Every finding on record at Wilton Retirement Community

Based on observation, clinical record review, policy review, and staff interview, the facility failed to secure medications to prevent a potential hazard for 5 of 5 cognitively impaired, independently mobile residents in the facility's Chronic Confusion and Dementing Illness (CCDI) unit. The facility reported a census of 29 residents.Findings:The Minimum Data Set(MDS) assessment tool, dated 11/20/25, listed diagnoses for Resident #26 which included non-Alzheimer's dementia, vascular dementia (caused by alterations in blood flow), moderate, with mood disturbance, and weakness. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. The facility policy Administering Medications, revised April 2019, stated the facility administered medications in a safe manner. The policy stated residents may self-administer their own medications only if determined safe to do so. Care Plan entries, dated 1/17/25, stated the resident had a self-care deficit related to dementia and memory loss. The entries directed staff to administer the medications as ordered.The resident's December 2025 Medication Administration Record(MAR), listed the following medications/order dates:pregabalin (used to treat nerve pain) 100 milligrams(mg) 11/22/24furosemide (used to rid the body of excess fluid) 20 mg 12/24/24cyanocobalamin (Vitamin B12) 500 micrograms(mcg)Vitamin C 1000 milligrams 11/23/24fish oil 1000 milligramsAn undated document, provided by the facility on 12/30/25, listed five residents in the CCDI unit who were independently mobile and cognitively impaired. On 12/30/25 at 7:50 a.m., Staff A Certified Medication Assistant (CMA) placed the following medications in a medication cup for Resident #26:pregabalin 100 mg, furosemide 20 mg .vitamin B12 500 mcg, vitamin C 1000 mg, and fish Oil 1000 mgStaff A, CMA stated that she just made sure that the resident took the medications. At 7:54 a.m., Staff A sat the medication cup next to Resident #26 at the dining room table as she ate her breakfast. Resident #26 sat at a table with Resident #30 on her right and Resident #9 on her left. Staff B Certified Nursing Assistant (CNA) sat across from Resident #26. Staff A then left the area and went to different parts of the unit including another resident's room, the nursing station, and a room behind the nursing station. At 7:57 a.m. Staff A went into the kitchenette, retrieved a plate of food, and sat down at a table approximately 20 feet from the resident. Staff A began to eat and did not have eyes on the resident or the resident's medications. While Staff A retrieved her food and ate, Staff B also walked away from the resident's table to retrieve a tissue and also went behind the nursing station to get a drink. Staff B then went into the kitchenette to retrieve a plate of food for herself. The resident's full medication cup remained at the table. Staff B, CNA then sat down at the table with the residents(including Resident #26) and began to eat. Both Staff A, CMA and Staff B, CNA were back and forth throughout the area during this time frame and neither continually had eyes on the medications. At 8:11 a.m., Resident #26 picked up the medication cup and placed it on her plate. The resident began to take her medications one at a time while Staff A stood behind the nursing station. On 12/30/25 at 1:10 p.m., Staff C, CMA stated there were no residents in the facility that staff could leave medications with. She stated she always watched residents take their medications and she would not leave the medications with them. On 12/30/25 at 1:16 p.m., Staff D, Registered Nurse(RN) stated she stood near the residents and watched them take their medications. She stated she would never ever leave medications with a resident. On 12/31/25 1:19 p.m., the Director of Nursing (DON) stated staff should watch residents swallow their medications. He stated it was concerning to learn that staff did not watch the ingestion of the medications and he would follow up on this.

Based on observations, training record review, policy review and staff interview the facility failed to complete handwashing and equipment sanitizing in between tasks during the puree process. The facility reported a census of 30 residents. Findings include: During an observation on 10/8/24 starting at 09:29 AM, Staff A, Dietary Aide completed the puree process for three puree diet orders. She started to puree tenderloin with a chicken base for three residents. After Staff A measured the puree, she poured it into the pan and put it to the warmer. Staff A used a dry rag to wipe the counter and her hands. Without washing her hands or using sanitizer on the counter, she then pureed the casserole with a tomato base, measured, and placed it in the warmer. At 9:59 AM, Staff A wiped the blender, container, lid, and counter with the same dry rag. She then wiped her left hand on her shirt. Without washing her hands or using sanitizer on the counter, Staff A then took the stewed tomatoes out of the warmer to puree. At 10:07 AM, without washing her hands or using sanitizer on the counter Staff A held a pan against her shirt and placed a liner in the pan for the pureed rice. At 10:12 AM, Staff A wiped her right hand on the side of her shirt. She then picked up the same towel to wipe splatter from the prep surface, the ninja, and lip of both the food container and lid. The towel had brown, red, and pink food stains which smeared on the counter as she tried to clean off spattered rice. During an interview on 10/08/24 at 10:27 AM, the Dietary Supervisor stated the Dietary Aide was nervous during her observation. She acknowledged the Staff A did not wash her hands or sanitize food surfaces between pureeing each food item. The Dietary Supervisor stated staff were trained at orientation regarding hand washing and sanitizing, and added this aide was retrained the week before regarding pureeing and hand washing. She stated this staff had received multiple training's regarding the kitchen, sanitation, and hand washing. At 10:42 AM the supervisor stated she spoke to the aide about the lack of hand washing and sanitizing during the observation and would need to continue to provide re-education. A document titled Food Preparation indicated foods needed to be prepared by methods that preserve nutritive value, flavor, and appearance, and was signed by Staff A on 4/1/24. A document titled Proper Handwashing and Glove Use documented proper handwashing as one of the most important ways to prevent the spread of foodborne illness, and was signed by Staff A on 5/1/24. An undated policy titled Hand Washing documented staff were expected to wash hands after handling soiled equipment or utensils, during food preparations, as often as necessary to remove soil and contamination, and to prevent cross contamination when changing tasks.

Based on interview, record review, and facility policy review, the facility failed to correctly code medical diagnoses and medications on the MDS (Minimum Date Set) for 4 of 5 residents reviewed for unnecessary medications. (Resident#13, Resident #15, Resident #24, Resident #26). The facility reported a census of 32. Findings include: 1. The MDS assessment dated [DATE] revealed the Resident #13 scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely cognitively impaired. The MDS revealed the resident received an antipsychotic 7 out of 7 days and received antipsychotics on a routine basis. The MDS failed to document the resident had a diagnosis of non-Alzheimer's dementia or unspecified dementia with behavioral disturbance. The Care plan dated 7/17/23 revealed a focus problem of psychotropic medications Seroquel related to behavioral management and progressive dementia. The interventions dated 10/28/21 revealed administration of psychotropic medications as ordered by the physician. The EMR (Electronic Medical Record) revealed the medical diagnosis of unspecified dementia with behavioral disturbance. The Physician Orders dated 4/6/23 revealed Seroquel 50 mg tablet- Give 1 tablet by mouth two times a day for agitation and delusions related to unspecified dementia with behavioral disturbance. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the medical diagnoses of unspecified atrial fibrillation, heart failure, and CAD (Coronary Artery Disease). The MDS revealed the resident received a diuretic 0 out of 7 days. The Care Plan dated 5/24/23 revealed a focus problem of altered cardiovascular status related atrial fibrillation with RVR (right ventricular response). Interventions dated 5/4/23 included administration of cardiac medications as ordered by physician; assessment of shortness of breath and bilateral leg swelling; and monitored vital signs as ordered by the physician. The EMR (Electronic Medical Record) revealed a diagnosis of chronic diastolic congestive heart failure dated 5/4/23. The Physician Orders dated 5/4/23 revealed an order for Furosemide 20 mg tablet- give one tablet by mouth one time a day. The Physician Orders dated 5/8/23 revealed a new order for Furosemide 40 mg tablet- give one tablet by mouth one time a day. During an interview on 7/20/23 at 10:15 AM, the DON (Director of Nursing) queried if a resident took an diuretic would it be expected to be on the MDS and she stated yes, she would think so. The DON queried if a resident took an antipsychotic medication for dementia if she expected the diagnosis on the MDS and she stated yes she would. During an interview on 7/20/23 at 10:44 AM, the MDS Coordinator queried if a diuretic needed coded on the MDS and she stated yes, it was a medication that needed coded. The MDS Coordinator asked if a diagnosis of dementia needed coded when a resident took an antipsychotic medication for dementia and she stated yes, there should be a diagnosis coded. She stated she should of coded dementia and put in the diagnosis of dementia. The Facility Electronic Transmission of the MDS dated [DATE] revealed the MDS coordinator's responsibility ensured that appropriate edits were made prior to transmitting MDS data. 45338 3. The Minimum Data Set (MDS) assessment dated [DATE] revealed Residet #26 scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had severely impaired cognition. Per this assessment, the resident had received antianxiety medication for 0 of the last 7 days. The Physician Order dated 4/6/23 through 7/14/23 revealed an order for Buspirone HCl Oral Tablet 5 MG (milligram) with instructions to give 1 tablet by mouth two times a day related to Generalized Anxiety Disorder. Review of the Medication Administration Record (MAR) dated April 2023 revealed the medication had been documented as administered twice per day between 4/6/23 through 4/30/23. On 7/20/23 at 10:43 AM, the MDS Coordinator explained she had not been responsible for MDS at the time, and acknowledged the medication should be included on the MDS. 48374 4. The Significant change data MDS for Resident #24 dated 4/28/23, revealed a BIMS of 12 out of 15, which indicated moderately impaired cognition. The MDS revealed depression medications received 7/7 days without a diagnosis of depression. The Care Plan dated 11/17/22 and revised on 7/19/23 revealed the resident uses antidepressant medication r/t Depression. The Physician order dated 4/21/23 revealed Mirtazapine Oral Tablet 7.5 MG (milligrams) with instruction to give 1 tablet by mouth at bedtime for Depression. The Physician order dated 4/22/23 revealed Escitalopram Oxalate Oral Tablet 5 MG with instruction to give 1 tablet by mouth one time a day for depression. The Medical Diagnosis for Resident # 24 lacked a diagnosis of depression. On 7/20/23 the Director of Nursing indicated the lack of documentation of regarding a significant change such as a diagnosis would cause it to trigger.

Based on interview, record review, and facility policy review, the facility failed to offer the resident the recommended pneumococcal vaccine for 1 of 6 residents reviewed for pneumococcal vaccine status (Resident #13). The facility reported a census of 32. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #13 scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely cognitively impaired. The resident's IRIS (Iowa Registry Immunization System) dated 7/18/23 revealed the resident received a PCV13 (pneumococcal conjugate vaccine) on 4/6/15. The EMR (Electronic Medical Record) revealed no documentation that a second dose of pneumococcal offered or refused by the resident or the resident's family. During an interview on 7/19/23 at 3:33 PM, the DON (Director of Nursing) queried when pneumococcal vaccine were offered to residents and she stated on admission. The DON stated if a resident was over [AGE] years old they had 2 pneumonia vaccines if they wanted them and the vaccines should be one year apart. The DON stated she didn't find a refusal for a the pneumococcal vaccine for Resident #13. The Facility Pneumococcal Vaccine Policy dated March 2022 revealed all residents offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The Facility Policy also included the following information: a. Pneumococcal vaccines administered to residents (unless medically contraindicated, already given, or refused) per our facility ' s physician-approved pneumococcal vaccination protocol. b. Administration of the pneumococcal vaccines made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on interview, record review, and facility policy review, the facility failed to address anticoagulant therapy on the care plan for 1 of 12 residents reviewed for care planning (Resident #15). The facility reported a census of 32. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the medical diagnoses of unspecified atrial fibrillation, heart failure, and CAD (Coronary Artery Disease). The resident received anticoagulant 7 out of 7 days. The Care Plan dated 5/24/23 revealed no documentation for addressing anticoagulant therapy. The EMR (Electronic Medical Record) revealed a diagnosis of unspecified atrial fibrillation dated 4/19/23. The Physician Orders dated 4/19/23 revealed an order for apixaban 2.5 mg tablet- Give one tablet by mouth every 12 hours. During an interview on 7/20/23 at 10:28 AM, the DON (Director of Nursing) queried the expectation of anticoagulant therapy being on the care plan and she stated the anticoagulant therapy should be care planned. During the interview on 7/20/23 at 10:44 AM, the MDS Coordinator queried the expectation of anticoagulant being on a care plan when a resident received anticoagulant therapy and she stated yes, she put it as a separate problem. She stated it should of been addressed on Resident #15 care plan. The Facility Care Plan Policy dated December 2016 revealed the comprehensive, person centered care plan addressed the following: a. Incorporate identified problem areas b. Incorporate risk factors associated and identified problems c. Reflect currently recognized standards of practice for problem areas and conditions

Based on record review, staff interview and facility policy reviewed indicated the facility failed to submit a Significant Change Minimum Data Set (MDS) assessment timely for 1 of 12 reviewed for MDS submission, (Resident # 24) The facility reported a census of 32 residents. Findings include: Review of the significant change MDS for Resident #24 reviewed an Assessment Reference date of 4/28/23, completed date of 5/12/23 and a submission date of 5/31/23. During an interview on 7/20/23 with the Director of Nursing acknowledged staff who had been doing MDS was on leave since late April and another staff member had been filling. When the DON was asked about the timely submission indicated they would have to review the record. The facility policy reviewed indicated our facility will conduct and submit resident assessments in accordance with Federal and State submission guidelines.

Based on staff interview and record review the facility failed to ensure one of five staff members had current Dependent Adult Abuse training (Staff A, Registered Nurse (RN). The facility reported a census of 32 residents. Findings include: Review of a DAA certificate for Staff A revealed DAA training had been completed on 3/2/2018. On 7/19/23 at 2:43 PM, the most recent DAA training certificate for Staff A had been requested via email from the facility's Administrator. On 7/20/23 at 2:06 PM, the Administrator acknowledged Staff A's DAA training had been past due. Review of the Facility Policy provided by the facility titled State of Iowa-Department of Human Services Dependent Adult Abuse-2 Hour Mandatory Reporter Training, undated, documented ,Within six (6) months of the start of employment, [Name Reacted] needs to have proof in your employee file that you have completed the State of Iowa's two-hour dependent adult abuse training. Completion of the two-hour course is valid for three (3) years.

