult Immunization Schedule for Pneumococcal Vaccination for adults age 50 or over directed when PPSV23 is the only pneumococcal vaccination received, then one dose of PCV15, PCV20, or PCV21 should be offered at least 1 year after the last PPSV23 dose. Resident #31 MDS assessment dated [DATE] documented Resident #31 in a persistent vegetative state with a diagnosis of cerebral palsy. The MDS further documented Resident #31 pneumococcal vaccination status as up to date. During an interview on 3/06/25 at 10:35 AM the MDS Coordinator explained she checks the residents EHR immunization record and reviews documentation in the resident's paper chart to see if the resident is up to date on the pneumococcal vaccination before coding the MDS. She voiced she had a call out to Resident #31 prior nursing home to see if they had records of Resident #31 vaccination status prior to coming to their facility. On 3/06/25 at 11:35 AM the MDS Coordinator reported she uses the RAI to code the MDS assessment. The LTC RAI 3.0 User's Manual, Version 1.19.1, October 2024 on Page 1-4 directs the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. Page O-17 under Coding Tips defines Up to date means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations. The ACIP develops recommendations on how to use vaccines to control disease in the United States and makes recommendations to the CDC Director. The 2025 Adult Immunization Schedule was adopted by the CDC Director on 10/24/24.

Based on interview and record review, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage daily (in a 24 hour period). The facility reported a census of 51 residents. Findings include: On 4/17/24 at 12:42 p.m., reviewed March 2024 and April 1-19/2024 schedules. Noted 3 days (4/6/24, 4/13/24 and 4/14/24) did not have 8 consecutive hours of RN coverage. On 4/17/24 at 12:50 p.m., the Licensed Nursing Home Administrator (LNHA), stated that the RN scheduled for 8 hours on 4/6/24, had to leave at 11:00 a.m., and was relieved by a Licensed Practical Nurse (LPN). The LNHA stated that the RN worked from 6:00 a.m. to 11:00 a.m. which left the facility short of the 8 hour RN coverage for that day. The LNHA stated that on 4/12/24 an agency nurse came in at 10:00 p.m. and worked through the night until 6:00 a.m. on 4/13/24. She stated the agency RN worked 6 hours from midnight (12:00 a.m.) on 4/13/24 to 6:00 a.m (6 hours), but that still left them short of the required 8 hours of RN coverage on 4/13/24. On 4/14/24, the LNHA stated there was no RN coverage for this day. The LNHA stated that LPN's covered the rest of the shifts in the 24 hour periods on 4/6/24 and 4/13/24. She stated LPN's covered all of the shifts on 4/14/24. Punch detail on 4/6/24, documented that Staff A, RN punched in at 5:58 a.m. and punched out at 11:41 a.m. An undated print out provided by the LNHA, documented that an agency RN worked from 9:00 p.m. to 6:00 a.m. The LNHA identified that this is the agency RN that came in on 4/12/24 p.m. and clocked out on 4/13/24 a.m. An undated RN Staffing Policy directed that: As per Medicare standard, (this facility) will maintain RN staffing hours for 8 consecutive hours per 24 hour period. The 24 hour period starts at midnight each calendar day.

Based on observations, interviews, and record review, the facility failed to follow a physician's order for 1 of 1 residents reviewed with a tube feeding (Resident #39). Resident #39 was ordered to have water every 2 hours through her PEG (percutaneous endoscopic gastrostomy) tube (a flexible feeding tube inserted through the abdominal wall and into the stomach for nutritional support). This resident received the water every hour. The facility reported a census of 51 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that Resident #39's diagnoses included Cerebral Palsy, seizure disorder and gastrostomy status. It documented that Resident #39 had a feeding tube. A Routine Medication record dated 4/1/24 to 4/30/24, directed staff that Resident #39 was to have her PEG tube flushed every 2 hours. It documented to auto flush through the pump. Admission Orders dated 2/25/24, directed staff to flush PEG tube with 30 cc (cubic centimeters) every 2 hours. Auto flush with pump. A Progress Note dated 4/6/24 at 3:00 p.m., documented that the pump was switched out and the recently used pump was sent to the supplier to be recalibrated. On 4/16/24 at 11:38 AM, Staff A Registered Nurse (RN), stated they are supposed to run water after the tube feeding at 30 cc (cubic centimeters) an hour. She was unable to find the order on the Routine Medication record. On 4/16/24 at 12:00 PM, Staff A stated the machine is calibrated to automatically run the flush. Staff A pointed out in the Medication Record the resident was to receive a 30 cc flush every 2 hours. Visualization of the machine at this time revealed the machine was running the flush at 30 cc every hour instead of every 2 hours. Staff A acknowledged that the rate should be every 2 hours instead of every 1 hour. On 4/16/24 at 12:02 PM, the Director of Nursing (DON), stated the pump was changed last week and it was sent to be recalibrated. This DON stated that the new pump may have been set up incorrectly when the facility calibrated the new pump. On 4/16/24 at 12:21 PM, the Licensed Nursing Home Administrator (LNHA), stated that they had taken care of the pump issue. She stated that they recalibrated the pump to reflect the current order. This LNHA acknowledged that they had calibrated the pump wrong. An undated Physician Order Policy and Procedure, directed that all physician's orders must be accurately transcribed.

