Every finding on record at Zearing Health Care, LLC

Based on observation, interview, and record review, the facility didn't clarify and implement an emergency overdose medication order upon admission, failed to maintain an available stock of emergency medication, didn't provide staff with access or training for the automated medication storage system, and failed to accurately measure and administer titrated liquid narcotic doses for 1 of 1 resident reviewed (Resident #1).The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 1:45 PM that began as of [DATE]. The Facility Staff removed the IJ on [DATE] through the following actions:-On [DATE] the Director of Nursing (DON) met with each nurse and Certified Medication Aide (CMA) showing the location of the Narcan in each medication cart and how to use it.- On [DATE] the Pharmacy delivered Narcan along with the fact sheet on the usage and a nasal spray of Narcan was placed in both medication carts. The DON met with all nursing staff on the usage of the Narcan spray.-On [DATE] an audit was completed for current Medbank users. Access was granted to Staff A, RN. The facility orientation packet has been updated to include enrolling nursing staff to have Medbank access. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and Narcan was available in each medication cart. The facility reported a census of 34 residents.Findings include:Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #1 functioned independently with bed mobility, transfers, and ambulation. The MDS included diagnoses of Huntington's disease (progressive brain disorder). The MDS documented Resident #1 received opioid medication during the last 7 days. The Care Plan (CP) with a target date of [DATE] revealed Resident #1 received pain medication therapy related to a disease process and previous injury. The CP documented Resident #1 took Methadone (strong pain reliever), an opioid that came with a black box warning (strict safety warning). The CP and black box warning documented the following directions:Staff must follow residents for signs and symptoms of respiratory depression (slowed breathing) and sedation (severe drowsiness); if the resident appeared visibly sedated, staff must evaluate the cause of the sedation;Must instruct personnel on how to measure and administer the correct dose of Methadone oral solution and use extreme caution when measuring the doseStaff must use a device that can measure and deliver the prescribed dose accuratelyStaff must ensure clear communication of the dose and accurate dispensing because dosing errors can result in accidental overdose or death. A. The Clinical Census revealed Resident #1 entered the facility on [DATE]. The Discharge Summary with a date of service from [DATE] to [DATE] documented Resident #1's principal diagnosis included acute hypoxic and hypercapnic respiratory failure (severe breathing failure with high carbon dioxide levels) secondary to respiratory depression (slowed breathing). The Discharge Summary revealed Resident #1 required intubation (breathing tube insertion) from medication-related side effects during the hospital stay. The After Visit Hospital Summary and Physician orders dated [DATE] documented the following orders:Methadone 10 mg (milligrams) tablets to take 9 tablets (90 mg total) daily for a diagnosis of opioid use disorder (drug addiction) in remissionNarcan (Naloxone) (emergency overdose drug) 0.4 mg/ml (milliliters) to inject 0.25 ml (0.1 mg total) intravenously (IV) (directly into the vein) as needed (PRN) if the patient became unarousable. Review of the [DATE] and [DATE] Medication Administration Records (MAR) revealed the following orders:Methadone 10 mg- give 9 tablets in the morning for pain management related to Huntington's disease with a start date of [DATE] and end date of [DATE].Methadone Hydrochloride (HCL) oral solution 10 mg/5 ml- give 90 mg in the morning with a start date of [DATE] and end date of [DATE]Methadone Oral Concentrate 10 mg/ml- give 9 ml in the morning with a start date of [DATE] and end date of [DATE]. The Clinical Record lacked documentation that staff clarified the Narcan IV order received on admission. Review of the [DATE] and [DATE] MARs lacked documentation of the Narcan order. The Progress Note dated [DATE] documented a Certified Nursing Assistant (CNA) alerted the nurse that Resident #1 didn't look right. Upon the nurse entering the room, Resident #1 lay in bed and presented as cyanotic (blue skin discoloration) with blue discoloration noted on the face, lips, and lower extremities. Resident #1 showed no verbal response to repeated sternal rubs (chest rubs). Respirations appeared shallow and compromised. The note documented Resident #1's blood pressure measured 78/44, pulse counted at 100, and staff couldn't obtain oxygen saturation. Staff notified Resident #1's family of the condition change, and the family requested a transfer to the emergency room (ER). Staff notified Resident #1's Physician, who gave an order to transfer Resident #1 to the ER and to administer Narcan medication if available. The note documented the facility didn't stock Narcan. Two staff members helped lower Resident #1 to the floor from the bed. At the time of the move, Resident #1 began to regain responsiveness. Resident #1 became increasingly more alert but exhibited disorganized thinking, confusion, and argumentative behavior, refusing to go to the ER. Emergency Medical Services (EMS) arrived and transferred Resident #1 to the ER for further evaluation. The Hospital Discharge Summary revealed Resident #1 stayed in the hospital from [DATE] to [DATE]. The summary documented Resident #1's diagnoses during the hospital stay included acute respiratory failure with hypoxia (severe breathing failure from low oxygen), unresponsiveness, acute respiratory failure with hypercapnia (severe breathing failure from high carbon dioxide), an elevated troponin level (heart damage protein), and opioid intoxication (drug overdose) without complication. The Progress Note dated [DATE] documented Resident #1 re-entered the facility with medication changes to decrease Lyrica (nerve pain medication) to 100 mg three times a day (TID) and to discontinue Zyprexa (antipsychotic medication). Resident #1 needed to continue the Methadone and other medications. A Physician Progress Note dated [DATE] documented a follow-up visit for Resident #1 after the hospital stay. The note documented staff found Resident #1 somnolent (abnormally drowsy) and nearly nonresponsive, and staff eventually administered Narcan despite a significant delay. Resident #1 woke up immediately, expressed anger at the disruption, and initially refused transport but eventually went. The physician decreased his Lyrica, discontinued his Zyprexa, and left his Methadone in place. On [DATE] at 1:20 PM, the Director of Nursing (DON) reported she lacked familiarity with Methadone or Narcan when Resident #1 entered the facility. She said the facility didn't administer IV medications. The DON stated she completed Resident #1's admission and didn't clarify the Narcan IV order or get the order changed. She said she since gained more familiarity with Narcan and Methadone. She said on [DATE] the Emergency Kit (E-kit) contained Narcan under the name Naloxone, but the nurse lacked familiarity with that name. She said staff didn't administer the Narcan on [DATE] because Resident #1 woke up and didn't need it. The DON said the facility Nurse Practitioner (NP) initially refused to admit Resident #1 due to the Methadone therapy. She said the NP eventually agreed after ensuring someone else managed the Methadone. She said Resident #1 took Methadone for a long time without any problems that she knew of. She said the facility since learned that Resident #1 developed some underlying medical conditions. On [DATE] at 4:50 PM, the DON said she placed Narcan nasal spray in each medication cart after the [DATE] incident. She said nursing staff received education on how to use it per the instruction sheets. The DON said Staff A, Registered Nurse (RN) typed the letters NAR into the computer when checking for Narcan in the Medbank or E-kit on [DATE] and didn't try the name Naloxone. The Inventory Snapshot for the Medbank from [DATE] to [DATE] documented that injectable Naloxone 0.4 mg/ml remained available. On [DATE] at 8:20 PM, Staff A reported that the previous shift nurse passed on in report that Resident #1 slept most of the day and responded slowly. She said when she went to check on him, he appeared cyanotic, his oxygen saturation level dropped, and his pulse felt low and thready. She said she performed a sternal rub a couple of times and didn't get a response. She said she turned him onto his side in bed and still didn't get a response. She said she made a couple of phone calls and then transferred him to the floor because she thought she needed to start Cardiopulmonary Resuscitation (CPR). She said as soon as Resident #1 hit the floor, he started to come around. She said she talked to Resident #1's NP and received instructions to give Narcan if available. She said she knew Resident #1 took Methadone and suspected the symptoms stemmed from that. She said after Resident #1 woke up, he spoke with disorganization and became argumentative. She said Resident #1 normally didn't exhibit such confusion and clearly didn't have his right mind. When asked about the Narcan, she said the medication didn't show as available. Staff A said she checked both medication carts for Narcan and couldn't find it. She said she searched the medication room and refrigerator. She said she checked the E-kit in the refrigerator, but it mostly contained insulins. She said a Medbank stood in the medication room, but very few people held access to it. She said she had no idea how to enter it and lacked a code for it. She said she didn't know if the Medbank contained Narcan and couldn't find a medication list for it. Staff A said during the confusion regarding the Narcan, another nurse told her they could go to the town clinic to get a vial of injectable Narcan if needed. Staff A agreed that traveling to the clinic to get the Narcan would delay administration. She said she believed the clinic stood a couple of blocks away from the facility. When asked if she received any education regarding Narcan, she said she read information online. She said she saw it administered once but never administered it herself. Staff A said she knew that Narcan also goes by the name Naloxone and she looked for both names in the medication carts and medication room. On [DATE] at 9:20 AM, the DON reported that someone always maintained access to the Medbank at the facility. She said medication aides and nurses hold access to it. She said the Pharmacy Representative told her that Narcan listed under Naloxone in the Medbank. She said when Staff A called her, Staff A reported checking the Medbank and typing the letters NAR into the computer without the medication appearing. She said everything occurred in a matter of minutes when Staff A called the NP, checked the Medbank, and then Resident #1 aroused. She said another staff member went to the NP's office in town to obtain Narcan, but they didn't need it because the NP's office stood about a block away. On [DATE] at 9:40 AM, an observation revealed Resident #1 had four vials of injectable or intramuscular (IM) Narcan in a plastic bag in the top drawer of the medication cart. The prescription label directed staff to give 0.4 mg/ml IM as needed and bore the date [DATE]. The [DATE] and [DATE] MARs lacked an order for Narcan IM as needed. On [DATE] at 10:30 AM, the Pharmacist reported the pharmacy sent four vials of IM Narcan on [DATE]. The Pharmacist said he noted that the physician order read IV. He reported he couldn't find a clarification order for the Narcan but confirmed the pharmacy sent the injectable or IM form to the facility. The Pharmacist reported the facility Medbank contents included injectable Narcan. On [DATE] at 10:39 AM, Resident #1's NP reported she lacked awareness of the Narcan IV order on admission. The NP said the facility doesn't maintain the ability to perform IV treatments. She said she didn't check to ensure an order for Narcan accompanied the Methadone, calling it a bad presumption on her part. When asked if she knew Resident #1 didn't receive the Narcan on [DATE], she said she didn't. She said the nurse presented the situation as though staff couldn't find the Narcan, which prompted a facility staff member to travel to her office to obtain it. Review of Google Maps revealed the facility sat 0.4 miles away from the local family practice clinic. On [DATE] at 2:25 PM, Staff A reported she received her code and password early that morning for the Medbank and E-kit. The DON attended the interview and reported that when she requested a list of medications for the Medbank from the pharmacy, she also requested a list of users and didn't realize Staff A didn't appear on the user list. When asked if anyone trained Staff A on how to use the Medbank, Staff A stated she held familiarity with other systems but staff hadn't shown her how to use the Medbank at this facility. Staff A reported she worked as an agency staff member prior to signing on at the facility at the beginning of [DATE]. She said she came to the facility for six to eight months prior as an agency nurse and didn't possess a code or password for the Medbank until that morning. The undated Pharmacy policy titled E-kit Procedures directed staff the following:Contact the prescriber for an order.Prior to calling the prescriber, staff must review the E-kit list to ensure the medication remains prescribed in the E-kit.Staff must contact the prescriber for the orderDocument the order in the resident's chart.To open the E-kitStaff must obtain the unique six-digit code to open the cube from the PharmacistRemove the prescribed medication. B. A Physician order dated [DATE] directed staff to titrate Resident #1's Methadone Oral Concentrate 10 mg/ml according to the following directions:Give 43 mg 2 times a day (BID) until [DATE]Give 42 mg BID until [DATE]Give 41 mg BID until [DATE]Give 40 mg BID until [DATE]. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #1's Methadone Concentrate documented that on [DATE] at 5:00 PM staff administered 4.3 ml of Methadone, leaving 48.6 ml in the bottle. On [DATE] at 6:25 AM the record documented an adjustment to the amount of remaining medication to 39.9 ml. Next to the adjustment, a note documented a discrepancy due to a measuring error related to a lack of a measuring tool. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #1's Methadone Concentrate documented that on [DATE] at 3:36 PM staff administered 4.0 ml instead of the ordered 4.2 ml. Review of the [DATE] MAR revealed an order for Methadone Oral Concentrate 10 mg/ml- give 41 mg two times a day related to opioid dependence (drug addiction) with a start date of [DATE] and an end date of [DATE]. Review of the Controlled Drug Receipt/Record/Disposition form directed staff to give Methadone Concentrate 10 mg/ml take 4.1 ml by mouth every 12 hours for 7 days with a start date of [DATE]. According to the form, staff administered 3.8 ml (38 mg) to Resident #1 twice on [DATE], twice on [DATE], and once on [DATE] instead of 4.1 ml. On [DATE] at 2:50 PM, Staff B, Registered Nurse (RN) explained that staff dosed Resident #1's liquid Methadone using a 10 ml syringe that measured in 0.2 increments. Staff B showed the 10 ml syringe in the medication cart attached to the Methadone bottle in a plastic bag. Staff B reported that sometimes they couldn't measure the medication accurately when the order directed odd dosages like 4.1 ml or 4.3 ml. She said she recorded 39.9 ml on the narcotic record since the level fell just below 40 ml. On [DATE] at 4:50 PM, the DON acknowledged concerns with the Methadone administration and noted that management needed to check the documentation more frequently. The DON said the pharmacy planned to start printing a new narcotic sheet each week when the dosage changes so the information on the form remained correct and matched the MAR. In addition, she said the pharmacy would send new syringes for the Methadone administration to ensure accurate dosing. The undated facility policy titled Administering Medications instructed that staff shall administer medications in a safe and timely manner, and as prescribed. The policy directed that staff must administer medications in accordance with the orders, including any required time frame.