Based on Record Review, Facility Policy Review and staff interview the facility failed to conduct a thorough investigation of a resident to resident altercations for 3 of 3 residents sampled. Facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 3/01/23 documented Resident #11 with a Brief Interview for Mental Status (BIMS) score of 3 indicated severely impaired decision-making abilities. The MDS lacked documentation of behaviors during the look back period. Resident #11 Care Plan revised 9/12/22 documented a behavior of wandering into other resident rooms. The Care Plan identified the resident exhibited a history flirtatious behavior and directed staff to monitor and redirect the resident as appropriate. 2. The MDS dated [DATE] documented Resident #12 with a BIMS score of 13 indicating intact cognition. The MDS documented the resident displayed verbal behavioral symptoms directed toward others on 1 to 3 days during look back period. Resident #12's Care Plan revised 9/12/22 directed the staff to assist to develop more appropriate methods of coping and interacting, to encourage to express feelings appropriately, to monitor for inappropriate comments or sexual expressions towards other residents or staff, to monitor resident's whereabouts and to redirect resident to correct behaviors and to state that resident is being inappropriate. Resident #11 and #12's Progress Notes dated 4/9/23 documented Resident #11 had been in Resident #12 room. Staff reported Certified Nurse Aid (CNA) entered the room and both residents were sitting on his bed. Resident #12 had his hand on Resident #11's breast with one hand and held her hand with other. Staff intervened and removed Resident #11 from his room back to her own room. During an interview on 4/25/23 at 9:03 a.m. with Staff A, Registered Nurse (RN) reported the incident reports are filled out for falls, skin tears, bruises, choking, behaviors and abuse. Altercations between residents need to complete an incident report, notify Director of Nursing (DON), families, doctor and depending on the type of altercation the police may need to be notified. If staff see any abuse they are to separate those involved right away. An interview with Staff B, Certified Medication Aid (CMA) on 4/25/23 at 9:09 a.m. reported she is to notify the nurse on staff or the DON of any falls, skin tears, change of status and behaviors so a report can be made. Altercation between residents requires the staff to separate the residents and the DON right away. Staff has abuse and dementia training yearly. On 4/25/23 at 9:29 a.m. Staff C, RN reported the nurses' complete incident reports for falls, altercations between residents and any skin concerns. Regarding resident to resident altercations, staff should separate them right away and notify The DON. The DON decides if a resident is able to consent for sexual contact. Any altercations between residents, the DON and Administrator will investigate. An interview on 4/25/23 at 10:00 a.m. with the Care Plan Nurse reported the Social Services Supervisor codes the behaviors on the MDS and care plans as needed. The Care Plan Nurse reads through the Progress Notes daily and updates behaviors on the care plan as needed. She is involved in the investigation process with altercations, behaviors and abuse. Staff are to separate those involved in altercations or abuse right away and notify the DON or the Administrator. The DON or the Administrator determines if an investigation is needed. Staff has abuse and dementia training every year. The DON reported on 4/25/23 at 10:27 a.m. the facility uses a policy for incident reports. Staff had training over abuse and incident reports in the fall of 2022. The DON expects the nurses to complete incident report for falls, skin injuries, abuse, resident to resident altercations and medication errors. The Administrator and DON review incident reports to determine if further investigation and state reporting is needed. Interventions are put in place and follow up is completed with staff and residents to see if interventions are effective. The DON verbalized she uses the BIMS score to determine resident's cognitive level for decision making abilities. An interview conducted on 4/25/23 at 10:35 a.m. revealed the Administrator uses the Accident/Fall Reporting Flowsheet to determine when an incident should be reported to the State. Regarding resident to resident altercations, the Administrator expects staff to watch for behaviors and put interventions in place. She reported she uses the BIMS score to determine cognition level of a resident for decision making abilities. The on-call nurse is to direct staff in interventions to put in place. Interventions are reviewed for effectiveness at the care plan meetings. The Medicare team meets weekly and they discuss the concerns of residents and interventions that need to be added to the resident's care plan. During an interview with Staff D, Licensed Practical Nurse (LPN) on 4/25/23 at 10:41 a.m. reported incident reports are completed for falls, resident to resident altercations and injuries of unknown origin. Staff D verbalized for resident to resident altercations to separate the residents and call the on-call nurse for further direction. The on-call nurse determines what is reported to the State. The Social Services Supervisor and DON decide on whether a resident is cognitive enough to make decisions. Staff D verbalized she did not remember any concerns with residents to report to the DON or Administrator. Staff has training on incident reports, abuse and dementia yearly. The Social Services Supervisor reported on 4/25/23 at 11:45 a.m. she's worked as the supervisor for the past four months and had not participated in investigations for abuse, behaviors or resident to resident altercations. The Care Plan Nurse is care planning behaviors. Staff E, LPN on 4/25/23 at 12:40 p.m. reported no concerns with residents on behaviors or resident to resident altercations but had given in nurse to nurse report that Resident #12 had talked sexually inappropriate with Resident #11. Staff E verbalized watching Resident #12 more due to him being more cognitive then Resident #11. Staff notified the DON of the inappropriate comments made by Resident #12. The Administrator reported on 4/25/23 at 2:53 p.m. the DON and herself report concerns to the State. The Administrator heard a few different stories on the altercation on 4/9/23 and the incident had not been reported to the State. The Administrator heard Resident #12 grazed the shoulder of Resident #11 and not touched the breast, but no thorough investigation had been done to determine. The Administrator verbalized the Physician did not do a cognitive assessment due to needing a consistent BIMS below 10 for Resident #11. A record review of the MDS assessments completed in last year revealed: a. MDS dated [DATE] documented a BIMS score of 03 b. MDS dated [DATE] documented a BIMS score of 03 c. MDS dated [DATE] documented a BIMS score of 03 d. MDS dated [DATE] documented a BIMS score of 03 e. MDS dated [DATE] documented a BIMS score of 04 During an interview on 4/26/23 at 8:20 a.m. Staff G, C.M.A. verbalized Resident #12 seeks out Resident #11. Staff G had not seen him physically touch Resident #11, but heard it has happened. Staff G reported she tries to keep both residents separated. If she sees Resident #11 heading towards Resident #12's room, she will try to distract her. She verbalized Resident #11's dementia is almost like reverting back to when she was a child and that is concerning to her. On 4/26/23 at 9:26 a.m. the Administrator provided further Behavioral Progress Notes for Resident #12 which revealed: a. On 4/9/23 at 13:03 p.m. Resident #12 made sexually inappropriate comments toward a female resident. b. Resident #12 on 3/18/23 at 10:18 p.m. acted flirtatious with a female resident. c. At 1:31 p.m. on 3/1/8/23, Resident #12 made sexual comments toward Resident #11. d. On 2/20/23 at 2:44 p.m. Resident #12 making inappropriate gestures to another female resident. Demonstrating to staff how he wanted to put his head in her breast. e. Resident #12 12/10/22 at 10:06 p.m. had talked dirty to Resident #11 at supper. f. On 12/9/22 at 10:57 p.m. Resident #12 talked sexually to a resident multiple times. He tried to touch the resident. Staff were able to redirect both residents. g. At 9:57 p.m. on 11/21/22, Resident #12 made blunt sexual comments to Resident #11 while staff was with them. Staff were able to redirect. h. On 11/3/22 at 8:19 p.m. Resident #12 told the nurse to sit on his lap. This nurse politely declined and told the resident that the statement was inappropriate. i. Resident #12 on 10/2/22 at 1:04 p.m. observed pacing back and forth in the hallway. Resident #12 kept looking in Resident #11 room and went in that room once. Staff redirected out of room. j. At 9/15/22 at 8:44 p.m. Resident #12 observed making inappropriate sexual comments to Resident #11 and the staff member wrote the comments down in the blue communication book. This nurse read the description and asked the CNA's to keep the residents separated if possible. This nurse called the on-call and informed him of the situation and he will pass it along tomorrow. k. On 9/12/22 at 1:10 p.m. Resident #12 making inappropriate comments to Resident #11. Asking what color panties she had on? , and voiced rude comments about about her breasts. Resident #11 told her that he wanted to give her something real nice for her birthday. That he knew she would be really good at it. Staff asked him to go to his room to rest for a while. l. Resident #12 on 9/11/22 at 3:20 p.m. reached out and touched another female resident on the buttocks. Staff also reported that yesterday he and this same female resident were in his room, door closed. When staff entered, both residents were sitting on the bed. He had his hand on the Resident #11's thigh. Both residents were calm, in no distress, and mutually agreed that they felt this was ok. Resident #11 and #12 were separated with each incident. Staff member will notify the DON of the situation. m. At 2:29 p.m. on 9/8/22 the CNA reported while assisting Resident #12 in shower he made inappropriate comments. He repeatedly asked the CNA to join him in the shower. The CNA reported the redirection was not effective. n. On 8/23/22 12:34 p.m. Resident #12 moved into the dementia unit today. o. On 7/14/22 at 3:52 p.m. Resident #12 verbalized to a C.N.A., how about I give you a shower instead. Following the shower, the patient told the nurse (speaking about CNA), I wish I could have taken her clothes off instead. Redirection effective. p. On 7/8/22 at 10:44 p.m. Resident #12 made inappropriate comment sexual comment to CNA. q. At 8:24 p.m. on 7/6/22, Resident #12 came up to the desk looked at a picture of a CNA and spoke inappropriatedly to the staff. He proceeded to kiss the picture. Then he said, no we're not going to do 'that' tonight. The picture placed in the medication room. On 4/26/23 at approximately 10:30 a.m. the facility provided a blue Chronic Confusion Dementing Illness (CCDI) unit Communication Notebook which showed a wide rule, 70-page notebook that contained only 15 pages of documented behavioral communications for the CCDI unit with 8 torn page breaks torn off within the tablet. The documentation entries supported Resident #12 had been seeking out and exhibiting sexual behaviors toward another female (Resident #11) on the CCDI unit. The Unit Communication Notebook contained the following staff documentation: a. On 9/15/23 Resident #12 whistled for Resident #11 to come over to his room because she was walking around the unit per usual. She started walking over toward his room and the staff redirected her. Before Resident #12 noticed the staff redirecting Resident #11, staff heard him say, man look at those big tits. Come on in and see how hard it is. Staff told him it was inappropriate. He got agitated then closed his door to his room. Resident #12 kept opening the door to his room looking for Resident #11 to come back his way. Resident #11 came to sit with staff and stated to the staff, that man is nerve racking and he's a very bad man. b. On 10/01/22 Resident #12 is so concerned and obsessed with Resident #11. Resident #12 stayed out after breakfast and every time aides were not in site would go over to Resident #11's table. After Resident #11 finished her breakfast, she went to her room to lay down. Resident #12 came out of his room and sat in the dining area. After a while, Resident #12 got up and walked into Resident #11 room. Staff informed him to not go into other resident's rooms without an invite. Resident #12 has been stalking Resident #11 most the day. c. On 10/15/22 Resident #12 walked into Resident #11's room while CNA had been providing care. Staff told Resident #12 it is not his room and he needed to leave. Resident #12 ignored the aide at first. When he was told a second time he said, I heard you. Staff reminded him a third time to leave before he complied. Staff are having to watch him extra close because he knows he is being watched and waits for an opportunity. Even in the dining room in front of staff, Resident #12 would grab Resident #11 butt or breast if she was close to him. The staff has to keep them separate. Review of Facility Bulletin Board on 4/26/23 at 12:38 p.m. lacked communication documentation on CCDI Communication Notebook used for Quality Assurance (QA) only since 1/1/2018. The [NAME] Retirement Community (WRC) Resident Sexual Expression Policy, undated, provided by the facility defined the following: 1. Consent may be evidenced through the language, gestures, conduct, activities, or other affirmative actions of a resident who: a. Exhibits and has cognitive decision-making capacity; or b. Exhibits diminished cognitive decision-making capacity (e.g., neurocognitive disorders such as Dementia/Alzheimer's Disease) but not to a degree, as determined by the interdisciplinary team (IDT), resident and resident representative, that would qualify the person as incapacitated. 2. Interdisciplinary Care Team (IDT): A group of healthcare professionals with diverse roles and a common purpose to achieve optimal health outcomes for residents. In collaboration with the resident and resident representative, the IDT determines the best health outcomes for the resident and establishes care/service goals. IDT members should be determined by the resident's needs. Community IDTs typically include the resident, resident representative, physician, nurse, social service worker, and direct care worker. However, the IDT can be extended as necessary to include family members, significant others, physical and/or occupational therapists, dietitians, speech pathologists, psychologists, or pastoral care. 3. Sexual Abuse: Any sex act between persons is sexual abuse by either of the persons when the act is performed with the other person in any of the following circumstances: a. Such other person is suffering from an incapacity which precludes giving consent or lacks the mental capacity to know the right and wrong conduct in sexual matters. The Policy Enactment directed: 1. Cognitive decision-making capacity: This policy applies to individuals who exhibit intact cognitive decision-making capacity and those who exhibit diminished cognitive decision-making capacity; but are not incapacitated. Because every resident's circumstance and level of capacity to consent differs, WRC must develop highly individualized approaches, rather than a single blanket approach, to assess each sexually related situation. In addition to provisions outlined in sections below and in furtherance of tailoring an individualized response and care plan: a. Some residents who exhibit intact cognitive decision-making capacity may still require a cognitive assessment conducted by resident's physician to confirm consent was and continues to be given. This determination should be made by the resident's IDT. b. Residents who exhibit diminished cognitive decision-making capacity (e.g. neurocognitive disorders such as Dementia/Alzheimer's Disease) WILL require a cognitive assessment conducted by a physician to confirm consent was and continues to be given. The Policy directed the Staff Responsibilities included: 1. WRC shall conduct a thoughtful review of situations and accounts of sexual expression among or between residents or with visitors to determine a solution that best meets the needs of and protects the residents involved. A description of the outcome of the review should be shared with the resident, resident representative if appropriate, and the IDT. The outcome of the review and steps to address sexual expression shall be documented in the residents' care plan. 2. Incidents of abuse or suspected abuse should be self-reported by WRC staff to the Iowa Department of Inspections and Appeals, Iowa Department of Human Services, or other agencies as required by law. 3. WRC should ensure that all staff members have received and reviewed the sexual expression policy (including updates to policy) and establish processes for ensuring that the procedures outlined in the policy is carried out by WRC staff. WRC should offer ongoing training, support, and resources to staff to equip them with the skills and knowledge related to sexual expression, resident rights, sensitization, boundaries, ethics, proper response strategies, and documentation and reporting procedures. 4. Staff should report to their Charge Nurse and Director of Nursing any instances of sexual expression that are not addressed in the existing policy so that updates or amendments can be made and so that the IDT can do a review of any new or changed resident sexual expression. 42133 3. The MDS dated [DATE] for Resident #13 showed a BIMS score of 5 indicating severe cognitive loss. The Resident independently transferred and ambulated. The MDS listed a diagnoses of Alzheimer's Disease and documented Resident #13 did not exhibit physical, verbal or other behaviors. The Care Plan revised 11/23/22 lacked documentation of interventions to address inappropriate male behaviors toward the resident. A Progress Note dated 4/09/23 at 1:03 p.m. by Staff F, LPN documented Resident #12 made inappropriate comments towards Resident #13. The note detailed Resident #12 stated he wanted to do things with Resident #13 and until her husband comes back, he verbalized he wanted her. He verbalized he wanted to have sex so bad. The staff intervened and both residents sat at separate tables for the remainder of the lunch meal. Observation on 4/24/23 at 4:00 p.m. revealed Resident #12 and Resident #13 sat across from each other at a dining room table prior to the supper meal. An interview conducted on 4/25/23 at 4:24 a.m. revealed Staff H, C.N.A. reported Resident #12 had inappropriate behaviors toward Resident #13 of a sexual nature a while back. Observation on 4/25/23 at 4:25 p.m. revealed Resident #12 and Resident #13 sat across from each other at a dining room table prior to the supper meal. On 4/25/23 at 4:28 p.m. Staff F, LPN reported Resident #12 had recently made inappropriate sexual remarks to Resident #13. She verbalized she documented at least two episodes of these inappropriate verbal interactions in the behavior notes within the past month. Resident #12 doesn't like his comments. A review of Resident #13's Progress Notes on 4/25/23 at 4:35 p.m. lacked documentation of any behavioral progress notes, assessment or new interventions for the 4/09/23 incident between Resident #12 and #13. On 4/26/23 at 7:15 a.m. the Administrator reported behaviors in the Chronic Confusion or Dementing Illness (CCDI) unit are documented in a book back on the unit. The Administrator went to the CCDI unit to get the behavior charting book to find a blank tablet had been replaced the evening before on 4/25/23. On 4/26/23 at 7:40 a.m. the Administrator reported the behaviors are documented in the electronic health record under an Order Administration Note. A review of Resident #13's Order Administration Notes at that time lacked documentation of any behavior documentation. During an interview on 4/26/23 at 8:20 a.m. Staff G, C.M.A. reported Resident #12 exhibited behaviors toward females since he had been in the unit. She tries to keep Resident #11 and #12 separated as much as possible. She has not seen him physically touch another female resident, but she had heard it happened. She has seen Resident #12 make inappropriate sexual comments towards Resident #13. Resident #12 likes to sit by Resident #13. They sit at the same table for all meals. She reported she does intervene when Resident #12 makes inappropriate verbal comments to Resident #12. Staff G identified if a resident exhibits behaviors, they document it in the behavior book at the nurses station (in the CCDI unit). They also report the behaviors to the nurse. Staff D identified if she is really concerned about a resident, she will leave a note on DON's office door. She never wants anything to happen to a resident on her watch. A blue CCDI Communication Notebook provided by the facility on 4/26/23 at approximately 10:30 a.m. showed a wide rule, 70 page notebook that contained only 15 pages of documented behavioral communications for the CCDI unit with 8 torn page breaks torn off within the tablet. Documentation entries supported Resident #12 had been seeking out and exhibiting sexual behaviors toward another female (Resident #11) on the CCDI unit besides Resident #13. On 4/26/23 at 11:32 a.m. Staff F reported she recalled the incident from 4/09/23 regarding Resident #12 and #13. She overheard Resident #12 stating inappropriate sexual comments to Resident #13 as they sat together at a table in the dining room. Staff F reported she documented the incident with quotations in the progress notes. Staff F intervened between the two residents and talk to Resident #12 about his inappropriate comments directed at Resident #13. Resident #13 didn't want to hear those comments. Staff F verbalized she eventually moved Resident #13 to a different dining room table as she couldn't stay to monitor the interactions between the two residents during meal. Staff F reported the incident to the charge nurse before she left shift that day. She did not recall who the charge nurse had been that day. It may have been Staff C as they work the same weekend. Staff F explained they get notebooks in the CCDI unit to write down anything they notice so that management can review. It's used to keep a record of what is going on so management can keep a record of everything. Staff F verbalized they do not get any feedback from management if anything is being done regarding the behavior documentation. They have not received any specific instruction other than to redirect the residents and document behaviors in the communication book. They have Relias training they complete on mandatory reporting. The management staff doesn't tell them if incidents are reported to DIA. During an interview on 4/26/23 at 11:53 a.m. Staff C reported Staff F is a nurse so she documents her own stuff regarding resident incidents. Staff C clarified there has been incidents in the past with Resident #12 in regards to females, but she doesn't work back in the unit regularly. She doesn't recall Staff F reporting any incidents between Resident #12 and #13 to her. Staff C explained they get instruction on what to look for (regarding behaviors) but they get no formal training on reporting those types of incidents. They do get mandatory adult abuse training, but it has been awhile. An email received from the Administrator on 4/26/23 at 11:15 a.m. detailed the Behavior Communication Book from the CCDI unit is only utilized for quality analysis (QA) purposes to ensure communication is effectively relayed between CNA/CMA's and other nursing staff. An observation on 4/16/23 at approximately 12:10 p.m. revealed the Administrator held a purple CCDI communication notebook labeled QA Purpose Only. The Administrator reported the Communication Book is used as part of the QA program for CNA and CMA's to be able to communicate with the RN's and LPN's. She stated she declared it as part of the QA program. The Administrator provided a copy of the Quality Assessment and Assurance Policy and the Quality Assessment and Assurance Committee Policy. Both Policies were undated. A review of the Policies on 4/26/23 at 12:26 p.m. showed the Policies lacked documentation the CCDI Communication Notebooks were utilized as QA tools for the Quality Assurance and Performance Improvement (QAPI) program. During an interview on 4/26/23 at 1:30 p.m. the Administrator reported the facility had not reported the incident between Resident #12 and #13 to DIA. She didn't know if there had been further investigation completed, but she would check with the DON. On 4/26/23 at 1:35 p.m. the DON revealed she did not have documentation to support further investigation had been completed for the 4/09/23 incident. She verbalized she didn't recognize the incident as a resident to resident altercation. On 4/26/23 at 1:45 p.m. the DON reported she had not recognized the situation between Resident #12 and #13 as an altercation. An incident report had not been completed and she had not done any further investigation into the incident. She planned to provide education to the nurses on identifying resident to resident altercations, completing incident reports and notifying a nurse supervisor timely. On 4/26/23 at 1:49 p.m. the Administrator reported the facility planned through their quality analysis program to provide education to CNA/CMA staff on identifing resident to resident altercation situations and reporting those incidents into the charge nurse. The facility planned to provide education to the nurses on filling out incident reports and notifying a nurse supervisor timely so the nurse supervisor could initiate an investigation and notifications could be made to DIA within 24 hours.

Based on clinical record review, observation, policy and staff interview the facility failed to notify the physician and family after a resident to resident altercation for 1 of 3 residents (Resident #13) sampled. The facility identified a census of 30 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 showed a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive loss. The Resident independently transferred and ambulated. The MDS listed a diagnosis of Alzheimer's Disease and, documented Resident #13 did not exhibit physical, verbal or other behaviors 2. Resident #12's Quarterly MDS dated [DATE] showed a BIMS score of 13, which indicated intact cognition. The MDS identified Resident #12 exhibited verbal behavioral symptoms directed toward others, wandered daily and had the ability to express ideas and wants, both verbal and non-verbal. The Resident independently transferred and ambulated within the unit. The MDS documented a diagnosis of Non-Alzheimer's Dementia. Resident #12's Progress Note dated 4/09/23 at 1:03 p.m. by Staff F, Licensed Practical Nurse (LPN) documented Resident #12 made inappropriate comments towards Resident #13. The Progress Note detailed Resident #12 stated he wanted to do things with Resident #13 and until her husband comes back, he verbalized he wanted her. Resident #12 verbalized he wanted to have sex so bad. The staff intervened and both residents sat at separate tables for the remainder of the lunch meal. A review of Resident #13's electronic health record progress notes and behavioral notes lacked documentation of the 4/09/23 incident and lacked documentation the physician and family had been notified of the resident to resident altercation. During an interview on 4/25/23 at 9:03 a.m. Staff A, Registered Nurse (RN) reported incident reports are filled out for falls, skin tears, bruises, choking, behaviors and abuse. Incidents involving altercations between residents require an incident report, notification to the Director of Nursing (DON), family, doctor and depending on the type of altercation the police. If there is any abuse, they would separate those involved right away. An interview conducted on 4/25/23 at 4:24 a.m. revealed Staff H, C.N.A. reported Resident #12 had inappropriate behaviors toward Resident #13 of a sexual nature a while back. Observation on 4/25/23 at 4:25 p.m. revealed Resident #12 and Resident #13 sitting across from each other at a dining room table prior to the supper meal. On 4/25/23 at 4:28 p.m. Staff F, LPN reported Resident #12 had recently made inappropriate sexual remarks to Resident #13. She verbalized she documented at least two episodes of these inappropriate verbal interactions in the behavior notes within the past month. Resident #12 doesn't like his comments. On 4/26/23 at 11:32 a.m. Staff F reported she recalled the incident from 4/09/23 regarding Resident #12 and #13. She overheard Resident #12 stating inappropriate sexual comments to Resident #13 as they were seated by each other at the same dining room table. Staff F reported she documented the incident with quotation marks in the progress notes. Staff F walked over to the dining room table to intervene between the two residents and talk to Resident #12. She informed Resident #12 of his inappropriate conversation directed at Resident #13. Resident #13 didn't want to hear those comments. Staff F verbalized she eventually moved Resident #13 to a different dining room table as she couldn't stay to monitor the interactions between the two residents during supper. Staff F explained she reported the incident to the charge nurse before she left shift that day. She did not recall who the charge nurse had been that day. It may have been Staff C, Registered Nurse as they work the same weekend. Staff F didn't recall filling out an incident report. On 4/26/23 at 1:45 p.m. the DON reported she didn't recognized the situation between Resident #12 and #13 as an altercation. An incident report hadn't been completed and she had not done any further investigation into the incident. She planned to provide education to the nurses on identifying resident to resident altercations, completing incident reports and notifying a nurse supervisor timely. During an interview on 4/26/23 at 2:42 p.m. the DON reported the physician and family are to be notified of all resident to resident altercations and abuse. It is documented in both the Abuse and Accident-Incidents Facility Policies. The Accident/Incident Policy, undated, provided by the facility documented the facility should provide a safe and secure environment for staff and residents. Therefore, all accidents or incidents occurring on facility premises or to facility employees while performing their jobs shall be reported and investigated. The Accident/Incident Policy directed the staff were to notify the resident's attending physician of the incident. The Policy directed the Nurse Supervisor and/or Department Director should conduct an immediate investigation of the accident/incident and use the information obtained during the investigation to complete a Report of Incident/Accident form. The following data shall be included on the Report of Incident/Accident Form: 1. The date and time the accident/incident occurred; 2. The nature of the injury or illness (e.g., needlestick, bruise, fall, nausea, etc.); 3. The circumstances surrounding the accident/incident; 4. Where the accident/incident occurred; 5. Name(s) of any witnesses and their account of the accident/incident; 6. The injured person's account of the accident/incident; 7. The time the injured person's Attending or Personal Physician was notified as well as the time the physician responded and his/her instructions; 8. The date and time the injured person's family was notified and by whom; 9. The condition of the injured person, to include his/her vital signs; 10. Disposition of the injured person (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); 11. Corrective action taken; 12. Follow-up information; 13. Other pertinent data as necessary or required; and 14. Signature and title of the person completing the report. The Abuse Neglect, Mistreatment and Misappropriation of Resident Property Policy, undated, provided by the facility directed the Administrator or designee would inform the resident and/or responsible party of the results of an abuse investigation after completion.