Based on interviews and record reviews, the facility failed to provide the bed hold policy for 1 of 2 residents reviewed (Resident #39). On 12/8/23 Resident #39 was sent to the hospital for seizures. A bed hold policy was not discussed/given to Resident #39's representative. The facility reported a census of 51 Residents. Findings include: A Census page for Resident #39 documented to stop billing on 12/8/23. A Progress Note dated 12/8/23 at 1:00 p.m., documented that this resident was loaded into the ambulance for seizure activity. A Progress Note dated 12/11/23 at 2:35 p.m., documented that this resident returned to the facility on a stretcher after an acute hospital stay. On 4/16/24 at 1:46 p.m., the Licensed Nursing Home Administrator (LHNA), stated they do not have a bed hold for 12/8-11/23 hospital stay for Resident #39. She stated that the nurse working was an agency nurse and must have missed it. An undated Bed Hold Policy, directed staff that the charge nurse would notify the resident's power of attorney, guardian or next of kin of transfer and the Bed Hold form.

Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to implement safety measures and interventions to protect residents on the Chronic Confusion and Dementing Illness (CCDI) Unit from resident to resident physical abuse from Resident #3, for 2 of 19 residents reviewed (Residents #2 and #7) that resided on the CCDI unit. Resident #3 had a history of physical violence directed at staff and resident's that included: On 7/8/23 alleged to have hit Resident #3 in the chest that caused an 8 X 10 centimeter (cm) purple bruise. On 7/10/23 Resident #3 was sent to the local emergency room (ER) for behavioral health placement before return to the facility. Resident #3 was described by facility on transfer documents as angry, agitated, with a history of physical aggression to residents and staff, raises fists to everyone. The resident returned to facility at 7:00 p.m. that same day and the facility implemented 15-minute checks. On 7/11/23 at 8:30 a.m. Resident #3 entered Resident #2's room and physically assaulted him as he laid in bed, striking him repeatedly in the head with his closed fist. The facility identified a census of 19 residents on the CCDI unit, total facility census 51. Findings Include: 1. The Minimum Data Set (MDS) for Resident #3 dated 6/14/2023 documented a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS documented hallucinations and verbal behavioral symptoms directed towards others in the past 1-3 days. The MDS also documented the resident significantly intruded on the privacy of others, rejection of care that occurred in the past 1-3 days, wandered daily which put the resident at significant risk of getting to a potentially dangerous place and intruded on the privacy or activities of others. The MDS documented the resident independent for bed mobility, transfer, toilet use and walking. The MDS identified diagnosis that included Alzheimer's disease. Review of the Care Plan included a Focus Area: Resident has potential for mood/behavior issues related to diagnosis of Lewy body Dementia with behavior disturbance. Interventions included the following: Administer medications as directed, provide consistent routine, encourage family visits, socialization and activity attendance, monitor for potential unmet needs and resolve, monitor for significant changes in mental status and mood/behaviors and notify physician, provide reassurance and 1:1 as needed, Urinalysis as per orders dated 7/5/23, Send to ER for evaluation and treatment dated 7/10/23 and 7/11/23. The Care plan additionally identified a focus area: The resident uses psychotropic medications to aid in the management of mood/behavior issues with the diagnosis of Lewy body dementia with behavioral disturbance and delusions initiated on 6/21/23. Interventions included the following: a. On 7/5/23 Ativan 0.5 mg twice a day (BID) X 3 days. (Anti-anxiety medication). b. On 7/7/23 Extend Ativan x 14 days. 7/8/23 Zyprexa 2.5 mg daily (decrease hallucinations). c. On 7/10/23 Increase Ativan to 1 mg po BID, as needed (prn) and Zyprexa to 5 mg every evening. Record review of a Progress Notes for Resident #3 included the following: a. On 6/8/23, admitted to the CCDI unit, agitated by staff, verbally threatening staff. b. On 6/27/23, Agitated at supper, tapped finger firmly on staff's chest. c. On 6/29/23, Attempted to push staff with the intent to knock over. Visual and auditory hallucinations. d. On 7/2/23, Yelled at peer, drawing fist back and threatened to hit if continued to call him names. e. On 7/4/23, Attempted to choke staff person, had hands wrapped around neck. f. On 7/8/23 at 7:00 a.m., aggressive behavior toward peer this morning before breakfast. Resident observed in Resident # 7's room, fist raised and hit bed with fist. g. On 7/8/23 at 1:45 p.m., threatening to kill staff unprovoked. Redirection, snacks, 1:1 without success. As needed antianxiety medication administered. h. On 7/8/23 at 2:30 p.m., Resident walked up to staff person and swung fist hitting in the face. i. On 7/10/23 10:30 a.m., Director of Nursing (DON) investigated peer complaint of striking her (Resident #7), and notes regarding increased aggression. Spoke with family and need to send to ER of choice. At 12:30 p.m., transport team and Sheriff at the facility, Resident #3 goes willingly. j. On 7/10/23 7:00 p.m., returned from emergency room . New orders to increase antianxiety medication and medication for hallucinations. Review of a facility form