Based on clinical record review, staff interviews and policy review the facility failed to implement weight loss interventions in a timely manner for 2 of 3 residents reviewed (Resident #6 and #3) for weight loss. The facility reported a census of 34 residents. Findings include:1. Resident #6's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS identified Resident #6 required substantial or maximal assistance with eating. The MDS included diagnoses of non-Alzheimer's dementia (brain function decline) and Huntington's disease (neurodegenerative disorder). The MDS documented Resident #6 experienced signs and symptoms of a swallowing disorder including loss of liquids or solids from the mouth when eating or drinking, holding food in the mouth or cheeks, maintaining residual food in the mouth after meals, and coughing or choking during meals or when swallowing medications. The MDS documented Resident #6 received a mechanically altered diet and a therapeutic (healing) diet. The Care Plan (CP) with a target date of 7/8/26 documented Resident #6 maintained an impaired or altered nutritional status. The CP directed the following interventions:10/13/22: Consult a dietitian per order10/13/22: Consult speech therapy if staff suspected swallowing issues10/13/22: Encourage intake of nutritional supplements between meals10/13/22: Provide companionship during mealtime11/18/25: Pureed diet with nectar thickened liquids12/30/25: Resident #6 ate in the dining room at a table for supervision and safety2/9/26: Two handled cup with lids and a Dycem (non-slip) mat on the table The Progress Note (PN) dated 4/7/26 documented staff transferred Resident #6 to the emergency room for an elevated temperature. The PN dated 4/8/26 documented Resident #6 admitted to the hospital with aspiration pneumonia (serious lung infection from inhaling foreign material) and received intravenous (IV) antibiotics. The PN dated 4/10/26 documented Resident #6 returned from the hospital and recorded a weight of 138.8 pounds (lbs.). The Hospital Discharge summary dated [DATE] documented a discharge weight of 95.7 lbs. The Weight Summary (WS) documented the following weights over the last six months and the scale staff used to obtain the weights:12/1/25 - 101.2 lbs.- standing1/12/26 - 108.4 lbs.- standing1/27/26 - 109 lbs.- wheelchair2/9/26 - 107.4 lbs.- standing3/9/26 - 110.2 lbs.- standing4/14/26 - 104.4 lbs.- standing6/5/26 - 91.0 lbs.- wheelchair The Dietary Note (DN) dated 4/15/26 revealed the Registered Dietitian (RD) requested a reweight to verify a weight change. The RD documented she'd follow up once staff obtained the new weight. The Consultant Dietitian Report (CDR) dated 4/22/26 requested a reweight for Resident #6. The report documented the request in red ink and directed staff to complete the items in red prior to the next RD visit. The CDR documented Resident #6 experienced a 5.3% weight loss in one month and lost 5.8 lbs. The DN dated 4/23/26 documented the completion of the quarterly assessment. Resident #6 maintained a current weight of 104.4 lbs., which reflected a 5.3% weight loss in one month and a 4.2% weight loss in three months. The RD documented she'd follow up once staff obtained a reweight and offered no new dietary recommendations. Review of the Clinical Record (CR) lacked documentation that staff notified the Physician or family of the 5.3% weight loss in one month. The facility paper form titled Monthly Weights for April 2026 documented Resident #6 weighed 104.4 lbs. Someone crossed out the 104.4 lbs. weight and documented a new weight of 98 lbs. The form lacked dates regarding when staff obtained the weights, and the electronic medical record (EMR) didn't contain the 98 lbs. weight. The CR lacked documentation that staff notified the RD of the 98 lbs. weight. The facility paper form titled Monthly Weights for May 2026 documented Resident #6 weighed 93.8 lbs. The form lacked a date regarding when staff obtained the weight, and the EMR didn't contain the 93.8 lbs. weight. The CR lacked documentation that staff notified the RD of the 93.8 lbs. weight. The CDR dated 5/9/26 requested a reweight for Resident #6 for the second month. The PN dated 6/4/26 documented the facility received an email from the Nurse Practitioner (NP) containing an order to increase the house supplement to 120 milliliters (ml) three times a day due to recent weight loss. The PN titled Weight Change Note (WCN) dated 6/10/26 documented a current weight of 91 lbs. on 6/5/26. Resident #6 weighed 110.2 lbs. on 3/9/26, reflecting a 17.4% weight loss (19.2 lbs.) in three months. Resident #6 weighed 101.2 lbs. on 12/1/25, reflecting a 10.1% weight loss (10.2 lbs.) in six months. On 6/24/26 at 11:52 AM Staff I, Dietitian reported that staff sometimes struggled to obtain reweights from the facility. She said without the reweights, she based her assessments on the EMR documentation. Staff I verified nobody notified her of any reweights for Resident #6. Staff I reported she only possessed access to the weights documented in the EMR. She said she never saw any weights on a paper form. Staff I said she worked remotely so she didn't have a way of knowing about weights unless the facility emailed her. She said the facility held awareness of her remote work status. She said she moved out of state and the facility's staff held the responsibility to document weights in the EMR. Resident #3's Minimum Data Set (MDS) dated [DATE] assessment identified a BIMS score of 14, indicating intact cognition. The MDS identified Resident #3 required supervision or touching assistance with eating. The MDS included diagnoses of Huntington's disease (neurodegenerative disorder). The MDS documented Resident #3 received a therapeutic diet. The CP with a target date of 7/6/26 documented Resident #3 faced a risk for aspiration (inhaling foreign material) related to dysphagia (difficulty swallowing). The CP directed the following interventions:9/11/25: Assist with eating or drinking as needed9/11/25: Diet as ordered9/11/25: Observe Resident #3 during meal times for any signs and symptoms of aspiration or difficulty swallowing9/11/25: Staff to report any signs or symptoms of aspiration to the nurse (choking, eyes watering, coughing) The WS documented the following weights over the last three months:3/22/26 - 190.8 lbs.3/29/26 - 184.4 lbs.4/14/26 - 189 lbs.4/26/26 - 183.4 lbs.5/10/26 - 180 lbs.5/18/26 - 183.4 lbs.5/24/26 - 180.4 lbs.5/31/26 - 177.8 lbs.6/5/26 - 175.2 lbs.6/7/26 - 176.2 lbs.6/21/26 - 172.2 lbs. The PN titled WCN dated 6/10/26 documented Resident #3 experienced a significant weight loss in the past three months. Resident #3's current weight measured 176.2 lbs. and his weight on 3/22/26 equaled 190.8 lbs., representing a 7.7% weight loss in three months (14.6 lbs.). The RD recommended adding a house supplement of 120 ml every day to promote weight stability. The facility form titled Physician Fax dated 6/10/26 documented Resident #3 experienced a significant weight loss in the last three months. The form recommended the house supplement of 120 ml every day to promote weight stability. The NP agreed with the recommendation and signed the form on 6/16/26, six days after the RD made the recommendation. None of the facility nursing staff noted the form. Review of the CR and June 2026 Medication Administration Record (MAR) revealed staff didn't start the house supplement per the Physician order. Resident #3 weighed 172.2 lbs. on 6/21/26 and lost an additional 4 lbs. since the RD made the recommendation on 6/10/26. On 6/23/26 at 1:45 PM the NP reported she held awareness of Resident #3's recent weight loss. She said she addressed the Physician Fax form dated 6/10/26 onsite on 6/16/26. She said the facility didn't fax or call her about the weight loss. The NP reported she'd expect staff to start supplements within 24 hours. She said this demonstrated a lack of process and communication at the facility. On 6/23/26 at 2:32 PM the Assistant Director of Nursing (ADON) acknowledged staff hadn't started Resident #3's supplement. She said she hadn't noted the form herself so she knew staff hadn't started the supplement. The ADON said she didn't hold awareness of the form and didn't feel sure how the form entered the medical record. She said the dietitian arrived as a new staff member and she'd never met her. She said the dietitian comes in late in the afternoons. When asked about staff notifying the Physician a week after staff noted the weight loss, she said she'd expect staff to email the information to the NP but she didn't see that information documented on the form either. She said the facility had some work to do with the dietitian. The ADON requested to have the form placed on her desk so she could address it. On 6/23/26 at 2:38 PM the ADON said she added the supplement to the June MAR. The Weight Management policy lacking a date instructed the facility to provide care and services related to weight management in accordance with state and federal regulations. The policy directed the following procedures:Staff must complete monthly weights by the fifth of each month.Dietary staff must evaluate all weights by the seventh of each month.Staff must obtain a reweight for any weight changes of plus or minus three lbs. from the previous weight unless the physician ordered other parameters.Staff must obtain all reweights immediately, and a licensed nurse must visualize the reweight process.Staff must document all weights in the resident's EMR.The resident's nurse must notify the physician and the resident or Resident Representative of any significant unexpected or unplanned weight changes and document the notification in the resident's EMR.

