Every finding on record at Westview of Indianola Care Center

Based on clinical record review and staff interview, the facility failed to ensure all staff were aware of the residents' health decisions regarding advanced directives (whether or not a resident wished to have staff provide cardiopulmonary resuscitation-CPR-if they needed it) and failed to document an accurate code status for one of twenty-four current residents reviewed for advanced directives (Resident #39). The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had [DIAGNOSES REDACTED]. Resident #39 admitted to the facility on [DATE] from the hospital. The care plan dated [DATE] revealed the resident had a potential for a medical emergency and had requested a full code status. The care plan directed staff to ensure the resident's name on the door included a green dot to indicate code status, initiate CPR (cardiopulmonary resuscitation) with a witnessed [MEDICAL CONDITION], and activate 911. The order summary report revealed a DNR (Do not resuscitate) order dated [DATE]. Review of the facility's electronic health record revealed Resident #39 had a DNR code status listed. A review of the Advanced Directive Acknowledgement form signed [DATE] revealed the resident had requested resuscitative efforts if she had a cardiopulmonary or respiratory arrest. The treatment administration record dated ,[DATE] revealed a DNR code status. The name plate by the resident's door revealed a green dot sticker by her name, which indicated the resident needed CPR in the event of a cardiac or respiratory arrest. In an interview [DATE] at 9:28 AM, Staff A, Certified Nursing Assistant (CNA) reported the resident's code status was listed on the care plan or kardex with a colored dot sticker by the resident's name on the door plate. Staff A reported if there was a red dot sticker by the name, staff were not to provide CPR; if there was a green dot sticker by the name, staff were to provide CPR. In an interview [DATE] at 9:35 AM, Staff B, CNA, reported she looked at the care plan or kardex when she needed to know the resident's code status. Staff B reported she did not know the meaning of the colored dot stickers by the resident's name on the door plate. In an interview [DATE] at 9:37 AM, Staff C, Licensed Practical Nurse (LPN) reported she looked at the code status listed on PCC (electronic health record) and the Treatment Administration Record (TAR) whenever she needed to know the resident's code status. Staff C reported she also checked if the resident's name by the door had a red or green dot sticker. A red dot sticker meant the resident had a DNR status and if they had a green dot sticker, the resident wanted staff to provide CPR in the event of a cardiac or respiratory arrest. In an interview [DATE] at 8:10 AM, the DON reported when the surveyor asked for documents on Resident #39 [DATE], she looked at her record and realized there was a problem with the code status listed. The DON reported staff contacted the physician right away and got an order for [REDACTED]. In an interview [DATE] at 9:13 AM, Staff D, LPN reported when a physician's orders [REDACTED].

Based on observation, staff interview, and facility policy review, facility staff failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not performing hand hygiene for one of two meal observations observed. The facility reported a census of 65 residents. Findings include: Observation on 10/7/19 at 11:35 AM, Staff E, Certified Nursing Assistant (CNA) provided feeding assistance to a couple of residents. Staff [NAME] placed a large spoonful of pureed food in Resident #33's mouth. Resident #33 had a moderate amount of pureed food on his mouth. Staff [NAME] used her bare hand and wiped the resident's mouth with a napkin, placed the soiled napkin on the table, then reached over and gave Resident #49 a spoonful of food. Staff [NAME] did not hand sanitize between residents. Staff [NAME] continued to use a towel and wiped Resident #33's mouth throughout the lunch meal service and assisted Resident #49 until another staff person came and assisted Resident #49. During observation 10/7/19 at 11:48 AM, Staff D, Licensed Practical Nurse (LPN) wiped a resident's mouth with a clothing protector after she gave the resident her medication. Staff D walked to the medication cart parked near the dining room, touched the mouse by the computer, opened the medication drawer, removed medication cards from the drawer, dispensed pills into a medication cup, then took the medication to another resident in the dining room. Staff D ran her fingers through her hair, then continued to dispense medication from the medication cart. Staff D failed to sanitize her hands. During an interview 10/10/19 at 9:11 AM, Staff F, Registered Nurse and infection control nurse reported she expected staff to use hand sanitizer between residents. A policy revised 11/17, titled Infection Prevention and Control - Hand Hygiene, directed staff to perform hand hygiene before and after assisting a resident with meals, after contact with mucous membranes or body fluids, and after handling soiled or used linens.

Based on observation and staff interviews, the facility failed to provide the residents a homelike and well-maintained environment. The facility identified a census of 63. Findings include: During observations on 7/17/18 starting at 8:25 AM, numerous rooms throughout the facility had scratched and marred walls, chipped doorways, exposed dry wall and gouges in kick panels on doors. These rooms included: Rm 2 Door marred and scratched; Rm 6 Paint missing on door and white dry wall visible; Rm 8 Bathroom door marred and scratched; Rm 10 Bathroom door frame marred; Rm 11 A marred wall behind the recliner and the wall, underneath the sink marred and had white sheetrock visible and the carpeted floor soiled; Rm 15 Door marred and scratched; Rm 17 Bathroom door marred; Rm 21 An approximate 5 inch hole in the wall behind the bed, the bathroom door marred with dents and scratches and paint chipped on wall by the sink and closet; Rm 23 Bathroom door marred; Rm 32 Missing bathroom wall tile; Rm 33 Exposed dry wall noted behind the bed; Rm 37 Door marred; wall near sink 8 inches from the floor and a 2 feet long section of exposed dry wall; Rm 38 Bathroom door splintered and wall along sink with exposed dry wall; Rm 40 Bathroom door marred and wall underneath the sink is chipped; Rm 41 A hole in the wall by the air conditioner; Rm 43 Door marred; Rm 45 Door frame chipped; Shower Room Hall A Door frame noted to be marred with gouges in the kick panel; Shower Room Hall B Door marred and paint chipped; Clean utility room; Hall B Paint missing on the door frame; Linen Door Hall D marred and scratched. 2. Environmental observations on 7/17/18 starting at 10:00 AM revealed the following areas of concern: a. room [ROOM NUMBER] had marred walls and divots of sheet rock visible behind the recliner and underneath the sink and counter and a soiled carpet with stains. b. room [ROOM NUMBER] had marred walls by the privacy curtain and recliner. c. The Dining Room ceiling had a large, brown stain in the middle of the room near the light and sprinkler head. d. The carpeted area by the bath/shower room on Evergreen Hall had a large brownish colored stain extending from the shower door into the hallway. e. The doorway and doorframe of the resident bath/shower room on Applewood Lane had multiple marred areas. In an interview 7/18/18 at 1:30 PM, Staff B, Certified Nursing Assistant reported she paged maintenance or filled out a work order when something needed repair. In an interview 7/18/18 at 1:55 PM, Staff C, Licensed Practical Nurse, stated she contacted maintenance when something needed to be repaired. In an interview 7/18/18 at 2:35 PM, the Director of Nursing (DON) reported staff contacted maintenance on their walkie if something needed to be fixed right away. The facility also had a work requisition form to maintenance for other repairs or maintenance requests. In an interview 7/19/18 at 8:35 AM, the Maintenance Supervisor reported they received a repair requisition form from staff or staff notified them over the walkie if something needed to be repaired. The Maintenance Supervisor stated he had to get an approval and work with the nurse or a manager first when resident rooms required repair work and determine when they could get into the resident's room to do the repairs. The resident had to be moved into another room when a room had extensive repairs, such as wall repairs or needed painted, at least until they completed the repair/painting job. The Maintenance Supervisor said it had been a problem getting walls repaired or painted in the resident rooms due to a lack of work space, an inability to accommodate relocation of a resident, or a newly admitted resident moving into the room right after another resident had discharged or moved out of the room. The Maintenance Supervisor said he had brought environmental issues and suggestions to the QA (Quality Assurance) meetings several times, but things had been put on the back burner. In an interview on 7/19/18 at 8:45 AM, the Administrator acknowledged the building had several environmental concerns, including gouged walls and stained carpet. The Administrator stated when maintenance fixed things, within a couple of months it would look the same because the beds and chairs had struck the walls and caused them to get defaced. The Administrator stated the rooms had not been designed for two beds, TVs, and all of the equipment required to care for residents in those rooms. In an interview 7/19/18 at 8:55 AM, Staff I, Housekeeping Supervisor three times a year, they deep cleaned the residents' rooms, moved all of the furniture out of the room and cleaned the carpets and curtains. At 2:05 PM, the Housekeeping Supervisor stated they cleaned the hallway carpets daily, but the spots in the carpet had kept coming back.