titled, Resident Transfer Information Form for Resident #3 dated 7/10/23, signed by the DON, documented the reason for transfer to the ER as: Resident physically assaulted another resident leaving a large bruise. Resident very angry, agitated, choked staff member, and raises fist to everyone. Requires behavioral health placement before return to the facility. Review of an un-named facility form documented every 15-minute checks were initiated on 7/10/23 at 7:00 p.m. The form is signed as completed at 15-minute intervals until 7/11/23 at 9:15 a.m., when documented that resident had left the building. Review of a Progress Note dated 7/11/23 included the following entries documented by Staff C, Registered Nurse (RN): a. At 8:00 a.m., in dining room for breakfast. b. At 8:15 a.m., standing in the hallway next to a laundry bin, located outside room [ROOM NUMBER]. c. At 8:30 a.m., as returning to the nurses desk, hear male resident calling out. DON on unit and rushed into room [ROOM NUMBER] where witnessed Resident #3 striking resident #2 repeatedly (5 or 6 times) in the face with a closed fist. d. At 8:32 a.m., 911 paged for need to transport resident. Resident at nurse's station until ambulance crew arrived. 1:1 staff at resident's side. e. At 9:10 a.m. Ambulance and two Sheriff's staff arrive, resident transported to local ER for evaluation. Review of a late entry on 7/11/23 at 7:35 a.m. documented that the provider was on the unit to see resident for second 30 day visit and follow up of ER visit yesterday. Resident pleasant. Interacts appropriately. In an interview on 9/26/23 at 2:10 p.m., Staff F, Certified Nursing Assistant (CNA) stated on 7/4/23 Resident #3 was in a female resident's room, Staff F responded and asked him to leave nicely, opened the door wider, and offered to take him to his room, and then all of the sudden he grabbed my neck and we both fell to the floor. Staff F described as very sudden, wasn't expecting, couldn't predict or anticipate. Stated that is was known that he could be physically and verbally aggressive, and if he was escalating or aggressive to call his wife and she would assist to calm him down, but this was so sudden. In an interview on 9/27/23 at 3:50 p.m., the DON and the Assistant Director of Nursing (ADON) reviewed the review of Progress Notes related to Resident #3's behaviors. They reported that they feel most of the residents on the CCDI unit have the risk of being physical and that they take adequate precaution. When asked about the decision to place Resident #3 on 15-minute checks when returned from the hospital instead of placing 1:1 supervision, the DON responded that they placed 15-minute checks because that was the resources they had available, and the ADON stated that in hindsight wished they had placed 1:1 supervision. 2. The MDS for Resident #7 dated 7/5/2023 documented a BIMS's score of 3 out of 15 indicating severe cognitive impairment. The MDS documented the resident had delusions and verbal behavioral symptoms directed towards others in the past 1-3 days. The MDS also documented rejection of care that occurred in the past 1-3 days. The MDS documented the resident independent for bed mobility, transfer, toilet use and walking. The MDS identified diagnosis that included unspecified dementia. Review of a Progress Note dated 7/8/23 at 7:00 a.m., initiated by Staff G, Licensed Practical Nurse (LPN) documented Resident #7 yelling. Staff responded to room and peer, Resident #3 was also in room. Resident #7 was noted to yell out, get this man out of my room, he hit me. Staff present reported that they had witnessed Resident #3 hit her bed, but not her person. 10:00 a.m. small blanchable pink area noted to Resident #7's left chest. 11:00 8 X 10.2 cm dark purple bruise to left chest. Review of a Progress Note dated 7/9/23 at 9:00 p.m., resident tearful when talking to staff about bruise to left chest. Resident #7 yells out at Resident #3 numerous times throughout the shift. During an interview on 9/28/23 at 10:10 a.m., Staff G, LPN stated that she was the nurse on the CCDI unit on 7/8/23. At approximately 7:00 a.m., Staff H, CNA came and got her because Resident #3 was in Resident #7's room. Staff H reported that she had witnessed Resident #3 in the room and hitting the bed, but not striking Resident #7. Staff G, LPN responded to the room and assessed Resident #7 who had a pink area on her left chest where she alleged had been hit by Resident #3. Staff G reported she had monitored the area and the same pink spot had developed into an 8 x 10 cm dark purple bruise by 11:00 a.m. Staff G recalled that throughout the shift Resident #7 had pointed at Resident #3 and made comments about him, indicating that she had not wanted him near her. Staff G stated that she was not aware of any special interventions for Resident #3 when agitated or aggressive and had been unaware that he had choked a staff person until after the incident had occurred on 7/8/23. During an interview on 9/26/23 at 1:07 p.m., Staff H stated Resident #3's behaviors had escalated and the interventions that had been working for him were no longer working, and he wouldn't allow care because staff were not his wife. Observation and interview on 9/27/23 at 4:30 p.m. Resident #7 was observed seated in the dining room for an activity. Resident #7 was pleasant and cheerful, smiling, and responded that she felt safe and comfortable. 