Based on Clinical Record Review, Facility Policy Review, Staff and family interviews the facility failed to report a resident to resident altercation to Iowa Department of Inspection and Appeals (DIA) for 3 of 3 residents sampled. The facility reported a census of 30 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) Assessment tool, dated 3/01/23, documented Resident #11 with a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired decision-making abilities. MDS lacked documentation of behaviors during the look back period. Resident #11 Care Plan revised 9/12/22 documented a behavior of wandering into other resident rooms. The Care Plan identified the resident exhibited a history of flirtatious behavior and directed staff to monitor and redirect the resident as appropriate. 2. The Quarterly MDS dated [DATE] documented Resident #12 with a BIMS score of 13, which indicated intact cognition. MDS documented the resident displayed verbal behavioral symptoms directed toward others on 1 to 3 days during look back period. Resident #12 Care Plan revised 9/12/22 directed staff to assist to develop more appropriate methods of coping and interacting, to encourage to express feelings appropriately, to monitor for inappropriate comments or sexual expressions towards other residents or staff, to monitor resident's whereabouts and to redirect resident to correct behaviors and to state that resident is being inappropriate. Resident #11 and #12's Progress Notes dated 4/9/23 documented Resident #11 was in Resident #12's room. Staff reported Certified Nurse Aid (CNA) entered the room and both residents were sitting on his bed. Resident #12 had his hand on Resident #11's breast with one hand and held her hand with other. Staff intervened and removed Resident #11 from his room back to her own room. Progress Note dated 9/11/22 at 3:26 p.m. docuemented the following; Resident#11 had been talking with and interacting with Resident#12 on the unit. Staff reported that Resident#11 appeared to be flirting with Resident#12 and enjoyed his company. The residents were observed in a room together, Resident#11 had been sitting on the bed and a male resident (Resident#12) had his hand on her thigh. Resident#12 also touched Resident#11's buttocks today. Resident#11 did not appear fearful of the situation, the residents were separated and monitoring continued. Progress Notes included that the doctor and family had been notified. During an interview on 4/25/23 at 9:03 a.m. with Staff A, Registered Nurse (RN) reported the incident reports are filled out for falls, skin tears, bruises, choking, behaviors and abuse. Altercations between residents need to complete an incident report, notify Director of Nursing (DON), families, doctor and depending on the type of altercation the police may need to be notified. If staff see any abuse they are to separate those involved right away. An interview with Staff B, Certified Medication Aid (CMA) on 4/25/23 at 9:09 a.m. reported she is to notify the nurse on staff or the DON of any falls, skin tears, change of status and behaviors so a report can be made. Altercation between residents requires the staff to separate the residents and the DON right away. Staff has abuse and dementia training yearly. On 4/25/23 at 9:29 a.m. Staff C, RN reported the nurses' complete incident reports for falls, altercations between residents and any skin concerns. Regarding resident to resident altercations, staff should separate them right away and notify the DON. The DON decides if a resident is able to consent for sexual contact. Any altercations between residents, the DON and Administrator will investigate. Interview on 4/25/23 at 10:00 a.m. with the Care Plan Nurse reported the Social Services Supervisor codes the behaviors on the MDS and Care Plans as needed. The Care Plan Nurse reads through the Progress Notes daily and updates behaviors on the Care Plan as needed. She is involved in the investigation process with altercations, behaviors and abuse. Staff are to separate those involved in altercations or abuse right away and notify DON or Administrator. The DON or Administrator determines if an investigation is needed. Staff has abuse and dementia training every year. The DON reported on 4/25/23 at 10:27 a.m. the facility uses a policy for incident reports. Staff had training over abuse and incident reports in the fall of 2022. The DON expects the nurses to complete incident report for falls, skin injuries, abuse, resident to resident altercations and medication errors. The Administrator and DON review incident reports to determine if further investigation and state reporting is needed. Interventions are put in place and follow up is completed with staff and residents to see if interventions are effective. The DON verbalized she uses the BIMS score to determine resident's cognitive level for decision making abilities. An interview conducted on 4/25/23 at 10:35 a.m. revealed the Administrator uses the Accident/Fall Reporting Flowsheet to determine when an incident should be reported to the State. Regarding resident to resident altercations, the Administrator expects staff to watch for behaviors and put interventions in place. She reported she uses the BIMS score to determine cognition level of a resident for decision making abilities. The on-call nurse is to direct staff in interventions to put in place. Interventions are reviewed for effectiveness at the care plan meetings. The Medicare team meets weekly and they discuss the concerns of residents and interventions that need to be added to the resident's care plan. During an interview with Staff D, Licensed Practical Nurse (LPN) on 4/25/23 at 10:41 a.m. reported incident reports are completed for falls, resident to resident altercations and injuries of unknown origin. Staff D verbalized for resident to resident altercations to separate the residents and call the on-call nurse for further direction. The on-call nurse determines what is reported to the State. The Social Services Supervisor and DON decide on whether a resident is cognitive enough to make decisions. Staff D verbalized she did not remember any concerns with residents to report to the DON or Administrator. Staff has training on incident reports, abuse and dementia yearly. The Social Services Supervisor reported on 4/25/23 at 11:45 a.m. she had been working as the supervisor for the past four months and has not participated in investigations for abuse, behaviors or resident to resident altercations at this time. Care Plan Nurse is care planning behaviors. Staff E, LPN on 4/25/23 at 12:40 p.m. reported no concerns with residents on behaviors or resident to resident altercations but had given in nurse to nurse report that Resident #12 had talked sexually inappropriate with Resident #11. Staff E verbalized watching Resident #12 more due to him being more cognitive then Resident #11. Staff notified the DON of the inappropriate comments made by Resident #12. On 4/25/23 at 1:14 p.m. interview with Resident #11 Power of Attorney (POA) reported she is aware of the resident to resident concerns over the past year with Resident #11 and Resident #12. She voiced no concerns with the incidents between residents. The POA verbalized Resident #11 has been promiscuous with men in the past and had always been touchy with them. The POA felt staff is doing everything they can to keep a watch over Resident #11 and #12. The Administrator reported on 4/25/23 at 2:53 p.m. the DON and herself report concerns to the State. The Administrator heard a few different stories on the altercation on 4/9/23 and the incident had not been reported to the State. The Administrator heard Resident #12 grazed the shoulder of Resident #11 and not touched the breast, but no thorough investigation had been done to determine. The Administrator verbalized the Physician did not do a cognitive assessment due to needing a consistent BIMS below 10 for Resident #11. A record review of the MDS assessments completed in last year revealed: a. MDS dated [DATE] documented a BIMS score of 03 b. MDS dated [DATE] documented a BIMS score of 03 c. MDS dated [DATE] documented a BIMS score of 03 d. MDS dated [DATE] documented a BIMS score of 03 e. MDS dated [DATE] documented a BIMS score of 04 During an interview on 4/26/23 at 8:20 a.m. Staff G, C.M.A. reported Resident #12 does seek out Resident #11. She has not seen him physically touch Resident #11, but she has heard it had happened. She tries to keep both residents separated. If she sees Resident #11 heading towards Resident #12's room, she will try to distract her. She verbalized Resident #11's dementia is almost like reverting back to when she was a child and that is concerning to her. On 4/26/23 at 9:26 a.m. the Administrator provided further Behavioral Progress Notes for Resident #12 which revealed: a. On 4/9/23 at 3:03 p.m. Resident #12 made sexually inappropriate comments toward a female resident. b. Resident #12 on 3/18/23 at 10:18 p.m. acted flirtatious with a female resident. c. At 1:31 p.m. on 3/1/8/23, Resident #12 made sexual comments toward Resident #11. d. On 2/20/23 at 2:44 p.m. Resident #12 making inappropriate gestures to another female resident. Demonstrating to staff how he wanted to put his head in her breast. e. Resident #12 12/10/22 at 10:06 p.m. had talked dirty to Resident #11 at supper. f. On 12/9/22 at 10:57 p.m. Resident #12 talked sexually to a resident multiple times. He tried to touch the resident. Staff were able to redirect both residents. g. At 9:57 p.m. on 11/21/22, Resident #12 verbalized blunt sexual comments towards Resident #11, Staff were able to redirect. h. On 11/3/22 at 8:19 p.m. Resident #12 told the nurse to sit on his lap. This nurse politely declined and told the resident that the statement was inappropriate. i. Resident #12 on 10/2/22 at 1:04 p.m. observed pacing back and forth in the hallway. Resident #12 kept looking in Resident #11 room and went in that room once. Staff redirected out of room. j. At 9/15/22 at 8:44 p.m. Resident #12 observed making inappropriate sexual comments to Resident #11 and the staff member wrote the comments down in the blue communication book. This nurse read the description and asked the CNA's to keep the residents separated if possible. This nurse called the on-call and informed him of the situation and he will pass it along tomorrow. k. On 9/12/22 at 1:10 p.m. Resident #12 making inappropriate comments to Resident #11. Asking what color panties she had on? talking about her breasts. Resident #11 told her that he wanted to give her something real nice for her birthday. That he knew she would be really good at it. Staff asked him to go to his room to rest for a while. l. Resident #12 on 9/11/22 at 3:20 p.m. reached out and touched another female resident on the buttocks. Staff also reported that yesterday he and this same female resident were in his room, door closed. When staff entered, both residents were sitting on the bed. He had his hand on the Resident #11's thigh. Both residents were calm, in no distress, and mutually agreed that they felt this was ok. Resident #11 and #12 were separated with each incident. Staff member will notify the DON of the situation. m. At 2:29 p.m. on 9/8/22 the CNA reported while assisting Resident #12 in shower he made inappropriate comments. He repeatedly asked the CNA to join him in the shower. The CNA reported the redirection was not effective. n. On 8/23/22 12:34 p.m. Resident #12 moved into the dementia unit today. o. On 7/14/22 at 3:52 p.m. Resident #12 verbalized to a C.N.A., how about I give you a shower instead. Following the shower, the patient told the nurse (speaking about CNA), I wish I could have taken her clothes off instead. Redirection effective. p. On 7/8/22 at 10:44 p.m. Resident #12 made inappropriate comment sexual comment to CNA. q. At 8:24 p.m. on 7/6/22, Resident #12 came up to the desk looked at a picture of a CNA and began speaking to it saying, hey baby you're a bad, bad girl. He proceeded to kiss the picture. Then he said, no we're not going to do 'that' tonight. The picture placed in the medication room. On 4/26/23 at approximately 10:30 a.m. the facility provided a blue Chronic Confusion Dementing Illness (CCDI) unit Communication Notebook which showed a wide rule, 70-page notebook that contained only 15 pages of documented behavioral communications for the CCDI unit with 8 torn page breaks torn off within the tablet. The documentation entries supported Resident #12 had been seeking out and exhibiting sexual behaviors toward another female (Resident #11) on the CCDI unit. The Unit Communication Notebook contained the following staff documentation: a. On 9/15/23 Resident #12 whistled for Resident #11 to come over to his room because she was walking around the unit per usual. She started walking over toward his room and the staff redirected her. Before Resident #12 noticed the staff redirecting Resident #11, staff heard him make inappropriate comments, Staff told him it was inappropriate. He got agitated then closed his door to his room. Resident #12 kept opening the door to his room looking for Resident #11 to come back his way. Resident #11 came to sit with staff and stated to the staff, that man is nerve racking and he's a very bad man. b. On 10/01/22 Resident #12 is so concerned and obsessed with Resident #11. Resident #12 stayed out after breakfast and every time aides were not in site would go over to Resident #11's table. After Resident #11 finished her breakfast, she went to her room to lay down. Resident #12 came out of his room and sat in the dining area. After a while, Resident #12 got up and walked into Resident #11 room. Staff informed him to not go into other resident's rooms without an invite. Resident #12 has been stalking Resident #11 most the day. c. On 10/15/22 Resident #12 walked into Resident #11's room while CNA had been providing care. Staff told Resident #12 it is not his room and he needed to leave. Resident #12 ignored the aide at first. When he was told a second time he said, I heard you. Staff reminded him a third time to leave before he complied. Staff are having to watch him extra close because he knows he is being watched and waits for an opportunity. Even in the dining room in front of staff, Resident #12 would grab Resident #11 butt or breast if she was close to him. The staff has to keep them separate, this is sexual assault. Staff are concerned for Resident #11 well being. Review of Facility Bulletin Board on 4/26/23 at 12:38 p.m. lacked communication documentation the CCDI Communication Notebook is used for Quality Assurance (QA) only since 1/1/2018. The [NAME] Retirement Community (WRC) Resident Sexual Expression Policy, undated, provided by the facility defined the following: 1. Consent may be evidenced through the language, gestures, conduct, activities, or other affirmative actions of a resident who: a. Exhibits and has cognitive decision-making capacity; or b. Exhibits diminished cognitive decision-making capacity (e.g., neurocognitive disorders such as Dementia/Alzheimer's Disease) but not to a degree, as determined by the interdisciplinary team (IDT), resident and resident representative, that would qualify the person as incapacitated. 2. Interdisciplinary Care Team (IDT): A group of healthcare professionals with diverse roles and a common purpose to achieve optimal health outcomes for residents. In collaboration with the resident and resident representative, the IDT determines the best health outcomes for the resident and establishes care/service goals. IDT members should be determined by the resident's needs. Community IDTs typically include the resident, resident representative, physician, nurse, social service worker, and direct care worker. However, the IDT can be extended as necessary to include family members, significant others, physical and/or occupational therapists, dietitians, speech pathologists, psychologists, or pastoral care. 3. Sexual Abuse: Any sex act between persons is sexual abuse by either of the persons when the act is performed with the other person in any of the following circumstances: a. Such other person is suffering from an incapacity which precludes giving consent or lacks the mental capacity to know the right and wrong conduct in sexual matters. The Policy Enactment directed: 1. Cognitive decision-making capacity: This policy applies to individuals who exhibit intact cognitive decision-making capacity and those who exhibit diminished cognitive decision-making capacity; but are not incapacitated. Because every resident's circumstance and level of capacity to consent differs, WRC must develop highly individualized approaches, rather than a single blanket approach, to assess each sexually related situation. In addition to provisions outlined in sections below and in furtherance of tailoring an individualized response and care plan: a. Some residents who exhibit intact cognitive decision-making capacity may still require a cognitive assessment conducted by resident's physician to confirm consent was and continues to be given. This determination should be made by the resident's IDT. b. Residents who exhibit diminished cognitive decision-making capacity (e.g. neurocognitive disorders such as Dementia/Alzheimer's Disease) WILL require a cognitive assessment conducted by a physician to confirm consent was and continues to be given. The Policy directed the Staff Responsibilities included: 1. WRC shall conduct a thoughtful review of situations and accounts of sexual expression among or between residents or with visitors to determine a solution that best meets the needs of and protects the residents involved. A description of the outcome of the review should be shared with the resident, resident representative if appropriate, and the IDT. The outcome of the review and steps to address sexual expression shall be documented in the residents' care plan. 2. Incidents of abuse or suspected abuse should be self-reported by WRC staff to the Iowa Department of Inspections and Appeals, Iowa Department of Human Services, or other agencies as required by law. 3. WRC should ensure that all staff members have received and reviewed the sexual expression policy (including updates to policy) and establish processes for ensuring that the procedures outlined in the policy is carried out by WRC staff. WRC should offer ongoing training, support, and resources to staff to equip them with the skills and knowledge related to sexual expression, resident rights, sensitization, boundaries, ethics, proper response strategies, and documentation and reporting procedures. 4. Staff should report to their Charge Nurse and Director of Nursing any instances of sexual expression that are not addressed in the existing policy so that updates or amendments can be made and so that the IDT can do a review of any new or changed resident sexual expression. 42133 3. The Quarterly MDS dated [DATE] for Resident #13 showed a BIMS score of 5 which indicated severe cognitive loss. The Resident independently transferred and ambulated. The MDS listed a diagnoses of Alzheimer's Disease and documented Resident #13 did not exhibit physical, verbal or other behaviors. The Care Plan revised 11/23/22 lacked documentation of interventions to address inappropriate male behaviors toward the resident. Resident #12's Progress Note dated 4/09/23 at 1:03 p.m. by Staff F, Licensed Practical Nurse (LPN) documented Resident #12 made inappropriate comments towards Resident #13. The Progress Note detailed Resident #12 stated he wanted to do things with Resident #13 and until her husband comes back, he verbalized he wanted her. Resident #12 verbalized he wanted to have sex so bad. The staff intervened and both residents sat at separate tables for the remainder of the lunch meal. Observation on 4/24/23 at 4:00 p.m. revealed Resident #12 and Resident #13 sat across from each other at a dining room table prior to the supper meal. An interview conducted on 4/25/23 at 4:24 a.m. revealed Staff H, C.N.A. reported Resident #12 had inappropriate behaviors toward Resident #13 of a sexual nature a while back. Observation on 4/25/23 at 4:25 p.m. revealed Resident #12 and Resident #13 sat across from each other at a dining room table prior to the supper meal. On 4/25/23 at 4:28 p.m. Staff F, LPN reported Resident #12 had recently made inappropriate sexual remarks to Resident #13. She verbalized she documented at least two episodes of these inappropriate verbal interactions in the behavior notes within the past month. Resident #12 doesn't like his comments. A review of Resident #13's Progress Notes on 4/25/23 at 4:35 p.m. lacked documentation of any behavioral progress notes, assessment or new interventions for the 4/09/23 incident between Resident #12 and #13. On 4/26/23 at 7:15 a.m. the Administrator reported behaviors in the Chronic Confusion or Dementing Illness (CCDI) unit are documented in a book back on the unit. The Administrator went to the CCDI unit to get the behavior charting book to find a blank tablet had been replaced the evening before on 4/15/23. On 4/26/23 at 7:40 a.m. the Administrator reported the behaviors are documented in the electronic health record under an Order Administration Note. A review of Resident #13's Order Administration Notes from the Progress Notes at that time lacked documentation of any behavior documentation. During an interview on 4/26/23 at 8:20 a.m. Staff G, C.M.A. reported Resident #12 exhibited behaviors toward females since his time in the unit. She tries to keep Resident #11 and #12 separated as much as possible. She hasn't seen him physically touch another female resident, but she has heard it happened. She has visualized Resident #12 make inappropriate sexual comments towards Resident #13. Resident #12 likes to sit by Resident #13. They sit at the same table for meals. She reported she does intervene when Resident #12 makes inappropriate verbal comments to Resident #13. Staff G identified if a resident exhibits behaviors, they document it in the behavior communication book at the nurses station (in the CCDI unit). They also report the behavior to the nurse. Staff G identified if she is really concerned about a resident she will leave a note on DON's office door. She never wants anything to happen to a resident on her watch. A review of the Electronic Health Record (EHR) Census on 4/26/23 showed Resident #12 admitted to the CCDI unit on 8/23/22. A blue CCDI Communication Notebook provided by the facility on 4/26/23 at approximately 10:30 a.m. showed a wide rule, 70 page notebook that contained only 15 pages of documented behavioral communications for the CCDI unit with 8 torn page breaks torn off within the tablet. Documentation entries supported Resident #12 had been seeking out and exhibiting sexual behaviors toward another female (Resident #11) on the CCDI unit besides Resident #13. On 4/26/23 at 11:32 a.m. Staff F reported she recalled the incident from 4/09/23 regarding Resident #12 and #13. She overheard Resident #12 stating inappropriate sexual comments to Resident #13 as they sat together at a table in the dining room. Staff F reported she documented the incident with quotations in the progress notes. Staff F intervened between the two residents and talk to Resident #12 about his inappropriate comments directed at Resident #13. Resident #13 didn't want to hear those comments. Staff F verbalized she eventually moved Resident #13 to a different dining room table as she couldn't stay to monitor the interactions between the two residents during meal. Staff F reported the incident to the charge nurse before she left shift that day. She did not recall who the charge nurse had been that day. It may have been Staff C as they work the same weekend. Staff F explained they get notebooks in the CCDI unit to write down anything they notice so that management can review. It's used to keep a record of what is going on so management can keep a record of everything. Staff F verbalized they do not get any feedback from management if anything is being done regarding the behavior documentation. They have not received any specific instruction other than to redirect the residents and document behaviors in the communication book. They have Relias training they complete on mandatory reporting. The management staff doesn't tell them if incidents are reported to DIA. During an interview on 4/26/23 at 11:53 a.m. Staff C reported Staff F is a nurse so she documents her own stuff regarding resident incidents. Staff C clarified there has been incidents in the past with Resident #12 in regards to females, but she doesn't work back in the unit regularly. She doesn't recall Staff F reporting any incidents between Resident #12 and #13 to her. Staff C explained they get instruction on what to look for (regarding behaviors) but they don ot get any formal training on reporting those types of incidents. They do get mandatory adult abuse training, but it has been awhile. An email received from the Administrator on 4/26/23 at 11:15 a.m. detailed the Behavior Communication Book from the CCDI unit is only utilized for quality analysis (QA) purposes to ensure communication is effectively relayed between CNA/CMA's to the nurses. An observation on 4/16/23 at approximately 12:10 p.m. revealed the Administrator held a purple CCDI communication notebook labeled QA Purpose Only. The Administrator reported the Communication Book is used as part of the QA program for CNA and CMA's to be able to communicate with the RNs and LPNs. She stated she declared it as part of the QA program. The Administrator provided a copy of the Quality Assessment and Assurance Policy and the Quality Assessment and Assurance Committee Policy. Both Policies were undated. A review of the Policies on 4/26/23 at 12:26 p.m. showed the Policies lacked documentation the CCDI Communication Notebooks were utilized as QA tools for the Quality Assurance and Performance Improvement (QAPI) program. A review of the Facility On-line Department of Inspection and Appeals (DIA) Report on 4/26/23 at 12:35 p.m. lacked documentation the facility had reported the resident to resident altercation between Resident #12 and Resident #13 on 4/09/23 to the DIA complaint and abuse website. During an interview on 4/26/23 at 1:30 p.m. the Administrator reported the facility had not reported the incident between Resident #12 and #13 to DIA. She didn't know if there had been further investigation completed, but she would check with the DON. On 4/26/23 at 1:45 p.m. the DON reported she had not recognized the situation between Resident #12 and #13 as an altercation. An incident report had not been completed and she had not done any further investigation into the incident. She planned to provide education to the nurses on identifying resident to resident altercations, completing incident reports and notifying a nurse supervisor timely. On 4/26/23 at 1:49 p.m. the Administrator reported the facility planned through their quality analysis program to provide education to CNA/CMA staff on identifying resident to resident altercation situations and reporting those incidents into the charge nurse so that a nurse supervisor could be notified timely and notification could be made to the department within 24 hours.