Based on clinical record review, staff interviews, observations, and facility policy, the facility failed to perform smoking assessments to identify hazards for residents who smoked, suffered burns while smoking, and failed to implement new interventions to replace the ineffective ones to prevent further burns or decrease the risk burns for 3 of 3 residents (Resident #6, #8, #9) reviewed for smoking. The facility reported a census of 34 residents. Findings include:1. Resident #6's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS identified Resident #6 required partial or moderate assistance with bed mobility and substantial or maximal assistance with transfers and oral hygiene. The MDS documented Resident #6 had functional limitations in range of motion and impairments on both sides for the upper and lower extremities. The MDS included diagnoses of non-Alzheimer's dementia (brain function decline) and Huntington's disease (neurodegenerative disorder). The Safe Smoking assessment dated [DATE] documented Resident #6 didn't smoke safely. The assessment documented Resident #6 didn't have fine motor skills needed to securely hold the cigarette. The assessment revealed Resident #6 required supervision by staff, volunteers, or family at all times when smoking. The assessment documented Resident #6 must wear a smoking apron or cape and use a clothes pin (adaptive device to hold the cigarette) while smoking. The Care Plan with a target date of 7/8/26 revealed Resident #6 smoked and required supervision when she smoked. The care plan directed the following interventions:10/13/22: All smoking materials will remain at the nurses' station10/27/22: Resident #6 to be monitored by staff while smoking10/27/22: Resident #6 to smoke only in designated areas10/24/25: Attempt redirection with Resident #6 when she wants to smoke and it isn't time6/23/26: Verify with staff if Resident #6 has or hasn't been out to smoke before telling her no Resident #6's Care Plan lacked documentation regarding safety interventions per the smoking assessment which included the smoking apron and clothes pin. The Progress Note on 2/18/26 documented Resident #6 had two areas that resembled burns to her abdominal area. The note documented staff obtained an order to apply Silvadene cream (topical antibiotic cream) twice a day (BID) until healed. The Skin Condition Record dated 2/18/26 documented two burns to the abdomen. The assessment didn't document the degree of burn. The assessment documented epithelial tissue type and bright red surrounding skin color. The areas measured the following:#1 (lower abdomen)- 1.0-centimeter (cm) x 1.2 cm#2 (upper abdomen)- 0.9 cm x 0.9 cm The Progress Note dated 2/24/26 documented the Nurse Practitioner (NP) conducted rounds at the facility and received an update on Resident #6's status. Staff received new orders to apply Silvadene cream to burn areas BID until healed. Review of the February 2026 Medication Administration Record (MAR) revealed staff didn't start the Silvadene treatment on 2/18/26 per the progress note. The treatment started on 2/24/26. The Progress Note dated 2/24/26 documented staff applied the initial scheduled application of Silvadene to the two burn sites on the trunk and abdominal region. The sites presented bright red in color with a blistered appearance but no longer intact. The note documented maintained safe smoking measures including a flame-resistant apron, staff supervision, and a cigarette held via an adaptive device. The Progress Note dated 2/28/26 documented Resident #6 had difficulty sitting still and dropped her cigarette a total of six times. The Progress Note dated 3/4/26 at 3:05 PM documented new cigarette burns to the lower abdomen and left thigh. The note documented staff assessed and measured the areas, and obtained a new order to apply Silvadene cream to the areas. The Skin Condition Record dated 3/4/26 documented two burns to the lower abdominal area and left thigh. The assessment didn't document the degree of burn. The assessment documented epithelial tissue type and normal surrounding skin color. The areas measured the following:#1 (Left thigh)- 2.0 cm x 1.5 cm x 0.1 cm#2 (abdomen)- 0.5 cm x 0.4 cm The Physician order dated 3/4/26 at 9:02 PM documented Silvadene to the abdomen and bilateral thighs due to burns BID until healed. The Skin Condition Record dated 3/4/26 lacked any documentation regarding a burn to Resident #6's right thigh. The Clinical Record lacked documentation that staff notified Resident #6's family regarding the burns and treatment order on 3/4/26. The Progress Note dated 3/7/26 documented Resident #6's dressing to the left thigh remained clean, dry, and intact, and a Silvadene treatment remained in place on the pubis area (groin area) due to cigarette burns. Review of the Clinical Record lacked any additional smoking assessments or safety interventions after the burns occurred on 3/4/26. The Progress Note dated 3/17/26 documented Resident #6 had various burn sites on her bilateral hands that presented with intact blistered areas. The burn site on the left inner thigh presented with dark red or brown intact scabbing. The Clinical Record lacked any skin assessments, treatments, or notification to the Physician regarding the burns or blistered areas on Resident #6's hands on 3/17/26. Review of the Clinical Record lacked any additional smoking assessments or safety interventions after the burns occurred on 3/17/26. The Progress Note dated 3/25/26 documented Resident #6 had several burn sites on bilateral hands. The note lacked clarity on whether the burns arrived as new or existed from 3/17/26. The note documented staff continued to monitor Resident #6's smoking of cigarettes to ensure safety. The note indicated even with staff available to watch Resident #6, burns continue to occur often and staff would likely begin a discussion on Resident #6's inability to remain safe while smoking. The Clinical Record lacked any skin assessments, treatments, or notifications to the Physician or family regarding the burn areas on Resident #6's hands on 3/25/26. Review of the Clinical Record lacked any additional smoking assessments or safety interventions after the burns occurred on 3/25/26. The Progress Note dated 4/6/26 documented Resident #6's cigarettes became stuck to her lips, resulting in a small burn to the upper chest. The Clinical Record lacked any skin assessments, treatment orders, or notifications to the Physician or family regarding the burn to Resident #6's chest on 4/2/26. Review of the Clinical Record lacked any additional smoking assessments or safety interventions after the burn occurred on 4/2/26. The Progress Note dated 4/8/26 documented the nurse reached out to Resident #6's sister to provide an update on Resident #6's condition. The note documented Resident #6 had been forgetting how to smoke and put the cherry (burning tip) of the cigarette towards her mouth. The note documented Resident #6 switched to a vape. On 6/29/26 at 11:10 AM, the Director of Nursing (DON) verified staff completed the last written smoking assessment for Resident #6 in February 2026. The DON reported she'd reassessed Resident #6 and identified that Resident #6 changed regarding her smoking but didn't put it in writing. When asked what new safety interventions staff put in place when the burns occurred, the DON said they switched Resident #6 to a vape at the beginning of April 2026. On 6/29/26 at 12:40 PM, the DON verified she didn't have any skin assessments for Resident #6's burns to her hands or chest. On 6/29/26 at 9:43 PM, Staff H, Licensed Practical Nurse (LPN) reported that she'd passed on in a report to the day shift that staff needed to evaluate Resident #6 for switching to a vape. Staff H said Resident #6 had started going downhill and she'd mentioned switching to a vape a while ago (3 to 6 months ago). Staff H said she'd taken Resident #6 out to smoke, just the two of them, and at times Resident #6 would hold the clothes pin and smoke, and at other times she'd drop the cigarette. She said she'd tell Resident #6 to slow down and take her time. She said she'd watch Resident #6 very carefully and ensure her smoking apron remained on and covered her neck and legs. She said when staff finally switched Resident #6 to a vape, Resident #6 made the comment that someone finally listened. When asked if Resident #6 sustained injuries from smoking, she said yes. She said staff performed treatments on Resident #6's bilateral thighs. She said one thigh required a bandage but she couldn't recall which one. Staff H said Resident #6 also had areas on her chest and abdomen. Staff H said due to Resident #6's burns, the facility needed to switch her to a vape. When asked if any staff members ever voiced concerns about Resident #6's smoking, she said yes, some Certified Nursing Assistants (CNAs) would voice that Resident #6 smoked too fast or didn't hold the clothes pin. She said sometimes Resident #6 would flick her wrist and she'd have concerns about where the cherry from the cigarette would end up or that she'd touch her hands with it. She said she'd instruct Resident #6 to slow down and calm down while smoking. When asked if Resident #6 would follow the instructions or cues, she said not necessarily but they tried. On 6/30/26 at 10:03 AM, Staff E, Registered Nurse (RN) reported she knew that the Silvadene treatment started right away on 2/18/26. She commented that staff must not have transcribed the order right away. On 6/30/26 at 10:07 AM, Staff C, Registered Nurse (RN) reported Resident #6 would burn herself occasionally while smoking. Staff C said if she witnessed Resident #6 burn herself while smoking, she'd stop the smoking and take her inside to assess the area. She said if the area blistered and remained intact, she'd leave it open to air. She said if the area remained open, she'd cleanse the area and cover it with a non-adherent dressing or wrap. She said Resident #6 did pretty well about leaving the dressing alone. Staff C said Resident #6 would get burns on her hands frequently. She said when it comes to interventions at the facility, staff have to think outside the box. She said staff want to keep a resident safe but let them enjoy the time they have left. She said she did make a suggestion of using [NAME] gloves when Resident #6 smoked to keep the cigarette cherry away from her skin. She said she felt uncertain whether the suggestion went anywhere. Staff C said she thought the [NAME] gloves would allow Resident #6 to keep smoking, remain safe, and stop the burns on her hands. She said discussions occurred about the family providing a vape. She said when she left the facility at the end of March 2026, Resident #6 still smoked cigarettes with the smoking apron and clothes pin. On 6/30/26 at 9:12 AM, the DON reported she didn't have any other documentation to provide for Resident #6. She said it took a while for Resident #6 to accept the vape. She said she'd been in contact with Resident #6's family member multiple times to keep her updated. The DON said she could do a better job at documenting the notifications. She said she hopes reviewers look at the whole picture. She said the facility performed a lot of interventions and that the facility housed 20 residents with Huntington's disease. She said she understood that if staff don't document it, then it didn't happen. 2. Resident #8's Minimum Data Set (MDS) dated [DATE] assessment identified a Staff Assessment for Mental Status, indicating severely impaired cognition. The MDS identified Resident #6 depended on staff with oral hygiene and chair or bed-to-chair transfers. The MDS documented Resident #8 had functional limitations in range of motion and impairments on both sides for the upper and lower extremities. The MDS included diagnoses of non-Alzheimer's dementia (brain function decline), Huntington's disease (neurodegenerative disorder), and chorea (involuntary movements). The Safe Smoking assessment dated [DATE] documented Resident #8 didn't smoke safely. The assessment documented Resident #8 didn't have fine motor skills needed to securely hold the cigarette. The assessment revealed Resident #8 required supervision by staff, must wear a smoking apron or cape, and must use a clothes pin while smoking. The Care Plan with a target date of 7/23/26 revealed Resident #8 enjoyed smoking. The care plan directed the following interventions:3/26/20: Resident #8 to smoke in designated areas only6/29/26: Resident #8 to have supervision while smoking9/16/21: Resident #8 to use a clothes pin to hold the cigarette to prevent burns to fingers3/26/20: Resident #8 to use smoking apron while smoking3/26/20: Smoking materials are kept at the nurses' station The Skin Condition Record dated 3/4/26 documented a cigarette burn to the right collar bone that measured 0.8 cm x 1.2 cm. The assessment didn't document the degree of burn or wound characteristics. The form documented staff received a verbal order for Silvadene to the area BID until healed. The Progress Note dated 3/5/26 documented Resident #8 had a burn mark on her right clavicle. The note documented the wound nurse held awareness of the injury and staff completed a skin sheet. Resident #8's March 2026 Medication Administration Record (MAR) lacked documentation of a Silvadene treatment to Resident #8's clavicle. Review of the Clinical Record lacked any additional smoking assessments or safety interventions after the burn occurred on 3/4/26. The Progress Note dated 4/23/25 documented a cigarette burn on Resident #8's first knuckle of her left hand. The clinical record lacked documentation of any treatment for the burn area. The Skin Condition Record dated 4/23/26 documented a cigarette burn on the left first knuckle that measured 1.0 cm x 0.7 cm. The assessment didn't document the degree of burn. The assessment documented no exudate (drainage) and normal surrounding skin color and wound edges. Review of the Clinical Record lacked any additional smoking assessments or safety interventions after the burn occurred on 4/23/26. The Progress Note dated 6/22/26 documented a burn or blister on Resident #8's left index finger. The note documented staff applied Silvadene to the area. The Skin Condition Record dated 6/22/26 documented a burn on the left first finger that measured 0.5 cm x 1.0 cm. The assessment didn't document the degree of burn. The assessment documented no exudate (drainage) and a bright red surrounding skin color. The Progress Note dated 6/23/26 documented the Nurse Practitioner (NP) conducted rounds at the facility and gave a new order to apply Silvadene cream to the burn on the finger BID until healed. On 6/29/26 at 9:43 PM, Staff H reported Resident #8 frequently sustained burns on her hands and clavicle. She said Resident #8 currently had a burn on her left index finger that staff treated with Silvadene. She said interventions in place for Resident #8 included a smoking apron, supervision, and a clothes pin. Staff H said she'd made comments to the day shift about switching Resident #8 over to a vape and staff told her Resident #8 wouldn't like it. Staff H said Resident #8 getting burns created a safety issue and something required adjustment. On 6/29/26 at 12:47 PM, Staff A, Registered Nurse (RN) reported she felt Resident #8 should use a vape. She said Resident #8 doesn't have the ability to hold the cigarette and her hands don't cooperate. Staff A said once in a while she'd brushed ashes off Resident #8's smoking apron. She reported Resident #8 currently had a burn on her finger and staff applied Silvadene to it. On 6/30/26 at 9:13 AM, Resident #8 sat outside in a reclining wheelchair with a smoking apron on. Resident #8 sat across from Staff J, Registered Nurse (RN). Resident #8's skin remained exposed around her neck and clavicle area. Resident #8 held the clothes pin with the cigarette and then threw it on the ground and concrete on the right side of her chair. Staff J didn't see Resident #8 throw the cigarette on the ground. Staff J looked in the other direction while smoking her own cigarette. Resident #1 picked up the cigarette off the ground and gave it to Staff J for disposal. Staff J made the comment, that's what happens when you look away for a second. On 6/30/26 at 10:05 AM, observed Resident #8's left index finger with a small, dry scabbed area with a small amount of redness around it. 3. Resident #9's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS identified Resident #9 required supervision or touching assistance with eating, and substantial or maximal assistance with oral hygiene and transfers. The MDS documented Resident #9 had functional limitations in range of motion and impairments on both sides for the upper and lower extremities. The MDS included diagnoses of non-Alzheimer's dementia (brain function decline), Huntington's disease (neurodegenerative disorder), chorea (involuntary movements), and tobacco use. The Safe Smoking assessment dated [DATE] documented Resident #9 didn't smoke safely. The assessment documented Resident #9 didn't have fine motor skills needed to securely hold the cigarette. The assessment revealed Resident #9 required supervision by staff, must wear a smoking apron or cape, and must use a clothes pin while smoking. The assessment documented Resident #9's family refused a vape and that the family held awareness of the risks and wanted to continue with the cigarettes. The Care Plan with a target date of 7/23/26 revealed Resident #9 enjoyed smoking. The care plan directed the following interventions:9/11/25: Resident #9 to smoke in designated areas only9/11/25: Resident #9 to use smoking apron while smoking9/11/25: Smoking materials are kept at the nurses' station9/11/25: Resident #9's family supplies smoking/tobacco supplies9/11/25: Resident #9 has 4 cigarettes per day, after meals and before bed at 8 PM The Progress Note dated 3/24/26 documented Resident #9 attended the 3 PM supervised smoking session. Staff reported Resident #9 leaned significantly forward while smoking, which caused an increased risk for a self-inflicted burn due to poor positioning and poor trunk control related to the progression of chorea. Resident #9 couldn't maintain an upright position and the staff member extinguished the cigarette due to safety concerns. The Progress Note dated 4/9/26 documented Resident #9 wouldn't sit up and kept burning herself with the cigarette, so staff took the cigarette away. The Progress Note dated 4/10/26 documented Resident #9 leaned significantly forward when smoking, which made it difficult for her to safely hold a cigarette. The Progress Note dated 4/26/26 documented Resident #9 demanded a cigarette. While outside, Resident #9 required several prompts to sit upright in the wheelchair while she smoked because she leaned down frequently, which caused staff concerns for a risk of falling. The Progress Note dated 6/28/26 documented Resident #9 smoked outside in the wheelchair with a smoking apron on. Resident #9 repeatedly leaned forward, requiring close supervision due to the nurse's concern about her falling from the wheelchair. Resident #9 finished smoking her cigarette, staff removed the cigarette, and she became verbally and physically aggressive with the staff. On 6/29/26 at 12:47 PM, Staff A reported she held concerns with Resident #9 smoking and felt she should use a vape. Staff A said Resident #9 leaned forward and needed constant reminders to sit up straight. She said it concerned her when Resident #9 leaned forward while smoking a cigarette. On 6/29/26 at 9:43 PM, Staff H reported Resident #9 leaned forward when she went out to smoke. Staff H said switching Resident #9 to a vape would represent a great change. She said she feared Resident #9 would either burn herself or fall face forward onto the concrete. She said she passed it on in a nurse-to-nurse report a couple of months ago but nothing changed. The Resident Smoking Policy dated August 2018 directed that facility staff or a resident's competent visitor must supervise all smoking residents unless staff assessed them as a safe smoker following completion of the smoking assessment. The policy instructed that the interdisciplinary team may complete a smoking evaluation at any time deemed necessary, which may result in a re-classification of smoking status. The Smoking Policy - Residents dated July 2017 directed the facility to establish and maintain safe resident smoking practices. The policy instructed staff to consult with the Attending Physician and the DON to determine if safety restrictions need placement on a resident's smoking privileges based on the Safe Smoking Evaluation. The policy directed staff to re-evaluate a resident's ability to smoke safely quarterly, upon significant physical or cognitive changes, and as determined by staff. The policy instructed that staff note any smoking-related privileges, restrictions, and concerns on the care plan, and alert all personnel caring for the resident to these issues. The policy directed that the facility may impose smoking restrictions on a resident at any time if staff determined that the resident cannot smoke safely with available levels of support and supervision. The policy instructed that any resident with restricted smoking privileges requiring monitoring must have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking.