3. The Minimum Data Set (MDS) for Resident #2 dated 6/7/2023 documented a BIMS's score of 3 out of 15 indicating severe cognitive impairment. The MDS documented verbal behavioral symptoms directed towards others in the past 1-3 days. The MDS also documented rejection of care that occurred in the past 1-3 days. The MDS documented the resident independent for bed mobility, transfer, toilet use and walking. The MDS identified diagnosis that included non-Alzheimer's dementia. Review of an ER note dated 7/11/23 at 9:21 a.m. revealed Resident #2 presented to the ER as an assault victim. Reported Resident was in his bed at approximately 8:30 a.m. when another resident at the nursing facility came into his room and allegedly in an unprovoked fashion hit multiple times with his fists, to both the head and face. Staff deny that he had a loss of consciousness. He admits to pain around his left cheek. Assessment revealed some early ecchymosis to the left maxilla (jawbone) and left periorbital (around the eye) region. The summary noted no obvious skull or facial fracture. Observation and interview on 9/27/23 at 4:15 p.m. revealed Resident #2 seated in the area near the nurse's station, having a snack. Resident smiled, and responded that he thought he felt safe. In an interview on 9/28/23 at 10:34 a.m. Staff C, Registered Nurse (RN) confirmed she had worked on the unit on 7/11/23 and responded to the Resident to Resident altercation between Resident #3 and Resident #2. Stated she had just seen resident #3 minutes before in the hallway near a laundry hamper, and had gone to give another resident medication. Confirmed Resident #2 was in his bed, helped to remove Resident #3 from the room and then went back to assess Resident #2. Staff C recalled that Resident #2 was shook up, like in shock and disbelief, kept asking why would he do that, and why was he still here. Resident #2 stated that he got punched in his cheek and jaw. Stated that Resident #2 no longer talks about it, but recalled that he had talked about it the next day, had stated that another resident had hit him in the face. Record review of an undated Resident Protocol, entitled What to do in a Resident to Resident Altercation included the following: 1. Immediately separate the residents. 2. Notify charge nurse, charge nurse to immediately assess resident for injuries. 3. Charge nurse to immediately notify DON or designee and a report must be made to the state by the DON or designee within 2 hours. 4. Incident reports will be filled out on both residents (aggressor/victim) including skin sheets if needed, neuro checks if needed. 5. Physician will be notified. 6. Family will be notified. 7. Have witnesses write out witness statements. 8. Everything charted in the nurse's notes. 9. Must have an immediate intervention. 10. Continue shift assessment x 24 hours. The Facility Policy Titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/22 defined, Resident to resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. The policy further stated that all residents have the right to be free from abuse.

Based on clinical record review, observation, staff interviews, Pharmacist interview, facility investigation review, and facility policy review, the facility failed to ensure 1 of 3 resident's reviewed (resident #1) remained free from misappropriation of Tramadol, a narcotic pain medication. The facility reported a census of 51 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #1 dated 4/12/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition and identified diagnosis which included Non-Hodgkin's Lymphoma. The pain assessment interview identified no pain or hurting at any time in the last 5 days. A Physician's Telephone Order Audit, dated 3/14/23, documented Tramadol 50 milligrams (mg) with directions to give 1 by mouth every 6 hours as needed for pain. Review of a Pharmacy Delivery Packing Slip documented on 3/14/23, 15 Tramadol, 50 mg tablets were signed as received from the local pharmacy by Staff A, Licensed Practical Nurse (LPN) for Resident #1. Review of Resident #1's March 2023 Medication Administration Record (MAR) documented the resident had been administered one 50 mg tablet of Tramadol on 3/18/23, 3/24/23 and 3/30/23, for a total of 3 tablets administered in March. Review of a Pharmacy Delivery Packing Slip documented on 3/30/23 an additional 15 Tramadol, 50 mg tablets were signed as received from the local pharmacy by Staff B, LPN. Review of a Pharmacy Delivery Packing Slip documented on 4/12/23 an additional 30 Tramadol, 50 mg tablets were signed as received from the local pharmacy by Staff B, LPN. A total of 60 Tramadol tablets were delivered to the facility for Resident #1 in March and April. Review of Resident #1's April 2023 Medication Administration Record (MAR) documented the resident had been administered one 50 mg tablet of Tramadol twice on 4/2/23 and once on 4/10/23 and 4/12/23, for a total 4 tablets administered in April and 7 total tablets in March and April. Review of the Investigation Report as part of a Facility Reported Incident (FRI) documented on 4/24/23 Staff A, LPN reported there was no Tramadol medication card and no corresponding Narcotic Count Sheet in the Narcotic Book. Staff A recalled that the medication card and the count sheet was present on Thursday 4/20/23 when she worked last. The investigation revealed there had been no change in the order, order was not discontinued, and the Pharmacy confirmed that no medication had been returned to the facility. At that time, it was discovered by the facility that two additional refills had been sent by the Pharmacy without any record at the facility of