Based on observations, staff interviews, and clinical record review, the facility failed to assess a resident for self-administration of medications before leaving medications with a resident for one of eight residents reviewed (Resident #19) during medication administration. The facility reported a census of 34 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #19's Care Plan Focus revised 3/2/21 indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan for Resident #19 lacked documentation related to Resident #19's ability to self-administer medications. On 5/17/22 at 6:50 AM, Staff A, Registered Nurse (RN), prepared nine medications in the dining room to administer to Resident #19. On 5/17/22 at approximately 6:54 AM, the nurse left medications with Resident #19 while at the dining table. On 5/17/22 at 7:01 AM and 7:09 AM, the medications remained on the table. On 5/17/22 at 7:14 AM, observation revealed Resident #19 sat at the table in the dining room and eating. The pills remained in the cup next to the resident. An observation revealed Staff A present in the dining room. Staff A asked another resident if they were ready for their medications. On 5/17/22 at 7:18 AM, Resident #19's pills remained at the table. Resident #19 picked up the pill cup, placed the plastic medication cup on their dishes, and began taking the pills with water. On 5/18/22 at 11:40 AM, when queried as to the process if medications were not taken when they had been offered to residents, the Director of Nursing (DON) acknowledged staff would stay with the resident until the medications were taken, and if refused they could come back to them. When queried if they should have been left with the resident, the DON explained not unless the nurse was supervising that. When queried if any of the residents had been assessed as fine to self-administer medications, the DON acknowledged they had not been. The undated Facility Policy titled Medication Administration Policy documented the following: 11. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 15. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR (Medication Administration Record), and action is taken as appropriate.

Based on clinical record reviews, facility policy reviews, and staff interviews, the facility failed to submit a Minimum Data Set (MDS) assessment in a timely manner for two of two residents reviewed for MDS (Resident #19 and Resident #21). The facility reported a census of 34 residents. Findings include: 1. Review of Resident #19's Quarterly MDS assessment, Assessment Reference Date (ARD) 3/16/22, documented as completed on 3/25/22. The assessment got submitted on 4/15/22, 21 days after the completion date. 2. Review of Resident #21's Annual MDS assessment, ARD 3/16/22, documented as completed on 3/25/22. The assessment got submitted on 4/15/22, 21 days after the completion date. On 5/19/22 at 3:01 PM, the MDS Coordinator acknowledged the assessments should have been submitted on 4/7, and acknowledged the assessments had been late. On 5/19/22 at 3:20 PM, when queried if they had been aware of any concerns with the MDS, the Director of Nursing (DON) acknowledged they had not been. The Facility Policy titled MDS Completion and Submission Timeframes dated 2001 documented, the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) verison 3.0 Manual dated October 2019 on page 5-3 documented that transmitting data: submission files are transmitted to the Quality Improvement and Evaluation System (QIES) Assessment Submission and. Processing (ASAP) system using the CMS wide area network. Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. — Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days)

Based on observations, staff interviews, and clinical record reviews the facility failed to include wandering, risk for elopement, and the use of antidepressant medications in the comprehensive plan of care for one of fourteen residents reviewed for care planning (Resident #21). The facility reported a census of 34 residents. Findings include: Resident #21's Minimum Data Set (MDS) assessment dated [DATE] documented a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating severe cognitive impairment. Per the assessment, Resident #21 wandered four to six days in the lookback period, but less than daily. The assessment documented that Resident #21 received antidepressant medication for seven out of seven days in the lookback period. Resident #21's Quarterly Wandering Risk Scale dated 12/28/21 identified the resident as a high risk to wander. The Behavior Note dated 3/2/22 at 1:16 AM documented, that staff reported that Resident #21 got up and needed to go home because the kids were home. The nurse talked with her, got her into her room, and got her feet up with the television (TV) on. Resident #21 observed to be awake but more calm. Resident #21's Care Plan lacked documentation related to wandering or risk for elopement. Resident #21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's Care Plan lacked documentation related to the use of antidepressant medication. On 5/18/22 at 8:21 AM, observation revealed Resident #21 in their room in their recliner chair, with the foot portion of the chair elevated. On 5/19/22 at 1:29 PM, when queried about the review of care plans, the MDS Coordinator explained that Care Plans got reviewed with a new MDS assessment, with falls, and a change in condition. When queried about a wandering care plan for Resident #21, the MDS Coordinator explained that due to her being in the locked unit, that she could easily be redirected, and if she got upset, staff could call her son who could redirect the resident. The MDS Coordinator acknowledged that if someone got assessed as an elopement risk or required a wanderguard that would be Care Planned. When queried about whether antidepressants would be care planned, the MDS Coordinator acknowledged it should go on the Care Plan. On 5/19/22 at 3:20 PM, when queried if antidepressants would be included on the care plan, the DON responded antidepressants would normally be on the care plan or included under high risk medications. When queried if identification of wandering behaviors on the MDS if it should be care planned, the DON responded that a Care Plan should get updated for a resident at risk for elopement and a wander risk assessment would be done as well. The Facility Policy titled Care Plans, Comprehensive Person-Centered, dated 2001 documented the following: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The Care Plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observations, staff interviews, and clinical record reviews the facility failed to update the Care Plan to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #13, and Resident #15). The facility reported a census of 34 residents. Findings include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] documented a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating severe cognitive impairment. The MDS included that Resident #8 showed physical behavioral symptoms directed toward others for one to three days in the lookback period. Resident #8's MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 used an antipsychotic medication for seven out of seven days in the lookback period. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse's Note dated 8/10/21 at 5:56 PM documented that the facility received a fax back from the MD (Medical Doctor) with new orders to start [MEDICATION(S)] (oral diabetic medication) 500 mg (milligrams) BID (twice a day), add DM (diabetes mellitus) type two to Resident #8's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's Niece verbalized understanding when informed that Resident #8 had new orders. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/16/22 at 11:36 AM, observed Resident #8 walked around the area of the facility where the resident resided. Resident #8's Care Plan lacked documentation related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #13's MDS dated [DATE] documented a score of 4 out of 15 on the BIMS assessment, indicating severe cognitive impairment. Per the assessment, Resident #13 received antidepressant medication for zero of the last seven days. The Care Plan dated 1/4/21 revised 2/18/21 documented, that Resident #13 used an antidepressant medication r/t (related to) dementia in other diseases classified elsewhere with behavioral disturbance. Resident #13's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/19/22 at 1:29 PM, when queried about the review of Care Plans, the MDS Coordinator explained that Care Plans got reviewed with a new MDS assessment, with falls, and a change in condition. The MDS Coordinator acknowledged that a couple were missed with changes of condition, and that was something that was being worked on. When queried how they would be updated with changes, the MDS Coordinator explained they would review miscellaneous records, would scan in orders changed, etc., and the staff were pretty good about letting them know. When queried if diabetes would be Care Planned, the MDS Coordinator acknowledged it would be something that she liked to Care Plan. When queried as to the process for Care Planning for the discontinuation of medications, the MDS Coordinator explained she believed she would go in and try to resolve it. On 5/19/22 at 3:20 PM, the Director of Nursing (DON) acknowledged diabetes would normally be on the Care Plan. When queried as to how long it would take for antidepressants to be removed from the Care Plan if the resident no longer received the medication, the DON responded she hoped right away, and if there had been a change she thought it should be updated. The Facility Policy titled Care Plans, Comprehensive Person-Centered, dated 2001 included that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 3. Resident #15's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified that Resident #15 required extensive assistance of one person with all activities of daily living. The assessment indicated that Resident #15 had an indwelling catheter. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan with the target date of 7/18/22 lacked documentation related to the use of an indwelling catheter or interventions on the proper care. Observations during the survey from 5/16/22 through 5/23/22 revealed Resident #15 had an indwelling catheter. On 5/18/22 at 10:48 AM, Staff B, Registered Nurse (RN), reported that if a resident had an indwelling catheter, it would be the responsibility of the MDS coordinator to ensure it had been addressed on the Care Plan. On 5/18/22 at 11:27 AM, the DON (Director of Nursing) reported she would expect the foley catheter to be addressed on the resident's Care Plan. On 5/19/22 at 1:38 PM, the MDS Coordinator reported that she expected the resident's care plan to address the indwelling catheter and that she forgot to add it to his Care Plan when he returned with it.

Based on clinical record reviews and staff interviews, the facility failed to document an assessment of a resident prior to and upon return from the hospital for one of two residents reviewed with hospitalization s (Resident #23). The facility reported a census of 34 residents. Findings included: Resident #23's MDS dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 11, indicating moderately impaired cognition. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified Resident #23 required extensive assistance of one person with bed mobility, transfers, locomotion on the unit, locomotion off the unit, dressing, and personal hygiene. Resident #23 required an extensive assistane of two persons with toilet use. The assessment documented that Resident #23 used an indwelling catheter. The MDS documented Resident #15 as always incontinent of urine and frequently incontinent of bowels. The Care Plan Focus revised 9/3/21 identified Resident #23 required an indwelling catheter due to an obstruction and stent placement on 8/9/21. The Care Plan interventions directed staff to monitor, record, and report to the physician signs and symptoms of a urinary tract infection ([CONDITION(S)]) such as: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and a change in eating patterns. Nurse's Notes review a. 2/2/22 at 4:01 PM Resident #23 returned from surgery by a van accompanied by staff. Resident #23's color appeared pink, warm, and dry with a temperature of 97.9. * The note lacked documentation of an assessment of Resident #23's indwelling catheter, appearance of urine, presence of pain, and etc. b. 2/3/22 at 3:57 AM Resident #23 had emesis (vomited) of bile. Notified Doctor of Resident #23's condition. * The note lacked an assessment of palpation of the abdomen, presence of bowel sounds, the amount, color of emesis, or vital signs (VS). c. 2/3/22 at 4:48 AM the doctor returned a phone call with new orders to send Resident #23 to the emergency room (ER). The nurse called an ambulance for transport. Resident #23 left the facility awake, alert with some confusion, and in no apparent distress. The facility called a report to the hospital staff, appropriate paperwork sent with the ambulance. * The note lacked documentation of the time and how Resident #23 got transported, a complete assessment of Resident #23 upon time of transfer. d. 2/7/22 at 12:43 PM Resident #23 returned to the facility by the facility van following his hospital stay for [CONDITION(S)] secondary to a [CONDITION(S)] (urinary tract infection) following a recent renal stent placement. VS: temperature of 96.9, heart rate of 81, respiration rate of 24, blood pressure of 136/62 and Sp02 (serum pressure and oxygen - the amount of oxygen in the body) 96% on RA (room air). Resident #23 denied pain. The nurse observed a catheter intact draining yellow urine. Staff assisted Resident #23 to transfer into bed, mild weakness observed during the transfer. The hospital physician's History and Physical dated 2/3/22 documented the following: patient presented with a history of [CONDITION(S)] fibrosis with double-J stenting (insertion of a plastic tube to help drain urine from the kidney). The patient had a stent exchange the day before. The patient noted to have a temperature of 101 with increased confusion that day. In the emergency room , he had a bolus of 500 mls (milliliters) and blood cultures sent. The patient received [MEDICATION(S)] (an antibiotic used to treat infections) for treatment and got admitted to the hospital. On 5/18/22 at 10:48 AM, Staff B, Reigsterd Nurse (RN) reported that when a resident got transferred to the hospital, the nurse should document some kind of assessment, document the communication with the physician and family, if the paramedics were called, and other way the resident got transported to the hospital. On 5/23/22 at 8:13 AM, the DON reported that she would have the following expectations: a. When a resident transferred to the hospital, the nurse should document the resident's assessment, that they notified the family and physician, the time and mode of how they were transported to the hospital. b. When a resident had symptoms of emesis and got transferred to the hospital, the nurse should document the amount, color, bowel sounds, and any other concerns c. When a resident returned from the hospital with an indwelling catheter, the nurse should document placement, functioning properly, and color of the urine. The Resident Examination and Assessment policy revised February 2014 documented the following: DOCUMENTATION The following should be documented in the resident's medical record a. the date and time the procedure was performed b. the name of the individual who performed the procedure c. all assessment data obtained during the procedure d. how the resident tolerated the procedure e. if the resident refused the procedure, why and interventions taken f. signature and title of the person recording the data REPORTING Notify the physician of any abnormalities such as but not limited to: a. abnormal vital signs; b. distended, hard abdomen or absence of bowel sounds c. worsening pain as reported by the resident