Based on clinical record review, observation, staff and resident interviews and facility policy review, the facility failed to provide a sanitary environment and maintain infection control practices to prevent the potential spread of infection or disease for 2 of 16 residents sampled (Residents # 44 and # 61). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #44 had [DIAGNOSES REDACTED]. The MDS documented she had a brief interview for mental status (BIMS) score of 15, indicating intact memory and cognition. Resident #44 required the assistance of one staff for locomotion in her room and for personal hygiene such as brushing her teeth and washing her hands and face. The care plan documented Resident #44 needed assistance with ADL's (activities of daily living) related to [MEDICAL CONDITION]([MEDICAL CONDITION] or stroke) and she had left sided [MEDICAL CONDITION] (paralysis on one side of the body). The resident enjoyed sitting at the sink and applying her make-up and performed her own oral cares at the sink. Observations on 7/18/18 revealed the following: a. At 7:20 AM, a bedpan sat on the edge of the sink in a resident's room (Rm 11). Two residents occupied the room. The flatter portion of the bedpan (where the bedpan would be placed under the resident's buttocks) faced outward on the sink and the rest of the bedpan sat under the faucet and occupied a portion of the bowl of the sink, rendering the sink inaccessible to use for the purpose of handwashing or other personal cares. The bedpan had no indication as to which resident the bedpan belonged to. b. At 7:25 AM, Staff D, Certified Nursing Assistant (CNA) assisted and walked Resident #44 to the bathroom. The Assistant Director of Nursing (ADON) stood in the room during the observation. c. At 7:32 AM, Staff D, CNA, moved the bedpan that sat on the edge of the sink and placed the bedpan on the opposite counter by the sink and under the towel dispenser. Staff D washed her hands. In an interview 7/18/18 at 7:35 AM, the ADON stated she didn't know why a bedpan had been stored on the counter by the sink, but stated she wasn't sure if a resident had used the bedpan. In an interview 7/19/18 at 9:30 AM, Resident #44 reported she used the sink in her room to brush her teeth and wash her hands and face. The resident confirmed a bedpan sat on the counter by the sink on 7/18/18, and stated it had not been the first time staff had put a bedpan by the sink in her room. She knew her roommate needed the bedpan. The facility's infection prevention and control program guidelines revised on 11/2017 instructed the facility provided a safe, sanitary and comfortable environment. The infection control program helped in prevention of the development and transmission of communicable diseases and infection. The policy revealed potentially contaminated articles needed stored and disposed of in appropriate containers, for example in a biohazard bag. 2. The admission MDS assessment dated [DATE] revealed Resident #61 had [DIAGNOSES REDACTED]. The MDS revealed the resident had a BIMS score of 15, which indicated intact memory and cognition. Resident #61 required the assistance of two staff for bed mobility and toilet use. The MDS indicated the resident had received an antibiotic medication for 5 of 7 days during the look back period. The care plan revealed Resident #61 needed assistance with ADL's related to a R BKA and limited mobility. The care plan recorded the resident used a bedpan and needed extensive assistance of one staff for toileting. During observation on 7/18/18 at 9:02 AM, Resident #61 told Staff D, CNA she spent half the night on and off the bedpan. Staff E, Registered Nurse stood in the room during the observation. Staff D provided pericare for Resident #61. Observation revealed Resident #61 had a reddened area under her left buttock. Staff D took the bedpan from the counter by the sink, placed it by the resident's bed, had the resident roll onto her left side, placed the bedpan under the resident's bottom, rolled the resident onto her back and onto the bedpan. In an interview 7/18/18 at 9:25 AM, Staff C, Licensed Practical Nurse (LPN) reported Resident #61 had complained of burning with urination. The resident had a history of [REDACTED]. Staff C stated she thought Resident #61 possibly had a yeast infection. In an interview 07/18/18 at 1:30 PM, Staff B, CNA, reported bedpans are decontaminated in the soiled utility room and stored in a garbage bag after resident use. Staff B stated bedpans are then stored on a shelf in the resident's bathroom. In an interview 7/18/18 at 4:50: PM, Staff F, CNA, reported Resident #61 typically used the bedpan. In an interview 7/19/18 at 9:20 AM, Resident # 61 reported she had used the bedpan that sat by the sink in her room on the morning of 7/18/18. The resident stated staff had stored a bedpan on the counter by the sink in her room before and she also had seen staff rinse the bedpan in the sink. In an interview 7/19/18 at 12:25 PM, the ADON stated she expected staff not store a bedpan on the counter by the sink in the residents room. In an interview 7/19/18 at 12:40 PM, Staff A, Certified Medication Aide (CMA) reported there was already a bedpan in Resident #61's room when she arrived at work on 7/18/18 starting at 6:00 AM. Staff A stated she had been told in report by the night shift they needed a UA (urinalysis specimen) collected on Resident #61. Staff A stated she did not know who put the bedpan in the room or if Resident #61 used the bedpan prior to her arrival that day.

Based on clinical record review, resident and staff interviews and review of manufacturer recommendations, facility staff failed to utilize safe transfer technique when they used an EZ lift (a mechanical transfer device) for 1 of 4 residents sampled who required a mechanical lift for transfers (Resident #61) and failed to provide adequate supervision and training for staff. The facility reported a census 63 residents. Findings include The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #61 entered the facility on 6/27/18. The resident had [DIAGNOSES REDACTED]. The MDS revealed the resident had a brief interview for mental status (BIMS) score of 15, which indicated intact memory and cognitive skills. Resident #61 required the assistance of two staff for bed mobility, toilet use and transfers. The MDS revealed the resident had falls prior to admission. The care plan revealed Resident #61 needed assistance with ADL's (activities of daily living) related to R BKA, limited mobility, and weakness. The care plan also revealed the resident had a history of [REDACTED]. The Kardex on the Point of Care electronic documentation system also documented Resident #61 required 2 staff and a Hoyer for transfers. The Kardex did not list the sling size or the type of sling the resident needed. A nurse progress note dated 7/15/18 at 3:00 PM revealed the following the nurse summoned to resident room because she became agitated about the mechanical lift sling. Multiple staff reported they had all attempted 1:1 and educated the resident but had been unsuccessful regarding proper use of lift sling. In an interview 7/16/18 at 9:45 AM, Resident #61 reported she had a concern with how staff transferred her in the lift transfer device on the morning of 7/15/18. The resident reported she almost fell out of the sling when staff transferred her and it scared her. During observation on 7/19/18 at 9:08 AM, Staff D, Certified Nursing Assistant (CNA) and Staff L, CNA, rolled Resident #61 from her back to the left side and tucked a tan sling with green straps under the resident and then rolled the resident onto her right side and pulled the sling under her. Staff D and Staff L rolled the resident onto her back, pulled a strap through the opening by the legs, attached the top straps and then the bottom straps to a bar on an EZ Way Smart Lift (the mechanical lift). The CNA used the remote and raised the resident in the lift sling. Observation revealed the sling located under the resident's back and thighs and the resident in a seated position as staff raised the lift. Staff L turned the resident's backside toward the wheelchair and held the sling as Staff D lowered the lift and Resident #61 into the wheelchair. Staff E, QA nurse, observed while staff performed transfer and provided cares. In an interview, 7/18/18 at 1:30 PM, Staff B, CNA stated she looked in the point of care (P[NAME]) documentation system to see the cares needed on residents, including how a resident transferred or if any equipment needed. In an interview 7/18/18 at 1:40 PM, Staff D, CNA reported Resident # 61 as a difficult transfer and if the sling not placed under the resident correctly, it could be a problem. Staff D stated they were not supposed to criss-cross the leg straps when transferring the resident, but instead use an [MEDICAL CONDITION] sling that had 4 pieces of cloth that pulled together and attached to the lift. Staff D, CNA, reported she worked the 6 am-2 PM shift on A hall on Sunday 7/15/18. Staff D stated Staff F, CNA, assisted her to transfer Resident #61 on 7/15/18 AM. As Staff F lifted Resident #61 with the lift, she told Staff F to lower the resident back down because the resident wasn't in the sling right and her bottom was coming out of the bottom of the sling. Staff D reported the sling wasn't under the resident in the right position. The resident's butt had slid off the wheelchair and the sling was only behind her back. She called for another aide to come help. The staff got the resident up in air and placed the sling and resident in the wheelchair the way it should be. Staff D wanted to put the resident back in bed when she first saw the sling placed incorrectly, but they continued to transfer and quickly put the resident into the wheelchair. Staff D confirmed the resident did not fall, but it made her nervous thinking the resident could have fallen or gotten hurt. Staff D reported an [MEDICAL CONDITION] sling needed to be used where the top of sling is like regular sling but had 4 pieces of cloth on the bottom portion of the sling where strings placed together and attached to the lift. Staff D reported she used black straps to attach the sling to the lift. Staff D acknowledged the sling needed to be placed under the resident's back and under the thigh area. Staff D reported she had been a CNA since 11/2017 and learned how to use the mechanical lift during orientation. During that time, someone showed her how to use the mechanical lift and transfer residents who required a mechanical lift device. Staff D acknowledged she had no other training, in-service or skills fair on the use of a mechanical lift. In an interview 7/18/18 at 2:40 PM, the Director of Nursing (DON) stated the CNA's had completed a competency/skills fair 6 to 7 months ago. The skills fair competencies included hand washing, catheter care and pericare. The DON reported staff training on the use of equipment and how to perform transfers is done as part of staff orientation. In an interview 7/18/18 at 4:50 PM, Staff F, CNA, reported she worked a 6 am - 6 PM shift on 7/14/18 and 7/15/18. Staff F reported she normally worked as a bath aide, but had worked in Hall A. Staff F reported she had been a CNA since 10/2017. Staff F stated she had completed Relias education (online learning) and had been shown how to use equipment such as the Hoyer / mechanical lift during her orientation period of 10 days. She had no other in-service or competency checks since she had worked at the facility or formal training for care of an [MEDICAL CONDITION] resident. Staff F reported she looked at the IPAD electronic device which had the resident information to see what cares needed on the residents, for example, how many staff needed or equipment needed to transfer a resident. Staff F reported Resident #61 had been alert and oriented to person, place and time and able to tell staff what she needed. The resident used a use Hoyer/mechanical lift and needed 2 staff when transferred. Staff F reported on 7/15/18 in the morning she assisted Staff D transfer Resident #61 from the bed to the wheelchair. Staff F reported they placed an [MEDICAL CONDITION] sling under the resident. Staff F reported she always hooked the black straps to the top bar and the green straps to the bottom of the lift bar. When they used the lift and raised the resident up, Resident #61 was lying flat in the sling and she kept sliding. Instead of putting the resident back into bed, they tried to lower the resident into the wheelchair. The resident continued to slide as they lowered her into the wheelchair, and the sling slid higher up her back. The resident's body was out straight. Staff F reported once they lowered the resident into the wheelchair, she had not been placed in the wheelchair seat far enough and they had called for another staff person to assist. Staff G, Medication Aide, came to the resident's room and helped to adjust the resident into the wheelchair. In an interview 7/19/18 at 9:50 AM, Staff J, CNA reported she had received training on the use of a Hoyer/ mechanical lift during orientation, but had no other in-service or education about the EZ lift. Staff J stated she had attended a skills fair that entailed competency testing for pericare, catheter care, handwashing and portable oxygen usage. Staff J stated they had different size slings for residents who used the Hoyer. Staff J stated she had worked at the facility long enough to know the residents and what type of sling needed, but the facility also had a list of residents and the sling sizes on the inside door where they kept the slings. At the time, Staff J took the surveyor to the linen closet, moved slings to expose the wall behind the slings and stated the list of residents and sling size was no longer posted. Staff J then reported the type of sling needed for a resident would be on the resident's care plan. Observation revealed a sign on the door had the following sling sizes/colors: Burgundy = Large; Tan = medium; Green = Extra Large. In an interview 7/19/18 at 10:00 AM, the DON reported they hadn't done any skills audits or observations on staff for at least 6 months. The DON reported if she had identified a problem through their internal QA (quality assurance) process, she would maybe perform an audit at that time. The DON reported she hadn't completed her investigation of some things that had happened recently. When asked what she meant, she stated it would be QA and she couldn't discuss it. The DON confirmed no audits done with staff for any type of transfers in the past 6 months. In an interview 7/19/18 at 10:05 AM, the Assistant DON reported Resident #61 had no incident reports since her admission. At 10:10 AM, the ADON reported they had no facility policy about transfers. In an interview 7/19/18 at 12:20 PM, Staff K, LPN, confirmed she had written a progress note on Resident #61 on 7/15/18 at 3:00 PM. Staff K reported she worked the back hall on 7/15/18, but had been asked by staff to speak to Resident #61 because the resident seemed agitated and upset about staff not knowing how to use the Hoyer and sling. Before she talked to the resident she pulled information up on the company's website to double check; there were two ways to do things and she saw they had two different kinds of slings that could be used for an [MEDICAL CONDITION] resident. Staff K stated the resident only wanted to use the [MEDICAL CONDITION] sling. Staff K reported the sling needed to go under the thigh with straps or each strap hooked to the bar. She told the resident they followed manufacturer recommendations on the use of the lift/ Hoyer. Staff K reported the type of sling used on each resident listed on the Kardex for CNA's to view in Point of Care documentation system (viewed on an IPAD by staff). Staff K pulled up Resident #61's Kardex on the computer and confirmed no sling type listed for Resident #61. Staff K reported in her opinion, Resident #61 would need an extra-large or a large sling. Staff K said they had no list containing resident names and the sling size used, it would be found on the care plan. In an interview, 7/19/18 at 12:25 PM, the ADON reported all of the staff would just know to use an [MEDICAL CONDITION] sling if they had an [MEDICAL CONDITION] resident. The ADON stated they only had one sling size for [MEDICAL CONDITION]. The manufacturer EZ lift (mechanical lift) operating instructions revealed the EZ lift is used to lift residents from the bed, chair, toilet and floor. Resident size, shape, weight and temperament needed to be considered when staff decided on the type of EZ sling most suitable for resident needs. The manufacturer recommended a multi-purpose sling for [MEDICAL CONDITION] and people who had large thighs. The manufacturer instructions included the following procedural steps when transferring a resident from the bed to a chair: a. Roll resident onto side b. Position the sling underneath the resident, center the sling along the spine, and the crotch of sling approximately two inches below the base of the tailbone. c. Roll resident and pull the rest of the sling out the other side. d. Roll resident onto back, and ensure the sling centered underneath the resident. e. Lift the thigh and pull the wing of the sling under the thigh, then place excess wing over the top of the thigh. Repeat on the opposite leg. If the resident's legs are rigid, place left wing under the right thigh, and the right wing under the left thigh instead of going between the legs. f. Attach the loops by the resident's shoulders to the lift, using the shortest loops g. Take the wing lying over the left leg and hook to the right hook on the longest loop, then take the wing lying over the right leg and hook to the left hook. Note: if wings placed under both legs, such as when used on a rigid resident, hook the longest loops straight up along the outside of the legs. h. Push the up button on the hand control i. Once tension noted on the loops, double check the loops and ensure the loops are secured in the hooks j. Lift resident to the desired height k. Use the spreader bar and adjust the legs of the lift around the wheelchair. l. Position the wheelchair under the resident. m. Stand behind the wheelchair and hold both side handles on the back of the sling or the middle handle, to ensure the resident seated in an upright position when seated in the wheelchair. n. Push the Down button on the hand control, until the resident seated in the wheelchair, and to release the tension on the loops. o. Unhook sling from the EZ lift. 2. The MDS assessment dated [DATE], revealed Resident #44 had a BIMS score of 15, indicating intact memory and cognition. Resident #44 required limited assistance of one staff for locomotion in her room. In an interview on 7/17/18 at 8:45 AM, Resident #44 reported staff didn't get along and argued about how to do things. The resident stated staff hadn't been trained the same. One staff person would say they learned to do a skill one way, and another staff member would say they learned the same skill another way. Resident #44 reported on the morning of 7/15/18, she witnessed staff use a mechanical lift on her roommate (Resident #61). Resident #44 stated staff argued about which strap to use when they hooked up the sling, before they moved Resident #61. Resident #44 stated she witnessed Resident #61 laying almost flat in the sling, horizontally with the floor when staff used the lift and as they transferred the resident. One CNA wanted to put the resident back into bed, but the other CNA didn't want to do that. Resident #44 thought it was scary and Resident #61 was going to slide out of the sling and land on the floor. Resident #44 reported the staff got Resident #61 into the wheelchair but they had called for additional help.