anyone faxing an order request or refill request. Pharmacy reported the medication was ordered by phone with no record of name, however both additional refills were signed as received by Staff B, LPN. Staff were interviewed by the facility and determined that no staff could recall there ever being more than one Tramadol card for Resident #1 even though 3 had been delivered to the facility. Reconciliation of the Packaging Delivery Slips with the March and April MAR for Resident #1 revealed that 53 Tramadol pills were unaccounted for. Reviewed with the DON and confirmed on 9/25/23 at 2:00 p.m. In an interview on 9/25/23 at 1:42 p.m., the local Pharmacist stated he had reviewed the Pharmacy documentation related to the Tramadol 50 mg tablets that were dispensed from the Pharmacy to the facility for Resident #1. The Pharmacist confirmed an initial order with refills available was received and filled on 3/14/23 with 15 pills. This was an as needed order (prn). On 3/30/23 a nurse, no name received, called in a verbal request to refill the order. The Pharmacist confirmed 15 additional pills were sent to the facility. The Pharmacist stated that they typically would get a name from the nurse that re-ordered but the request was made late in the day, close to the delivery dispatch route time and so they were rushed in processing and hadn't gotten a name. Again, on 4/12/23 a nurse, no name again for the same reason, requested a refill and 30 tabs were dispensed to the facility. On 4/25/23, an additional 15 pills were dispensed after the facility discovered the card of Tramadol was missing from the medication cart. The Pharmacist confirmed that verbal refill requests had been allowed but no longer are allowed from the facility based on changes the facility had implemented. In an interview on 9/25/23 at 3:42 p.m., Staff D, LPN confirmed that when she left work at 6:00 a.m. on 4/23/23 the narcotic count was correct and recalled that there was a Narcotic Card for Resident #1 in the cart. In an interview on 9/25/23 at 2:20 p.m., Staff A, LPN recalled that on 4/24/23 had completed the shift count as the oncoming evening nurse with Staff B, LPN. Stated she hadn't noticed right away that there wasn't a card and a sheet for the Tramadol for Resident #1, but recalled that there had been a partially full card of Tramadol on 4/20/23. Staff A reported that she investigated and could find no reason for the card to have been removed from the cart. Stated that every resident with a narcotic medication had a tab in the locked drawer of the medications cart, but Resident #1's tab was empty. Staff A reported that she alerted the Director of Nursing/Provisional Administrator (DON). Staff A responded that the facility had changed the request process for refills but was not aware of any safeguards that would have prohibited someone from taking both the card and corresponding Narcotic Control Sheet. In an interview on 9/25/23 at 1:07 p.m., Staff C, Registered Nurse (RN) recalled only one partially full card of Tramadol for Resident #1 in the medication cart. Staff C stated that she was not aware of any safeguards that would have prevented staff from taking both the card and the Narcotic Sheet together. Clarified that there wouldn't be any way to know both were gone except by memory. In an interview on 9/21/23 at 1:01 p.m., Staff B, LPN admitted that she had verbally ordered a refill for Resident #1 on 3/30/23. When the refill was delivered to the facility she stole the existing card and the corresponding Narcotic Count Sheet, and put the refill card from the Pharmacy in the cart. On 4/12/23 Staff B reported that she again called the Pharmacy for a refill and again stole a card of Tramadol from Resident #1, but couldn't recall if it was the refill or the existing card. On 4/23/23, Staff B admitted that she took Resident #1's remaining Tramadol card from the locked Narcotic Sheet and the corresponding Narcotic Count Sheet. In an interview on 9/25/23 at 3:50 p.m., the DON stated that they had failed to have a process of reconciling the Narcotic Sheets that would have prevented staff from taking a Narcotic Card and the corresponding narcotic sheet. Clarified that they had kept both the packaging slip and the Narcotic Control Sheet but had not reconciled the sheets. On 9/26/23 the DON provided the updated form required by the facility to be faxed to the Pharmacy for controlled (at risk of diversion) medications. The form had been changed to bright yellow in color and was demonstrated to be kept on a clipboard at the nurse's station and then reconciled with the packaging slip when the medication was delivered and sent to the DON. The DON stated this process was put in place to prevent verbally ordering the medication and receiving the medication without documentation. In an observation on 9/25/23 at 2:07 p.m. Staff E, LPN and Staff A, RN completed shift count accounting for all medications in the locked narcotic drawer with the corresponding sheet in the Narcotic Record Book. Both nurses were observed to verify the number of medications that remained with the number indicated on the Controlled Medication Sheet. The Facility Policy Titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/22 documented the following definition of misappropriation: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This includes misappropriation or diversion of resident medications. The policy further stated that all residents have the right to be free from abuse, neglect, misappropriation of resident property.