Based on clinical record review, facility investigation file, observation, staff interviews, and facility policy review, the facility failed to have two staff members present when narcotic medications were destroyed for 4 of 4 residents reviewed for controlled substance use (Resident #1, #2, #3, #4). Additionally, the facility failed to remove expired medications from the medication cart in a timely manner (Resident #3 and Resident #4) and have a system in place to adequately dispense and reconcile controlled drugs (Resident #1 and #6). The facility reported a census of 34 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #1 functioned independently with bed mobility, transfers, and ambulation. The MDS included diagnoses of Huntington's disease (neurodegenerative disorder). The MDS documented Resident #1 received opioid medication during the last 7 days. Resident #1's March 2026 Medication Administration Record (MAR) revealed an order for Methadone Hydrochloride (HCL) (opioid medication) 10 milligrams (mg)- give 9 tablets in the morning for pain management related to Huntington's disease. The order started on 3/24/26 and ended on 3/28/26. A Physician order dated 3/27/26 directed staff to change Resident #1's Methadone 90 mg in the morning to liquid form. The March 2026 MAR revealed an order for Methadone HCL oral solution 10 mg/5 milliliters (ml)- give 90 mg in the morning for pain with a start date of 3/28/26. The Controlled Drug Receipt/Record/Disposition form for Resident #1 documented the facility received 90 tablets or 10 doses of Methadone (10 mg) on 3/23/26 from the pharmacy. The form documented Staff C, Registered Nurse (RN) on 3/28/26 at 9:30 PM destroyed 54 Methadone tablets via the drug buster (drug disposal system) without a witness. The Controlled Drug Receipt/Record/Disposition form for Resident #1 directed staff to administer Methadone Concentrate 10 mg/ml- take 9 ml (90 mg total) daily. The form on 4/16/26 at 8:15 AM documented staff administered 9 ml and left 117 ml. A note written next to the two nurses' signatures documented staff wasted 4 ml. On the next line on the form dated 4/16/26 at 8:27 AM documented staff administered 4 ml and left 113 ml. The May 2026 MAR directed staff to give Methadone Oral Concentrate 10 mg/ml- give 44 mg by mouth twice a day (BID) for pain related to opioid dependence (opioid addiction) with a start date of 5/22/26 and end date of 5/25/25. The Controlled Drug Receipt/Record/Disposition form for Resident #1 revealed staff didn't update the form on 5/22/26 with the new Methadone orders. The form documented on 5/22/26 at 12:40 PM, Staff D, Licensed Practical Nurse (LPN) gave 4.4 ml with a negative balance of 1.2 ml left. According to the record, the bottle contained 3.2 ml when Staff D administered the medication. Staff A, Registered Nurse (RN) documented a note on the next line adjusting the remaining amount in the bottle to 4 ml. On 6/24/26 at 2:30 PM, Staff E, Registered Nurse (RN) reported she spilled Resident #1's Methadone during administration on 4/16/26. Staff E said she'd measured the Methadone using a syringe and put the 9 ml in a medication cup. She said after the medication spilled, 5 ml remained in the cup so she knew 4 ml spilled out. On 6/25/26 at 9:24 AM, Staff D verified she documented the negative 1.2 ml on the narcotic record with Staff A present as a witness. She said the stopper in the bottle holds liquid and once she removed the stopper, the liquid came out. She said she'd enough to give 4.4 ml per the order because she removed the stopper. She said she then adjusted the remaining amount in the bottle with Staff A to reflect what remained in the bottle. On 6/25/26 at 2:25 PM, Staff A said staff struggled to see the marks on the Methadone bottle so they marked the bottle with some tape. She said Staff D needed to give 4.4 ml and the bottle contained more than the 3.2 ml documented on the narcotic record. Staff A said ideally the bottle shouldn't contain enough to give the dose, which caused a negative balance on the narcotic record. She said after Staff D administered the 4.4 ml, she dumped out the medication into a medication cup and then measured the medication with a syringe. She said 4 ml remained and she updated the record. She said the syringes don't fit well in the stopper and some of the medication gathers around the stopper. She said the liquid bottles aren't ideal. She said they couldn't do better than eyeballing it unless they dumped out the medication each time and measured with a syringe each time. 2. Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #2 functioned independently with bed mobility, transfers, and ambulation. The MDS included diagnoses of Huntington's disease (neurodegenerative disorder). The March 2026 MAR revealed an order for Adderall (central nervous system stimulant) 10 mg in the morning for ADHD (attention deficit hyperactivity disorder) related to Huntington's disease. Staff put the medication on hold starting 3/5/26 and discontinued it on 3/24/26. The Controlled Drug Receipt/Record/Disposition forms for Resident #2 documented the facility received 30 tablets of Adderall 10 mg on 2/23/26 and received an additional 30 tablets on 3/20/26 from the pharmacy. The forms documented Staff C on 3/28/26 at 9:30 PM destroyed 51 Adderall tablets via the drug buster without a witness. 3. Resident #3's Minimum Data Set (MDS) dated [DATE] assessment identified a BIMS score of 14, indicating intact cognition. The MDS identified Resident #3 functioned independently with bed mobility, transfers, and ambulation. The MDS included diagnoses of Huntington's disease (neurodegenerative disorder). The February 2026 MAR revealed an order for Clonazepam (central nervous system depressant) 1 mg BID for Huntington's Disease with a start date of 10/31/25 and end date of 3/11/26. Review of the Clinical Record revealed Resident #3 entered the hospital on 2/16/26 and returned to the facility on 3/11/26. The Hospital Discharge Summary on 3/11/26 directed Resident #3 to stop taking the Clonazepam medication. Resident #3's Clonazepam medication remained in the medication cart during Resident #3's hospitalization and stayed in the cart after its discontinuation until 3/28/26. The Controlled Drug Receipt/Record/Disposition form for Resident #3 documented the facility received 30 tablets of Clonazepam 1 mg on 2/10/26 from the pharmacy. The forms documented Staff C on 3/28/26 at 9:30 PM destroyed 24 Clonazepam tablets via the drug buster without a witness. 4. Resident #4's Minimum Data Set (MDS) dated [DATE] assessment identified a staff assessment for mental status, indicating severely impaired cognition. The MDS identified Resident #4 required substantial/maximal assistance with bed mobility and transfers. The MDS included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia (brain function decline), and restless leg syndrome (uncomfortable leg sensations). The MDS documented Resident #4 received hospice care while residing at the facility. The Pharmacy Review form dated 7/9/25 documented Resident #4 had an order for Lorazepam 0.25 mg by mouth every four hours as needed. The form documented to continue the medication for 180 days and reevaluate. The January 2026 MAR documented staff discontinued the Lorazepam order on 1/12/26. The clinical record lacked documentation that the physician re-evaluated the order for Lorazepam. Resident #4's Lorazepam medication remained in the medication cart after its discontinuation on 1/12/26 until 3/28/26. The Controlled Drug Receipt/Record/Disposition form for Resident #4 documented the facility received 30 tablets of Lorazepam 0.5 mg (60 doses 1/2 tab each) on 6/18/25 from the pharmacy. The forms documented Staff C on 3/28/26 at 9:30 PM destroyed 57 1/2 doses of Lorazepam via the drug buster without a witness. 5. Resident #6's Minimum Data Set (MDS) dated [DATE] assessment identified a BIMS score of 9, indicating moderately impaired cognition. The MDS identified Resident #6 required partial/moderate assistance with bed mobility and substantial/maximal assistance with transfers. The MDS included diagnoses of non-Alzheimer's dementia (brain function decline) and Huntington's disease (neurodegenerative disorder). The June 2026 MAR revealed an order for Clonazepam 0.5 mg give 0.25 mg BID for mood disturbance (Give 1/2 tab BID to equal 0.25 mg). The order had a start date of 6/3/26. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #6 revealed the directions on the form didn't match the physician order on the June 2026 MAR. The form documented the facility received 60 tablets of Clonazepam 0.5 mg tablets on 4/10/26. Someone crossed out the quantity received of 60 and wrote the number 30 next to it. The number of documented doses equaled 30. On 6/17/26 at 2:00 PM, observation of Resident #6's Clonazepam medication card revealed the pharmacy label on the card directed to administer Clonazepam 0.5 mg take 1 tablet by mouth BID and take 1 tablet by mouth daily as needed. On the top right-hand corner of the medication card, black marker writing directed to take 1/2 tab (0.25 mg) BID and one tab (0.5 mg) every 24 hours. The medication card had 8 whole tablets in the card. Observation of the back of the medication card revealed several pieces of tape demonstrating staff previously put the Clonazepam medication back into the card to use at a later time. The Director of Nursing (DON) attended the observation and reported the facility commonly taped the unused half tablet back in the medication card for the next dose. On 6/17/26 at 1:35 PM, Staff F, Certified Medication Assistant (CMA) reported when the pharmacy sent a whole tablet of a controlled substance and the order specified a half tablet, some staff would put the unused half of the tablet back in the card for the next dose. Staff F said when she administered medication, she'd tape the half tablet back in the medication card and put a date and her initials on it. She said some nurses say technically you can't do that and that you should destroy the unused half of the tablet rather than putting it back in the card. She said last night when passing medications to Resident #6 she had to break the Clonazepam tablet in half. She said she taped the unused half of the tablet back into the card. On 6/17/26 at 2:55 PM, Staff G, Registered Nurse (RN) reported she'd heard over the years that you shouldn't put a medication back in the medication card. She said most pharmacies send the correct dosage. She said with Resident #6, staff taped the unused half of the Clonazepam tablet back into the medication card. She said she'd saved half of the tablet to waste and someone told her to tape it back in place as the facility practiced that. On 6/17/26 at 3:43 PM, Staff H, Licensed Practical Nurse (LPN) reported she usually worked nights and didn't administer Resident #6's clonazepam. She said the nurses do have to score it and they put the unused medication back in the medication card. She said when doing narcotic counts, staff find half tablets taped back in the medication card and the narcotic count reflected the half doses. On 6/18/26 at 11:00 AM, the Assistant Director of Nursing (ADON) reported staff should dispose of narcotic medications right away when they are discontinued. She said the narcotic count sheet and medication card should be together when disposing of the medications. She said two nurses must pop out the medication in a cup to verify the correct amount, put the medications in the drug buster, and both sign off on the paperwork verifying the destruction of the medication. The ADON reported CMAs could act as a witness. She said the Pharmacy Consultant reported anyone over the age of 18 could act as a witness and sign off on the medication record. On 6/18/26 at 12:07 PM, the ADON verified the facility discontinued Resident #4's Lorazepam off the MAR in January and Resident #3's Clonazepam upon return from hospitalization in March. On 6/22/26 at 9:25 AM, Staff C reported several narcotics needed destruction as they no longer had active orders. She said she wanted it done before the Department of Inspections, Appeals, and Licensing (DIAL) entered the facility as she didn't want DIAL to find the medications. She said she'd planned to destroy the discontinued narcotic medications with Staff G when she arrived for the third shift. She said she'd reached out to the ADON regarding the medications without active orders and getting rid of them. She said Staff G arrived late for the third shift, a common occurrence. Staff C said she popped out the narcotic medications into separate cups so they could be counted when Staff G got to work. She said she locked the medication cups in a drawer in the medication cart as she needed to check on a resident. Staff C acknowledged she shouldn't have popped out the pills ahead of time. She said when she returned and opened the drawer on the medication cart, she found a knocked-over cup and loose pills inside the drawer. Staff C said she couldn't have loose narcotics in the drawer so she disposed of all the medications into the drug buster. Staff C said she should've had the CMA who worked watch her. She said the drug buster almost overflowed. She said she left the drug buster on the counter and didn't go back into the medication room. Staff C acknowledged she knew some issues would arise from her actions. She said an expectation existed to have a witness when destroying narcotics. When asked which residents' narcotics she destroyed, she said she didn't remember their names but reported several residents. Staff C said she panicked because Staff G didn't arrive on time. She said she expressed frustration as it happened every time Staff G worked. She said she should've expected Staff G to be late and disposed of the narcotic medications the right way. Staff C said the facility suspended and later terminated her for failing to follow facility protocol. When asked who held responsibility for removing discontinued medications from the medication carts, Staff C reported the facility designated one person to do rounds with the Nurse Practitioner. She said the ADON would do the rounds and then give a list of new orders to the nurses. She said staff didn't always remove the medication card when a medication discontinuation occurred. She said the same thing happened when a psychotropic medication stopped after a certain duration. She said the psychotropic medication would fall off the MAR but remain in the cart. She said medication discontinuations didn't trigger the nurses to pull the card. On 6/24/26 at 9:18 AM, the DON said she received a phone call from Staff G, who reported Staff C's solo destruction of narcotic medications and request for Staff G to sign off. She said Staff G expressed distress. She said Staff G laid everything out to her and identified the involved residents and the number of medications Staff C destroyed for each resident. She said she called the Administrator and started an investigation immediately. She said she called Staff C and learned Staff C wanted to leave and Staff G arrived late for work. She said Staff C admitted to her actions and knew she committed an error. The Discarding and Destroying Medications policy dated June 2025 directed staff to dispose of medications in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. The policy instructed that disposal of controlled substances must take place immediately, defined as no longer than three days, after discontinuation of use. The policy directed that the medication disposition record contain the following information:a. The resident's nameb. Date of medication disposalc. The name and strength of the medicationd. The name of the dispensing pharmacye. The quantity of disposalf. Method of dispositiong. Reason for dispositionh. Signature of witnesses

Based on clinical record review, staff interview, physician interview and policy review, the facility failed to obtain a follow up urinalysis (UA) after completion of an antibiotic for a urinary tract infection (UTI) as ordered by the Physician for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 34 residents.Findings include: Resident #5's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #5 was dependent on staff with transfers to the toilet and toileting hygiene. The MDS documented Resident #5 was always incontinent of bowel and bladder. Resident #5's MDS included diagnoses of Huntington's disease (neurodegenerative disorder) and non-Alzheimer's dementia. The Care Plan with a target date 6/18/26 lacked documentation regarding Resident #5's urinary incontinence or risk for UTIs. The Progress Note dated 3/20/26 documented a new order was received to obtain UA with culture and sensitivity (C&S) if indicated. According to the note the UA was obtained via sterile technique. The Progress Note dated 3/22/26 documented the UA culture was positive for E-coli (bacteria that normally lives in the intestines). New orders were received to start Cipro (antibiotic) 500 mg (milligrams) twice a day for 10 days and to recheck a UA in 14 days. The final Microbiology Report dated 3/22/26 documented the UA culture grew out greater than 100,000 cFu/ml (colony-forming units per milliliter) Escherichia coli (E-Coli). Resident #5's April 2026 Medication Administration Record directed staff to recheck the UA with a start date of 4/6/26. The MAR documented 9 on 4/7/26 which indicated to see the nursing progress notes. The Progress Note on 4/7/26 documented staff was waiting for direction from Resident #5's Physician on using a straight catheter to obtain the UA per the night nurse request. Review of the Clinical Record lacked documentation a clarification order was received from the Physician or that the UA was obtained. On 6/23/26 at 1:45 PM, Resident #5's Primary Care Physician (PCP) reported she had ordered an antibiotic for a UTI and wanted the UA rechecked to ensure the UTI was resolved. She said she wanted to make sure Resident #5 was comfortable. The PCP reported she was not aware the UA was not obtained and would have expected the order to be followed. On 6/23/26 at 3:43 PM, the Assistant Director of Nursing (ADON) reported she could not locate any documentation that Resident #5's UA was rechecked per the physician order. The facility policy titled Urinary Tract Infection/Bacteriuria revised April 2018 documented the physician and nursing staff would review the status of individuals who are being treated for a UTI and adjust treatment accordingly. Follow up urine cultures after antibiotic treatment are not indicated routinely, but may be helpful if the symptoms are not resolving or complications are present.

Based on clinical record review, staff interviews, resident interview and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 1 of 3 residents reviewed (Resident #7) for skin. The facility reported a census of 34 residents.Findings include:Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #7 required partial/moderate assistance with putting on/taking off footwear and was independent with transfers/ambulation. The MDS included diagnoses of diabetes mellitus with diabetic nephropathy (kidney damage caused by poorly controlled diabetes). The Care Plan with a target date 9/7/26 revealed Resident #7 had diabetes mellitus. The care plan directed staff to monitor, document, and report to Physician as needed for signs/symptoms of infection to any open areas such as redness, pain, heat, swelling or pus formation. In addition, the care plan directed staff to refer to podiatrist for foot care needs. The Progress Note dated 5/21/26 documented Resident #7 received a shower and a blister to the back of the left heel was identified from her sandals. Review of the clinical record lacked skin assessments, interventions and treatment for the left heel blister. The clinical record lacked documentation Resident #7's Physician was notified of the blistered area. Resident #7's care plan lacked information regarding the skin impairment to the left heel. On 6/24/26 at 10:59 AM, the Director of Nursing (DON) reported she could not locate Physician notification regarding the blister to the left heel. She said the skin nurse was not aware of the area so there were no skin sheets or skin assessments completed. On 6/24/26 at 11:15 AM, the DON said she expected a skin assessment, Physician notification, intervention and follow up assessments completed when a blister was identified. On 6/24/26 at 11:20 AM, observation revealed Resident #7 had sandals on her feet with a strap that went around the back of her heels. Resident #7 had a Band-Aid in place to the back of the left heel. Resident #7 reported she had a Band-Aid on her left heel so the area did not get worse. She said the strap on the sandals rub on the back of her heel. She said the sandals she had on were the only sandals she could wear due to her neuropathy. She said the area on the back of the left heel comes and goes and that the area was dry. Resident #7 said she would ask for a Band-Aid for the left heel and the staff would give it to her. She said she advocated for herself and took good care of her feet since she was a diabetic. The facility policy titled Skin Management revised November 2018 documented skin assessment findings would be documented on the head-to-toe skin check form. Any alterations or changes in skin integrity, any break in resident's skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds, are to be recorded in the skin book. The policy documented a change of condition form to be completed and a new physician's order obtained for a new incident of compromised skin integrity. The nurse would assure treatments, interventions, care plan, and the appropriate skin documentation records were initiated in a timely manner according to practice guidelines.