Based on observations, clinical record reviews, and staff interviews, the facility failed to ensure the catheter tubing had been kept up off the floor for 3 out of 3 residents reviewed (Residents #1, #15 and #23). The facility also failed to ensure indwelling catheter bags got placed in a dignity bag for 2 out of 3 residents reviewed with catheters (Residents #15 and #23). The facility reported a census of 34 residents. Findings included: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #1's MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coded that Resident #1 required extensive assistance of two person with bed mobility, transfers, dressing, personal hygiene, and toilet use. The Care Plan Focus revised 2/12/21 identified Resident #1 used an indwelling catheter for [CONDITION(S)] on. The Care Plan lacked direction regarding the care of the catheter while in the wheelchair or in bed. It did not have interventions that directed staff to keep the catheter tubing off the floor. The following observations of the resident revealed the catheter tubing on the floor at: a. 5/17/22 at 9:12 AM Staff C, Certified Nurse Aide (CNA), pushed Resident #1 in her wheelchair out to the activity area as the catheter tubing dragged across the floor. Staff C did not reposition the tubing from off the floor before leaving Resident #1. b. 5/17/22 at 9:19 AM Staff C, assisted another resident to sit at a table next to Resident #1 while the catheter tubing remained on the floor. Staff F, CNA, and Staff C did not adjust Resident #1's catheter tubing before leaving the area. c. 5/19/22 at 9:32 AM observed catheter tubing remained on the floor. Staff F, did not reposition the tubing before leaving the area. d. 5/17/22 at 9:58 AM observed the tubing off the floor, as Resident #1 remained in the activity area playing Bingo. e. 5/17/22 at 11:40 AM witnessed Resident #1 sitting in her wheelchair in the main dining room with her catheter tubing noted on the floor. Staff A, Registered Nurse (RN) sat beside the resident's tablemate and did not reposition Resident #1's catheter tubing. f. 5/17/22 at 11:44 AM catheter tubing remained on the floor. Staff A walked up to Resident #1 and asked if she could give her medications. Staff A returned to the medication cart and did not pick up tubing off floor before she went. g. 5/17/22 at 11:50 AM Staff A sat beside Resident #1 at the main dining room table and began to spoon feed her medications as the catheter tubing remained on the floor. Staff A did not reposition the catheter tubing before she left the table. h. 5/17/22 at 12:00 PM Staff C assisted the resident's tablemate away from the table as Resident #1's catheter tubing remained on the floor. Staff C did not reposition the tubing off floor before leaving the dining room. i. 5/17/22 at 12:03 PM catheter tubing remains on floor, Staff A walked up to resident's table and mixed medications in the resident's cup of juice and did not reposition tubing before she returned to the medication cart. j. 5/17/22 at 12:15 PM catheter tubing remains on floor, Staff A remained in the dining room did not reposition the tubing. k. 5/17/22 at 12:22 PM Staff C pushed Resident #1 in her wheelchair while the catheter tubing remained on the floor. After Staff C left Resident #1, they didn't reposition the tubing off floor. 2. Resident #15's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. Resident #15 MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It identified that Resident #15 required extensive assistance of one person with most activities of daily living (ADLs). Resident #15's MDS documented he used an indwelling catheter. The Care Plan with the target date of 7/18/22 lacked documentation related to an indwelling catheter or interventions on the proper care. The following observations of the resident revealed the catheter tubing and or tubing on the floor at: 5/17/22 at 9:09 AM while the resident slept in the recliner in his room with the catheter bag out of the dignity bag lying on the floor in front of him and the catheter tubing also noted on the floor. 5/17/22 at 9:16 AM assessment unchanged, tubing and bag remained on the floor. 5/17/22 at 9:34 AM assessment unchanged, catheter bag and tubing remained on the floor 5/17/22 at 10:03 AM door to room closed 5/17/22 at 12:04 PM resident able to self-propel out of the main dining room with the catheter tubing dragging along the floor. Staff F CNA pushed another resident behind this resident and did not reposition tubing off the floor. 5/17/22 12:20 PM asked Resident #15 to sit in the recliner in his room as he held the catheter bag in his lap with the catheter tubing on the floor. 3. Resident #23's MDS dated [DATE] identified a BIMS score of 11, indicating moderately impaired cognition. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coded Resident #23 required extensive assistance of one person with bed mobility, transfers, locomotion on the unit, locomotion off the unit, dressing, and personal hygiene. Resident #23 required extensive assistance of two persons with toilet use. The Care Plan Focus revised 9/3/21 identified Resident #23 with an indwelling catheter due to an obstruction and stent placement on 8/9/21. The Care Plan lacked interventions that directed staff to keep the catheter bag and tubing off the floor. The following observations of Resident #23 revealed the catheter tubing on the floor: a. 5/17/22 at 6:53 AM seen him self-propelled around the dining room table to move his tablemate's chair closer to the table as she requested. As he moved around in the wheelchair, his catheter tubing dragged across the floor. Staff A began to assist his tablemate to move closer to the table. Staff A did not check his catheter tubing to reposition it off the floor. b. 5/17/22 at 6:57 AM catheter tubing remained on the floor c. 5/17/22 at 7:05 AM Staff A administered medications to the resident's tablemate. Staff A did not reposition Resident #23's tubing off the floor before she left the table. d. 5/17/22 at 7:16 AM Resident #23's catheter tubing remained on the floor. Staff E, CNA assisted another resident to sit behind Resident #23, Staff E did not reposition his cathteter tubing off the floor. e. 5/17/22 at 7:20 AM Staff E sat beside Resident #23 and talked to him. She did not reposition his catheter tubing which remained on the floor. f. 5/17/22 at 7:31 AM catheter tubing remained on the floor, Staff F stood beside the resident briefly, but did not reposition the tubing off the floor. Staff F and Staff E sat at table beside Resident #23, neither one repositioned the catheter tubing off the floor. g. 5/17/22 at 11:36 AM he sat in the dining room in his wheelchair with his catheter tubing on the floor. h. 5/17/22 at 11:43 AM he remained in the dining room in his wheelchair with his catheter tubing still on the floor. i. 5/17/22 at 11:53 AM his catheter tubing remained on the floor as Staff A stood beside Resident #23 as he asked her a question. Staff A did not reposition the tubing before she left the table. j. 5/17/22 at 12:02 PM his catheter tubing remained on the floor. Staff A remained in dining room by medication cart and did not reposition the tubing off floor. k. 5/17/22 at 12:12 PM Staff C stood beside Resident #23 and asked him a question. Staff C then walked toward another table without repositioning the catheter tubing that remained on the floor. l. 5/17/22 at 12:13 PM his catheter tubing remained on the floor. Staff A stood beside Resident #23 and did not reposition the tubing before she left the table. m. 5/17/22 at 12:15 PM his catheter tubing remained on the floor. Staff A remained in the dining room and did not reposition the tubing. n. 5/17/22 at 12:24 PM Staff D, CNA, pushed Resident #23 in his wheelchair, while his catheter tubing dragged across the floor, to his room. o. 5/18/22 7:17 AM he sat in his wheelchair in main dining room. Staff B stood in front of him and asked if he needed help. Resident #23's catheter tubing remained on the floor as he self-propelled around the table. On 5/18/22 at 10:08 AM, Staff D reported that she would need to check to make sure correct placement of the strap on their leg, make sure the bag is not touching the floor, in a privacy bag, make sure the drainage tube got clamped, make sure the urine drains correctly, and not kinked anywhere. Staff D explained that she would never handle a catheter with her bare hands. On 5/18/22 at 10:14 AM, Staff E reported that she would need to check residents with an indwelling catheter to see if it had output, make sure correct placement of the leg strap and not pulling, clean tubing, no leaking from the bag, ask the resident if they had any pain and if so, they need to let the nurse know. Staff E explained that she would make sure the foreskin got pulled down, a privacy bag covered the catheter bag, watch for any blood or sediment starting to form as it could be a possible [CONDITION(S)] starting, make sure keep to them hydrated and let the nurse know. She also reported she would never handle the catheter with her bare hands. On 5/18/22 at 10:22 AM, Staff F reported that she would need to check residents with catheters their output, the position of the bag to make sure the bag is not touching the floor and check that the resident does not have any pain. She also reported she would never handle the catheter with her bare hands. On 5/18/22 at 10:30 AM, Staff G, CNA, explained that she would need to check that the leg strap did not pull on the resident, make sure the bag hanged below their hips, that it flowed right, and make sure the clamps were closed so nothing leaked out. She also reported she would never handle the catheter with her bare hands. On 5/18/22 at 10:48 AM, Staff B reported that she would expect the CNAs to check on residents with an indwelling catheter to ensure the catheter is intact, the strap is on the leg, the catheter is secure, that the line is patent and not kinked, the bag isn't leaking, the spout is clipped and not dragging on the floor. Ensure the catheter bag is in a dignity bag, check the color of the urine, and to let the nurse know if there is anything abnormal. On 5/18/22 at 11:27 AM, the DON (Director of Nursing) reported she would expect the CNAs to check on residents with indwelling catheters to ensure correct placement of the catheter, that a dignity bag covered the urinary bag, secured clamps, and secured leg bags. If staff saw the tubing on the floor, she would expect them to pick up the tubing off the floor. During a follow-up interview on 5/19/22 at 7:45 AM, the DON reported they didn't complete audits, but she did re-educate the staff on perineal care and catheter care. A review of the outline for the staff meeting held 10/21/21 contained a copy of a competency assessment for emptying a urinary drainage bag. The competency assessement directed the staff to keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. The Urinary Catheter Care policy revised September 2014 documented under the section infection control to be sure the catheter tubing and drainage bag were kept off the floor

Based on observations, clinical record reviews, and staff interviews the facility failed to 1. Don (put on) gloves prior to handling a indwelling catheter for one of three residents reviewed with catheters (Resident #15) 2. Failed to change gloves after cleaning wounds and before applying new treatments for one of two residents reviewed with wounds (Resident #16). The facility reported a census of 34 residents. Findings included: 1. Resident #15's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified that Resident #15 required extensive assistance of one person with all activities of daily living. The assessment indicated that Resident #15 had an indwelling catheter. The Care Plan with the target date of 7/18/22 lacked documentation related to the use of an indwelling catheter or interventions on the proper care. Observations of catheter care revealed the following: a. 5/17/22 at 12:37 PM Staff C, Certified Nurse Aide (CNA), and Staff D, CNA, entered Resident #15's room as his urinary catheter tubing laid on the floor. b. At 12:43 PM Staff C washed her hands and filled a wash basin with water. Staff C then placed the wash basin on top of a tray table without a barrier. c. At 12:44 PM after both aides pulled Resident #15's pants down Staff C did not have gloves on when she touched the urinary catheter just below the insertion site with her bare hands. After touching the urinary catheter tubing, Staff C then used alcohol hand sanitizer. On 5/18/22 at 10:08 AM, Staff D reported that she would need to check to make sure correct placement of the strap on their leg, make sure the bag is not touching the floor, in a privacy bag, make sure the drainage tube got clamped, make sure the urine drains correctly, and not kinked anywhere. Staff D explained that she would never handle a catheter with her bare hands. On 5/18/22 at 10:14 AM, Staff E, CNA, reported that she would need to check residents with an indwelling catheter to see if it had output, make sure correct placement of the leg strap and not pulling, clean tubing, no leaking from the bag, ask the resident if they had any pain and if so, they need to let the nurse know. Staff E explained that she would make sure the foreskin got pulled down, a privacy bag covered the catheter bag, watch for any blood or sediment starting to form as it could be a possible [CONDITION(S)] starting, make sure keep to them hydrated and let the nurse know. She also reported she would never handle the catheter with her bare hands. On 5/18/22 at 10:22 AM, Staff F, CNA, reported that she would need to check residents with catheters their output, the position of the bag to make sure the bag is not touching the floor and check that the resident does not have any pain. She also reported she would never handle the catheter with her bare hands. On 5/18/22 at 10:30 AM, Staff G, CNA, explained that she would need to check that the leg strap did not pull on the resident, make sure the bag hanged below their hips, that it flowed right, and make sure the clamps were closed so nothing leaked out. She also reported she would never handle the catheter with her bare hands. On 5/18/22 at 10:48 AM, Staff B, Registered Nurse (RN), reported that she would expect the CNAs to check on residents with an indwelling catheter to ensure the catheter is intact, the strap is on the leg, the catheter is secure, that the line is patent and not kinked, the bag isn't leaking, the spout is clipped and not dragging on the floor. Ensure the catheter bag is in a dignity bag, check the color of the urine, and to let the nurse know if there is anything abnormal. On 5/18/22 at 11:27 AM, the DON, Director of Nursing, reported that she would expect the CNAs to check on residents with indwelling catheters to ensure correct placement of the catheter, that a dignity bag covered the urinary bag, secured clamps, and secured leg bags. If staff saw the tubing on the floor, she would expect them to pick up the tubing off the floor. During a follow-up interview on 5/19/22 at 7:45 AM, the DON reported they didn't complete audits, but she did re-educate the staff on perineal care and catheter care. The Urinary Catheter Care policy revised September 2014 directed staff to wash their hands, fill a wash basin with water, and don gloves. The policy lacked direction to place a barrier underneath the wash basin. 2. Resident #16's MDS dated [DATE] identified a BIMS score of 13, indicating intact cognition. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented Resident #16 required extensive assistance of two persons with bed mobility, transfers, toilet use, and personal hygiene. The MDS indicated Resident #16 had a risk to develop pressure ulcers. Resident #16 had open [CONDITION(S)] on his feet that required applications of dressings. Resident #16 took antibiotics for seven out of seven days in the lookback period. The Care Plan Focus revised 10/21/21, identified Resident #16 had an open area to his buttock, he had multiple areas to his BLE (both lower extremities/legs), and had the potential for pressure ulcer development. The Care Plan lacked direction to change their gloves during wound care, after handling soiled dressings, or when going from a soiled area to a clean area. An observation of wound care on 5/17/22 at 10:09 AM revealed the following: Staff A, RN and the DON entered Resident #16's room, they both washed their hands and donned gloves. At 10:13 AM Staff A removed Resident #16's dressings to his right foot. At 10:15 AM Staff A cleaned Resident #16's wounds with a wound spray and dabbed the wound with gauze dressings. At 10:18 AM without changing her gloves, Staff A used wound cleanser to clean the open areas of Resident #16's toes. At 10:19 AM Staff A removed her gloves, washed her hands, and donned new gloves. At 10:29 AM Staff A squirted normal saline on collagen dressings , then without changing her gloves before she picked up the large [MEDICATION(S)] dressing and she applied it to the top of the collagen dressings At 10:31 AM without changing her gloves, Staff A opened up packets of skin prep, then she applied it to Resident #16's open areas on his toes on both feet. Without changing her gloves, Staff A used a cotton tipped applicator to apply Santyl ointment with collagen to Resident #16's open areas on his toes. On 5/18/22 at 10:48 AM, Staff B, RN, reported that when a nurse completed wound care or dressing changes, they should change their gloves any time their gloves got soiled, for example, after cleaning a wound and before you applying clean treatments or dressings. Staff B explained they should change their gloves in between different wounds so you are not transferring bacteria from one wound to another wound. On 5/18/22 at 11:27 AM, the DON reported that when a nurse completed wound care or dressing changes, she would expect the nurse to change their gloves any time they enter the room, whenever they go from dirty to clean, after removing a dressing, and before placing a new dressing. The Wound Care policy revised October 2010 lacked direction for staff to change their gloves after removing a dressing, after cleansing a wound, before placing a new dressing, or treatment on the wound.

Based on observation, record review and staff interview, the facility failed to address and identify interventions for 3 of 12 residents reviewed in the standard sample, for anti-anxiety medications given as needed for Resident #10, orders for hospice services for Resident #13, the presence of a cast for Resident #75. The facility reported a census of 25 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) admission assessment completed 7/14/20 identified the resident as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete the interview), required extensive staff assistance with most activities of daily living. During an interview on 9/23/20 at 2:11 p.m., Staff B, Registered Nurse (RN) reported when a resident has orders for as needed (PRN) antianxiety medications, that this should be addressed on the Care Plan and interventions should include attempting non-pharmacological interventions prior to administering the PRN medication. She also reported the MDS Coordinator had the responsibility to update and develop the Care Plans. In an interview on 9/23/20 at 2:29 p.m., Staff A, Licensed Practical Nurse, MDS Coordinator, reported that she had been responsible for developing and updating the Care Plans and when a resident has orders for PRN antianxiety medications, that this should be addressed on the Care Plan and interventions should include: attempt non-pharmacological interventions such as repositioning, snack, toileting or change clothing. During an interview on 9/24/20 7:32 a.m., the Director of Nursing (DON) reported if a resident has orders for PRN antianxiety medications, she would expect this to be addressed on the Care Plan, that the MDS Coordinator had been responsible for developing and updating the care plan and that interventions should include attempt three non-pharmacological interventions before giving the PRN medication. 2. Resident #13's MDS admission assessment completed 8/5/20 had documentation of the following Diagnoses: [REDACTED]. A review of the Care Plan with the target date of 11/9/20 did not identify the resident with the problem of terminal prognosis related to severe protein calorie malnutrition until 9/23/20. A review of the Physician Orders revealed an order dated 8/28/20 for a referral to Hospice services of family choice. A review of the Notice of Patient Admission to Hospice revealed a date of admission of 8/29/20. During an interview on 9/23/20 at 2:11 p.m., Staff B, RN reported if a resident received Hospice services, that this should be addressed on the Care Plan and interventions should include diet, comfort measures, notify Hospice staff any time there is a condition change or family requests for different interventions. In an interview on 9/23/20 at 2:29 p.m., Staff A, LPN, MDS Coordinator, reported that she had been responsible for developing and updating the Care Plans and when a resident has Hospice services, this should be addressed on the Care Plan and interventions should include work on plan of care with Hospice, comfort measures and notify hospice of any changes. During an interview on 9/24/20 7:32 a.m., the DON reported if a resident has hospice services, she would expect this should be addressed on the Care Plan and interventions should include notifying Hospice of any changes and keeping the resident comfortable. 3. Resident #75's MDS Admission Assessment completed 9/17/20 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively impaired with a BIMS score of 7 out of 15 and required limited assistance with most activities of daily living. A review of the Baseline Care Plan dated 9/10/20 identified the resident with a Colles [MEDICAL CONDITION] radius, did not identify the resident had a cast or splint or document interventions required for the care of the cast/splint. A review of the September 2020 Medication Administration Record [REDACTED]. A review of the Admission Assessment completed 9/10/20 identified the resident with a splint to the right wrist with complete hand bruising. A review of the nurse's notes revealed an entry dated 9/10/20 at 3:33 p.m. that the resident had a cast on the right wrist, fingers dark purple with swelling noted to the fingers and able to move all without difficulty and rated pain is at a 7 pain level. During an interview on 9/23/20 at 2:11 p.m., Staff B, RN reported if a resident had a cast, that this should be addressed on the Care Plan and interventions should include: check for swelling, pulses, breakdown of the skin or any signs of infection. In an interview on 9/23/20 at 2:29 p.m., Staff A, LPN, MDS Coordinator, reported that she had been responsible for developing and updating the Care Plans and when a resident has a cast she would expect this to be addressed on the Care Plan and interventions should include checking for circulation, motion and sensation, presence of pain, the appearance of the cast and weight bearing status. During an interview on 9/24/20 7:32 a.m., the DON reported if a resident has a cast, she would expect this to be addressed on the Care Plan and interventions should include: check circulation, motion and sensation to the extremity, any swelling around the cast, any hot spots on the cast. The resident had a splint, which is soft on the top, but she would still expect staff to check for all the previous interventions she identified earlier. A review of the facility policy titled: Care Plans - Baseline, dated as last revised December 2016) had documentation of the following: The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a Baseline Care Plan to meet the residents' immediate care needs including but not limited to: a. Initial goals based on admission orders [REDACTED] b. Physician orders. c. Therapy services. A review of the facility policy titled: Care Plans, Comprehensive Person-Centered, dated as last revised December 2016, had documentation of the following: a. The comprehensive person-centered Care Plan will: -Incorporate identified problem areas. -Incorporate risk factors associated with identified problems. -Identify the professional services that are responsible for each element of care. Reflect currently recognized standards of practice for problem areas and conditions. b. Assessments of residents are ongoing and Care Plans are revised as information about the residents and the residents' conditions change.

Based on record review and staff interview, the facility failed to document attempts of non-pharmacological interventions for one of one residents with orders for administer as needed (PRN) anti-anxiety medications included in the sample. (Resident #10). The facility reported a census of 25 residents. Findings include: 1. Resident #10's Minimum Data Set admission assessment completed 7/14/20 identified the resident as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete the interview), required extensive staff assistance with most activities of daily living. During an interview on 9/23/20 at 2:11 p.m., Staff B, Registered Nurse (RN) reported when a resident has orders for PRN antianxiety medications, she would attempt 3 different non-pharmacological interventions before administering the medication and should be charted in the Electronic Medication Administration Record. In an interview on 9/23/20 at 2:29 p.m., Staff A, Licensed Practical Nurse (LPN), MDS Coordinator, reported when a resident has orders for PRN antianxiety medications, the nurse should attempt 3 non-pharmacological interventions such as repositioning, offer a snack, toilet, or change clothing which then should be documented in the progress note of the Medication Administration Record [REDACTED] During an interview on 9/24/20 at 7:32 a.m., the Director of Nursing (DON) reported if the resident has orders for PRN antianxiety medications, she would expect the nurse to attempt 3 non-pharmacological interventions prior to giving the medication and document in the progress notes. A review of the Care Plan identified the resident with the problem of using an anti-anxiety medication related to anxiety disorder with the date initiated 7/27/20 and goal target date of 10/25/20 and did not include the intervention to provide 3 interventions before giving this medication until 9/23/20. A review of the Medication Administration Records and Nurse's Notes revealed the resident received PRN antianxiety medication [MEDICATION NAME] 0.25 mg one tablet on the following dates and times without documentation to show 3 non-pharmacological interventions had been attempted prior to administration: a. On 7/9/20 at 12:00 p.m. and 9:50 p.m. b. On 7/11/20 at 3:47 p.m. c. On 7/12/20 at 4:45 a.m. and 8:02 p.m. d. On 7/15/20 at 6:20 a.m. and 7:00 p.m. e. On 7/17/20 at 1:12 p.m. f. On 7/18/20 at 11:35 a.m. g. On 7/19/20 at 3:57 p.m. h. On 7/21/29 at 4:34 p.m. i. On 8/220 at 6:15 p.m. j. On 8/4/20 at 6:10 p.m. k. On 9/1/20 at 6:15 p.m. l. On 9/4/20 at 6:10 p.m. A review of the undated facility policy titled: [MEDICAL CONDITION] Medications directed the staff if they administer antipsychotic medications (which include anti-anxiety medications) they must clearly show multiple attempts to implement Care-Planned non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions.