Based on clinical record review and staff interviews, the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner using the Resident Assessment Instrument (RAI) as directed by Centers for Medicaid and Medicare Services (CMS) for 11 of 20 residents reviewed (Resident #5 #7 #17 #25 #29 #33 #34 #35 #40 #41 and #148). The facility reported a census of 47 residents. Findings Include: Review of a facility created document during the days the Survey conducted of 2/13/23 to 2/16/23 and signed by the Administrator and the Assistant Director of Nursing (ADON)/MDS Coordinator listed 11 residents with overdue MDS assessments. The document included the following dates the MDS Assessments due: a. Resident #5 Quarterly Assessment due 12/28/22 b. Resident #7 Quarterly Assessment due 2/8/23. c. Resident #17 Quarterly Assessment due 1/4/23. d. Resident #25 Quarterly Assessment due 1/4/23. e. Resident #29 Quarterly Assessment due 11/30/22. f. Resident #33 Quarterly Assessment due 11/30/22. g. Resident #34 Quarterly Assessment due 12/7/22. h. Resident #35 Quarterly Assessment due 12/28/22. i. Resident #40 Quarterly Assessment due 1/4/23. j. Resident #41 Quarterly Assessment due 1/25/23. k. Resident #148 Quarterly Assessment due 11/23/22. The document stated that all overdue MDS assessments would be completed by 3/1/23. During an interview on 02/14/23 at 2:09 PM, the Administrator stated the facility did not have a MDS Policy. The Administrator stated assessments should be completed as directed in the RAI manual. The Administrator stated she was aware of overdue MDS assessments. During an interview on 02/15/23 11:30 AM, the ADON/MDS Coordinator stated assessment and submission of MDS's fell behind in the fall of 2022. The facility planned to have all assessments current by 3/1/23.

Based on facility record review and staff interview, the facility failed to ensure staff trained in Cardiopulmonary Resuscitation (CPR) were on duty at all times as per regulations. The facility reported a census of 47. Findings Include: Review of the facility Licensed Nursing Schedule for [DATE] through February 15, 2023 revealed the facility lacked CPR certified staff in the facility on the following dates and shifts: a. On [DATE] day shift. b. On [DATE] evening shift. c. On [DATE] evening shift. d. On [DATE] night shift. e. On [DATE] evening shift. The facility identified 8 residents who requested CPR be initiated if indicated. On [DATE] at 1:08 PM, the Administrator stated it was the expectation all licensed staff at the facility be certified in CPR and they take the initiative and responsibility to ensure it is kept up to date. She stated the Licensed Practical Nurse (LPN) who had let her CPR Certification expire was to be recertified this week. She reported she had a plan to have a local paramedic come to the facility on a regular basis throughout the year to complete CPR training for the licensed staff to ensure they remain CPR certified. On [DATE] at 1:22 PM, the Administrator reported the facility does not have a policy specifically related to ensuring CPR certified staff are present in the facility at all times.

Based on clinical record review and staff interviews, the facility failed to update an individual Care Plan for 1 of 8 residents reviewed (Residents #7). The facility reported a census of 47 residents. Findings Include: The Minimum Data Set (MDS) assessment for Resident # 7 dated 11/2/22, included diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, kidney and ureter disorder. The MDS listed the Brief Interview for Mental Status (BIMS) score of 7 out of 15, suggesting severe cognitive impairment. The MDS documented the resident required limited assist of one with dressing, toileting and personal hygiene, required physical assistance with bathing. The MDS coded resident required Hospice Care. The Care Plan initiated 8/16/22, documented focus areas for advance directives, potential for COVID-19, activity deficit, incontinence, altered respiratory status, pain, mood, self-care deficit, altered cardiovascular status and cognition that noted hospice services in place for the focus areas. Resident #7's Care Plan documented focus areas of risks related to Alzheimer's diagnosis, skin care areas documented ongoing Hospice Services and unavoidable decline anticipated. The Care Plan documented reviews dated 2/1/23, 2/9/23 and 2/16/23. A Progress Note dated 1/13/23 documented, call received from Hospice, resident no longer meets criteria for Hospice Services On 02/14/23 at 12:40 PM, Staff A, Licensed Practical Nurse (LPN), relayed the resident no longer received Hospice Services. Staff A relayed the resident improved and no longer qualified for Hospice. On 02/14/23 01:00 PM, the Assistant Director of Nursing (ADON), reported the Care Plan update was missed, and work needed to be done to ensure updated Care Plans reflect resident's care, relayed the expectation is Care Plan updates should be completed with changes affecting resident care that included the start or stop of Hospice Services. The ADON explained the facility did not have a Care Plan Policy. The ADON acknowledged Care Plans direct resident care and should be revised as conditions change. The Administrator stated on 2/16/22 at 9:30 AM, the facility failed to have a Care Plan Policy. She acknowledged Care Plans should be updated timely to reflect resident care.