Based on kitchen service observations, interviews and record review, the facility failed to use gloves correctly to prevent cross contamination. The facility's kitchen staff applied gloves and left them on while touching food and nonfood items. The facility reported a census of 31 residents. Findings include:On 1/20/26 at 11:00 PM, observed the staff puree food. The Dietary Manager (DM) donned (applied) gloves to both hands. After donning gloves she touched the ladle, the pan containing the rolls, placed 6, 6-ounce servings of soup in a container. With the same gloves on, she added 6 rolls, then dumped the contents of the container into a food processor and pureed the food. The DM grabbed the package of bread with the same gloved hands, opened it, and grabbed the 3 pieces of bread out. With the same gloved hands, she tore up the bread, placed them in the food processer and pureed the contents more. The DM poured the soup back into the pan and put the pan in the oven to heat up more. Without changing her gloves or completing hand hygiene, the DM grabbed plates and bowls before arranging them while getting ready for service. She continued wearing the same gloves without hand hygiene, pulled the soup out of the oven, moved some rolls around on the pan and then placed them in the oven.At 12:10 PM Staff C, Dietary Aide (DA)/Cook, came into the kitchen, put gloves on her hands and made sandwiches. She touched the outside of the bread package, the bread, the jar of mayonnaise, slices of bologna, the peanut butter jar, and the knife. Staff C grabbed a container of crackers and took the lid off. The DM grabbed the crackers out of the container as she continued to wear the same gloves and put it on plates alongside the bowls of soup. She used the tongs to grab the rolls. After the completion of the lunch service, the DM acknowledged she did everything mentioned. She stated she should have used tongs for the crackers and she should have changed her gloves after touching non-food items. The DM acknowledged Staff C should have done the same thing. She stated they would change the practice right away. On 1/20/26 at approximately 3:00 PM, the Administrator acknowledged the above concerns. An undated Glove Use & Meal Service policy directed in an effort to protect food products from contamination, all products should be served using utensils. The policy instructed the following:Staff must wash their hands often per the Handwashing policy. Their hands should be washed thoroughly between tasks. Employees should use utensils such as spatulas, scoops, forks and tongs to serve food. If an employee handled raw food, leaves and enters the kitchen, touches equipment handles (i.e. refrigerators, trash can lid) or touches any area of their body - they MUST immediately wash their hands.Gloves may be worn during food preparation but only for single task items (i.e. handling raw chicken).

Based on clinical record review, resident and staff interviews, and policy review the facility failed to develop a comprehensive, person-centered Care Plan for 3 of 4 residents reviewed for falls (Residents #2, #10 and #29). Staff members reported each resident had a history of putting themselves on the floor, but their Care Plans didn't reflect the behavior. The facility reported a census of 31.Findings include: In an interview on 1/21/26 at 3:15 PM with Staff A, Registered Nurse (RN), and the Assistant Director of Nursing (ADON), Staff A stated Resident #2 tries to get out of bed, so they have a mattress and pads on the floor. Staff A added its Care Planned as she is compulsive and gets agitated. She said Resident #10 rolls herself out of bed when she wants up as she does not use the call light. The ADON stated if she rolled out 2-3 times, they would get her up as she probably wanted up. Resident #29 is noncompliant with lots of things and is known to put himself on the floor.In an interview on 1/22/26 at 9:40 AM with the Administrator and the Director of Nursing (DON), the DON stated Resident #2 didn't use the call light and got herself out of bed. They have it Care Planned. They have a mattress and pads on the floor because of the behavior. The DON said Resident #10 rolls herself out of bed and does not use her call light. Resident #29 is known to put himself on the floor and is very noncompliant. The Administrator stated all 3 residents have their behaviors Care Planned.1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] indicated she made herself understood and usually understood others. The staff assessment for mental status reflected she had severely impaired cognitive skills for daily decision making. She had physical behavioral symptoms director towards others for 1 to 3 days in the lookback period. The MDS included diagnoses of Huntington's Disease (a genetic illness that affects the boy that involves uncontrollable dance-like movements, cognitive, and psychiatric symptoms), progressive neurological conditions, and depression. Resident #10 rejected care daily in the lookback period. She had 2 falls without injury in the lookback period. The Care Plan Focuses initiated 3/26/20 indicated Resident #2 had:Multiple risk factors for falls such as: Dementia, high risk medications, and an unsteady gate.A potential for an alteration in behaviors show by physical and verbal episodes with being uncooperative with care and being resistive with activities of daily living (ADLs).The Care Plan lacked documentation that Resident #2 gets herself out of bed and falls.In an interview on 1/21/26 at 3:20 PM Staff B, LPN stated that Resident #2 rolls herself out of bed and it is care planned. She is impulsive and doesn't use her call light. It is a behavior.2. Resident #10's MDS assessment dated [DATE] indicated she usually made herself understood and usually understood others. The MDS identified the staff assessment for cognitive skills for daily decision making listed her as severely impaired. Resident #10 had physical and verbal behaviors in the lookback period. In addition, she rejected care daily in the lookback period. The MDS included diagnoses of repeated falls, Huntington's Disease, and depression. Resident #10 had 1 fall without injury since admission or the last assessment. The Care Plan Focus revised 4/1/22 indicated Resident #10 had a potential for falls related to choreatic movement. The Intervention reflected she had her bed on the floor without a bed frame. She had a fall mat next to the mattress for her safety. The Care Plan lacked documentation that Resident #10 purposely rolled herself out of bed.In an interview on 1/21/26 at 3:20 PM Staff B, Licensed Practical Nurse (LPN), stated Resident #10 rolls out of bed and the facility has it Care Planned. It is a behavior as she is impulsive.3. Resident #29's MDS assessment dated [DATE] indicated he made himself understood and usually understands others. The MDS identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. He rejected care daily in the lookback period. The MDS included diagnoses of progress neurological conditions, non-Alzheimer's dementia, Huntington's disease, and difficulty walking. Resident #29 had 2 falls without injury during the lookback period. On 1/22/26 at 9:05 AM when questioned if he put himself on the floor on purpose, Resident #29 responded yes, then added just kidding when questioned why he does it. When asked if just kidding is why he puts himself on the ground he stated, Yes.In an interview on 1/22/26 at 9:40 AM the Administrator and the DON, the Administrator stated Resident #29 told him that he put himself on the floor because he didn't want to lose Hospice and his massages.The Care Plan Focus revised 10/4/24 reflected Resident #29 needed assistance of 1 staff with ADLs. The Interventions described Resident #29 as very noncompliant with using his call light and getting assistance for care. He attempted to perform his own care and ended up falling. The Care Plan lacked documentation that Resident #29 put himself on the floor on purpose.In an interview on 1/22/26 at 9:40 AM with the Administrator and the DON, the DON stated she expected the staff to document all falls and behaviors with vital signs and an assessment. If the person hit their head or no one witnessed them putting themselves on the floor, she expected them to complete neurological (neuro) checks (a type of assessment to make sure no injury or change in consciousness). She added no one told her that falls are not getting documented. The Administrator added that if a fall is unwitnessed, then it is not a behavior. He brought in the ADON and stated she needed to hear the concerns as all their Care Plans needed reviewed. The ADON stated the residents changed often and she didn't want to be too specific.In a document titled Fall Prevention, Management, and Documentation dated 6/14/25, instructed all falls, whether witnessed or unwitnessed, must be assessed, managed, and documented promptly, accurately and consistently.The facility didn't provide the requested Care Plan policy prior to the exit conference.

Based on clinical record review and staff interview the facility failed to obtain informed consent for psychotropic medications that have black box warnings (the most serious safety warning the Food and Drug Administration (FDA) uses and requires the healthcare provider to have a comprehensive discussion with the resident/representative about the risks, benefits and alternatives for use) for 5 of 5 resident reviewed for psychotropic medications (Resident #1, #2, #3, #4 and #10). The facility reported a census of 31 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS included diagnoses of depression and cerebral palsy (disorder affecting movement, posture, and coordination due to non-progressive damage to the developing brain). Resident #1 received an antidepressant and benzodiazepine (2 types of psychotropic drugs that are used to manage various mental health conditions by balancing chemical neurotransmitters in the brain, which are then released by nerve cells to transmit signals across tiny gaps to other neurons, muscles, or glands, allowing communication for all functions like thought, movement, mood, and sensation in the brain) medication during the 7-day lookback period. The review of Resident #1's clinical physician orders on 1/21/26 included orders for 2 antidepressant medications (sertraline and mirtazapine) and 1 benzodiazepine medication (clonazepam). The Electronic Health Record (EHR) for Resident #1 lacked documentation related to psychotropic consents. 2. Resident #3's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. The MDS included a diagnosis of anxiety. Resident #3 received an antidepressant medication during the 7-day lookback period. The review of Resident #3's clinical physician orders on 1/21/26 revealed orders for an antidepressant medication (Lexapro). The EHR for Resident #3 lacked documentation related to psychotropic medication consents. 3. Resident #2's MDS assessment dated [DATE] identified a staff assessment for mental status indicating they had severely impaired cognitive skills for daily decision making. The MDS included diagnoses of Huntington's disease (HD) (a progressive neurological condition), dementia, and depression. Resident #2 took an antipsychotic and an antianxiety medication in the 7-day lookback period. The Order Summary Report for active orders as of 1/22/26 included orders for clozapine (antipsychotic) for HD and lorazepam (antianxiety) for aggression, restlessness, anxiety and agitation. The EHR lacked documentation of informed consents for psychotropic drug use. 4. Resident #4's MDS assessment dated [DATE] identified a BIMS score of 14, indicating no cognitive impairment. The MDS included diagnoses of HD, dementia, and anxiety. Resident #4 took an antipsychotic and an antidepressant medication in the 7-day lookback period. The Order Summary Report with active orders as of 1/22/26 included orders for clozapine (antipsychotic) for HD, trazodone (antidepressant) for HD, and Paxil (antidepressant) for sexual aggression. The EHR lacked documentation of informed consents for psychotropic drug use. 5. Resident #10's MDS assessment dated [DATE] identified a staff assessment for mental status indicating they had severely impaired cognitive skills for daily decision making. The MDS included diagnoses of HD, dementia and depression. Resident #10 took an antipsychotic, antidepressant and antianxiety medication in the 7-day lookback period. The Order Summary Report with active orders as of 1/22/26 included orders for risperidone (antipsychotic) for HD, bupropion (antidepressant), and lorazepam (antianxiety) for agitation, anxiety and aggression. The EHR lacked documentation of informed consents for psychotropic drug use. On 1/21/26 at 2:05 PM the Administrator reported all medications are done via telehealth with Iowa City so the family and/or resident received information of the medications. The Director of Nursing stated that she didn't have informed consents for psychotropic medications. The facility lacked a policy related to informed consents for psychotropic drug use.

Based on clinical record review, staff interviews, and policy review, the facility failed to separate residents from alleged perpetrator of verbal abuse in a timely manner for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 32 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 3/14/22. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required supervision or touching assistance with eating and substantial/maximal assistance with mobility. The MDS included diagnoses of Huntington's disease and non-Alzheimer's dementia.The Care Plan Focus revised 8/6/25 reflected Resident #1 had a potential nutritional problem related to swallowing issues. The Interventions instructed the following:a. Resident #1 needed a calm, quiet setting at meals with adequate time to eat.b. She used curved utensils, a Kennedy cup (spill proof cup with handle and straw), and a lip plate to promote independence with eating.c. She ate a pureed diet with nectar thickened liquids.The Care Plan Focus dated indicated Resident #1 had a risk for skin integrity and falls related to choreatic movements (involuntary, jerky, and unpredictable muscle movements), poor balance, and impaired ambulation due to Huntington's disease. The Interventions directed to wear a soft helmet for safety.During an interview on 8/26/25 at 8:54 AM, Staff B, Registered Nurse (RN), stated on 7/30/25 around 5:30 PM, she entered the dining room and found Staff A, Certified Nursing Assistant (CNA), sitting next to Resident #2 at the dining table. She witnessed Resident #1 leaning forward in her chair with her head (wearing her soft helmet) down under the table. At the time Staff A used her personal phone. As Staff B approached the table she asked Staff A, what was happening? Staff A responded loudly and aggressively, She fucking does this all the time. She fucking throws her food on the floor. She won't fucking let you feed her. Staff B stated, They (CNAs) weren't doing anything, the resident didn't purposely do these things. Staff B, continued speaking, while Staff A used her phone on speakerphone with her boyfriend, who also used loud profane language. Staff C, CNA, interjected by saying okay, enough with the ‘F' word. Staff A continued laughing and persisted with her behavior. Resident #1 had food all over her with her helmet shifted, covering her eyes and obstructing her vision. Staff B stated she then positioned herself between Staff A and Resident #1 to de-escalate the situation. While cleaning up Resident #1, she spoke gently in an effort to comfort her. Staff B assisted Resident #1 with eating the remainder of her meal without issue. While assisting Resident #1, Staff A continued making sarcastic verbal remarks including Yeah, she doesn't talk, but when I'm in her room and she doesn't like something, she'll fucking let it rip then. Staff B, stated she didn't address any concerns about the incident with Staff A. She added she knew Staff A didn't work with Resident #1 for the rest of the shift. Staff B explained she contacted the Administrator around 9:00 PM, when things calmed down. The Administration instructed Staff B to send Staff A home. Staff B added, she should have pulled Staff A aside and had her leave the facility at the time of the incident and reported it to the Facility Administrator at that time. In an interview on 8/26/25 at 10:45 AM, Staff C explained, Resident #1 had crazy uncontrolled movements because of having Huntington's chorea, that caused her to repeatedly drop her spoon and the CNAs constantly had to pick it up. On 7/30/25 as the CNAs help the resident's eat supper, Resident #1 leaned forward, reaching down under the table to grab her spoon that fell on the floor. Because of the material of Resident #1's helmet it kept catching on the underside of the table making it so she couldn't sit back up. At the time Staff B, asked what was going on, they had to move the table so Resident #1 could sit back up. Staff C added Staff A got frustrated and used the F bomb saying she did this all the fucking time. Staff C stated Staff A stayed at the dining table assisting another resident finish eating dinner and continued to provide care for residents throughout the shift. Staff C, reported being confused when she received a call the next day about the incident with Resident #1. The situation happened at supper around 5-6 PM, Staff B didn't act on the situation at all. Staff C said Staff B should have asked someone to stay for Staff A and sent her home. An interview on 8/26/25 at 1:24 PM, Staff D, CNA, reported, Resident #1 kept dropping her silverware. When Staff B approached asking what was going on, Staff A responded she does this all the fucking time. At the time, Staff B assisted Resident #1 eat the rest of her meal. Staff D, stated her shift ended at 6:30 PM and Staff A still worked when she left. During an interview on 8/27/25 at 11:35 AM, Staff A, stated Resident #1 got stuck under the table. Staff A and another CNA had to move the table for her to be able to sit back up. At that time Staff B entered the dining room and said I've never seen her (Resident #1) like this. Staff A, acknowledged she responded out of frustration, she does this all the fucking time. After the incident Staff A, stated she finished helping resident eat dinner, got them settled in to bed, and the rest of the night ran like normal. At 9:55 PM Staff A, stated Staff B approached her and told her that her language could be considered verbal abuse. Staff B notified the facility Administrator, and they directed Staff B to tell her to leave the facility. Staff A reported she didn't have any communication after the incident at dinner until Staff B told to leave at 9:55 PM. The Abuse Prevention, Identification, Investigation, and Reporting policy, reviewed 10/17/24, directed the following:a. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative.b. Upon receiving a report of an allegation of resident abuse, neglect, exploitation, or mistreatment, the facility shall immediately implement measures to prevent further potential of abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: i. Suspending the employee ii. Segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances iii. Separating the employee accused of abuse from the resident alleged to have been abused but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents.