Based on clinical record review, staff interview and facility policy review, the facility failed to report a resident's allegation of abuse for Resident #3 and an incident of resident-to-resident abuse between residents # 16 and #13 to the state agency. The survey sample included 14 current residents. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive and memory impairment. The assessment documented the resident had clear speech, the ability to express his/her ideas and wants and that s/he usually understood others. The assessment also documented that Resident #3 displayed no signs or symptoms of [MEDICAL CONDITION], no potential indicators of [MEDICAL CONDITION] and no behavioral symptoms during the assessment period. The resident's Progress Notes dated 3/3/16 at 2:32 a.m. documented the resident stated someone gouged him/her trying to rob him/her. The Progress Notes dated 3/3/16 at 7:50 a.m., documented the resident stated a burglar hit him/her in the left eye. The Progress Notes dated 3/4/16 documented that at 8:51 a.m. Resident #3 stated somebody jumped him/her and tried to gouge out his/her eyes. The resident stated that staff did not believe him/her. The Progress Notes dated 3/5/16 at 7:00 am. documented the resident cried and stated someone poked the resident's left eye last night and no one believed the resident. The Progress Notes dated 3/5/16 at 8:45 p.m. the resident stated their roommate had hired someone to jab his/her eye. The Progress Notes dated 3/6/16 at 11:30 a.m. documented the resident stated someone hit his/her eye and stated that staff did not believe the resident. During an interview on 5/24/16 at 12:36 p.m. Staff D, licensed practical nurse, stated the overnight nurse reported Resident #3 stated someone gouged the resident in the eye. Staff D stated she assessed the resident and reported the resident's statements to Staff B, registered nurse, Co-Director of Nursing (DON), and Staff C, registered nurse, Co-DON. Staff D stated she did not consider the resident's statements as an allegation of abuse due to the resident's cognitive status and the resident had no injury. In an interview on 5/24/16 at 9:00 a.m., Staff C and Staff B stated the allegations of abuse made by Resident #3 had not been reported to Iowa DIA (Dept. of Inspections and Appeals). At 9:20 a.m., Staff B and Staff C stated they felt the incident fell into the category of not reportable due to dementia/hallucinations. Staff B and Staff C confirmed they first heard about the allegation of abuse during morning meeting on 3/4/16 and took no further action. 2. The MDS assessment dated [DATE] for Resident #16 identified a BIMS score of 7 indicative of severe cognitive and memory impairment. The MDS revealed the resident walked independently and displayed no behavioral symptoms. The care plan printed 10/8/15 documented sometimes Resident #16 had a difficult time controlling his/her mood or actions. The entry documented the resident should come and alert staff if s/he was in an argument with other residents to help calm the situation before an incident occurred. The Incident Report Progress Note dated 11/21/15 at 11:43 a.m. documented Resident #16 and roommate (Resident #13) argued in their room. A housekeeper witnessed Resident #13 hitting Resident #16 in his/her arm. The not documented that staff educated both residents to find staff if there was an issue so staff could intervene before an incident occurred. 3. The MDS assessment dated [DATE] for Resident #13 identified a BIMS score of 12 indicative of moderate memory and cognitive impairment. The MDS revealed the resident walked independently and that s/he had no behavioral symptoms during the assessment period. The resident's care plan contained a hand-written entry dated 11/21/15. The entry informed the resident to come and alert staff if arguing with roommate to prevent outbursts/incident. Staff crossed the entry off on an unknown date and noted the issue had been resolved with a roommate change and referenced the SS (social service) document. Resident #13's Behavior Progress Note dated 11/21/15 at 11:27 a.m., documented Resident #13 hit another resident in the arm that day. The entry documented the nurse educated Resident #13 that s/he could not put hands on other residents. The nurse recorded Resident #13 had not been very compliant in speaking with the nurse, turned on the TV, and turned the volume up very loud. The entry noted education provided to Resident #13 not to hit others and if another resident upset him/her to tell staff. The Social Service Progress Note dated 11/24/15 at 10:55 a.m. documented Resident #13 moved to a new room. The resident did not get along with his/her roommate and wanted to change rooms. The Mandatory Reporting of Dependent Adult Abuse, Crimes and Other Notifications facility policy revised 8/11/11 directed the following under Policy: Staff members and employees in our health care facilities and assisted living programs will make every effort to insure that reasonable suspicions of dependent adult abuse and other required notifications are reported within the timeframes established by law and administrative rules. The Resident-to-Resident Occurrences facility policy revised 9/29/11 directed the following under Policy and Procedure: *Policy - Employees of our health care facilities and assisted living programs will make every effort to protect residents and tenants from sexual offense, financial exploitations (including misappropriation of property), or verbal or physical assault perpetrated by another resident or tenant. *Procedure, Point #3 - See Mandatory Reporting of Dependent Adult Abuse, Crimes and Other Notifications policy and procedures. In an interview on 5/25/16 at 11:10 a.m., the Administrator stated that resident-to-resident scenario of a resident hitting another resident would be something to report to Iowa DIA. In an interview on 5/25/16 at 11:25 a.m., Staff C stated the nurses would have been expected to report the resident-to-resident contact to their supervisor or the on-call supervisor. Staff C stated the incident with Resident #13 hitting Resident #16 had not been reported to DIA.

Based on clinical record review and staff interviews, the facility failed to provide an ongoing program of activities designed to meet the assessed needs of 1 of 5 residents reviewed. (Resident #4). The facility identified a census of 65 current residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4 indicating severely impaired memory and cognition. Resident #4's [DIAGNOSES REDACTED]. The assessment documented that Resident #4 required the assistance of 2 staff with bed mobility and transfers and that s/he did not walk. The assessment documented the resident had little interest or pleasure in doing things, felt down or hopeless, had sleep trouble, had little energy and trouble concentrating during the assessment period. The MDS identified Resident #4 with activity preferences which were very important to him/her which included listening to music and keeping up with the news. The assessment documented the resident felt it to be somewhat important to be around animals such as pets and to do their favorite activities. According to the Activity Interview for Daily and Activity Preferences dated 8/14/14, Resident #4 documented it as very important for the resident to be around animals, such as pets. Resident #4 loves all types of animals, especially horses, and the facility has horse magazines and Pet Therapy Dogs visit. It was very important to keep up with the news and the resident listened to the news on TV. It was somewhat important for Resident #4 to go outside to get fresh air when the weather is good and for this activity preference to be made available by having the resident's family or staff take Resident #4 out on nice days. The resident's care plan with the target date of 10/16/15 identified that large group activities are difficult for Resident #4. The resident needed help with simple small group activities like ball toss, art, puzzles, exercises, reading, etc. The care plan listed interventions that included the resident enjoyed going outside in nice weather, the resident had a cell phone for independence with calls to and from family and friends and if the resident became agitated or had behaviors, to remove the resident from a group activity and assist the resident with a 1:1 activity. In interviews on 9/16/15 at 11:00 a.m. and at 1:55 p.m., Staff F, Activities Assistant, stated that Resident #4 enjoys music and 1:1 activities on occasion. Resident #4 sometimes becomes over stimulated and may request to leave some activities and at other times may refuse an activity or be asleep and may not be awakened to ask. Staff F indicated they document Resident #4's activities, but not necessarily the times when Resident #4 is invited but then refuses activities. Staff F stated Resident #4 is not asked to attend every activity, because he/she has expressed anxiousness in the past regarding group activities. Staff F stated Resident #4 is not invited to devotion or bible studies as the resident is usually sleeping or visiting with his/her spouse. When asked what alternatives are offered to Resident #4, Staff F stated 1:1 activities as time allows. Staff F stated 1:1 activities are not scheduled. In interviews on 9/16/15 at 11:20 a.m. and at 1:50 p.m. Staff G, Activities Director, stated that Resident #4 attends some music events which are documented on a monthly calendar and computer system. Resident #4 is provided 1:1 activities on occasion. When asked about the care plan process. Staff G stated care plans are reviewed quarterly and adjusted as needed. Staff G stated Resident #4 was invited to all daily activities by Staff F, but 90% of the time refuses. Staff G stated she does not document invitations to activities and refusals. Staff G asked what alternatives are offered when Resident #4 refuses to attend an activity, Staff G stated 1:1 activities but noted they are not scheduled. When asked how Resident #4's activities goal was being worked towards or measured, Staff G stated she was not sure about the measuring part, but staff are doing the 1:1 activities. Staff G stated that staff go outside with the resident, help him/her with the phone and when he/she gets agitated in the group, they do 1:1 activities. According to the Activities Calendar for June 2015, Resident #4 went outside and to a music event on 6/12 and attended a music event on 6/16. The calendar recorded staff offered no other activities recorded on the calendar. According to Activities Calendar for August 2015, Resident #4 attended bible study on 8/5 and 8/12, went outside on 8/12 and 8/27 and had his/her nails painted on 8/15. The calendar recorded staff recorded no other activities on the calendar. The resident's Activities Progress Notes documented no entries in June 2015 or August 2015.