Based on observation, staff interview, and record review the facility failed to ensure a dignified dining experience in the dining room off the unit during the lunch meal on 8/29/21. The facility reported a census of 48 residents. Findings include: Observation on 8/29/21 at 12:22 PM, revealed four residents seated at a table in the dining room. Staff E, Certified Nursing Assistant (CNA), assisted the four residents standing at times while meal assistance provided, and moved around the table and switched between the four residents present while she assisted them. Additional observations on 8/29/21 at 12:29 PM, 12:37 PM, 12:42 PM, 12:43PM, 12:54 PM, and 1:01 PM revealed Staff E stood while she provided assistance with dining. On 8/31/21 at 3:15 PM, the facility Administrator acknowledged staff should sit next to the resident while assisting a resident with dining. The Administrator also acknowledged a maximum of two residents should be assisted if staff was sitting in between them. The facility policy titled, Resident Rights Policy, undated, documented that, To ensure that every resident in the nursing home is provided a copy of their rights while residing in [Facility Name]. This bill of rights ensures that every resident receives a standard of care within the nursing facility. -

Based on clinical record review, observation, interview, and facility policy review the facility failed to consistently document Do Not Resuscitate (DNR) status in the clinical record for 1 of 1 resident reviewed for advanced directives (Resident #20). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 out of 15 on a brief interview for mental status exam, which indicated the resident was cognitively intact. The Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of Care Update Report dated [DATE], located in the resident's hospice chart, documented the following Advanced Directives information: no resuscitation, comfort measures only, no tube feedings. A red sticker was present on the spine of the paper chart for Resident #20. The first page present in the paper chart contained the name of the hospice company and documented DNR status. The Authorization to Perform/Withhold Cardiopulmonary Resuscitation form dated [DATE] selected the option for No CPR. The Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #20, had marked options for DNR/Do Not Attempt Resuscitation and Comfort Measures Only. The face sheet present in the resident's paper record dated [DATE] highlighted the following Advanced Directive information: FULL CODE. Interview on [DATE] at approximately 12:20PM, Staff A, Registered Nurse (RN) explained they would look at the resident's chart at the face sheet, and further explained this information was usually highlighted. Staff A further explained right after the face sheet would be the DNR order, a green sticker present on the spine of the chart indicated a full code, and a red sticker on the spine of the chart indicated DNR status. Interview on [DATE] at 3:08 PM, Administrator advised that the facility did not utilize the electronic record and the face sheet would not always be updated in the electronic record. If a resident went onto hospice from a full code to a DNR, there was a sheet in the front of the resident's chart. The face sheet normally was created when the resident would come in, and changes would be handwritten. The Administrator acknowledged the sticker indicated the most up to date information. Observation and interview on [DATE] at 9:23AM revealed Resident #20 seated in his recliner chair in the resident's room. Resident #20 advised that wishes regarding cardiopulmonary resuscitation (CPR), or being a full code versus DNR had not been discussed with him. The Facility Policy titled Advanced Directives Policy and Procedure, undated, revealed, [Facility Name] will educate and inform the residents of their rights, promoting the resident their right to accept or refuse medical treatment and ask if they have an advanced directive in assisting the resident to exercise his/her rights. Resident choices will be incorporated into treatment, care, and services. All advance directive document copies will be obtained and located in the resident's chart. -

Based on clinical record review and staff interviews, the facility failed to ensure one of four residents reviewed for falls received adequate supervision and nursing care. Resident #1 did not receive adequate supervision and sustained a hip fracture sometime after a staff left the resident unattended in the bathroom and during the time a newer staff had been working with the resident. The facility reported a census of 50 residents. Findings include: According to the Admission Record dated 6/7/11, Resident #1 had [DIAGNOSES REDACTED]. According to the Minimum (MDS) data set [DATE] indicated Resident #1 had an admission 6/7/11. Resident #1 understood others and could be understood but could not participate in the Mental Status Interview. The resident made poor decisions and required cues and supervision. Resident #1's behavior fluctuated, he/she showed signs and symptoms of delirium with inattention, and disorganized thinking. Resident #1 required limited assistance of 2 people for bed mobility, walking, dressing and toilet use. The resident required limited assistance of 2 staff for transfers. The MDS documented the resident ' s balance as not steady and only able to stabilize with human assistance when walking and when turning around. Review of Resident #1's Care Plan dated 6/20/11 directed the staff to transfer/ambulate with walker with assistance of 1-2 staff, to utilize a wheelchair as needed, encourage compliance with staff assist with mobility and document refusals. The Care Plan dated on 6/23/11 directed the staff to transfer Resident #1 with 2 