Based on record review, policy review, resident, and staff interviews, the facility failed to treat residents with dignity and respect while assisting with their activities of daily living (ADL) for 2 of 5 residents reviewed (Residents #1 and #2). The facility reported a census of 32 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 3/14/22. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required supervision or touching assistance with eating and substantial/maximal assistance with mobility. The MDS included diagnoses of Huntington's disease and non-Alzheimer's dementia.The Care Plan Focus revised 8/6/25 reflected Resident #1 had a potential nutritional problem related to swallowing issues. The Interventions instructed the following:a. Resident #1 needed a calm, quiet setting at meals with adequate time to eat.b. She used curved utensils, a Kennedy cup (spill proof cup with handle and straw), and a lip plate to promote independence with eating.c. She ate a pureed diet with nectar thickened liquids.The Care Plan Focus dated indicated Resident #1 had a risk for skin integrity and falls related to choreatic movements (involuntary, jerky, and unpredictable muscle movements), poor balance, and impaired ambulation due to Huntington's disease. The Interventions directed to wear a soft helmet for safety.During an interview on 8/26/25 at 8:54 AM, Staff B, Registered Nurse (RN), stated on 7/30/25 around 5:30 PM, she entered the dining room and found Staff A, Certified Nursing Assistant (CNA), sitting next to Resident #2 at the dining table. She witnessed Resident #1 leaning forward in her chair with her head (wearing her soft helmet) down under the table. At the time Staff A used her personal phone. As Staff B approached the table she asked Staff A, what was happening? Staff A responded loudly and aggressively, She fucking does this all the time. She fucking throws her food on the floor. She won't fucking let you feed her. Staff B stated, They (CNAs) weren't doing anything, the resident didn't purposely do these things. Staff B, continued speaking, while Staff A used her phone on speakerphone with her boyfriend, who also used loud profane language. Staff C, CNA, interjected by saying okay, enough with the ‘F' word. Staff A continued laughing and persisted with her behavior. Resident #1 had food all over her with her helmet shifted, covering her eyes and obstructing her vision. Staff B stated she then positioned herself between Staff A and Resident #1 to de-escalate the situation. While cleaning up Resident #1, she spoke gently in an effort to comfort her. Staff B assisted Resident #1 with eating the remainder of her meal without issue. While assisting Resident #1, Staff A continued making sarcastic verbal remarks including Yeah, she doesn't talk, but when I'm in her room and she doesn't like something, she'll fucking let it rip then.In an interview on 8/26/25 at 10:45 AM, Staff C explained, Resident #1 had crazy uncontrolled movements because of having Huntington's chorea, that caused her to repeatedly drop her spoon and the CNAs constantly had to pick it up. On 7/30/25 as the CNAs help the resident's eat supper, Resident #1 leaned forward, reaching down under the table to grab her spoon that fell on the floor. Because of the material of Resident #1's helmet it kept catching on the underside of the table making it so she couldn't sit back up. At the time Staff B, asked what was going on, they had to move the table so Resident #1 could sit back up. Staff C added Staff A got frustrated and used the F bomb saying she did this all the fucking time. An interview on 8/26/25 at 1:24 PM, Staff D, CNA, reported Resident #1 kept dropping her silverware. When Staff B approached asking what happened, Staff A responded she does this all the fucking time. Staff B helped Resident #1 eat the rest of her meal. During an interview on 8/27/25 at 11:35 AM, Staff A, stated Resident #1 got stuck under the table. Staff A and another CNA had to move the table for her to be able to sit back up. At that time Staff B entered the dining room and said I've never seen her (Resident #1) like this. Staff A, acknowledged she responded out of frustration, she does this all the fucking time. 2. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderate cognitive impairment. Documented behaviors including delusions and other behaviors not directed towards other. Resident #2 used a wheelchair and could propel self. The MDS included diagnoses of stroke, schizophrenia, anxiety disorder, borderline personality disorder, and a history of falls.The Care Plan Focus revised 8/14/25, indicated Resident #2 had an indwelling urinary catheter. The Care Plan Focus revised 9/18/23 identified Resident #2 had a behavior problem related to borderline personality disorder. The Interventions directed the following:a. At times, using a stern mom voice is the only way to get Resident #2 to focus on reality and not hallucinations.b. Caregivers provide an opportunity for positive interactions and attention. They should stop and talk to her as they pass her.The Care Plan Focus revised 12/5/19 reflected Resident #2 had bowel incontinence related to her diet.The Care Plan Focus revised 12/5/19 indicated Resident #2 had an ADL self-care performance deficit. The Interventions instructed the following:a. She required a standing mechanical lift with the assistance of 2 staff. b. Praise all efforts of self-care.c. Resident #2 required the assistance of 2 staff to use the toilet.d. Encourage her to participate to the fullest extent possible with each interactions.In an interview on 8/26/25 at 10:45 AM, Staff C stated on 8/5/25 around 12:00 PM Resident #2 sat in her wheelchair propelling herself from the lobby area to her room. When she got tired, she started to cry because she needed to have a bowel movement. Staff C went to get Resident #2's foot pedals for the wheelchair. Staff C encouraged Resident #2 to propel herself to the beginning of the hallway. Staff C stated by the time she found the pedals, Staff E, Certified Medication Aide (CMA), positioned themselves in front of Resident #2 and pushed her backwards in the wheelchair, with her feet dragging on the floor, as 2 other CNAs watched. During this time, Resident #2 cried due to having to go to the bathroom. Staff C stated the facility's policy and proper procedure is to always use foot pedals on the wheelchair when moving residents from one area to another.During an interview on 8/26/25 at 1:45 PM, Staff E stated Resident #2 returned from the hospital on 8/5/25 and could propel her wheelchair independently. When Resident #2 propelled around she said she had to go poop right away and couldn't hold it. Staff C told Resident #2, they had to go get foot pedals to put on the wheelchair to push her to the bathroom. Staff E stated, while Staff C was getting the foot pedals, she (Staff E) turned Resident #2's wheelchair around and stood in front of her and pushed her backwards down the hallway but could not recall if Resident #2's feet were bouncing on the floor or not. Staff E explained, she stood in front of Resident #2 in case she slipped or came out of the wheelchair, she could stop her from falling. Staff E acknowledged the protocol as wheelchairs needed foot pedals on when pushing residents in the wheelchair.The Resident's Rights Policy, reviewed 10/7/24, stated, each and every resident of this facility has the following rights:a. To be treated with respect and dignity in recognition of individuality and preferences.b. The right to quality of care and treatment that is fair and free from discrimination. The Resident Dignity policy reviewed 10/17/24, instructed to the facility to treat each resident with respect and dignity, with care delivered in a person-centered way to preserve individuality, autonomy, and quality of life. The facility is committed to promoting and protecting the dignity of all residents. The staff, contractors, volunteers, and visitors must treat residents with respect, uphold their right, and foster an environment where choices, preferences, and self-determination are honored at all times. Every resident has the right to a dignified existence and self-determination. The facility must treat individuals with respect and care in a way that supports their quality of life and individuality. The Cell Phone policy, reviewed 10/7/24, instructed the following:a. Personal cell phone use during work hours must not interfere with resident care, staff responsibilities, or the professional atmosphere of the facility.b. Resident dignity and privacy are the highest priority; staff are strictly prohibited from using cell phones in ways that compromise confidentiality.The Wheelchair Foot Pedal Use policy, reviewed 10/17/24, directed wheelchairs require foot pedals (footrests) and used whenever a resident is being transported regardless of independence level to prevent lower-limb injury and maintain safe positioning.

Based on observation, clinical record review, staff interviews, and facility policy/procedure review, the facility failed to follow the 5 rights of medication administration and physician orders to prevent a medication error from occurring. On 5/3/25, during the morning medication pass, a Registered Nurse (RN) took Resident #2's oral medications and gave them to Resident #1. The facility reported a census of 34 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected they could usually make themselves understood and understood others. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS listed Resident #1 as dependent in all activities of daily living (ADL). The MDS included diagnoses of non-Alzheimer's dementia and Huntington's disease. The Care Plan included Focuses of: a. Revised 2/26/20: Resident #1 has impaired cognitive function/dementia or impaired thought processes related to Huntington's Disease. The Interventions directed the following: i. Needs assistance with all decision making. ii. Administer medications as ordered. The Employee Counseling/Disciplinary Form dated 5/3/25 at 11:00 AM labeled Incident Description, documented on 5/3/35 approximately 11:00 AM, Staff A, Registered Nurse (RN), administered a noon does of clonazepam (a medication to treat seizures and panic disorder) 2 milligrams (mg) and Hydroxyzine 25 mg (used to help manage anxiety and tension) intended for Resident #2 to Resident #1 in error. Staff A identified the error approximately 10 minutes later when they went to document the medication administration in the electronic Medication Administration Record (MAR) and noted Resident #2's photo did no match the individual who received the medication. Upon recognizing the error, Staff A, immediately followed protocol. She notified the administrative staff, on-call provider, and Resident #1's family. She did a full assessment of Resident #1 and found no adverse reactions at the time. Staff A contacted the pharmacy to replace the administered medications. Staff A documented the incident per facility protocol, and submitted a medication error report. The Health Status Note 5/3/25 at 1:25 PM, identified at 12:40 PM, the staff discovered Resident #1 received 2 milligrams (mg) clonazepam (antianxiety medication) and 25 mg hydroxyzine (anti-itch medication used to treat anxiety) which he didn't normally get. The staff immediately assessed Resident #1. The assessment revealed the following vital Signs: a. Blood pressure (BP) - 94/58 (average 120/80) b. Temperature - 97.5 (average 98.6) c. Pulse - 92 (average 80 - 100) d. Respirations - 18 (average 12 - 20) e. Oxygen saturation - 96% on room air (average greater than 90%) Resident #1 didn't display any signs or symptoms of pain/discomfort. The staff notified the Advance Registered Nurse Practitioner (ARNP) and Power of Attorney (POA). The staff received an order to monitor for 48 hours, then continue to monitor per facility protocol. The POA reported she would call back later in the day to check on Resident #1, and would follow up with any changes. An email to the attending physician dated 5/3/25 at 1:37 PM, indicated the facility sent a quick update that Staff A gave Resident #1, Resident #2 noon medications. (clonazepam and hydroxyzine). Per protocol, they notified the provider and submitted a medication error report. They monitored Resident #1 closely, and he had vitals at baseline with no noticeable lethargy or reaction noted. They planned to continue to monitor. On 5/4/25 at 9:13 AM, the attending physician replied, thank you duly noted. The Health Status Note dated 5/3/25 at 4:52 PM indicated the staff assessed Resident #1 due to noted lethargy (sleepiness) and decreased interactivity when staff approached him to get him up from his nap to have supper. The assessment reflected the following: a. Temperature - 97.0 b. Pulse - 70 c. Respirations - 15 d. Blood Pressure - 123/68 e. Spo2 - 98% on room air. Resident #1 had his head of bed (HOB) elevated. The staff repositioned Resident #1 and noted his pupils as equal and reactive to light. Resident #1 opened his eyes but didn't respond to questions or react to verbal stimuli. The note described Resident #1's color as pink, with warm and dry skin. Resident #1 had even respirations with noted audible (loud breath) chest congestion (a gurgle sound). The staff documented no coughing or sobbing noted. The staff spoke with the facility's on call-provider to discuss Resident #1's condition. They instructed to monitor for the time being. The Health Status Note dated 5/4/25 at 12:18 AM identified Resident #1 as more and more alert when the nurse looked in on him to assess his condition that night. The nurse did several checks with vital signs, neuro checks and providing stimuli to assess resident responsiveness and level of consciousness. Resident #1's vital signs remained with in normal limits with each assessment and by the end of the shift, he responded with change in affect (facial expression). The nurse held Resident #1's medications as they didn't notice he could swallow safely. The nurse attempted to give Resident #1 small sips of thickened water but he didn't swallow. The staff left Resident #1's HOB left up and planned to attempt more as he became more alert. The note included the following vital signs: a. Temperature - 96.9 b. Pulse - 69 c. Respirations - 18 d. Blood Pressure - 120/52 e. Spo2 - 96% on room air. The Health Status Note dated 5/4/25 at 1:34 PM reflected the facility continued monitoring Resident #1. He had episodes of lethargy that shift but did respond at times, he had a decreased appetite noted, but had vital signs within normal limits (WNL). He didn't interact much with staff, but didn't have signs or symptoms of pain or discomfort. They facility planned to continue to follow-up. The Health Status Note dated 5/5/25 at 12:20 AM, described Resident #1 as alert and reactive, responding per his baseline (how he usually acts). The nurse assessed some mild audible congestion in his lungs, however he can cough and clear the congestion. Resident #1 didn't get up for dinner that night but received fluids and medications late that evening. The Health Status Note dated 5/5/25 at 3:55 AM described Resident #1 as awake, responding, and smiling earlier in the night shift. He awoke easily and had no visible signs of pain or discomfort noted. The Health Status Note dated 5/5/25 at 2:49 PM described Resident #1 as awake and alert that shift. He interacted with staff. He did have delayed swallowing at the morning meal, but had no other complaints or concerns that shift. 2. Resident #2's MDS assessment dated [DATE], identified a BIMS score of 9, indicating moderately impaired cognition. The MDS included diagnoses of non-Alzheimer's dementia, Huntington's (a disease passed on from family that causes breakdown of the brain's nerve cells. The illness is rare, it causes uncontrollable movements, changes in behavior and memory) disease, anxiety and difficulty in walking. The MDS documented Resident #2 received antipsychotic, antianxiety and antidepressant medications in the lookback period. The Care Plan Focus initiated 6/14/21 indicated Resident #2 had anxiety related to an altered mentation (changes in behavior, alertness, and memory) and changes in the environment. The Interventions directed to: a. Administer his medications per the physicians' orders b. Takes hydroxyzine, this medication is an anti-anxiety, also takes clonazepam, this is an anti-convulsant and has a black box warning. c. Concomitant (Use of multiple medications) use of benzodiazepines (antianxiety medications) and opioids (controlled pain medications) may result in profound (extreme) sedation (tiredness), respiratory depression (inability to breath), coma (inability to wake up from sleep), and death. Reserve (try to not use) concomitant prescribing of those drugs for use in patients who had inadequate alternative treatments options. Limit dosages to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. The Progress Notes lacked documentation of a medication error on 5/3/25. On 5/29/25 observed Staff A during the medication pass. She followed the 5 rights for administration of medications and followed the physician orders as written. On 5/29/25 at 1:00 PM, Staff A reported around 11:00 AM, she took medications out of the medication cart and proceeded to get them ready for Resident #2. Staff A explained that as they went to Resident #2, they accidentally gave the medication to Resident #1. Staff A, stated they knew right away the medication error occurred. They called the on-call provider, Director of Nursing (DON), and Resident #1's family. Staff A, explained they received the education for the 5 rights of medication administration and following physician orders. On 5/29/25 at 2:15 PM, the DON verified they expected the nursing staff to follow the physician's orders as written and follow the medication administration policy for the 5 rights. The Medication Administration Policy dated January 2025 described the purpose of the policy as to ensure safe, accurate, and consistent administration of medications to residents in the nursing home in compliance with professional standards of practice, Federal, and State regulations. The policy applied to all licensed nursing staff, medications aides, and other personnel authorized to handle or administer medications within the facility. The Five (plus one) Rights of Medication Administration directed the following: a. Right resident (verify two identifiers) b. Right medications (compare to MAR) c. Right dose d. Right route e. Right time/frequency f. Right documentation (document immediately after administration)