Based on clinical record review, facility policy review and staff interviews, the facility failed to operationalize policies and procedures for investigating injuries of unknown origin for 1 of 5 residents reviewed (Resident #4). The facility identified a census of 65 current residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4 indicating severely impaired memory and cognition. Resident #4's [DIAGNOSES REDACTED]. The assessment documented that Resident #4 required the assistance of 2 staff with bed mobility, transfers and toilet use, the assistance of one staff member with eating and personal hygiene and that s/he did not walk. The assessment documented the resident had no falls since admission or the previous assessment. The MDS did not document that Resident #4 received anticoagulant medication. Record review of Resident #4's progress notes dated 7/26/15 indicated an Incident Report late entry at 6:50 p.m. written by Staff E, licensed practical nurse. Staff E documented that while applying a treatment to Resident #4's knees, she noticed a 6 centimeter by 3 centimeter light reddish/purple bruise on the front of the resident's left knee. Resident #4's spouse was in the room at the time and stated the bruise was not there earlier that morning and thought the bruise had been caused by staff pushing Resident #4 too close to the dining room table. Resident #4's spouse asked who fed Resident #4 and at that time a CNA entered the room and stated she did that evening. The staff member denied having Resident #4 pushed too close to the table. Resident #4 could not recall hitting his/her knee. The entry documented a preliminary recommendation to ensure the resident's legs and feet are in proper placement while in the wheelchair. During an interview on 9/16/15 at 4:09 p.m. Staff E stated that on 7/26/15 she discovered a bruise on Resident #4's left knee. Staff E inquired as to what happened and Resident #4 did not know. Staff E filled out an incident report and skin sheet and contacted her supervisor, DON2. In an interview on 9/16/15 at 4:20 p.m. when asked about the resident's bruising discovered on 7/26/15, the Co-Director of Nursing (DON2) stated she could not recall the incident or whether she was contacted. DON2 stated that incident reports are reviewed every morning, Monday through Friday. DON2 could not recall reviewing the incident on 7/26/15 or whether anyone investigated the cause. In an interview on 9/16/15 at 4:41 p.m. the Co-Director of Nursing (DON1) stated that when there is an injury or bruise discovered, staff are to fill out an incident report and skin sheet and notify their supervisor. Staff are to inquire as to the cause and report their findings. The incident reports are reviewed each morning and discussed. DON1 stated she recalled the incident involving Resident #4's bruise on his/her left knee on 7/26/15. DON1 stated the bruise had no known cause and no further investigation into the cause. DON1 stated the bruise was small and not significant enough to report. When asked if anyone had spoken with the day shift caregivers to see if there may have been an incident that day that might explain the bruise, DON2 stated no. Review of the facility's Abuse Prevention, Training and Investigation Policy dated 2/22/11 related to identification instructed staff that: Point #20) All employees are required to report incidents - anything unusual or unexpected at the time of occurrence, to their supervisor or person in charge of the facility for further investigations, regardless of whether the incident results in obvious or visible injury. Point #21) All employees are required to report evidence of injury to any resident/tenant immediately upon discovery to their supervisor or person in charge of the facility for further investigation. Point #22) An investigation will be conducted by the facility to identify the cause of any resident/tenant injury. If the cause of the injury cannot be determined, statements must be obtained from every person who provided care or treatment to the resident/tenant within the preceding 24 hours. This includes persons that may not be directly employed by the facility, i.e. therapists, hospital staff, clinic staff, families, volunteers, etc.

br>Based on facility record review and staff interviews, the facility failed to provide in-service education (a minimum of 12 hours per year) sufficient to ensure the continuing competence of nurse aides. The facility identified a census of 65 current residents. Findings include: Review of the training records for Staff A, certified nurse aide with a hire date of 5/3/12 revealed that between the dates of 5/3/14 and 5/2/15, Staff A received 11 hours of training instead of the 12 hours required. Review of the training records for Staff B, certified nurse aide with a hire date of 3/8/12 revealed that between the dates of 3/8/14 and 3/7/15, Staff B received 8.75 hours of training instead of the 12 hours required. Review of the training records for Staff D, certified nurse aide with a hire date of 6/25/12 revealed that between the dates of 6/25/14 and 6/24/15, Staff D received 7.75 hours of training instead of the 12 hours required. In an interview on 9/15/15 at 4:45 p.m. the Co-Director of Nursing (DON2) indicated the facility tracked certified nurse aide training. When asked who in the facility was responsible to ensure that training requirements for aides were being met, the DON2 stated again the facility tracked the training but did not identify a responsible person. In an interview on 9/15/15 at 5:10 p.m. the Administrator stated he was ultimately responsible for ensuring aides received their annual training requirements. The Administrator did not identify anyone else as responsible to track certified nurse aide training. In an interview on 9/15/15 at 5:30 p.m. the Co-Director of Nursing (DON1) indicated she completes annual performance evaluations on certified nurse aides. DON1 did not recall any competency issues identified in the performance evaluations of aides in which she wouldn't have addressed at the time in which it was identified. DON1 stated if an aide was having difficulties, she would re-educate the aide and follow up with audits of that aides performance.

Based on observation, facility policy review and staff interview, the facility failed to ensure food thickener powder did not have the scoop handles stored in the thickener powder and failed to ensure kitchen equipment was sanitizable. The facility reported a census of 59 residents. Findings include: 1. On 6/23/15 at 7:45 a.m., observation revealed two blue scoops inside an 8 ounce container of Hormel Thick and Easy (a food and beverage thickener), and one blue scoop inside another 8 ounce container of Hormel thick and easy thickener. Observation revealed the scoop handles below the surface of the powder. At 11:57 a.m., Hormel thick and easy thickener sat on a shelf in the kitchen. Observation revealed a blue scoop submerged in the powdered content. At 4:10 p.m., observation revealed two snack carts parked in the hallway by the nurses station and kitchen doorway. An 8 ounce container of Hormel thick and easy thickener sat on the cart with the blue scoop inside and a portion of the scoop handle was submerged in the powder. 2. During initial tour of the kitchen on 6/22/15 at 8:55 a.m., observation revealed 4 of 6 cutting boards heavily etched and the surface of the cutting boards appeared fuzzy. During interview on 6/25/15 at 12:42 p.m., the dietary manager reported cutting boards are replaced once a year and are due to be replaced in the next month or so. Review of a USDA Food Safety Information document titled Cutting Boards and Food Safety revealed all cutting boards wear out over time. After cutting boards became excessively worn or developed hard to clean grooves, they should be discarded. 3. Observation on 6/22/15 at 12:05 p.m., revealed Staff D, Restorative Aide assisting Resident #13 with lunch. Staff D removed a can of Hormel thick and easy thickener from the tray table placing it on top of the fireplace. Observation at 12:35 p.m., revealed the Hormel thick and easy thickener ½ full with the blue scoop inside the container with the handle in the thickener. 4. Observation on 6/24/15 at 3:00 p.m., revealed the Director of Nursing with a container of Hormel thick and easy thickener 7/8 full with the blue scoop down inside the thickener powder.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary resident environment. The facility reported a census of 59 residents. Findings include: 1. Observation on 6/22/15 at 12:35 p.m., in the back dining room revealed the base board heating units on the west and north walls had paint scraped off showing exposed metal along both units. At 1:10 p.m., the east bathroom up front revealed the inside of the wood door as badly marred in several areas leaving exposed wood and paint was peeling in the upper corner of the west wall. 2. Observation on 6/23/15 at 7:20 a.m., revealed the hallway carpet right outside the back dining room had several large stains in the carpet. 3. During environmental tour on 6/24/15 at 1:30 p.m., with the Administrator, the Maintenance Supervisor and the Housekeeping and Laundry Supervisor they acknowledge the above listed items. During interview on 6/24/15 at 4:00 p.m., the Administrator remarked the radiators in the back dining room would be fixed by morning. Observation on 6/25/15 at 7:25 a.m., the back dining room revealed the above items remained in disrepair.

Based on facility record review and staff interview, the facility failed to have trained staff in Cardio [MEDICAL CONDITION] Resuscitation (CPR) during the night shift 10:00 p.m. to 6:00 a.m. for 5 of 6 days of the scheduled survey week. The facility identified a census of 59 residents. Findings include: 1. During initial tour [DATE] at 9:25 a.m., Staff C License Practical Nurse, LPN explained the red dot by the resident name referred to Do Not Resuscitate (DNR) and the green referred to full code or to use CPR. On [DATE] at 9:00 a.m., the facility provided a list of ten staff certified in CPR. Review of the nursing schedule revealed Staff E LPN worked 5 of 6 night shifts 10:00 p.m. to 6:00 a.m. and was not on the list of certified CPR responders provided by the facility. On [DATE] at 3:00 p.m., Staff B Co-Director of Nursing stated Staff E was scheduled for CPR class [DATE].