Based on record review, staff interviews and review of the facility policy/procedures, the facility failed to ensure the facility failed to ensure 1 of 4 residents were free from abuse (Resident #2). Resident #1 entered the room of Resident #2 and pulled Resident #2 from the bed and onto the floor which resulted in a [MEDICAL CONDITION] to Resident #2. The facility had a census of 34 residents. Findings include: 1. According to the MDS (Minimum data set) assessment, with a reference date of 09/19/16, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident with long and short term memory problem and moderately impaired of cognitive skills for daily decision making. The MDS identified Resident #1 as requiring extensive assistance of one staff member for dressing, toilet use, personal hygiene, and limited assist of one staff member for bed mobility and resident to be independent without device for ambulation. The MDS documented the resident to have physical behavior symptoms directed towards others that significantly disrupt care or living environment, and resident to reject cares 1 to 3 days a week. The MDS documented the resident with admission date of [DATE] to the facility. The nurse's Progress Note dated 10/24/16 at 5:41 a.m. indicated nursing staff found Resident #1 lying on resident #3's bed. The resident lived in the secured CCDI (Chronic Confusion and Dementing Illness). Nursing staff redirected Resident #1 from Resident #3's room and Resident #1 became agitated and went into Resident #2's room. The nursing staff observed Resident #1 standing over Resident #2 and Resident #2's legs were off his her/bed. Nursing staff went into Resident #2's room to intervene and Resident #1 raised his/her fist to the staff member. Another nursing staff member stepped in and redirected the Resident #1 to his/her room. Documented at 6:08 a.m., nursing staff indicated Resident #1 noted to be agitated and aggressive when approached and staff unable to redirect Resident #1 at this time. Resident #1 noted to be shaking and facial color as red. Documented at 6:09 a.m., nursing staff administered [MEDICAL CONDITION] medication to Resident #1 for severe agitation. Documented at 8:13 a.m., nursing staff indicated the [MEDICAL CONDITION] medication to be effective. Review of the Incident/Accident report dated 10/24/16 at 5:40 a.m. identified Resident #1 pulled Resident #2 out of bed by the legs. Resident #2's knees on the floor with legs bent under the bed. Resident #2 assessed by nursing staff and sent to the hospital via ambulance for possible right [MEDICAL CONDITION]. On 10/26/16 at 8:34 a.m. and 10/27/16 at 10:46 a.m. Staff J, RN was interviewed. Staff J stated she had worked the night shift from 10/23/16 to the morning of 10/24/16. Staff J, RN, stated she does not remember if Resident #1 to be up at that time but does recall Resident #3 to be up at that time sitting in recliner in the common/lounge area. Staff J, RN, reported she received report from Staff A, CAN, who was to be the only staff member in the unit Staff J stated around 5:50 a.m. she heard the call come over the walkie-talkie from Staff A, CNA, stating she needed assist in the CCDI unit. Staff J stated Staff I, CNA, responded to the unit form the Nursing Facility area and she remained there as the other CNA staff member outside emptying the trash, stating she had to wait for that CNA to return before leaving the Nursing Facility area. Staff J stated when she got to the CCDI unit and she observed Staff A, CNA, standing with Resident #3 by the nurse's station and common area. Staff J stated Staff A, told her that Resident #1 went into Resident #3 room and laid down in bed while Resident #3 in common area. Staff J, reported that Staff A, reported Resident #1 became agitated when Staff A redirected resident out of room. Staff J reported Staff A told her Resident #1 then started to follow her around as Staff A attempted to assist Resident #3 who is attempting to self-transfer out of recliner in common area. Staff J reported Staff A informed her she had been responding to Resident #3 who was attempting to self-transfer, from recliner, again, in the common area and observe Resident #1 at this time enter into Resident #2 room. Staff J stated Staff A assisted Resident #3 back to sitting in recliner in common area and went to redirect Resident #1 out of Resident #2's room and found Resident #1 standing by Resident #2 ' s bedside, very agitated, had apparently pulled Resident #2 ' s legs out of bed with knees on floor, legs behind him/ her under bed and with top half of body on bed. Staff J stated Staff A told her she assisted Resident #2 ' s legs back into bed to prevent him/her falling to floor and Resident #1 remained in the room while doing so and attempting to hit Staff A with a closed fist. Interview was conducted on 10/25/16 at 4:14 p.m. and 10/25/16 at 11:09 a.m. with Staff A, CNA. Staff A stated she works the 3rd shift from 10:00 p.m. 6:00 a.m. Staff A reports she came into work the night of 10/23/16 to the morning of 10/24/16 and was assigned to the CCDI unit where Resident #1, #2, and #3 reside at, and to be the only staff member in the unit. Staff A stated before 5:50 a.m., Resident #3, who requires one assist due to being a fall risk, to be up in common area and making several attempts to self-transfer and ambulate. Staff A stated during this time Resident #1 to be up and wondering the halls, agitated and closing resident ' s doors. Staff A stated Resident #1 then entered Resident #3's room and laid down in the bed. Staff A indicated she left Resident #3 who was sitting in a recliner in the common area to redirect Resident #1 out of Resident #3's room. Staff A stated when she got into Resident #2's room she witnessed all bed coverings pulled off him/her and to be lying on the floor. Staff A stated Resident #1 grabbing Resident's #2 feet at the foot/edge of the bed. Staff A stated when she entered the room Resident #1 let go of Resident #2 feet which fell to the floor at that time. Staff A reported at this time she called for staff assistance via walkie-talkie. Staff A stated she intervened, placed Resident #2 legs back in bed to prevent him/her from falling to floor, and Resident #1 attempted to strike her with a closed fist at this time. The facility policy/procedures titled Dependent Adult Abuse (not dated), directed the facility will not permit residents to be subjected to abuse by any person, including staff members, other residents, consultants, volunteers, staff or other agencies serving the resident. The facility had abated the immediacy on 10/24/16, prior to the start of the investigation. The facility began immediate 1:1 supervision of Resident #1 and increased staffing numbers in the CCDI unit during the night hours.

Based on observation, record review, staff interviews and review of the facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from other residents and from self and failed to plan for and direct the services so each resident ' s needs are met. The sample consisted of 11 residents and the facility reported a census of 34 residents (Resident #1, #2, #4). In the CCDI (Chronic Confusion and Dementing Illness) unit, Resident #1 pulled Resident #2 out of the bed which resulted in a hip fracture to Resident #2. The CCDI only had 1 staff person working during the night shift (10 residents). Resident #4 received cares in bed and the staff person turned away from the bed. Resident #4 fell out of the bed and onto the floor which resulted in a fractured hip. Findings include: 1. Resident #1 had an admission MDS (Minimum Data Set) assessment, with a reference date of 09/19/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had long and short term memory problems and moderately impaired cognitively for daily decision making. The MDS identified Resident #1 required extensive assistance of one staff member for dressing, toilet use, personal hygiene, and limited assistance of one staff member for bed mobility. The MDS indicated the resident had physical behavior symptoms directed towards others that significantly disrupted care or living environment. The resident rejected cares 1 to 3 days a week. The Care Plan with an onset date of 09/27/2016, identified the resident as having dementia and had the potential to be physically aggressive with hitting at staff and resistive to cares at times, has anxiety and gets anxious at times, and is prescribed an psychotropic medication as needed. The Care Plan listed interventions/approaches that directed staff to: 1. If the resident resist cares of activity of daily living (ADL's), staff are to reassure resident, leave the resident and reproach the resident in 5-10 minutes and try again. 2. Staff are to administer psychotropic medications as ordered by the resident's physician and monitor for side effects and effectiveness. 3. Staff are to analyze times of day, places, circumstances, triggers, and what de-escalates the resident's behaviors and to document this. 4. Staff are to assess and anticipate the resident ' s needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. 5. Staff are to monitor/document/report any signs or symptoms of resident posing danger to self or others. 6. Staff are to know the resident tolerates people at times, resident needs his/her personal space, and staff are to approach with hand holding for calming the resident. 7. When the resident becomes agitated, staff are to intervene before agitation escalates, guide resident away from source of distress, engage calmly in conversation with the resident, and if the resident ' s response is aggressive, staff are to walk away and approach later. The Care Plan added additional interventions on 10/24/16 that included: a) Staff are to check on the resident every 15 minutes. b) Staff are to administer anti-anxiety medication every night at hour of sleep. c) Staff are to provide one to one monitoring when the resident is agitated. Review of Resident #1 ' s clinical record at this facility identified the Progress Notes from a prior facility that the resident was admitted from, that included notes of: On 8/31/16 at 10:45 a.m. Resident #1 admitted to facility. On 9/2/16 at 10:51p.m., the nursing staff talking with a family member of Resident #1. The family member reported the resident does have some behaviors. The nursing staff documented Resident #1 walking up and down the hallway door and attempted to leave before supper. The staff redirected Resident #1 to the nurse ' s desk and then the resident wandered into another room. Resident #1 became very agitated with nursing staff when staff attempted to redirect the resident. The resident raised clenched fists and attempted to strike at staff when staff attempted to redirect resident back into his/her room. On 9/4/16 at 8:29 p.m. at the start of this shift, Resident #1 was very agitated. Resident #1 grabbed several staff members and with closed fist threatened to hit staff. Staff made sure other residents were out of Resident #1 ' s way. Resident #1 went down the hallway to the door 5 times. The resident hit and kicked the door and attempted to open the door. The nursing staff indicated Resident #1 to be swearing and staff made aware of this and gave Resident #1 a wide area to walk in. Resident #1 walked rapidly with his/her blanket to and from the nurse ' s station and back. On 9/7/16 at 3:20 p.m., the nursing staff at the nurse ' s station heard a female resident yelling for help from down the hallway. Staff documented Resident #1 had been in this female resident ' s room and followed this resident out into the hallway. Resident #1 to be holding onto the female resident ' s walker that she was using in the hallway while she was attempting to get away from Resident #1. However, Resident #1 kept pulling her walker with one hand and almost pulled the female resident down to the floor. Nursing staff documented Resident #1 with the other hand holding onto his/her pants which were pulled down low to the hip area. The nursing staff approached Resident #1 in an attempt to redirect, Resident #1 looked at the staff member and then back to the female resident with a red face and noted to be sweating. The nursing staff member attempted again to redirect Resident #1 when Resident #1 pulled up his/her pants and grabbed the staff member on the arm and started walking up the hallway. When the staff member and Resident #1 got to Resident #1 room he/she started to pull the staff member ' s arm very tightly, squeezing and attempting to pull the staff member into his/her room. After the staff member attempted to redirect Resident #1, he/she would not let go of the staff member's arm and continued to pull and squeeze staff's arm and Resident #1 face became red. After redirection again, the resident let go of the staff person ' s arm and walked into his/her room. Review of the facility ' s Pre-Admission Dementia Care Behavior assessment dated [DATE] indicated Resident #1 had exhibited behaviors in the last 7 days included pacing, once staff could not locate the resident and found resident in another resident ' s room. The resident attempted to elope, agitation and aggression of getting upset and resisting assistance from staff, rapid mood changes, irritable, angry, short tempered, potential threat to self and others, grabbed a staff member's wrist once, once repeatedly dress and undress throughout day and in public areas, and occasionally attempted to kiss others. Review of Resident #1 facility Post Admission Behavior assessment dated [DATE] indicated the resident exhibited behaviors that included pacing around without purpose, being awake at night wandering and pacing, occasionally having difficulty falling asleep, agitation, aggression, difficult to handle, argumentative, rapid mood changes, angry, irritable, and short tempered. Review of facility ' s Progress Notes for Resident #1 included the following: On 9/12/16 at 9:05 a.m., the resident admitted to the facility from another facility. The resident wanders and gets anxious easily. On 9/12/16 at 9:56 a.m. family member of Resident #1 told nursing staff that resident medicated at home with Haloperidol 0.5 mg (milligrams) (psychotropic medication) twice a day due to behaviors. Staff indicated to family that they will monitor the resident ' s behaviors and treat when necessary. On 9/12/16 at 7:56 p.m., staff reported the resident wandered throughout CCDI (chronic confusion or dementing illness) unit. The resident noted to be more resistant to cares from female staff and responded better to male staff interactions. On 9/17/16 at 5:01 p.m. the nursing staff administered medication of oral Haloperidol 0.5 mg as ordered for the resident ' s aggressive behaviors towards female staff. The behaviors included striking out, squeezing hand and attempting to kiss staff members during attempts to re-direct the resident. On 9/18/16 at 5:21 a.m. the nursing staff member reported the resident touched him/her inappropriately earlier and appeared to be angry at times when assisting resident. On 9/19/16 at 8:04 a.m., the resident described as agitated when female staff member attempting to provide cares and the resident ripped off undergarments. A male staff member approached and assisted the resident with cares. On 9/20/16 at 6:44 p.m., the resident hit, slapped staff and staff unable to redirect the resident. The nursing staff administered medication of Haloperidol 0.5 mg as ordered. On 9/23/16 at 5:25 a.m., the resident has been up much of the night sitting in the lounge are. Earlier, the resident seemed to be angry and said to a female resident Give it to me! , staff not knowing what resident referring to, (staff) stepped in between the resident and female resident at that time. On 9/24/16 at 8:48 p.m. resident wandering some and became agitated when staff approached the resident. On 9/28/16 at 1:13 a.m. indicated resident coming out of his/her room periodically since 10:30 p.m. Resident remove his/her pajama bottom and is attempting to go into another resident's room, wandering and agitated. On 9/29/16 at 5:20 p.m. resident very agitated and hitting staff. Interventions of redirecting, snack, and toileting did not help his/her agitation. Staff administered psychotropic medication of Haloperidol 0.5 mg as ordered. On 10/1/16 at 5:45 a.m. the resident noted to be in the lounge area most of the night. On 10/4/16 at 12:30 a.m. the resident ' s in and out of bed, wandering and attempting to exit the facility. On 10/4/16 at 12:23 p.m., the resident noted to awake at 11:00 a.m. this morning with nursing staff assistance and resident became agitated and raised clench fist towards staff. On 10/9/16 at 1:45 p.m., resident noted to be in his/her room most of the day, ate lunch but refused breakfast. Resident followed a female staff worker into the bathroom and cornered the staff worked in the bathroom while striking her on the shoulder. The female staff worker called for help and another staff member intervened and directed the resident out of the bathroom. On 10/12/16 at 1:40 a.m. the resident at of his/her room, angry, pushing chairs in lounge area and a staff member intervened. On 10/14/16 at 5:54 a.m. the resident noted to be up walking round and around, not cooperative with cares at first then complied; resident was redirected. On 10/16/16 at 1:14 p.m. the resident became agitated with staff during lunch today. The resident raised a clenched fist at staff and struck the staff member on the chin, resident redirected. On 10/18/16 at 5:44 a.m. the resident extremely agitated, walking into rooms, exit seeking out of the facility, and strongly resisted being redirected. Resident noted to be breathing loud and rapid and eyes were wild. The resident required one on one staff supervision by nursing staff. Nursing staff attempted to administer medication Haloperidol 0.5 mg but resident refused to take. Review of the facility ' s Nurse ' s Progress Note dated 10/24/16 at 5:41 a.m. indicated the resident out of his/her room and the nursing staff found Resident #1 lying in Resident #3 ' s bed. The nursing staff redirected Resident #1 from Resident #3 ' s room and Resident #1 became agitated and went into Resident ' s #2 room and was observed standing over Resident #2 and Resident #2 ' s legs were off the bed. The nursing staff went into Resident ' s #2 room to intervene and Resident #1 raised his/her fist to the staff member and the staff member moved away from Resident #1. Another nursing staff member stepped in and redirected the Resident #1 to his/her room. Documented at 6:08 a.m., nursing staff indicated Resident #1 noted to be agitated and aggressive when approached and staff unable to redirect Resident #1at this time. Resident #1 noted to be shaking and facial color as red. Documented at 6:09 a.m., the nursing staff administered psychotropic medication to Resident #1 for severe agitation. At 8:13 a.m., the nursing staff indicated the psychotropic medication to be effective. Documented at 8:23 a.m., nursing staff indicated Resident #1 physician prescribed anti-anxiety medication to be administered every night at hour of sleep to the resident. Documented at 10:30 a.m., nursing staff indicated Resident #1 in and out of his/her room multiple times, not staying in one place longer than 30 minutes and staff are making frequent checks are being made on resident. Review of the facility ' s Incident/Accident report dated 10/24/16 at 5:40 a.m. indicated Resident #1 pulled Resident #2 out of bed by the legs. Resident #2 knees on the floor with legs bent under bed. Resident #2 assessed by nursing staff and sent to the hospital via ambulance for possible right hip fracture. Review of Resident #2 ' s nursing Progress Notes dated 10/24/16 at 5:50 a.m. indicated CNA (certified nurse aide) went into the resident ' s room and observed Resident #1 in room. Resident #2 had his/her legs off the bed with knees on floor and legs bent under bed and upper body leaning back on the bed. The staff member moved Resident #2 ' s legs onto the bed to prevent resident from following to floor. Nurse responded and assessed Resident #2 and noted right leg to be shorter with outward rotation of foot and indicating pain to the right hip area. According to Resident #2 History and Physical report dated 10/24/16 at 12:20 p.m. The resident brought to the emergency room from the facility with complaints of right hip pain after pulled from his/her bed by another resident. As per the nursing staff, another resident with dementia went into this resident ' s room and started pulling on his/her leg, and this resident was pulled off bed to the floor. After the event the Resident started crying of pain and transferred to the emergency room . In the emergency department, x-rays were obtained of the right hip which identified a fracture of the femoral neck (hip). Resident admitted for further evaluation and management. Observation on 10/26/16 at 11:35 a.m. to 12 noon identified Resident #1 in the CCDI unit and interacting with staff by hitting a balloon around in the air. The resident would randomly stop the activity and start pacing/wandering throughout unit. Staff noted to stay with the resident while ambulating and using hand holding with resident during this time. Resident attempted to go into another resident room while ambulating with staff member holding hands. Staff attempted to redirect resident from entering another resident ' s room and resident became agitated, pulling on the staff members hand in attempting to go into room and loudly mumbling. Another staff member intervened and directed the resident to recliner in the common area and offering resident his/her blanket. On 10/25/16 at 3:48 p.m. the Director of Nursing (DON) was interviewed and stated the facility investigation indicated Staff A, Certified Nurse Aide (CNA) witnessed Resident #1 go into Resident ' s #3 room and Staff A redirected Resident #1 out of the room. The DON stated Staff A then witnessed Resident #1 enter Resident #2 ' s room and Resident #1 pulled Resident #2 ' s bedding off of him/her and began pulling on Resident #2 ' s legs and out of bed and onto the floor. The DON stated Staff A reported he/she intervened and placed Resident #2 ' s legs back into bed. DON stated that Staff A called for additional staff assist on the walkie-talkie at that time, and Staff A to be the only staff member in the unit at that time. The DON stated Resident #1 has a history of wandering, getting anxious with face becoming red and clenching fist and swinging at staff members. The DON stated prior to this incident, the staffing in the CCDI unit consisted of 2 staff on day shift, 2 staff on second shift and one staff on night shift with staff available when needed on the nursing facility side when summoned. The DON stated after this incident between Resident #1 and Resident #2, the facility assigned 1:1 supervision for a couple of hours and then 15 minute checks. The DON stated she has increased staffing from 1 staff member to 2 staff members during the night shift due to the behaviors of Resident #1. An interview was conducted on 10/25/16 at 5:50 p.m. with Staff B, CNA. Staff B stated Resident #1 has behaviors of getting agitated, physically aggressive and verbally aggressive with staff. Staff B stated Resident #1 prefers male staff members over female staff members. Staff B reported Resident #1 to also have a behavior of wandering in the unit and going into other resident rooms. An interview was conducted on 10/25/16 at 5:22 p.m. with Staff C, Licensed Practical Nurse (LPN). Staff C stated Resident #1 does get physically aggressive with staff and his/her sleeping schedule is turned around with the resident sleeping more in the day and less at night. Staff C stated when the resident gets agitated, his/her face will turn red and then will pace around. Staff C reported the medication of Haloperidol 0.5 mg helps his/her behaviors. On 10/26/16 at 9:04 a.m. Staff E, Registered Nurse (RN) was interviewed and stated she arrived at work around 5:53 a.m. on 10/24/16. Staff E stated she heard a call for assistance in the CCDI unit. Staff E stated she went to the unit and Resident #2 ' s room. Staff F was assessing the resident in bed. The resident stated I think I broke something . On 10/26/16 at 9:22 a.m. Staff G, CAN was interviewed and stated Resident #1 has behaviors and gets angry and agitation. Staff G stated Resident #1 requires the assistance of 1 staff person for cares and he/she wanders into other resident ' s rooms. On 10/26/16 at 1:34 p.m. Staff H, LPN (licensed practical nurse) was interviewed and stated she responded to the call for assist on 10/24/16 in the CCDI unit. Staff H stated upon arrival to the unit she noted Resident #1 ' s room door to be closed and Resident #2 door to be closed. Staff H stated Resident #1 observed coming out of his/her room door with CNA who was attempting to redirect the resident. Staff H stated Resident #1 appeared to be anxious, shaking, and facial color to be red. Staff H stated had been informed of the incident between Resident #1 and Resident #2 and she administered the Haloperidol 0.5 mg at that time. Staff H stated she had the staff do 1:1 supervision for Resident #1 and assisted with the transport of Resident #2 to the emergency room . Staff H stated she believes that there always should be at least 2 staff members in the CCDI unit for resident supervision. On 10/26/16 at 8:34 a.m. and 10/27/16 at 10:46 a.m. Staff J, RN, was interviewed and stated assigned to Resident #1 and Resident #2 during the night shift from 10/23/16 to the morning of 10/24/16. Staff J reported she received report from Staff A, CNA, who was to be the only staff member in the unit. Staff J reported around 5:50 a.m. she heard the call come over the walkie-talkie from Staff A, CNA, stating she needed assistance in the CCDI unit. Staff J reported she had to wait a minute to two minutes more for the other CNA to come back from taking the trash out so she could respond. Staff J stated she got to the unit 1 to 2 minutes after the first call from Staff A. Staff J stated when she got to the CCDI unit she observed Staff A, CNA, standing with Resident #3 by the nurse ' s station and common area. Staff I, CNA, noted to be walking with Resident #1, and Resident #2 lying on bed. Staff J reported Staff A informed her she had been responding to Resident #3 who was attempting to self-transfer, from recliner, again, in the common area and observe Resident #1 at this time enter into Resident #2 room. Staff J stated Staff A assisted Resident #3 back to sitting in recliner in common area and went to redirect Resident #1 out of Resident #2;s room and found Resident #1 standing by Resident #2 ' s bedside, very agitated, had apparently pulled Resident #2 ' s legs out of bed with knees on floor, legs behind him/ her under bed and with top half of body on bed. On 10/25/16 at 4:14 p.m. and 10/25/16 at 11:09 a.m. Staff A reported she came into work the night of 10/23/16 to the morning of 10/24/16 and was assigned to the CCDI unit where Resident #1, #2, and #3 reside. Staff A stated she was the only staff member in the unit. Staff A stated before 5:50 a.m., Resident #3, who required one assistance due to being a fall risk, to be up in the common area and making several attempts to self-transfer and ambulate. Staff A stated during this time Resident #1 to be up and wondering the halls, agitated and closing resident room doors. Staff A stated Resident #1 then entered Resident #3 ' s room and laid down in the bed. Staff A stated she left Resident #3 who was sitting in the recliner in the common area to redirect Resident #1 out of Resident #3 ' s room. Staff A stated when she got into Resident #2 ' s room she witnessed all the bed coverings pulled off him/her and to be lying on the floor. Staff A stated Resident #1 grabbing Resident ' s #2 feet at foot/edge of bed. Staff A stated when she entered the room Resident #1 let go of Resident #2 feet which fell to the floor at that time. Staff A reported at this time she called for staff assistance via walkie-talkie. Staff A stated she intervened, placed Resident #2 legs back in bed to prevent him/her from falling to the floor, and Resident #1 attempted to strike her with a closed fist at this time. Staff A stated she attempted to redirect Resident #1 out of Resident #2 room she noted Resident #3 up, unassisted, in the common area. Staff A stated she redirected Resident #1 to follow her out of Resident #2 ' s room so she could respond to Resident #3. Staff A reported she than called for assistance, the second time, via the walkie-talkie. Staff A indicated it would have helped to have a second staff member scheduled in the unit. Prior to the resident's admission, the facility knew the resident had dementia and had the potential for being aggressive and hitting at staff and resistive to cares. Prior to the abatement date of 10/24/16, The staff needed to develop adequate supervision strategies in order to keep other residents safe from Resident #1. On 10/24/16, the facility abated the immediate jeopardy and provided 1:1 supervision of Resident #1 and increased the staffing numbers in the CCDI unit during the night hours. 2. The quarterly Minimum Data Set (MDS) assessment, with a reference date of 5/10/16, identified Resident #4 with a moderately impaired cognition. Resident #4 required extensive assistance of one-two staff members with bed mobility, transfers, and hygiene cares. The functional status assessment section noted the resident had impairments of the lower and upper extremities on one side of the body and impairment of the opposite upper extremity. The [DIAGNOSES REDACTED]. The MDS identified the resident had two falls (no injuries) during the three months prior to assessment and at high risk for falls. Resident #4 ' s plan of care, revised on 5/16/16 noted the resident had a self-care deficit and staff were directed to provide total assistance with check and change (due to incontinence) before and after meals, at bedtime, and as needed and to turn and reposition the resident every two hours. Other interventions included a winged mattress, a fall mat at the bedside, a Broda chair (tilt and recline padded wheelchair), and a bed in low position. The Incident/Accident Report dated 7/26/16 identified Resident #4 rolled out of bed while receiving hygiene care from Staff A, Certified Nurse ' s Aide (CNA). The report noted the CNA turned to reach wipes and the resident rolled out of bed and hit his/her head on the right temporal area. The resident had bruising noted on the temporal area and the right elbow. The resident ' s range of motion was within normal limits and vital signs were stable. The resident had no signs or symptoms of pain. The Nurse ' s Notes from the time of the fall through 7/31/16 identified the resident as monitored frequently and did not exhibit any signs of pain or injury. At 1:57 AM on 7/31/16 nursing assessment revealed the resident ' s right thigh was edematous and he/she grimaced when the leg was moved. The leg had a slight rotation. At 12:57 PM on 7/31/16 the resident was transferred to the emergency room and admitted to the hospital for surgical repair of a right hip fracture. Review of the hospital radiology report dated 7/31/16 noted the resident had an intertrochanteric fracture of the right femur (hip fracture). The report identified the bones were osteoporotic (osteoporosis is a disease in which the density and quality of bone are reduced leaving the bone weakened and prone to fractures). The resident returned to the facility after surgery, declined rapidly, and passed away on 8/12/16. On 9/20/16, Staff A, CNA, was interviewed and stated she walked by the room and noted Resident #4 needed hygiene cares. Staff A stated she washed her hands and stood by the resident ' s bed. She turned the resident to check the incontinency pad and returned the resident to a supine position (on back). The CNA turned to the side with one step to get wipes and the resident fell out of bed. The CNA stated the small side rail at the head of the bed was up and she previously moved the fall mat against the wall before starting cares. Staff A quickly called for help and the nurse, Staff B, responded and assessed the resident before returning the resident to bed. On 9/20/16 at 1:00 PM Staff B, Registered Nurse (RN), was interviewed and stated she heard she was needed in the resident ' s room. When she entered, she noted Resident #4 on the floor, moving from back to side, and stated head hurt . Staff B stated she assessed the resident who did not complain of pain other than the head pain. Range of motion performed did not reveal any discomfort in the lower extremities. Staff B stated she pushed on the resident ' s hips and the resident did not complain of pain. The RN stated both the head and foot side rails were down when she entered the room. Staff B stated the resident could squirm around in the bed and could have rolled out of bed by self. Staff B witnessed the resident sit up on the side of the bed by him/herself previously. Staff B stated she would expect nursing staff to keep the bed rail at the head of the bed (quarter rail) up while providing cares. On 9/20/16 at 1:50 PM a re-enactment of the incident was conducted with Staff A and the Director of Nursing (DON). The CNA moved the floor mat to the side and stood close by the bedside. She demonstrated how she stepped sideways and reached into the bottom drawer of the bedside table located against the wall at the end of the bed to reach the wipes. Staff A stated as she turned, she heard the resident hit the floor. Staff A stated she has no idea how the resident was able to get up over the side rail at the head of the bed which the CNA demonstrated was up at the time of the incident. On 9/21/16 a second re-enactment of the incident was conducted with the CNA. The CNA was asked to be more specific in the details of how the incident occurred. This time Staff A stood farther from the bed (approximately 12-18 inches) then in the original re-enactment. The CNA stated after the resident fell she put the head side rail down in anticipation of moving the resident back into bed. She stated the side rail was up when she started cares. Staff A stated she was baffled as to how the resident fell out of bed. The facility policy and procedure titled Perineal Care, revised October 2010, directed the staff to assemble all supplies in preparation of providing cares.