Based on record review, staff interviews, policy review and staff timecard punch detail, the facility staff who witnessed an alleged abuse to a resident on 1/3/25 failed to report the incident to the facility administration or the Department of Inspections, Appeals, and Licensing. Due to the facility's staff failing to report the alleged abuse to the Administration, the facility Administration failed to separate the alleged abuser from the resident for 1 residents reviewed for alleged abuse (Resident #1). The Administrator reported he didn't learn of the situation until 1/10/25, allowing the alleged abuser to continue to work with Resident #1 and other residents in the facility for approximately 7 days after the incident. Please refer to deficiency F609 for additional information. The facility reported a census of 35 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. The MDS included a diagnosis of Huntington's disease (causes nerve cells in the brain to decay over time, affecting the person's movements, thinking ability, and mental health). The Care Plan Focus revised 10/27/22 described Resident #1 as a smoker, who required supervision to smoke. During an interview on 2/17/25 at 12:25 PM, Staff A, Certified Nurse Aide (CNA), reported she worked with Staff B, CNA, and Staff C, CNA, on 1/3/25. After she came in the building after she took residents out to smoke, Resident #1 came up to smoke late. Staff A reported as she assisted another resident take off her coat, Resident #1 grabbed a smoking protector. Staff D, Registered Nurse (RN), yelled at Resident #1 saying it was too late to smoke. As Resident #1 tried to go out the door, Staff D pulled her arm and grabbed her away from the door. Resident #1 then walked down the hallway to her room. Staff A reported Staff B and her wrote written statements, then slid them under the Administrator's door but the statements never got to the Administrator. During a follow-up interview on 2/17/25 at 12:51 PM, Staff A reported after she witnessed Staff E, Licensed Practical Nurse (LPN), grab Resident #1's other arm when she tried to go outside to smoke, she didn't separate the alleged abuser from the residents because her brain froze. During an interview on 2/18/25 at 3:40 PM, the Administrator reported he first learned of the allegation of abuse against Resident #1 on 1/10/25 after Staff A's staffing agency, who employed her, contacted him via the phone reporting Staff A reported the alleged abuse to the staffing agency. The Administrator added he expected the staff report allegations of abuse right away. Review of Staff D's timecard punch detail reflected she worked the following dates and times, after the alleged incident prior to her suspension: a. 1/3/25: 7:58 PM-6:20 AM b. 1/4/25: 7:58 PM-6:37 AM c. 1/5/25: 9:52 PM-6:26 AM d. 1/7/25: 8:00 PM-6:23 AM e. 1/8/25: 7:58 PM-6:39 AM f. 1/9/25: 7:53 PM-6:26 AM Review of facility policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 indicated upon an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents.

Based on record review, staff interview and policy review, the facility failed to report an allegation of abuse timely for 1 of 1 residents reviewed for alleged abuse (Resident #1). The facility reported a census of 35 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. The MDS included a diagnosis of Huntington's disease (causes nerve cells in the brain to decay over time, affecting the person's movements, thinking ability, and mental health). The Care Plan Focus revised 10/27/22 described Resident #1 as a smoker, who required supervision to smoke. During an interview on 2/17/25 at 12:25 PM, Staff A, Certified Nurse Aide (CNA), reported she worked with Staff B, CNA, and Staff C, CNA, on 1/3/25. After she came in the building after she took residents out to smoke, Resident #1 came up to smoke late. Staff A reported as she assisted another resident take off her coat, Resident #1 grabbed a smoking protector. Staff D, Registered Nurse (RN), yelled at Resident #1 saying it was too late to smoke. As Resident #1 tried to go out the door, Staff D pulled her arm and grabbed her away from the door. Resident #1 then walked down the hallway to her room. Staff A reported Staff B and her wrote written statements, then slid them under the Administrator's door but the statements never got to the Administrator. During a follow-up interview on 2/17/25 at 12:51 PM, Staff A reported witnessing Staff E, Licensed Practical Nurse (LPN), grab Resident #1's other arm when she tried to go outside to smoke and moved her away from the door. Staff A stated she didn't separate the alleged abuser from the residents because her brain froze. During an interview on 2/17/25 at 12:42 PM, Staff B explained on 1/3/25 Resident #1 didn't come with the other residents for their 8:00 PM smoke break, adding she came up at 8:06 PM. Staff B described Staff D, RN, as adamant Resident #1 couldn't go out to smoke since she came late. At that time Resident #1 became very upset and began having behaviors. Staff B reported Staff D and Staff E grabbed Resident #1 in the triangle area by the nurse's station and the beginning of the 200 hallway, then dragged her down the hall to the inside of her room while Resident #1 screamed and tried to get out of their grasp. Staff B reported Resident #1 screamed for 1/2 an hour because she couldn't go out to smoke. Staff B reported she couldn't write a statement at the time of the incident due to being busy but wrote one out the next day with the dates and times, then turned it into the office. Staff B explained she reported the allegation within 24 hours as the facility didn't have anyone to report it to that night due to the involvement both of the nurses working. During an interview on 2/17/25 at 1:25 PM, Staff C reported as she came out of the dining room on 1/3/25 around 8:00 PM, she saw Staff D coming onto her shift, then she saw Staff D yank Resident #1's right arm. Staff C explained Resident #1's had her back to the wall by the exit door, when Staff D told her they wouldn't allow her to go outside and smoke because she missed the smoke break. Staff C reported Resident #1 left the doorway area and walked down to her room independently. Staff D walked the opposite direction following the incident. Staff C reported Staff E also yelled at Resident #1 but like a puppet as she followed Staff D. Staff C reported she would have seen if Staff E grab Resident #1's other arm, which she didn't as Staff E stood behind Staff D. Staff C stated Staff A and Staff B told her what they witnessed and she told them to report it to whomever they needed to tell. Staff C stated she reported the incident to the Assistant Director of Nursing (ADON) at work the next time, the next Tuesday, she saw her at work. Review of facility policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 indicated all allegations of resident abuse should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made. If the person in charge is the alleged abuser, the staff member shall directly report the abuse to the Department immediately, pursuant to the deadlines established above. During an interview on 2/18/25 at 3:40 PM, the Administrator reported he first learned of the allegation of abuse against Resident #1 on 1/10/25 after Staff A's staffing agency, who employed her, contacted him via the phone reporting Staff A reported the alleged abuse to the staffing agency. The Administrator added he expected the staff report allegations of abuse right away.

Based on observations, policy review, and staff interviews, the facility failed to lock an unattended treatment cart and medication cart in a resident care area. The facility reported a census of 33 residents. Findings include: Observations on 6/27/22 revealed the following: a) 7:30 AM- Unattended treatment cart with keys on a lancet hanging from the unlocked locking mechanism near the nurse's station. b) 7:31 AM - Administrator walked by and removed the keys from the cart but did not lock the cart. c) 7:32 AM - Administrator walked by the unlocked cart. d) 7:33 AM - A resident and one staff member walked by the unlocked cart. e) 7:36 AM - Two staff members walked by the unlocked cart. f) 7:37 AM - Two residents and two staff members walked by the unlocked cart. g) 7:39 AM- One staff member walked by the unlocked cart. h) 7:40 AM- One resident walked by the unlocked cart. i) 7:41 AM- The Director of Nursing (DON) approached the unlocked treatment cart and locked it. Upon request the DON unlocked the treatment cart and observed numerous prescription treatments in the cart. The DON acknowledged that the treatment cart had been unlocked and was left unattended. On 6/28/22 at 1:52 PM the DON revealed that she expected the treatment carts to remain locked when staff were not present. During an observation 6/28/22 at 3:36 PM, Staff A, Registered Nurse (RN), walked away from the medication cart without locking it in a resident care area near the nurse's station. Staff A went to administer medications to a resident in the 100 hallway. The medication cart remained unlocked and unattended from 3:29 PM until 3:31 PM when Staff A returned to the medication cart. Staff A acknowledged that the medication cart had been unlocked. The facility policy titled Administering Medication revised 5/1/20 revealed the following: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications should be kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. During an interview on 6/28/22 at 3:40 PM the DON revealed she expected the staff to keep the medication carts locked when staff weren't present.

Based on clinical record review, policy review, and staff interviews the facility failed to follow through completing the Pre-admission Screening and Resident Review (PASRR) for 1 of 1 reviewed with PASRR (Resident #29). The facility reported a census of 33. Findings included: Resident #29's Minimum Date Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition for daily decision making. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #29 as not considered state level II PASRR to have a serious mental illness and/or intellectual disability. Resident #29's Care Plan Focus dated 8/19/19 indicated that she had a potential for alteration in behavior manifested by physical and verbal episodes. Resident #29 could be uncooperative with cares and resistive with activities of daily living (ADL). The included goal with a target date of 7/25/22 directed staff to redirect her during episodes of inappropriate behavior. The Care Plan lacked information about a PASRR assessment. The information form titled [Company Name] for Resident #29 included they reported through level I on 10/1/21. Resident #29's clinical record lacked a PASRR assessment. The document titled Policy/Procedure updated 8/31/21 under the section labeled Intent indicated it was the policy of the facility to assure that all residents admitted to the facility received a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. On 6/28/22 at 2:53 PM the Administrator acknowledged that the PASRR did not get completed. He explained that after talking to the PASRR company, the facility had two accounts and the PASRR company sent a response to the other account so nothing changed on her PASRR from the level one. The Administrator reported that they were rebuilding PASRR that day.

Based on clinical record reviews, policy review, family, and staff interviews the facility failed to provide updated information when change occurred with a resident for 1 of 1 resident (Resident #33). The facility reported a census of 33 residents. Findings included: Resident #33's Minimum Data Set (MDS) dated [DATE]documented that her Cognitive Skills for Daily Decision Making were Severely impaired (never/rarely made decisions). The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33 Care Plan Focus dated 5/1/19 indicated that she had an impaired cognitive function. The interventions revised 9/16/21 directed staff to provide her with a homelike environment and to administer her medications as ordered. The Care Plan also included a Focus related to a nutritional problem dated 4/9/19. The included intervention directed staff to provide diet as ordered, provide, and serve the supplements as ordered. The document Resident Bill of Rights dated 11/16 included the following: Notification of changes. 1. A facility must immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority the resident representative when there is a. An accident involving the resident which in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental or psychosocial status. c. A need to alter treatment Resident #33's Progress Notes included the following: a. The Health Status Note dated 2/5/21 at 9:37 AM indicated the facility received a call from the Advanced Registered Nurse Practitioner (ARNP). The ARNP gave an order to draw labs on 3/4/21 lab day b. The Health Status Note dated 2/25/21 at 11:49 PM documented that during Resident #33's shower, the Certified Nurse Aides (CNA's) found a large bruise that measured 16 inches (in.) by 6 in, from Resident #33's left arm pit to her right breast. The bruising noted to be dark purple to green trim in color. The nurse called ARNP. c. The Health Status Note dated 3/11/21 at 2:54 PM recorded that the ARNP came to the facility for rounds. The ARNP reviewed Resident #33's labs and gave an order change Resident #33's [MEDICATION(S)] from a tablet form to a liquid form. The ARNP ordered to recheck Resident #33's [CONDITION(S)] lab in eight weeks. d. The Health Status Note dated 5/6/21 at 8:59 PM indicated that Resident #33 had a shower, and the staff observed a bruise to top of her head. Resident #33's daughter did not get contacted due to time. The ARNP contact through book. No known cause. The area measured 3 centimeters (cm) with a circular and light purple appearance. The progress notes lacked notification to Resident #33's Representive related to the above items. On 7/5/22 at 2:07 PM the Director of Nursing (DON) explained she would expect the staff to notify the family with any change of condition change in medication, really with anything.

Based on clinical record reviews and staff interviews, the facility failed to notify residents of charges for services provided for 1 of 3 residents reviewed in a timely manner (Resident #184). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE] for Resident #184. The MDS listed a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition for decision making. The Centers for Medicare & Medicaid Services (CMS) form documented the last day of Medicare A services as 3/5/22. The CMS form documented Resident #184 reached his goals to strengthen and could go home. Resident #184 signed the form on 3/4/22. Review of progress notes revealed Resident #184 discharged from the facility 3/5/22. During an interview 6/29/2022 at 1:35PM the Administrator revealed that he expected residents to be given 2 days notice regarding services ending unless they left Against Medical Advice (AMA), hospice, a change in their level of care, or if the resident left early.