This deficiency relates to facility reported incident -I Based on staff interviews and facility policy review, the facility failed to ensure an account of all controlled medications is maintained and periodically reconciled in accordance with the facility's policy. The facility identified a census of 60 current residents. Findings include: In an interview on 2/18/15 at 10:44 a.m. Staff A, Licensed Practical Nurse, indicated she completed a narcotic count with Staff B at around 1:30 p.m. on 1/28/15 and received the medication cart keys. Staff A (the offgoing charge nurse) later gave report to Staff C (the oncoming charge nurse). Since Staff A had recently completed a narcotic count, Staff A asked Staff C if she wanted to do the narcotic count and Staff C declined stating she trusted Staff A. Staff A admitted that not completing a narcotic count prior to turning over the medication keys was against facility policy. In an interview on 2/18/15 at 12:00 p.m. Staff C, Registered Nurse, indicated she arrived to work on 1/28/15 at around 2:00 p.m. Staff A had just counted narcotics with Staff B, so Staff C (oncoming charge nurse) declined to count again with Staff A (offgoing charge nurse). Staff C received the medication cart keys from Staff A. On 1/29/15, the facility noted a possible medication diversion in the facility and initiated an investigation. The facility reported the concern to the Department of Inspections and Appeals on 2/2/15. The Facility's Controlled Medication/Controlled Schedule II Legend Drugs policy dated 6/17/13 directed: Point #8 - A shift count verification must be completed every shift by the Charge Nurse going off duty and the Charge Nurse coming on duty. The Employee Counseling Form dated 1/29/15 indicated Staff A did not count at the end of shift with oncoming nurse, instructed Staff A to always count when passing keys and that failure to comply with the standard will result in a 3 day suspension. The Employee Counseling Form dated 1/29/15 indicated Staff C did not count at the end of shift with oncoming nurse, instructed Staff C to always count when passing keys and that failure to comply with the standard will result in a 3 day suspension.

The following deficiency relates to complaint # -C: Based on clinical and facility record review, staff interviews and physician interview, the facility failed to maintain acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible for 1 of 5 residents reviewed (Resident #4). The facility reported a census of 60 current residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had a brief interview for mental status score of 7 indicating severe cognitive and memory impairment. Resident #4 required the physical assistance of 2 staff with bed mobility, transfers, dressing and toilet use. The resident required the physical assistance of one with wheelchair locomotion, eating and personal hygiene. The assessment documented Resident #4 weighed 138 pounds and s/he had no loss of 5% of their weight in the last one month and or 10% loss in the last 6 months. Resident #4's [DIAGNOSES REDACTED]. Resident #4's plan of care initiated on 8/12/14 identified a focus of needing assistance with activities of daily living (ADLs) related to stroke and dementia with interventions which included: ? Eating: Resident #4 required extensive assistance by one staff to eat sometimes. Resident #4 usually started out feeding him/herself, but needed assistance to finish. Resident #4's plan of care also documented a focus of having a swallowing problem related to coughing or choking during meals or medication. The resident ' s intakes are less than 75% of meals. Interventions included 2.0 supplement as ordered, the resident ate better with 1:1 in his/her room or the living room back desk or library for less stimulation (initiated 1/15/15), double cereal at breakfast (initiated 1/30/15), provide adaptive flatware (started 2/9/15) and offer super cereal at lunch and supper (started 2/19/15). Resident #4 Medication Administration Record [REDACTED]. On 1/19/15, the facility increased the 2 cal to 3 ounces four times a day. The facility started obtaining daily weights on 1/12/15 (135.9 lbs). On 1/22/15, the resident weighed 130.3 lbs and on 1/30/15, s/he weighed 138.3 lbs. The resident ' s Skilled Nursing Facility (SNF) Daily Assessment note upon admission 8/12/14 recorded that Resident #4 weighed 150.8 lbs and Resident #4 stated at one time he/she weighed 250 pounds. Resident #4 was on a general diet with nectar thick liquids. Physician orders [REDACTED]. The Weights and Vitals Summary form for Resident #4 documented: 8/18/14 - 152 lbs; 9/5/14 - 152 lbs; 10/2/14 - 145 lbs (a 4.6% loss in 28 days); 11/9/14 - 143 lbs; 12/4/14 - 140 lbs (a 7.9% loss 90 days); 1/2/15 - 136 lbs (a 10.5% loss 120 days); 2/5/15 - 138 lbs (a 1.5% gain 30 days). In an interview on 2/24/15 at 9:40 a.m. Staff D, Co-Director of Nursing, explained the facility ' s identification of weight loss process and the facility ' s response. Staff D stated that upon admission residents are weighed daily for seven days and then weekly for one month. By the end of that time both nursing and the dietician will have had an opportunity to assess and review the weights and based on those assessments determine the continued frequency of weight checks. Each month the resident's weight is recorded on the computer for nursing and the dietician to review (Weights and Vital Summary). The computer will flag any significant weight loss or gain. When flagged, the dietician or nursing will fill out a notification form with recommendations and fax it to the physician. Additionally this prompts the facility to notify the family and any recommended changes will be forwarded to the food service, dietician and care plan coordinator. Staff D was provided the Weights and Vitals Summary form for Resident #4. The form reflected no "warning" that Resident #4 had had significant weight loss. Staff D indicated Resident #4 had had no significant weight loss in 30 days (5%) or 6 months (10%). Upon review of the form, Staff D acknowledged the weight loss but stated she didn't believe the ninety day standard was a regulation and stated that she planned to look it up. Interpretive Guidelines for F325 and referenced by the Centers for Medicare and Medicaid Services (CMS) suggest that parameters for evaluating the significance of unplanned and undesired weight loss are: ? One month - a loss of greater than 5% is considered significant; ? Three months - a loss of greater than 7.5 % is considered significant; ? Six months - a loss of greater than 10 % is considered significant. In an interview on 2/24/15 at 2:51 p.m., Staff E, Registered Dietician (RD) stated that new admits will have their weights checked daily for a week and weekly for a month. Continued weight frequency is then determined based on the individual ' s needs. Staff E indicated she reviews resident weights each month and all weights during quarterly reviews. If a resident falls into a significant loss or gain, Staff E would notify the physician and provide recommendations. Staff E indicated Resident #4 never triggered as a significant weight loss. Staff E stated a significant or severe weight loss would be 5% in 30 days or 10% in 6 months. Staff E asked if a resident had a 7.9% loss in 90 days, would that be a significant or severe loss. Staff E stated she would address that if she knew of the loss. Staff E did not offer an opinion as whether the 7.9% weight loss in 90 days was a significant loss. Staff E agreed that a 10.5% loss in 120 days was a severe loss and it would need to be addressed. Staff E had done quarterly assessments on Resident #4 and starting in January 2015, 2 cal was added to Resident #4's diet and then increased to four times a day later that same month. Super cereal was also added to his/her diet. Staff E could think of no other interventions used to address Resident #4's weight loss prior to January 2015. The Nutritional Assessment completed by Staff E following admission and dated 8/18/14 indicated Resident #4 on a general nectar thick liquids diet. Staff E documented no fortified foods or supplements were needed. The resident weighed 152 lbs. and had a fair appetite. Staff E identified a nutritional problem of inadequate oral intakes, with the etiology of a decreased appetite. The Summary of her Recommendations documented the resident entered the facility on a Regular diet and his/her spouse stated the resident eats everything. The resident and spouse denied food allergies [REDACTED]. The resident had no observed problems with chewing or swallowing. The resident also had a very attentive spouse who had been the resident ' s primary care giver. Resident #4 was very soft spoken, but answered questions. Weights are being monitored daily and are stable. The assessment documented to move to weekly weights monitoring. The Nutritional assessment dated [DATE] documented Resident continued on general diet with nectar thick liquids without supplements or fortified foods. The assessment documented intakes of 100% at breakfast, 58% at lunch and 73% at supper. The assessment documented a weight decrease of 6%. The assessment documented the resident had the nutritional problem of inadequate oral intakes with the etiology of a decreased appetite. The Summary of Recommendations documented that Resident #4 received a regular diet with nectar thick liquids. Staff E observed the resident at breakfast and s/he received assistance with set up and cues to eat. The resident had no observed problems with chewing or swallowing. Resident #4 is very soft spoken, but answered questions. The resident was positive about his/her breakfast and fed him/herself slowly. The meal was served on a bedside table to allow independence. The resident had been receiving an antibiotic for a urinary tract infection. Nutritional Assessment completed by Staff E on 2/9/15 indicated Resident #4 remained on a general diet with nectar thick liquids. Staff E documented that no fortified foods. The resident began receiving Hormel Med Pass 3 ounces four times a day. The resident weighed 138 lbs, had a good appetite good and a BMI (body mass index) of 26.1 (overweight). The resident had a weight gain of 1.4% 30 days and a 9% loss in 6 months. Staff E documented a nutritional problem of inadequate oral intakes with an etiology of a decreased appetite. The resident had oral intakes of less than 75%. The Summary of Recommendations documented that Resident #4 received a regular diet with nectar thick liquids. Staff E observed the resident at breakfast and s/he received assistance with set up and cues to eat. The resident had no observed problems with chewing or swallowing. Resident #4 is very soft spoken, but answered questions. The resident was positive about his/her breakfast and fed him/herself slowly. Meals are served on a bedside table to allow independence. The resident ' s fluid intakes were poor and staff encouraged increased intakes. Staff E observed no concerns. In an interview on 2/24/15 at 3:13 p.m. Staff F, Licensed Practical Nurse stated she contacted Resident #4's physician on 1/7/15 in part due to Resident #4 being anxious, not eating well and having weight loss. Staff F received an order for [REDACTED]. Physician orders [REDACTED]. In an interview on 2/24/15 at 4:14 p.m., Staff G, Registered Nurse, stated she and other nurses were concerned about Resident #4's weight loss. Resident #4's spouse noted Resident #4 took the 2 cal well and wondered if it could be increased. Staff G contacted Resident #4's physician and got an order to increase the supplement to four times a day. Physician orders [REDACTED].#4 ' s 2 cal supplement to 3 ounces to four times daily. In an interview on 2/24/15 at 4:45 p.m. Resident #4's physician indicated Resident #4 had been in excess of 200 lbs prior to having a stroke (subarachnoid hemorrhage). Since that time Resident #4 had developed dementia and increased anxiety. The physician stated she did not know of any direct medical reason for Resident #4's weight loss, but the resident ' s anxiety and condition may interfere with his/her appetite and eating. The physician indicated the weight loss was not surprising. When asked whether the weight loss was unavoidable, the physician stated that it might be. The physician was then informed that since starting Resident #4 on supplements and super cereal, the resident had gained two pounds in one month. The physician stated that knowing this, the weight loss may have been avoidable had they added supplements to his/her diet earlier. In an interview on 2/24/15 at 5:20 p.m. Staff D when asked if Resident #4's weight loss from 9/5/14 (152 lbs) to 1/2/15 (136 lbs) was avoidable or unavoidable, Staff D indicated the loss as unavoidable because Resident #4 was his/her own person and made his/her own decisions including whether he/she wanted to eat or not and what he/she would eat, despite staff ' s efforts to assist and encourage the resident. Staff D indicated Resident #4 had a major stroke 8 months ago and weighed over 200 lbs prior to being admitted to the facility and had demonstrated a gradual weight loss since that time. Resident #4 had a [DIAGNOSES REDACTED]. Staff D stated Resident #4's weights were not insidious. When asked whether, Resident #4's condition had changed (better, worse, stayed the same) since he/she lost weight from 9/5/14 through 1/5/15, Staff D responded that she didn't believe there had been much change, noting the resident ' s BMI and lab work were good, the resident remained alert and oriented and could make his/her wants and needs known. Staff D stated there was nothing the facility could have done to prevent Resident #4's weight loss between 9/5/14 and 1/2/15. Staff D was then informed that after 1/2/15 a supplement was added (on 1/8/15) and increased (on 1/19/15) to Resident #4's diet and double servings of super cereal were added to breakfast (on 1/30/15) and since that time Resident #4 had gained two pounds. Staff D replied " no " when asked if had the facility added supplements in October 2014, if these may have prevented the resident ' s weight loss. The facility ' s Weight Monitoring Policy dated 1/99 directed: POLICY: Every resident will be accurately weighed at least monthly and the healthcare team will compare that weight with 30 day and 180 days prior. Weights will be communicated to the physician and family immediately as significant changes occur. The healthcare team will implement appropriate interventions based on weight changes to provide optimal resident care. (The facility policy only uses a 30 day 5% and 6 month 10% criteria when identifying significant or severe weight loss). Point #7 - Monitoring: Weekly weights are to be reviewed by the DON or designee and the Consultant RD to identify weight change trends that need to be acted upon quickly.......A significant unintentional weight change is one of two factors that can trigger the need to complete a full MDS and update the care plan. (There was no indication in the record that Resident #4's severe weight loss was identified and acted upon quickly). Point #8 - Notification: The physician and family are both to be notified immediately of any significant unintentional weight changes, whether expected or not. (There was no indication in the record that the physician was ever notified of Resident #4's severe weight loss documented on 12/4/14 until the facility notified her on 1/7/15). Point #10 - Intervention: Nutrition interventions are to be initiated by the healthcare team immediately when an unintentional weight loss occurs that poses a nutritional risk (whether significant or not)......interventions may include additional portions, increased fat and protein, nutrient-dense snacks between meals, supplements between meals or with medications and favorite foods brought in by the family. (There was no indication in the record that the DON or Consultant RD identified the unintentional weight loss of Resident #4 or were involved in the nutrition interventions initiated in January 2015). Point #11 - Expected Weight Decline: The healthcare team and/or resident's physician may determine that a resident, based on overall decline in health, is expected to have weight decline despite facility efforts. This should be clearly stated on the care plan with the factors that contribute to the resident's inability to meet estimated nutritional needs. (There is no statement in Resident #4's plan of care indicating an expectation of weight decline due to health or any other factors).