Based on record review, staff interviews and resident interviews, the facility neglected to develop strategies to prevent Resident #1 from mistreatment or abusing other residents. Record review established Resident #1 showed physical aggression and mistreatment to other residents. Staff interviews identified the facility failed to develop interventions strategies to prevent occurrences. The sample consisted of 4 residents and the facility reported a census of 34 residents. Findings include: 1. According to the admission MDS (Minimum data set) assessment tool with a reference date of 09/19/16, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident with long and short term memory problem and moderately impaired of cognitive skills for daily decision making. The MDS identified Resident #1 as requiring extensive assistance of one staff member for dressing, toilet use, personal hygiene, and limited assist of one staff member for bed mobility and resident to be independent without device for ambulation. The MDS documented the resident to have physical behavior symptoms directed towards others that significantly disrupt care or living environment, and resident to reject cares 1 to 3 days a week. The Care Plan with onset date of 09/27/2016, identified the resident as having dementia and is a potential to be physically aggressive hitting at staff and resistive to cares at times, has anxiety and gets anxious at times, and is prescribed an [MEDICAL CONDITION] medication as needed. The Care Plan listed interventions/approaches that directed staff to: 1. If resident resist cares of activity of daily living (ADL ' s) staff is to reassure resident, leave resident and reproach resident in 5-10 minutes and try again. 2. Staff is to administer [MEDICAL CONDITION] medications as ordered by the resident ' s physician and monitor for side effects and effectiveness. 3. Staff is to analyze times of day, places, circumstances, triggers, and what de-escalates resident ' s behaviors and to document this. 4. Staff is to assess and anticipate resident ' s needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. 5. Staff is monitor/document/report any signs or symptoms of resident posing danger to self or others. 6. Staff is to know resident tolerates people at times, resident needs his/her personal space, and staff is to approach with hand holding for calming the resident. 7. When the resident becomes agitated staff is to intervene before agitation escalates, guide resident away from source of distress, engage calmly in conversation with resident, and if resident ' s response is aggressive, staff is to walk away and approach later. The Care Plan added additional interventions on 10/24/16 that included: a) Staff is to check on resident every 15 minutes. b) Staff is to administer anti-anxiety medication every night at hour of sleep. c) Staff is to provide one to one monitoring when resident is agitated. Review of Resident #1's clinical record at this facility revealed Progress Notes from a prior facility resident was admitted from, that included notes of: -8/31/16 at 10:45 a.m. Resident #1 admitted to facility. - 9/2/16 at 10:51 p. m., indicated nursing staff talking with a family member of Resident #1 and family member reporting resident does have some behaviors. Nursing staff documented Resident #1 before supper walking up and down hallway door and attempted to leave. Resident #1 redirected to nurse ' s desk then resident wandered into another room. Resident #1 became very agitated with nursing staff when attempting to redirect resident. Resident rising clenched fists and attempted to strike at staff when staff attempting to redirect resident back into his/her room. -9/4/16 at 8:29 p.m., indicated at the start of this shift Resident #1 was very agitated. Resident #1 grabbed several staff members and with closed fist threatened to hit staff. Staff made sure other residents were out of Resident #1 way. Resident #1 went down hallway to door 5 times hitting, kicking the door and attempting to open door. Nursing staff indicated Resident #1 to be searing and staff made aware of this and gave Resident #1 a wide area to walk in. Resident #1 walking rapidly with his/her blanket to and from the nurse ' s station and back. -9/7/16 at 3:20 p.m., indicated nursing staff at nurse ' s station and heard a female resident yelling for help from down the hallway. Staff documented Resident #1 had been in this female resident ' s room and followed this resident out into the hallway. Resident #1 to be holding onto the female resident ' s walker that she was using in the hallway while she was attempting to get away from Resident #1. However Resident #1 kept pulling her walker with one hand and almost pulled the female resident down to the floor. Nursing staff documented Resident #1 with the other hand holding onto his/her pants which were pulled down low to hip area. Nursing staff approached Resident #1 to attempt to redirect, Resident #1 looked at the staff member and then back to the female resident with a red face and noted to be sweating. The nursing staff member attempted again to redirect Resident #1 when Resident #1 pulled up his/her pants and grabbed the staff member on the arm and started walking up the hallway. When the staff member and Resident #1 got to Resident #1 room he/she started to pull the staff member ' s arm very tightly, squeezing and attempting to pull the staff member into his/her room. After the staff member attempted to redirect Resident #1, he/she would not let go of the staff member ' s arm and continued to pull and squeeze staff ' s arm and Resident #1 face became red. Nursing staff indicated Resident #1 after redirection again did let go of staff ' s arm and walked into his/her room. Review of the facility ' s Pre-Admission Dementia Care Behavior assessment dated [DATE] indicated Resident #1 to exhibited behaviors in the last 7 days included pacing, once staff could not locate resident and found resident in another resident ' s room, resident attempting to elope, agitation and aggression of getting upset and resisting assist from staff, rapid mood changes, irritable, angry, short tempered, potential threat to self and others, grabbed a staff member ' s wrist once, once repeatedly dress and undress throughout day and in public areas, and occasionally attempts to kiss others. Review of Resident #1 facility Post Admission Behavior assessment dated [DATE] indicated the resident to exhibited behaviors that included pacing around without purpose, being awake at night wandering and pacing, occasionally having difficulty falling asleep, agitation, aggression, difficult to handle, argumentative, rapid mood changes, angry, irritable, and short tempered. Review of facility ' s Progress Notes for Resident #1 included: -On 9/12/16 at 9:05 a.m., resident admitted to facility from another facility. Resident wanders and gets anxious easily. - 9/12/16 at 9:56 a.m. family member of Resident #1 told nursing staff that resident medicated at home with [MEDICATION NAME] 0.5 mg (milligrams) ([MEDICAL CONDITION] medication) twice a day due to behaviors. Staff indicated to family that they will monitor the resident ' s behaviors and treat when necessary. -9/12/16 at 7:56 p.m., staff reported the resident wandered throughout CCDI (chronic confusion or dementing illness) unit. Resident noted to be more resistant to cares form female staff and responded better to male staff interactions. -9/17/16 at 5:01 p.m. nursing staff administered medication of oral [MEDICATION NAME] 0.5 mg as order for resident ' s aggressive behaviors towards female staff that included striking out, squeezing hand and attempting to kiss staff members during attempts of staff to re-direct the resident. -9/18/16 at 5:21 a.m. nursing staff member reported resident touched him/her inappropriately earlier and appeared to be angry at time when assisting resident. -9/19/16 at 8:04 a.m., resident is agitated when female staff member attempting to provide cares and resident ripped off undergarments. Than Male staff member approached and assisted resident with cares. - 9/20/16 at 6:44 p.m., resident is hitting, slapping staff and staff unable to redirect resident. Nursing staff administered medication of [MEDICATION NAME] 0.5 mg as ordered. -9/23/16 at 5:25 a.m., resident has been up much of the night sitting in lounge area, Resident earlier to be angry and said to female resident give it to me! , staff not knowing what resident referring to, staff stepped in between resident and female resident at that time. -9/24/16 at 8:48 p.m. indicated resident wandering some and became agitated when staff approached resident. -9/28/16 at 1:13 a.m. indicated resident coming out of his/her room periodically since 10:20 p.m. Resident remove his/her pajama bottom and is attempting to go into another resident ' s room, wandering and agitated. -9/29/16 at 5:20 p.m. reported resident very agitated and hitting staff. Interventions of redirecting, snack, and toileting did not help his/her agitation. Staff administered [MEDICAL CONDITION] medication of [MEDICATION NAME] 0.5 mg as ordered. -10/1/16 at 5:45 a.m. resident noted to be out in lounge area most of night. -10/4/16 at 12:30 a.m. indicated resident is in and out of bed, wandering and attempting to exit the facility. -10/4/16 at 12:23 p.m., resident noted to awake at 11:00 a.m. this morning with nursing staff assist and resident became agitated and raised clench fist towards staff. - 10/9/16 at 1:45 p.m., resident noted to be in his/her room most of day, ate lunch but refused breakfast. Resident followed a female staff worker into the bathroom and corned the staff worked in the bathroom while striking her on the shoulder. The female staff worker called for help and another staff member intervened and directed resident out of bathroom. - 10/12/16 at 1:40 a.m. indicated resident up at of his/her room, angry, pushing chairs in lounge area and a staff member intervened. - 10/14/16 at 5:54 a.m. resident noted to up walking round and around, not cooperative with cares at first than complied, resident was redirected. -10/16/16 at 1:14 p.m. documented resident became agitated with staff during lunch today. Resident raised a clenched fist at staff and struck staff member on the chin, resident redirected. -10/18/16 at 5:44 a.m. indicated resident extremely agitated, walking into rooms, exit seeking out of the facility, and strongly resisted being redirected. Resident noted to be breathing loud and rapid and eyes were wild, resident required one on one staff supervision by nursing staff. Nursing staff attempted to administer medication [MEDICATION NAME] 0.5 mg but resident refused to take. -10/20/16 at 4:06 a.m., noted resident in and out of his/her room and wandering. -10/21/16 at 4:43 a.m. indicated resident up several times, sitting in lounge area and also wandering. Resident open closed door of another resident who is receiving cares from staff. Resident #1 redirected out of other resident ' s room. At 5:57 a.m. resident up wandering and noted to have slight agitation. - 10/ 24/16 at 5:15 a.m., indicated resident up at beginning of shift went to his/her room at 1:50 a.m. and back out of room at 5:00 a.m. Review of the facility ' s Nurse ' s Progress Note dated 10/24/16 at 5:41 a.m. of Resident #1 indicated resident out of his/her room and nursing staff found Resident #1 lying in Resident #3 ' s bed. Nursing staff redirected Resident #1 from Resident #3 ' s room and Resident #1 became agitated and went into Resident ' s #2 room and observed standing over Resident #2 and Resident #2 ' s legs were off his her/bed. Nursing staff went into Resident ' s #2 room to intervene and Resident #1 raised his/her fist to the staff member and the staff member moved away from the Resident #1. Another nursing staff member stepped in and redirected the Resident #1 to his/her room. Documented at 6:08 a.m., nursing staff indicated Resident #1 noted to be agitated and aggressive when approached and staff unable to redirect Resident #1 at this time. Resident #1 noted to be shaking and facial color is red. Documented at 6:09 a.m., nursing staff administered [MEDICAL CONDITION] medication to Resident #1 for severe agitation. Documented at 8:13 a.m., nursing staff indicated the [MEDICAL CONDITION] medication to be effective. Documented at 8:23 a.m., nursing staff indicated Resident #1 physician prescribed anti-anxiety medication to be administered every night at hour of sleep to the resident. Documented at 10:30 a.m., nursing staff indicated Resident #1 been in and out of his/her room multiple times, not staying in one place longer than 30 minutes and staff are making frequent checks are being made on resident. Review of the facility ' s Incident/Accident report dated 10/24/16 at 5:40 a.m. indicated Resident #1 pulled Resident #2 out of bed by the legs. Resident #2 knees on the floor with legs bent under bed. Resident #2 assessed by nursing staff and sent to the hospital via ambulance for possible right [MEDICAL CONDITION]. Resident ' s physician and family notified of incident. Review of Resident #2 ' s Progress Nurse ' s Notes dated 10/24/16 at 5:50 a.m. indicated CNA (certified nurse aide) went into resident ' s room and observed Resident #1 in room. Resident #2 had his/her legs off the bed with knees on floor and legs bent under bed and upper body leaning back on the bed. Staff member moved Resident #2 legs back onto the bed to prevent resident from following to floor. Nurse responded and assessed Resident #2 and noted right leg to be shorter with outward rotation of foot and indicating pain to the right hip area. At 6:15 a.m. 911 was called and at 6:30 a.m. First Responders arrived and resident transferred to emergency room . According to Resident #2 History and Physical report dated 10/24/16 at 12:20 p.m. indicated resident brought to the emergency room from the facility with complaints of right hip pain after pulled from his/her bed by another resident. As per the nursing staff, another resident with dementia went in this resident ' s room and started pulling on his/her leg, and this resident was pulled off bed to the floor. After the event the Resident started crying of pain and transferred to the emergency room . In the emergency department x-rays were obtained of the right hip which revealed a [MEDICAL CONDITION] neck. Resident is being admitted for further evaluation and management. As per family member residents only problem is dementia and he/she did ambulate independently prior to this incident with no assistance. Observation on 10/26/16 at 11:35 a.m. to 12 noon revealed in the CCDI unit revealed Resident #1 interacting with staff of hitting a balloon around in the air. Resident was noted to randomly stop activity and start pacing/wandering throughout unit. Staff is noted to stay with resident while ambulating and using hand holding with resident during this time. Resident attempted to go into another resident ' s room while ambulating with staff member holding hands. Staff attempted to redirect resident from entering another resident ' s room and resident became agitated, pulling on the staff members hand in attempting to go into room and verbally loud mumbling. Another staff member intervened and directed resident to recliner in common area and offering resident his/her blanket. Resident sat in recliner with staff by his/her side for approximately one minute and got up out of recliner and again started pacing. Staff member walked with resident and took resident ' s blanket to room. Staff member entered room with resident behind her and resident then backed up through door and pulled door behind him/her with staff inside room and resident outside of room. Resident then grabbed hold of door knob and held onto it as staff member attempted to open door. Staff member after a brief time opened door and re-directed resident to dining room table. Staff offered drinks to resident and encouraged him/her to sit as lunch is being served. Resident noted to sit less than a minute and got up wandering again with staff at his/her side. Staff attempted to redirect resident to dining room table to eat lunch with other residents and resident set for a very brief time and took a couple bites of lunch and then back up pacing with staff. During this observation it was noted that one to two staff members were with resident at all times to redirect resident. Interview was conducted on 10/25/16 at 3:48 p.m. with the Director of Nursing (DON). The DON reported the facility investigation indicated that Staff A, Certified Nurse Aide (CNA) witnessed Resident #1 went into Resident ' s #3 ' s room and Staff A redirected Resident #1 out of room. The DON indicated Staff A then witnessed Resident #1 enter Resident #2 ' s room and Resident #1 pulled Resident #2 ' s bedding off of him/her and began pulling on Resident #2 ' s legs out of bed onto the floor. The DON stated Staff A reported he/she intervened and placed Resident #2 legs back into bed. DON stated that Staff A called for additional staff assist on the walkie-talkie at that time, and Staff A to be the only staff member in the unit at that time. The DON stated Resident #1 as having a history of wandering, getting anxious with face becoming red and clenching fist and swinging at staff members. The DON stated prior to this incident the staffing in the CCDI unit consisted of 2 staff on day shift, 2 staff on second shift and one staff on night shift with staff available when needed on the nursing facility side when summoned. The DON stated after this incident between Resident #1 and #2 she has increased staffing from 1 staff member to 2 staff members on the night shift due to Resident #1 behavior. An interview was conducted on 10/25/16 at 5:50 p.m. with Staff B, CNA. Staff B stated Resident #1 has behaviors of getting agitated, physically aggressive and verbally aggressive with staff. Staff B stated Resident #1 prefers male staff members over female staff members. Staff B reported Resident #1 to also have a behavior of wandering in the unit and going into other residents ' room. An interview was conducted on 10/25/16 at 5:22 p.m. with Staff C, Licensed Practical Nurse (LPN). Staff C stated Resident #1 does get physically aggressive with staff and his /her hour of sleep is turned around, that resident sleeps more during the day and awake during the night. Staff C indicated resident does get agitated their face will become red and paces around. Staff C reported the medication of [MEDICATION NAME] 0.5 mg helps his/her behaviors. An interview was conducted on 10/25/16 at 5:38 p.m. with Staff D, CNA. Staff D stated Resident #1 does not like female staff members. Staff D indicated resident does wander the CCSI unit and does go into other residents ' room. Staff D stated resident sleeps during the day and awake at night wandering. Staff D reports Resident #3 is assist physical assist of one staff member for transfers, ambulation, and activity of daily living (ADL ' s). Staff D indicated Resident #3 attempts to transfer and ambulate per self and staffs need to respond to him/her immediately when doing so. An interview and statement review was conducted on 10/26/16 at 9:04 a.m. with Staff E, Registered