staff, to provide cues to maintain no weight bearing status to their right leg, utilize a pivot disc for transfers as needed and to start Physical and Occupational Therapy. The Care Plan directed the staff to utilize floor pads while in bed and utilize a raised ledge mattress in bed. Review of Resident #1's Nurse's Notes on 6/17/11 at 10:30 p.m., indicated Staff A walked into Resident #1's restroom and found them laying on the floor. A staff nurse assessed Resident #1 who denied any injury or pain. The staff ambulated the resident into their bed. The Nurses Noted indicated Resident #1 complained on increasing pain as the night progressed. On 6/18/11 at 7:00 a.m. staff summoned the local ambulance and transferred Resident #1 to a local hospital. Resident #1 had a [DIAGNOSES REDACTED]. Review of a local hospital's discharge summary dated 6/23/11 indicated Resident #1 had an admission to the hospital on [DATE] with a right hip intertrochanteric fracture of their femur secondary to a fall. The right hip fracture required surgical pinning. Review of the Quality Improvement Document dated 6/17/11, staff found Resident #1 on their bathroom floor with their legs bent. The resident stated,"I fell when getting off the toilet". The staff ambulated Resident #1 back to their bed, with a slightly unsteady gait and full weight bearing. The Quality Improvement Document indicated the facility re-educated the staff not to leave a resident who utilized an alarm alone in the bathroom. During an interview with Staff A on 7/19/11 at 9:00 a.m., Staff A stated when they arrived on the night shift at 10:30 p.m. on 6/17/11 they passed the evening nurses aide at Resident #1's bedroom doorway. Staff A walked into Resident #1's bathroom and found them on the floor. Staff A stated they summoned the nurse to alert them of Resident #1 fall. Staff A indicated they did not hear any noises or yells when they entered the secured locked unit at the beginning of their shift at 10:30 p.m. During an interview with Staff B on 7/18/11 at 7:45 a.m., Staff B stated Resident #1's bed alarm sounded, the resident requested to use the bathroom. Staff B walked the resident to the bathroom, leaving the resident on the toilet and walked out of the resident's bathroom. Staff B stated the resident's representative requested staff allow for privacy. Staff B stated she stepped out of the room after hearing another alarm as Resident #1 remained on the toilet but before she left, she asked the resident if he/she was done, and the resident responded no. Staff B stated she called for a person and Staff A came down to the room. Staff B stated the resident had his/her pants down when she left the room. Staff B stated she walked out of the bedroom while Staff A entered Resident #1's room. Staff B stated this was Staff A's first night working by herself as a CNA and she was " freaking out " . Staff B reassured Staff A she would be fine. Staff B walked past the nurse's station and picked up her belongings and talked to staff and then clocked out. Staff B stated Staff A yelled and stated she found Resident #1 on the floor. Staff B when to the room and stated she noticed Resident #1's pants were now up and his/her walker had been moved to the other side. Staff B stated after the nurse assessed the resident, she assisted him/her from the floor to his/her bed. A document dated 6/29/11, with the Administrator's signature indicated the following: Staff A was left alone with the resident right after shift change in the CCDI unit. Staff A was on the unit for approximately 5 to 10 minutes, when she reported to the nurse the resident was on the floor and that was how she found him/her. The resident was not to be left alone and as the two staff people changed shift, the other person passed by Staff A and left the area. It took 5-10 minutes for Staff A to get the nurse. The facility determined that either Staff A left the resident alone or was part of his/her fall. The documented indicated Staff A would not tell what happened in those 5- 10 minutes prior to her summoning the nurse. During an interview with the 6/17/11 Night Nurse, Staff C on 7/18/11 at 6:40 a.m., she stated when they entered Resident #1's restroom, they did not hear Resident #1's alarm sounding but found Resident #1 on their floor in their restroom with their walker in front of them and his/her PJ (pajamas) on (fully dressed). In a written statement, dated Sunday AM (no date), Staff C documented she could monitor Staff A better on the main (unit) and knew what she wasn't doing. Staff C documented, " I will say for as much orientation as she had out here she was not at all sure what to do! " During an interview with Staff D, on 7/19/11 at 11:29 a.m., she stated she did not have an orientation checklist for Staff A, and Staff A's orientation had been on the third shift. During an interview with the Director of Nurses (D.O.N.) on 7/19/11 at 11:30 a.m., the D.O.N. stated they received reports from staff that Staff A acted anxious as it was their first CNA job. The night nurse reported they did not trust Staff A to perform their job. Staff A worked alone for the first time on 6/17/11 on the Locked Secure Unit. The Locked Secure Unit had a census of 17 residents with 15 of those residents care planned to have personal alarms at night. The D.O.N. stated the nurse floats between the Locked Unit and the other parts of the facility. During an interview with the Assistant Director of Nurses (A.D.O.N.) on 7/19/11 at 11:46 a.m. revealed the night shift always is staffed with one nurse and 2 nurses aides. The staffing for the night shift on 6/17/11: 1 CNA on the Locked Secure Unit, 1 CNA for the general floor and 1 nurse. The nurse floats between both units and 1 aide is assigned to work alone on the Locked Secure Unit.