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and failed to revise the implementation of the written health care plan for 1 of residents identified at risk of falling (Resident #1). The facility identified a census of 58 current residents. Findings include: Resident #1 had an admission Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11. A score of 11 identified the resident with moderately impaired cognitive skills. Resident #1 required limited assistance of 1 person for ambulation, toilet use, bathing, dressing and personal hygiene. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident wandered. The Admission Care Plan dated [DATE] identified the resident at high risk for injury in regards to falls. The goal identified the resident would be free of injury from falls each day. The interventions directed staff to assist with transfers and ambulation by 1 staff person. The head of the bed and the 2 side rails should be in an up position, the resident should be assessed for orthostatic changes and lie in a hi-lo bed with call light within reach. Resident #1's Care Plan, dated [DATE], identified the resident at risk for falls related to a history of falls and poor balance. The interventions directed staff to: a. Call light within reach and encourage resident to use it. b. Continue to remind resident of safety, not to get up by self and use call light when wanting up. c. Assure the resident wore appropriate foot wear. d. Resident transfers and ambulates with walker and assist of one. e. Half rails on the bed for mobility. f. Assure bed is in lowest position when resident is in bed. g. Place personal items close to resident. h. Review falls and attempt to determine root cause and alter plan of care as needed. An IPN (Interdisciplinary Progress Note) dated [DATE] reflected Resident #1 arrived at the facility at 12:35 p.m. At 3:00 p.m. Resident #1, staff noted Resident #1 getting up several times independently. Staff educated resident to seek assistance when getting up. At 7:00 p.m., the resident had not used call light even though s/he demonstrated appropriate use. The resident continued to get up independently with and without walker. An IPN note dated [DATE] at 1:05 a.m. reflected the resident had confusion noted. The resident did not make needs/wants known and did not use the call light; the resident got up independently at times. At 1:30 p.m. the resident got up several times during the day with and without his/her walker, despite staff educating resident to wait for assistance and use the call light. The care givers intervened as able, but the resident got up constantly. Resident #1 almost fell on e time, but two care givers were present and able to catch him/her. The resident's gait is not steady at all times. An IPN dated [DATE] at 2:00 a.m. reflected the resident had confusion noted. Resident #1 did not make his/her needs known or use the call light and got up independently at times. At 1:00 p.m., the staff documented the resident continued to not use his/her walker despite reminders. At 6:00 p.m. the staff noted the resident could voice his/her wants and needs, but does not use call light. An IPN dated [DATE] at 1:25 a.m. reflected the resident was noted with confusion. Resident #1 did not make his/her needs known or use the call light. The resident got up several times this shift. At 4:30 p.m. staff noted Resident #1 had been up numerous times without using his/her walker. Staff educated the resident on the importance of safety. At 7:30 p.m. staff found the resident on the floor in the room doorway and the resident stated she/he hit his/her head. The resident wore non-skid shoes, the floor had no clutter and his/her call light and pendant were within reach. Resident #1 stated he/she tried to go to the bathroom and knew she/he should use the call light. The resident ' s legs were wobbly and body jittery, unable to obtain orthostatic blood pressures. Staff received a new order for pain medication (APAP (Tylenol) 325 milligrams 2 tablets every 4 hours for pain and for staff to obtain a urinalysis specimen. Interdisciplinary Progress Note dated [DATE] at 1:00 a.m. indicated confusion noted. Resident #1 has a pendant and does not use it. At 1:30 p.m. the resident had been out of their room most of the day. The resident gets up independently and wanders. Staff intervene quickly. At 6:00 p.m. the resident required the assist of two staff with transfers and ambulation due to being "jittery" and unsteady. An IPN note dated [DATE] at 6:00 p.m. identified the resident required the assistance of 2 staff with transfer and ambulation due to the resident being jittery and unsteady and would not hold onto the walker with both hands. Resident seemed to do a lot of competitive movement. The resident voiced confusion with conversation. An IPN dated [DATE] at 1:00 a.m. identified confusion noted. Resident #1 had not used pendant or call light this shift and had been up 2 times independently. At 12:30 p.m. staff noted finding Resident #1 in the bathroom that morning and staff went in just as resident started to fall. Staff prevented the resident from falling. An IPN dated [DATE] at 3:30 p.m. reflected Resident #1 placed on an antibiotic for a urinary tract infection. An IPN dated [DATE] at 7:50 p.m. reflected Resident #1 as "jittery" today. An IPN dated [DATE] at 7:55 p.m. reflected Resident #1 as more weak; she/he required the assist of one, "jittery" and with verbal ticks. An IPN dated [DATE] at 11:40 a.m. reflected Resident #1 with less wandering behavior. An IPN dated [DATE] at 1:10 p.m. reflected Resident #1 was found sitting on the floor on a wheel chair pedal in the bedroom doorway. The resident wore shoes and the wheel chair brakes were not locked. Resident #1 most likely tripped over a wheel chair pedal. The call light was in reach, shoes on and recently viewed by staff and toileted within the last two hours. An IPN dated [DATE] at 10:30 a.m. reflected Resident #1 provided 1 staff to this resident as emotional today. An IPN dated [DATE] at 2:00 p.m. reflected Resident #1 moved to room ,[DATE]. Staff found the resident frequently up and ambulating independently; they redirected the resident. An IPN dated [DATE] at 1:00 p.m. reflected Resident #1 up frequently wandering the hall. At times, the resident struggled to raise his/her right foot and staff provided assistance. At 9:40 p.m. the resident continued to get up on his/her own, wandering in the room and hallway. Staff reminded the resident to notify staff; however, the resident did not. An IPN dated [DATE] at 3:35 a.m. reflected the nurse and aide heard a thud and entered Resident #1's room. Resident #1 sat on the floor next to the hallway door. Resident #1 indicated he/she tried to use the bathroom. Resident #1 did not use his/her walker. At 10:10 a.m., staff found the resident lying on the floor near the bathroom. Resident #1 moaned and complained of leg and back pain. Staff noted external rotation and pain in the left lower extremity. Resident #1 then transferred to hospital for an x-ray and evaluation. At 5:03 p.m. a report from the hospital identified Resident #1 would be returning to the facility with a left femoral fracture. Resident #1 was placed on comfort cares. The IPN dated [DATE] at 4:00 a.m. revealed Resident #1 expired at the facility. On [DATE] at 12:51 p.m. Staff A (Licensed Practical Nurse) was interviewed and stated she worked the day shift on ,[DATE] 14 and had been assigned the back hallways. Staff A stated Resident #1 had been assisted to the toilet between 9:30 a.m. and 9:45 a.m. and was settled into his/her recliner. Aides summoned Staff A to Resident #1's room after hearing a thud. Staff found Resident #1 on the floor near the bathroom with his/her walker beside him/her. Staff A had been told by other nurses to keep an eye on Resident #1 because he/she would get up unassisted. Staff A had no discussions with the Director of Nursing regarding any special instructions to monitor Resident #1. The facility had no formal scheduled toileting or checks for Resident #1. On [DATE] at 1:14 p.m. Staff B (Certified Nurse Assistant) was interviewed and stated she worked the day shift on [DATE] and had been assigned to Evergreen Hall. That morning, staff found Resident #1 up and unassisted walking towards the bathroom. Staff then assisted Resident #1 and escorted him/her to the dining room for breakfast. After breakfast (8:45 a.m.), Resident #1 went back to his/her room, staff helped the resident to the bathroom and then into his/her recliner. At around 9:30 a.m. Staff B passed snacks and recalled providing Resident #1 with juice. Resident #1 sat in his/her recliner at the time. Shortly after 10:00 a.m. Staff B discovered Resident #1 on the floor. Staff B stated she had been informed Resident #1 liked to get up on his/her own and that staff needed to check on him/her frequently. Staff B stated Resident #1 should be toileted in the morning, before and after meals and as needed. Staff B stated the facility had no formal checks or toileting schedule, but noted staff are up and down the halls frequently and look in on Resident #1. In an interview on [DATE] at 1:30 p.m. Staff C (Certified Nurse Assistant) indicated she worked the day shift on [DATE] and had been assigned to Chestnut Hall. Staff C worked on another hall and did not care for Resident #1 that day; however she was familiar Resident #1 and that he/she frequently wandered. Staff C noted when she sees Resident #1 she would walk with him/her, offer a snack, toilet him/her and provide a 1:1 activity. Staff C stated Resident #1 was checked on frequently, but noted that no formal checks or toileting schedules were established. On [DATE] at 12:43 p.m. Staff D (Certified Nurse Assistant) indicated she was familiar with Resident #1's cares and needs. Resident #1 wandered a lot and got up unassisted. Staff D had been instructed by nursing to keep an eye on him/her, but the facility had no formal check or toileting schedules. Staff D indicated Resident #1 had the same care schedule as any other resident...toileting in the morning, before and after meals and before laying down. Staff D stated the staff frequently went down the hall and looked in on Resident #1. On [DATE] at 1:43 p.m. Staff E (Licensed Practical Nurse) was interviewed and stated she worked the back halls and felt familiar with Resident #1's cares and needs. Staff E stated following Resident #1's first fall, they discovered a urinary tract infection and treated Resident #1 with an antibiotic. The second fall resulted in Resident #1 being moved to the back hallway where the staff to resident ratio is smaller and traffic is heavier. Staff passed by Resident #1's room and checked on him/he frequently. Resident # 1 did fine with the move and it was beneficial when he/she had his/her third and fourth falls. Staff E stated the facility did not have a formal toileting schedule or checks, but staff checked on Resident #1 frequently. When Resident #1 tried to get up, staff would toilet him/her, offer a snack and provide 1:1 activity. On [DATE] at 3:12 p.m. Staff F (Co-Director of Nursing) stated Resident #1 was admitted to the facility with known history of falling while at home. Resident #1 had two falls prior to [DATE]. Nursing staff gave a daily report of all incidents and then they are discussed and interventions established. Following the first fall, Resident #1 had a urinary tract infection. Staff also educated Resident #1 on using his/her call light for safety. After the second fall, Resident #1 moved to a different room in which he/she could be better and more frequently supervised. Staff F stated Resident #1 was observed and assisted several times prior to and in between these falls. In an interview on [DATE] at 3:54 p.m. Staff G (Co-Director of Nursing) stated Resident #1 was admitted to the facility on [DATE] with a report by family that resident had multiple falls at home. Resident #1 had a fall on [DATE] and staff discovered he/she had a urinary tract infection which was then treated. A second fall occurred on [DATE] and Resident #1 transferred to another room with increased supervision. The third and fourth falls occurred on [DATE] within 7 hours of one another. Staff G stated the Medication Administration Record was faxed to the pharmacy for review. In a statement dated [DATE], Staff H, (Certified Nurse Assistant) stated she had helped Resident #1 put on a second pair of pants at around 9:15 a.m. on [DATE]. Resident #1 was assisted to the toilet where she voided. Resident #1 then returned to his/her recliner, legs elevated, TV on, remote in hand and call light within reach. Staff H stated Resident #1 was confused.