Nurse (RN). Staff E reported she arrived at work around 5:53 a.m. the morning of 10/24/16. Staff E stated at that time she heard a call for assistance in the CCDI unit. Staff E stated she responded to that call to the unit to Resident #2 ' s room. Staff E stated when she arrived to Resident ' 2 room, Staff member F, RN, and Staff A, CNA, to be Resident #2 ' s room and resident lying in bed. Staff E reported Staff F assessing resident. Staff E stated Resident #2 stated I think I broke something . An interview was conducted on 10/26/16 at 9:22 a.m. with Staff G, CNA. Staff G stated Resident #1 does have behaviors that included hitting at staff when he/she becomes angry/agitated. Staff E reports staff can tell when resident becomes agitated as his/her face will get red and breathing becomes hard and fast. Staff G stated resident can become angry/agitated like this all of a sudden, with no incident leading up to this and staff will attempt to redirect resident. Staff G stated Resident #3 is a resident in the CCDI unit and requires assist of one staff member for transfers, ambulation, and cares. Staff G reported Resident #1 wanders and goes in other residents room. Interview and record review of written statement was conducted on 10/26/16 at 1:34 p.m. with Staff H, LPN. Staff H stated she responded to the call for assist on 10/24/16 in the CCDI unit. Staff H stated upon arrival to the unit she noted Resident #1 ' s room door to be closed and Resident #2 door to be closed. Staff H stated Resident #1 observed coming out of his/her room door with CNA who was attempting to redirect the resident. Staff H stated Resident #1 appeared to be anxious, shaking, and facial color to be red. Staff H stated had been informed of the incident between Resident #1 and Resident #2. Staff H stated she administered the prescribe medication of [MEDICATION NAME] 0.5 mg at that time due to Resident #1 due to behaviors. Staff H stated she had staff do one to one supervision for Resident #1 and assisted with the transport of Resident #2 to the emergency room . Staff H stated she believes that there always should be at least 2 staff members in the CCDI unit for resident supervision. Interview and review of written statement was conducted on 10/27/16 at 10:23 a.m. with Staff I, CNA. Staff I stated she working in the nursing facility side when she heard Staff A calling for assistance via the walkie-talkie sometime before 6:00 a.m. and she responded. Staff I stated when she arrived in the unit Staff A is standing at nurse ' s station with Resident #3 and Resident #1 is standing close to them. Staff I stated when Resident #1 saw her he/she immediately came to her and held her hands, asking her to come with him/her. Staff I stated Resident #1 not combative but did appear to be afraid and nervous. Staff I reported she walked with resident and then redirected him/her room and sit in recliner, turned the television on, and talked with resident. Interview and review of written statement was conducted on 10/26/16 at 8:34 a.m. and 10/27/16 at 10:46 a.m. with Staff J, RN. Staff J, RN, stated to be the nurse assigned to Resident #1 and Resident #2 during the night shift from 10/23/16 to the morning or 10/24/16. Staff J, RN, stated she was in the CCDI unit that morning around 5:10 a.m. Staff J, RN, stated she does not remember if Resident #1 to be up at that time but does recall Resident #3 to be up at that time sitting in recliner in the common/lounge area. Staff J, RN, reported she received report from Staff A, CNA, who was to be the only staff member in the unit, reported to her that Resident #1 to be up earlier wandering. Staff J, RN, reported later around 5:50 a.m. she heard the call come over the walkie-talkie from Staff A, CNA, stating she needed assist in the CCDI unit. Staff J, RN, indicated Staff I, CNA, responded to the unit form the Nursing Facility area and she remained there as the other CNA staff member outside emptying the trash, stating she had to wait for that CNA to return before leaving the Nursing Facility area. Staff J stated Staff A again requested assistance in the CCDI unit, via walkie-talkie, and Staff J reported she had to wait a minute to two minutes more for the other CNA to come back from taking the trash out so she could respond. Staff J stated she got to the unit 1 to 2 minutes after the first call from Staff A. Staff J stated when she got to the CCDI unit she observed Staff A, CNA, standing with Resident #3 by nurse ' s station and common area, Staff I, CNA, noted to be walking with Resident #1, and Resident #2 lying on bed with no covers on. Staff J stated Staff A, told her that Resident #1 went into Resident #3 room and laid down in bed while Resident #3 in common area. Staff J, reported that Staff A, reported Resident #1 became agitated when Staff A redirected resident out of room. Staff J reported Staff A told her Resident #1 then started to follow her around as Staff A attempted to assist Resident #3 who is attempting to self-transfer out of recliner in common area. Staff J reported Staff A informed her she had been responding to Resident #3 who was attempting to self-transfer, from recliner, again, in the common area and observe Resident #1 at this time enter into Resident #2 room. Staff J stated Staff A assisted Resident #3 back to sitting in recliner in common area and went to redirect Resident #1 out of Resident #2;s room and found Resident #1 standing by Resident #2 ' s bedside, very agitated, had apparently pulled Resident #2 ' s legs out of bed with knees on floor, legs behind him/ her under bed and with top half of body on bed. Staff J stated Staff A told her she assisted Resident #2 ' s legs back into bed to prevent him/her falling to floor and Resident #1 remained in the room while doing so and attempting to hit Staff A with a closed fist, Staff A stepped away. Staff J indicated Staff I, CNA went to immediately help and when Staff A when she first called for assist, and noted Staff A standing with Resident #3 and Resident #1 standing by them. Staff I, CNA, redirected Resident #1 away by walking with resident as Staff A redirecting Resident #3 back to sitting in recliner. Staff J stated she went immediately to Resident #2 ' s room and assessed the resident. Interview was conducted on 10/25/16 at 4:14 p.m. and 10/25/16 at 11:09 a.m. with Staff A, CNA. Staff A stated she works the 3rd shift from 10:00 p.m.to 6:00 a.m. Staff A reports she came into work the night of 10/23/16 to the morning of 10/24/16 and was assigned to the CCDI unit where Resident #1, #2, and #3 reside at, and to be the only staff member in the unit. Staff A stated before 5:50 a.m., Resident #3, who requires one assist due to being a fall risk, to be up in common area and making several attempts to self-transfer and ambulate. Staff A stated during this time Resident #1 to be up and wondering the halls, agitated and closing resident ' s doors. Staff #a stated Resident #1 then entered Resident #3 ' s room and lay down in the bed. Staff A indicated she left Resident #3 who was sitting in recliner in common area to redirect Resident #1 out of Resident #3 ' s room. Staff A stated when she got into Resident #2 ' s room she witnessed all bed coverings pulled off him/her and to be lying on the floor. Staff A stated Resident #1 grasping Resident ' s #2 feet at foot/edge of bed. Staff A stated when she entered the room Resident #1 let go of Resident #2 feet which fell to the floor at that time. Staff A reported at this time she called for staff assistance via walkie-talkie. Staff A stated she intervened, placed Resident #2 legs back in bed to prevent him/her from falling to floor, and Resident #1 attempted to strike her with a closed fist at this time. Staff A stated she attempted to redirect Resident #1 out of Resident #2 room she noted Resident #3 up, unassisted, in the common area. Staff A stated she redirected Resident #1 to follow her out of Resident #2 ' s room so she could respond to Resident #3. Staff A reported she than called for assistance, the second time, via the walkie-talkie. Staff A stated that Staff I, CNA, entered the unit and directed Resident #1 away. Staff A stated Staff J, RN, entered the unit and went to Resident #2 room. Staff A reported she redirected Resident #3 to a recliner in the common area and proceeded to assist in Resident #2 ' s room. Staff A indicated it would have helped to have a second staff member scheduled in unit. Prior to the resident's admission, the facility knew the resident had dementia and had the potential for being aggressive and hitting at staff and resistive to cares. Although the physician had prescribed psycotropic medication, the staff needed to develop strategies to keep other residents safe from Resident #1 prior to the abatement date of 10/24/16. On 10/24/16, the facility abated the immediate jeopardy prior to the start of the investigation. The facility immediately provided 1:1 supervision of Resident #1, after the incident, and increased the staffing numbers in the CCDI unit during the night hours.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to protect two (2) of ten (10) residents from hazards during transfers. On 8/8/15 Resident #7 attempted to self-transfer and fell sustaining a hip fracture. Record review and staff interviews revealed Resident #7 frequently required one or two staff to assist with transition from sitting to standing. The Director of Nursing acknowledged the resident's main concern had been transitioning from sitting to standing. The resident's care plan only directed staff to provide stand by assistance with ambulation. Observations showed two staff transferring and walking with Resident #5 without a gait belt on two separate occasions. The facility reported a census of 31 residents. Findings include: 1. Record review identified Resident # 7 admission to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 07/31/2015 revealed memory deficits with both long and short term memory and severe cognitive decision-making skills. The MDS identified facility staff provided one staff assistance for bed mobility, transfers, toilet use, personal hygiene, walking in room, walking on the unit, and walking off the unit. The MDS documented 2 falls without injury and 1 with minor injuries during this assessment period. Resident #7 had [DIAGNOSES REDACTED]. Resident # 7 resided on the special dementia care unit. The plan of care dated 05/14/2015 directed facility staff to ambulate with stand by assist, and for Resident #7 to wear gripper socks or shoes to minimize the risk of falls. A review of the progress notes from documented the following: 05/02/2015 9:04 p.m. Resident # 7 backing out of another resident's room, lost balance and sat on bottom and laid down on the floor. 05/02/2015 at 3:00 a.m : staff providing limited assistance with ambulation when going to the bathroom. The care plan dated 5/14/15 indicated on 5/3/15, gripper socks on at all times when shoes are not on. The progress notes date 05/04/2015 at 12:330 a.m. documented : Resident fell , complained of stiffness and back pain. Two staff assisted Resident #7 to the bathroom. Stand by assist when resident went back to bed. The progress notes documented the following: 05/14/2015 at 4:55 a.m.: Resident assisted to bathroom. 06/09/2015 at 5:14 a.m.: Staff reported the resident ambulating poorly tonight, unsteady and leaning to the left. 06/12/2015 at 11:00 a.m.: Resident found seated on floor, incontinent of stool. Two staff assisted Resident #7 to stand. The care plan dated 5/14/15, showed on 6/12/15, staff would complete toileting on a 2 hour schedule. The progress noted documented the following: 06/15/2015 at 3:30 a.m. : Significant coaxing and 2 staff assistance to get the resident to stand and return to bed. Mumbling and unable to understand. 06/18/2015 at 4:20 a.m. Extensive assistance of 1 to assist with toilet. The resident had difficulty following directions. 06/19/2015 at 11:13 a.m. Resident lowered to floor. Walking with nurse to common room and lost balance. 07/05/2015 at 3:45 a.m.: Three (3) attempts to stand and transfer resident to chair from bed. The resident had poor posture and standing bent over. Transferred poorly back to bed. 07/14/2014 at 1:45 a.m.: Resident found sitting on the floor leaning against the bed. Two staff assisted the resident up and assisted to the bathroom. 07/16/2015 at 9:40 p.m.: Resident found by aide on floor lying on the left side. The resident's forehead on the left side had a 2 inch by 2 inch abrasion, a bruise on the back side of the left elbow (4 inches by 2 inches) which was black and fluid filled, and bruised knuckles. The resident had noticeable swelling to the left side of their face. The resident had been held up by staff to keep from falling. The resident did not ambulate with staff or bear weight on the left extremity. Resident #7 had been sent to the emergency room and returned to the nursing home with no fracture. Resident still not able to ambulate without assistance. The progress notes dated 07/17/2015 identified Physical Therapy evaluation documented Resident #7 refused to use a walker. The care plan dated 5/14/15 indicated gripper strips at bedside on 7/14/15. On 7/16/15, Resident #7 ' s care plan indicated he/she became a member of the falling star program. (The care plan did not identify what new or different interventions this included.) The progress notes documented the following: 07/18/2015 at 10:39 a.m.: Resident #7 required hand in hand ambulation. 07/25/2015 at 1:23 p.m.: Resident # 7 required intermittent assistance from staff for ambulation when lethargic. 07/26/2015 at 10:20 a.m.: The resident required assistance with transfers and ambulation 1 to 2 times. 07/26/2015 at 4:10 a.m.: In the past, resident came out of his/her room and wandered in the hall of the unit. This is done rarely at this time. Some nights the resident required 1 assist to ambulate to the bathroom. 07/30/ at 3:10 a.m.: Resident required extensive assist to get up and down from toilet. 07/31/2015 at 4:20 A.M. Extensive assist to get up from toilet. 08/08/2015 at 10:30 A.M.: Resident tripped when walking away from the dining table, which had been witnessed. Resident #7 landed on his/her bottom, and then laid on his/her back. Staff completed range of motion and assisted Resident # 7 to stand when staff documented the resident would not put weight on the left leg. A Mobile X-ray confirmed an acute left femoral neck fracture and the resident had been sent to hospital for surgery. The hospital history and physical documented Resident #7 fell today (8/8/15) and had been unable to straighten his/her leg. The report documented the resident had a fracture through the femoral neck. The progress notes dated 8/11/15 at 2:14 p.m., documented the resident had been transferred to another hospital in Cedar Rapids due to his/her injury. The progress notes dated 8/13/15 at 3:51 p.m. documented Resident #7 readmitted back to the facility needing the assistance of two staff for transfers from wheelchair to bed. The fall assessment completed on 7/31/15 (Morse Fall Scale) determined Resident #7 at high fall risk for falls with a fall score of 65. Resident #7 ' s assessment identified impaired gait impaired (difficulty rising from chair, uses chair arms to get up, bounces to rise). The Morse Fall scale revealed individuals with a score of 45 and greater is considered at high risk for falls. On 10/01/2015 at 9:15 A.M., the Physical Therapist who worked with Resident # 7 verbalized due to poor cognition, the resident was unable to understand how to use the walker. He described the resident as a very fast walker with more difficulty getting up and starting than with actual ambulation. The resident often pushed chairs around when ambulating. The Therapist verbalized Resident # 7 could ambulate fairly well with supervision at the end of therapy. During an interview on 09/30/2015 at 3:00 P.M., the Director of Nursing and the Care Plan Coordinator/Assistant Director of Nursing verbalized Resident # 7 did not require staff assistance for ambulation but remained independent until the fall of 08/08/2015. The ADON stated the resident's main problem was going from siting to standing and not with ambulation. The fall and fracture occurred when the resident got up from the dining chair and tripped. No staff assisted at that time. 2. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident # 5 demonstrated long and short term memory problems with severe decision-making capabilities. According to the MDS, Resident #5 needed one staff assistance with ambulation. The MDS documented the resident had no falls during this time period. Resident # 5 used antipsychotic medications which can cause drowsiness and potential issues with lowering the blood pressure. Resident #5 had a [DIAGNOSES REDACTED]. The plan of care updated on 07/06/2015 documented Resident # 5 as a high risk for falls due to diminished cognition, impaired balance and poor communication. Interventions included gripper strips at the door to room and by the bed, and every 2 hour toileting. A notation hand written in ink and without a date, directed staff to try holding hands to assist with ambulation. During an observation on 09/29/2015 at 7:55 a.m. two staff, Staff C and Staff D (both Certified Nursing Assistants) pulled Resident # 5 up and out of a recliner by grasping the resident under the arms and by the hands. Resident # 5 still groggy from being asleep in the chair. Once standing, Staff C and D grasp the resident's forearms and hands and ambulated into the bathroom without the use of a gait belt for safety. On 09/30/2015 at 7:46 A.M., Resident # 5 sat in a recliner asleep in the lounge of the dementia unit. Staff A (Certified Nursing assistant) and Staff B (Certified Medication Aide) grasp the resident by his/her forearms and both hands and pulled the resident up and out of the recliner. The 2 assistants kept a grip on the resident's forearms and hands while ambulating to the bathroom. Neither staff used a gait belt during the transfer. The undated Gait Belt Policy stated gait belts would be used to prevent accidents or injury to a resident while transferring or ambulating with staff. Gait belts would be used when transfers with more than 1 staff person was needed and when the resident's gait was assessed as temporarily unsteady. On 09/30/2015 at 3:00 P.M. the Director of Nursing and the Assistant Director of Nursing/ Care Plan Coordinator voiced Resident # 5 did not like the gait belt and became very upset when the aides used it. Both felt the hand held ambulation technique worked better and was sufficient. The Care Plan Coordinator did not feel the resident required enough assistance for the hand to hand technique to be a safety issue without a gait belt as specified in the facility policy. The undated Gait Belt Policy also documented if dementia residents became agitated when a gait belt was used, staff should use Contact Guard Assist. **In an interview with the Physical Therapist on 10/01/2015 at 9:30 a.m. the therapist clarified that Contact Guard Assist meant to hold the resident's hand and staff should place their other hand behind the resident's back but not necessarily touching the resident's back.