Based on clinical record review and resident and staff interviews, the facility failed to promote care for residents in a manner and an environment that maintains or enhances each resident's dignity and respect for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 67 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 8/31/13 which reflected the resident had a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 identified Resident #1 had no cognitive and memory impairment. The assessment documented the resident experienced no behavioral symptoms. Resident #1 required extensive assistance from 1 staff member for transfers, dressing, toilet use, personal hygiene and bathing. Resident #1's [DIAGNOSES REDACTED]. Resident #1's current Care Plan reflected a focus area of remaining active and attending the organized activities that interested the resident. Interventions included: a. The resident sits outside visiting with others to smoke. Resident #1 could light their (his/her) own cigarettes and knows he/she needed to turn in the lighter and cigarettes to the nurse upon entering the facility. b. Effective 10/7/13, staff should go out and light cigarette for resident. The resident could no longer take the lighter out independently. Resident #1's care plan also contained a focus of mental illness ([MEDICAL CONDITION]). Staff interventions included: a. Always approach the resident with positive, kind and patient mannerisms. The resident responded best to this approach. b. Provide the resident with 1:1 during periods of anxiety to assist with reassurance. If 1:1 is not effective, try re-approaching the resident at a later time. c. When Resident #1 is agitated, allow the resident time and re-approach him/her in a little while. On 10/29/13 at 4:30 p.m. Resident #1 was interviewed and stated that on 10/4/13, she/he came in from smoking and returned to his/her room. Staff A, LPN (Licensed Practical Nurse) approached the resident and told him/her to give over the cigarettes. Resident #1 stated he/she thought she/he had turned them (cigarettes) in. Resident #1 stated Staff A grabbed at him/her and Resident #1 propelled self away. Staff B, RN (Registered Nurse) then arrived grabbed Resident #1 and put him/her on the floor. Staff B then assisted Resident #1 back into the wheelchair and then again put him/her back onto the floor. Resident #1 kicked at staff and Staff A grabbed at Resident #1. Resident #1 stood to push staff away. Staff C, CNA (certified nursing assistant) then arrived and Staff B 'threw' Resident #1 down the hallway. Resident #1 stated he/she hit his/her head. Staff then walked away and said to call them if she/he needed any help. Resident #1 got back into his/her wheelchair and then into bed. Resident #1 stated he/she was unconscious for a while after the incident. Interdisciplinary Progress Notes dated 10/4/13 at 8:30 p.m., written by Staff A, documented Resident #1 as very upset that evening. Resident #1 went outside to smoke and came back in and did not turn back in (return) the lighter or cigarettes. Staff A went to the resident's room and politely asked Resident #1 for the lighter and cigarettes. Resident #1 stated he/she already turned those (cigarettes) in and the resident did not have them. Staff A asked again and the resident denied having the lighter or cigarettes. Resident #1 became loud and angry, cursing at Staff A. Staff A then attempted to physically take the lighter and cigarettes from Resident #1. Resident #1 became combative and continued screaming. Staff A wrote she obtained the cigarettes, but not the lighter. Staff A again asked Resident #1 to return the lighter and Resident #1 began propelling him/herself out of the room and into the hallway. Another nurse (Staff B) asked Resident #1 to return the lighter and Resident #1 refused. Both Staff A and Staff B attempted to physically remove the lighter from Resident #1. Resident #1 then again became combative. The resident stood up, attempted to strike out at staff and Staff B and B documented lowering the resident safely to the floor. The resident continued yelling profanities and refused to get up. Resident #1 remained on the floor and did not want help from staff. Resident #1 then climbed back up into wheelchair 5 minutes later and returned to his/her room. In an interview on 10/29/13 at 4:03 p.m. Staff A (licensed practical nurse) stated that on 10/4/13 she witnessed Resident #1 coming into the facility from outside and she/he went directly to his/her room. Staff A noticed Resident #1's cigarettes were not at the nurse's station where they are normally. Staff A went to Resident #1's room and asked if the resident would please return his/her cigarettes and lighter. Resident #1 refused to return them multiple times when asked. Staff A stated she saw the cigarettes in Resident #1's pocket and retrieved them as Resident #1 would not give them willingly. Resident #1 became very angry, started yelling profanities and then wheeled into the hallway. Staff B then approached Resident#1 and inquired why she/he yelled. Staff B asked Resident #1 to return the lighter several times and Resident #1 became combative, hitting and standing up from the wheelchair. Staff A saw the lighter in Resident #1's pocket and retrieved it too. Staff then had to lower Resident #1 to the floor. Resident #1 continued yelling profanities and when asked if he/she needed help back up in wheelchair, the resident refused. Staff left Resident #1 on the floor to re-approach later. When checked upon later, Resident #1 had gotten him/herself back into the wheelchair. Staff A stated she explained to the resident after the incident that the cigarettes would be kept in the medication room and a staff member would have to take one cigarette out and light it for her/him. Staff A stated the resident did not respond. On 10/30/13 at 12:11 p.m. Staff B (registered nurse) was interviewed and stated during the evening on 10/4/13, she worked in another room when she heard yelling and swearing. Staff B entered the hallway and found Resident #1 wheeling him/herself in a wheelchair with Staff A behind. Staff A informed Staff B that Resident #1 had a lighter. Staff B stopped Resident #1, reminded the resident of the facility policy and asked Resident #1 to return the lighter. The resident began to yell, swear and swing at Staff B. Resident #1 grabbed Staff B's arm and pulled him/herself up, swinging with his/her other arm. The wheelchair moved backwards and staff then lowered Resident #1 to the floor as he/she retained a hold of Staff B's arm. Resident #1 then laid back and began kicking, releasing Staff B's arm. Staff B stated she did not see the lighter, but then saw Staff A holding the lighter. Staff B stated Staff A remained with Resident #1 and Staff B went to the nurse's station. In an interview on 10/30/13 at 12:45 p.m. Staff C (certified nursing assistant) stated that on the evening of 10/4/13 she washed her hands in the dirty utility room and heard yelling and cussing. Staff C responded and found Staff A and Staff B standing next to Resident #1 in his/her wheelchair. Resident #1 then began to stand and Staff A and Staff B assisted Resident #1 onto the floor. Resident #1 then began kicking at Staff C and Staff C decided to step away and allow the nurses to handle the situation. In an interview on 10/30/13 at 10:48 a.m. Staff D, Co-Director of Nursing stated the facility policy permits residents to have cigarettes and lighters outside while smoking, but prohibits residents from having a lighter in their possession in their rooms. On several occasions, Resident #1 tried to keep the lighter and cigarettes which required nurses to track them down. Staff D stated that on 10/4/13, the nurse was assertive in trying to talk Resident #1 into giving up the lighter and Resident #1 repeatedly refused. Resident #1 had the lighter in his/her pocket, the nurse tried to remove it and Resident #1 got physical. The nurse did not get physical. Staff D stated she believes the actions of her nurse were justified and doesn't believe taking the lighter from an unwilling resident created the altercation. On 10/30/13 at 11:30 a.m. Staff F, Co-Director of Nursing, was interviewed and stated she expected staff to approach residents in a professional manner and ask to have the lighter returned. If staff are unable to get the lighter, they should then ask another staff member to approach the situation. Staff should make the best decision related to the situation at hand while maintaining the resident and facility's safety without abusing the resident. Staff F stated she would not expect the resident's arms be restrained or hands forced open, but it may be appropriate to reach into the pocket and remove the lighter with the resident's knowledge.

Based on record review and staff interviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated of 6/22/13 revealed Resident #1 had [DIAGNOSES REDACTED]. The same MDS revealed Resident #1 displayed intact cognition and required extensive assistance with assist of one to two staff with transfers, ambulation (walking), dressing, personal hygiene and toilet use. Resident #1's plan of care dated 2/19/13 documented Resident #1 as at risk for falls and directed staff to assist the resident with ambulation and transfers during day hours (6:00 a.m. to 6:00 p.m.) with one staff and assist of two staff during evening hours (6:00 p.m. to 6:00 a.m.) with hemiwalker and gait belt. (6/25/13) In an interview on 8/12/13 at 3:11 p.m. Staff A, certified nurse aide (CNA), reported on 7/12/13, she and Staff B, CNA, entered Resident #1's room to assist him/her to the bathroom. Both staff assisted Resident #1 with the transfer/ambulation using a gait belt and walked him/her to the bathroom. Staff A remained with Resident #1 as Staff B exited the bathroom to obtain supplies. Music was playing in the resident's room. Resident #1's spouse was singing and whistling. Resident #1 told staff he/she was unable to go, was done and ready to get up. Staff A then, without alerting Staff B, assisted Resident #1 up from the toilet with a gait belt and started to walk out of the bathroom. Resident #1 was slowly swaying his/her hips to the music, when he/she lost balance and his/her foot slipped. Staff A held the gait belt tightly, held Resident #1 closely to her body and lowered the resident. Staff A reported the resident did not hit anything and felt the lowering to the floor was very controlled. Staff A believed the resident was doing well, but acknowledged she should not have assisted him/her up without assistance. Both Staff A and Staff B assisted Resident #1 up and to his/her bed, then notified the nurse of the incident. In an interview 8/12/13 at 2:59 p.m. Staff B, certified nurse aide, indicated on 7/12/13, she and Staff A went to help Resident #1 get ready for bed. Both Staff B and Staff A assisted Resident #1 onto the toilet. Staff B left the bathroom to dispose of dirty clothes. Staff A then got Resident #1 up by herself and started walking him/her to his/her bed. There was music playing and Staff A was pretending to dance with Resident #1. Resident #1 then lost his/her balance and Staff A lowered him/her to the floor using her gait belt. The Interdisciplinary Progress Notes (IPN) in Resident #1's file dated 7/12/13 at 9:30 p.m. and written by Staff C, documented CNA summoned this nurse to resident's room at approximately 6:45 p.m. this evening stating her and another CNA had lowered resident to the floor and he/she had a skin tear. When arrived to room, resident was already sitting on bed. Upon assessment, Resident #1 had a skin tear on left elbow 1 centimeter (cm) in diameter and skin able to unroll and cover open area, steri-strips placed after cleansing area. Resident #1 also has a skin tear on left first knuckle, 1 cm x 1 cm and no skin to cover open area, so area cleansed and Band-Aid placed. No further injuries noted.

Based on record review and staff interviews the facility failed to provide the necessary care and services (assessment and intervention), to maintain the resident's highest practicable physical, mental and psychosocial well being for 1 of 4 residents reviewed. (Resident #1). The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated of 6/22/13 revealed Resident #1 had [DIAGNOSES REDACTED]. The same MDS revealed Resident #1 displayed intact cognition and required extensive assistance with assist of one to two staff with transfers, ambulation (walking), dressing, personal hygiene and toilet use. Resident #1's plan of care dated 2/19/13 documented Resident #1 as at risk for falls and directed staff to assist the resident with ambulation and transfers during day hours (6:00 a.m. to 6:00 p.m.) with one staff and assist of two staff during evening hours (6:00 p.m. to 6:00 a.m.) with hemiwalker and gait belt. (6/25/13) In an interview on 8/12/13 at 3:11 p.m. Staff A, certified nurse aide (CNA) stated she and Staff B took Resident #1 to the bathroom. When Staff A walked with the resident back from the bathroom using a gait belt, but without Staff B's assistance, Resident #1's foot slipped and she lowered the resident #1 to the floor. Both Staff A and Staff B assisted Resident #1 up and to his/her bed, then notified the nurse of the incident. Staff A reported the facility standard of care when residents fall is that a nurse is supposed to complete an assessment before the resident is moved or assisted back up. In an interview 8/12/13 at 6:11 p.m. Staff C, Licensed Practical Nurse, indicated on 7/12/13 she was summoned to the room of Resident #1 by Staff A and Staff B and informed Resident #1 had a skin tear. Staff A and Staff B informed Staff C that Resident #1 had been lowered to the floor, but upon arriving to the room, Resident #1 had been moved to the bed. Staff C stated Resident #1 had received a skin tear, but had no additional injuries or complaints of pain. Staff C reported the facility standard of care when residents fall is that a nurse is supposed to complete an assessment before the resident is moved or assisted back up. In an interview 8/8/13 at 5:04 p.m. the Director of Nursing (DON) indicated the expected standard of care when a resident falls or is lowered to the floor is the resident is not to be moved until they are assessed by the nurse. Interdisciplinary Progress Notes (IPN) dated 7/12/13 at 9:30 p.m. written by Staff C, Licensed Practical Nurse, indicated an aide summoned her to Resident #1's room at approximately 6:45 p.m. stating her and another aide lowered Resident #1 to the floor and then assisted the resident up. The LPN documented Resident #1 sustained 2 skin tears.

Based on record review and interviews the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents reviewed. (Resident #1). The facility reported a census of 64 residents. Findings include: The Minimum Data Set (MDS) with an assessment reference date of 3/17/12 indicated Resident #1 with a Brief Interview for Mental Status score of 12 indicating minimal recall impairment and impaired cognitive skills for daily decision making. Resident #1 required limited assistance with assist of one staff with bed mobility, transfers, ambulation, dressing and personal hygiene and extensive assistance with toilet use and bathing. Resident #1's [DIAGNOSES REDACTED]. Resident #1's plan of care dated 4/21/11 indicated Resident #1 a fall risk with goal that Resident #1 will be free of injury when fall occurs and interventions which included: a. Transfer with assist of one and walker. (10/25/11) b. Keep call light within reach. c. Keep pathway free of clutter. d. After assisting resident, assure all needed items are within reach. e. Post notes in room to remind resident to use call light and not get up independently. (5/16/11) f. Chair/bed alarm. (5/16/11) g. Resident will often try to get up and shut off alarm. (10/30/11) h. Personal alarm when in dining room. (11/1/11) i. Personalized voice alarm when in dining room chair. (11/8/11). Incident reports: On 5/15/11 Resident #1 found on floor, left side with head resting on trash can. All interventions in place. Resident #1 removed the personal alarm. Chair alarm added as a new intervention. On 6/30/11 Resident #1 fell while being transferred in dining room. No injury noted. 7/17/11 Resident #1 found on floor. Alarm sounding. Resident #1 failed to use call light. Sustained scrape to right arm with no other noted injuries. In an interview on 6/14/12 at 4:00 p.m. by phone, Staff A indicated she worked the overnight shift on 5/28/12 and was assigned with Staff B to provide cares for the front halls, including Hall A (where Resident #1 resided). Staff A indicated at around 4:15 a.m. she entered the room of Resident #1. Resident #1 was anxious and wanted to go to the bathroom. Staff A assisted dressing Resident #1 and assisted him/her to the bathroom. The alarm sounded as Staff A moved Resident #1 from his/her recliner and Staff B responded to the alarm, saw, Staff A assisting Resident #1 and shut the alarm off. Staff A assisted Resident #1 back into his/her recliner and noted the chair alarm in place and functioning, call light within reach and walker placed next to the resident. Staff A left at around 4:30 a.m. and proceeded down Hall B to care for other residents. Staff A and Staff B were at the end of Hall B with the door closed at around 5:00 a.m. Staff B left the room first, while Staff A remained behind and visited with the resident. A few minutes later, Staff B exited the room and, as she walked up the hallway, saw Staff B sitting on the floor of Hall A with Resident #1 beside her. Staff A noted no alarm sounding. Staff A indicated Resident #1 stated he/she is sorry for shutting off the alarm. Staff A indicated it was common for Resident #1 to get up unassisted and shut off his/her alarms. Staff A reported just a few days earlier, she found Resident #1 up unassisted and walking toward the door to shut off the alarm. Staff A indicated Resident #1 could use the call light, but often forgot. In an interview on 6/19/12 at 9:00 a.m. by phone, Staff B confirmed she worked the overnight shift on 5/28/12 and was assigned with Staff A to provide cares for the front halls, including Hall A. Staff B indicated at around 4:15 a.m. she heard an alarm sounding and responded to Resident #1's room. Staff B discovered Staff A assisting the resident and shut the alarm off. At around 4:40 a.m., Staff B and Staff A entered the last room on Hall B and closed the door. Shortly after 5:00 a.m., Staff B exited the room, proceeded up the hall and heard someone cry for help. Staff B saw Resident #1 lying on the Hall A hallway, just outside his/her room. Staff B called for help and other staff responded. Staff B indicated she did not hear an alarm sound, but noted Resident #1 reported he/she got up, went to the doorway to shut off his/her alarm, turned to go back into the room and fell . Staff B reported often responding to the alarm and finding Resident #1 already standing, unassisted, at the door. In an interview on 6/18/12 at 1:48 p.m. by phone, Staff C reported at around 4:00 a.m. on 5/29/12 she saw Staff A and Staff B enter Resident #1's room. At around 5:00 a.m., Staff C passed by Hall A as she entered Hall C to pass medications. Resident #1 was not in the hallway nor were alarms sounding at that time. At around 5:10 a.m., Staff C is indicated she was summoned to Hall A stat, where she found Resident #1 lying in the hallway on his/her back. No alarm was sounding. Staff C conducted an assessment and given Resident #1's condition and complaints, called for an ambulance. Staff C reported Resident #1 told her he/she got up to shut off the alarm and fell . Staff C stated it was not uncommon for Resident #1 to get up unassisted and attempt to shut off his/her alarms. In an interview on 6/20/12 at 1:35 p.m., Staff F indicates she works evening shift and is familiar with Resident #1. Staff F reported Resident #1 attempted to get up without assistance one to two times a shift, usually out of confusion rather than for any specific need. When Resident #1 heard his/her alarm he/she attempted to shut it off. Staff commented Resident #1 is fast and when Staff F hears the alarm, she runs to the room. In an interview on 6/20/12 at 2:33 p.m., Staff G indicated she works evening shift and is familiar with Resident #1. Staff G stated Resident #1 will get up several times during her shift unassisted and forgets to use his/her call light. Staff G reported Resident #1 is confused and believes his/her alarm is a door bell or phone and attempts to shut the alarm off. In an interview on 6/20/12 at 2:50 p.m., Staff H (Director of Nursing) indicated Resident #1 is a challenge, but notes several interventions are in place to keep Resident #1 safe. Interventions include having Resident #1 near the nurse's station, Administrator's office or high traffic areas. Staff H described Resident #1 as pleasantly confused and someone who often forgets to utilize his/her call light. Staff H reported following the most recent fall, the facility may consider utilizing a voice alarm as it has been fairly effective with Resident #1 when in the dining room. Staff H also reported the facility is considering using alarms which page the care givers.