Based on clinical record reviews and staff interviews the facility failed to complete a comprehensive assessment after a significant change for 3 of 3 residents reviewed (Residents #1, #14, and #25). The facility reported a census of 33 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident received hospice care during the last 14 days of the lookback period. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's electronic health record lacked documentation of a significant change comprehensive assessment after Resident #1 went on hospice level of care. 2. Resident #25's MDS dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident received hospice care during the last 14 days of the lookback period. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #25's electronic health record lacked documentation of a significant change comprehensive assessment after Resident #25 went on hospice level of care. The Acute Change in Condition Policy, implemented 3/19/12 under the section Documentation Guidelines indicated that documentation may include initiating a change of condition on the MDS. During an interview 7/5/22 at 11:35 AM the MDS nurse acknowledged that she did not complete a significant change as expected for Resident #1 or Resident #25 when they started on hospice services. 3. Resident #14's MDS dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired (poor decisions and supervision required) cognition for daily decision making. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented that Resident #14 used hospice services within the last 14 days in the lookback period. Resident #14's Care Plan Focus revised 4/16/22 indicated that he used hospice services. The Focus included an intervention that directed staff to reassure him that they would meet his care needs and would provide comfort. The Physicians Order dated 1/11/22 included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #14's Hospice Plan of Care indicated his certification period as 1/13/22 to 4/12/22. On 6/29/22 at 11:44 AM the Administrator acknowledged that he would expect a significant change MDS to be done when a resident admitted to hospice services. On 7/5/22 at 11:41 AM the MDS Coordinator reported that she did not realize she needed to do a significant change MDS when a resident went on hospice services.

Based on clinical record reviews, policy review, and staff interviews, the facility failed to limit an as needed (PRN)antipsychotic medications to fourteen days and failed to ensure an in person evaluation got completed by the prescribing practitioner prior to continuation for 1 of 1 residents reviewed (Resident #22). The facility reported a census of 33 residents. Findings include: Resident #22's Minimum Data Set (MDS) dated [DATE] included diagnoses of [CONDITION(S)] and anxiety disorder. The Medication Administration Records (MAR) for the months of March 2022, April 2022, May 2022 revealed an order started on 3/25/22 for [MEDICATION(S)] 5 milligrams (MG) by mouth PRN for antipsychotic. The order documented a discontinuation date of 5/10/22. The clinical record lacked documentation related to a new order for the PRN [MEDICATION(S)]. In addition the clinical record lacked documentation to indicate the prescribing Practitioner evaluated Resident #22 after 14 days. The facility policy titled, Pharmacy Services-Drug Regimen Free From Unnecessary Drugs dated 8/31/21 recorded that PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing Practitioner evaluates the resident for the appropriateness of that medication. During an interview on 6/29/22 at 10:33 AM the Administrator revealed he couldn't locate a physician's visit every 14 days as expected since the start of the PRN [MEDICATION(S)] until the order got discontinued.

Based on observation, record review and resident and staff interviews, the facility failed to assess and provide timely interventions for 2 of 4 residents reviewed with adverse symptoms and change in skin conditions (Resident #3, #6). The facility reported a census of 34 residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 9/7/16 assessed Resident #3 with a brief interview for mental status score of 15 (no cognitive impairment). The resident required limited staff assistance with transfers, dressing, toileting and personal hygiene. The MDS identified the resident with open [MEDICAL CONDITION] other than ulcers and identified the resident at risk for pressure sores. The MDS identified the resident used pressure reduction for the chair and bed and applications of dressings and ointments. On 9/22/16 at 11:18 a.m. the resident stated he/she had a bed sore on the right buttock. The resident stated he/she had the sore off and on for the past few weeks. The resident stated staff sometimes puts cream on the area. The resident stated nothing was on it at the present time. On 9/28/16 at 2:45 p.m. Staff D CNA assisted the resident to a standing position. Observation identified a red area with 25 cent size whitish peeling area in the center of the red area. There was nothing covering the area and no appearance of ointment on the area. On the same date at 3:05 p.m. the surveyor asked the director of nursing (DON) to measure the area. At that time, Staff D stated she applied ointment to the buttock area after the surveyor observed the area. The DON cleansed the ointment Staff D just applied from the area and measured a 1.3 centimeter (cm.) by 1 cm. scabbed peely area. The DON applied [MEDICATION NAME] to the area. [MEDICATION NAME] is foam dressing suitable for a wide range of wounds like pressure ulcers. The DON stated the area comes and goes. The nursing Progress Notes dated 1/10/16 identified the staff initially observed an abrasion to the right buttock measuring 0.6 cm. by 0.2 cm. Documentation dated 5/7/16 at 12:57 p.m. indicated the area was improving. The record lacked evidence the area healed. On 7/3/16 at 2:11 p.m. the nursing notes identified a red area noted to the right buttock. Staff documented the area was a skin issue before. There were no further entries regarding the right buttock until 7/21/16 at 2:23 p.m. when staff documented they completed skin sheets for the right buttock area and also advised to begin the application of [MEDICATION NAME]. A non-pressure skin condition report identified staff first identified an area to the coccyx/buttocks on 7/20/16. On 7/21/16 the area measured 4 cm. by 0.5 cm. On 8/1/16, the area measured 3 cm. by 0.5 c.m. The report had no further evidence of a measurement (assessment) until 8/31/16 when the area measured 1 cm. by 0.5 cm. The area measured 0.2 cm on 9/9/16. The next measurement was 9/22/16 and the area measured 0.2 cm. On 9/28/16 the DON added her entry to reveal the area measured 1.3 cm. by 1 cm. The CNA shower sheets identified CNAs wrote the following regarding the right buttock in August 2016: 8/13/16 open area 8/24/16 spot on right butt cheek 8/27/16 small area on right buttock that looks open Consolidated orders signed and dated 9/21/16 identified an order for [REDACTED]. Change every 3 days until healed since 4/25/16. Review of the July 2016 treatment administration record (TAR) identified no Meplilex on the July 2016 TAR. Review of the August 2016 TAR identified [MEDICATION NAME] on the TAR but no staff signed they applied the [MEDICATION NAME]. Review of the September 2016 TAR revealed staff began initialing they applied Meplilex on 9/22/16. The nursing Progress Notes indicated the DON notified the ARNP (advanced registered nurse practitioner) on 9/29/16 at 10:10 a.m. of the right buttock skin concern. The ARNP ordered Mepliex and [MEDICATION NAME] AG (silver dressing). Staff should change the Mepliex every 3 days until healed. On 9/29/16 observation showed the resident seated in a recliner without pressure reduction at 11 a.m., 11:55 a.m., 12:10 p.m., 1:30 p.m., 2:30 p.m. and 3:40 p.m. The facility policy/procedures titled Skin Management, revised on November 2014; identified residents with wounds and /or pressure ulcers and those at risk are identified, assessed and provided appropriate treatment to encourage healing. Staff would provide ongoing monitoring and evaluation to ensure optimal resident outcomes. The skin management portion of the policy directed staff, they would document weekly on the non-pressure skin condition record. The current Care Plan contained an addendum intervention, undated, that identified the resident at risk for skin issues related to scooting in chair and sometimes sleeping in a recliner. The intervention directed the staff to encourage the use of an anti-pressure cushion with cover to promote easier scooting and inform charge nurse of any new skin issues. On 9/29/16 the facility conducted a staff in-service on skin concerns. It directed staff to report all concerns to the charge nurse, measure areas and notify physician immediately for new or worsening areas, notify family, complete and update skin sheets, follow orders as written and document progress and notify and complete all steps if no improvement weekly. 2. Resident #6 had a MDS assessment with a reference date of 6/8/16. The MDS indicated Resident # 6 had a BIMS score of 11 (moderate cognitive impairment). The resident required limited staff assistance with bed mobility and ambulation in the corridor. The resident required extensive assistance with transfers, dressing, toileting and personal hygiene. The resident did not ambulate in the room. The resident had [DIAGNOSES REDACTED]. The MDS did not identify any skin concerns. The nursing Progress Notes dated 8/26/16 at 12:55 p.m. indicated the resident left the facility for admission to the hospital. Documentation reflected on 8/26/16 at 11:20 a.m. the resident's inner buttocks very red and sore. There were no other skin issues identified prior to transfer. Hospital wound assessments revealed the following: On 8/26/16 at 2:32 p.m. the hospital identified non-blanchable (indicative of pending pressure ulcer) redness with small scattered open areas on the coccyx. On the same date at 2:33 p.m. hospital records identified the resident with a red groin and small open area to the scrotum. The surrounding tissue was red and inflamed. The nursing Progress Notes dated 8/30/16 indicated the resident returned to the facility at 12:53 p.m. Observation: On 9/22/16 at 3 p.m. observation identified the resident's inner thighs, groin, buttocks and coccyx contained large areas of redness. The areas appeared very red. At that time, Staff B CNA (certified nurse aide) and Staff C, CNA stated the resident was so sore. When staff cleaned the resident following incontinence, the resident stated it hurt because it was so sore. A non-pressure skin condition report dated 8/30/16 identified the resident with red excoriated buttocks and groins with PLH cream (compound ointment) ordered from the hospital. A consolidated orders report dated 9/21/16 revealed an order for [REDACTED]. The order directed staff to apply the ointment BID (twice a day) PRN (as needed) with each loose stool. The August 2016 and September 2016 medication (MAR) and treatment (TAR) records revealed the compound ointment order on the TARs without any initials indicating staff applied the ointment or any other type of treatment to promote healing. The 8/30/16 skin condition report lacked follow up until 9/21/16 when staff documented on an area over the bilateral coccyx with no size listed. The documentation identified the area as healing and continued chafed. The next entry dated 9/26/16 identified the area over the bilateral coccyx as healing and continued with redness and chafing. The skin report did not contain measurements of areas. The September 2016 MAR and TAR did not identify any treatment to the resident's skin impaired areas until staff began using [MEDICATION NAME] cream on 9/22/16 at 8 p.m.

Based on observation, record review and resident and staff interviews, the facility failed to ensure Resident #2 is treated with consideration and respect and free from abuse from Resident #1. The sample consisted of 5 residents and the facility identified a census of 34 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 8/31/16. The MDS indicated the resident had a brief interview for mental status (BIMS) score of 14. A score of 14 identified no cognitive impairment. The MDS indicated the resident had no behavior symptoms and independent withe transfers, dressing, toileting and personal hygiene. The resident required supervision with ambulation in the room and corridor. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. An Incident Accident Report dated 9/18/16 at approximately 7:50 p.m. indicated a CNA (certified nurse aide) informed Staff A LPN (licensed practical nurse) that Resident #1 attempted to kiss another resident and then put his/her hand between the other resident's legs. Review of the Progress Notes (nurse ' s notes) did not identify the 9/18/16 incident or any prior incidents. On 9/27/16 at 11:10 a.m. Resident #1 denied being close friends with any residents at the facility. When asked about Resident #2, Resident #1 stated he/she kissed Resident #2 on the cheek because they are close friends. Resident #1 stated he/she kissed the other resident more than once on the cheek. Regarding the alleged incident, Resident #1 stated he/she held hands with Resident #2 and Resident #2's hands were in his/her lap. On 9/28/16 at 1:09 p.m. Staff A LPN stated Staff B CNA informed Staff A that she saw something concerning between the residents around 8 p.m. Staff B reported to Staff A that she went on break and when she returned she saw Resident #1 with Resident #2 in the lobby. At that time, Resident #1 attempted to kiss Resident #2 and Resident #2 put his/her hand up and said no. Staff B then left the area to answer a call light and, as she came up the hall from answering the call light, she observed Resident #1 put his/her hand between the inner thighs of Resident #2 and Resident #1 removed the hand when he/she saw Staff B. Staff A told Staff B to write a statement and they separated the residents. Staff A reported the incident to the Administrator when he phoned in the next morning around 4:30 a.m. which he does every morning. The Administrator told her she should have phoned him last night. On 9/22/16 at 3:46 p.m. Staff B CNA stated she came back from break and observed Resident #1 sitting in a regular chair next to the office door beside Resident #2 who sat in a wheelchair. Staff B went down the hall to answer a call light and when she came back, she observed Resident #1 try to kiss Resident #2. Resident #1 was on the right of Resident #2. Staff B saw Resident #2 push the other resident away. Resident #1 then shoved his/her hand between the inner thighs of Resident #2 and started rubbing up and down. Resident #1 rubbed up and down twice. Staff B stated she observed the residents sitting by each other before in April 2016 and it appeared that Resident #1 tried the same thing before but a nurse aide said Resident #1 just grabbed the other resident's hand while it was in Resident #2's lap. Staff B stated if Resident #1 comes around Resident #2 that Resident #2 will sometimes start pulling his/her hair and babbling and other times Resident #2 will sit quietly when Resident #1 was present. On 9/27/16 at 3:50 p.m. Staff B stated she had a clear view of the incident. Resident #2's right arm was beside the wheelchair and Staff B did not see where the resident's left hand was. On 9/27/16 at 2:35 p.m. Staff C CNA stated Resident #1 sits by Resident #2 and holds his/her hand. Staff C stated Resident #1 has held the other resident's hand and then placed their hands on Resident #2's leg so Resident #1's hand rested on the other resident's leg. Staff C informed a nurse. Another time Resident #1 patted Resident #2's belly and when told he/she couldn't do that, Resident #1 asked why not. Staff C did not report that incident to anyone. Staff C stated Resident #1 would stop if staff told him/her to stop. Both incidents occurred about a month ago. 2. Resident #2 had a MDS assessment with a reference date of 8/4/16. The MDS assessed Resident #2 with a BIMS of 0 (severe cognitive impairment). The resident had communication difficulty and was sometimes understood with ability limited to simple and direct communication only. The resident had verbal and socially inappropriate behavior symptoms. The resident required extensive staff assistance with transfers, ambulation and eating and total staff assistance with locomotion in wheelchair on the unit, toileting, personal hygiene and bathing. The resident had [DIAGNOSES REDACTED]. The resident had an admission date of [DATE]. Resident #2's nursing progress notes did not contain documentation regarding the alleged incident. On 9/27/16 at 3:55 p.m. observation identified Resident #2 in bed. The resident responded to a knock on the door and his/her name. At that time, the resident stated yes when asked if another resident that sat by him/her at the facility tried to kiss him/her. The resident denied the resident kissed him/her on the cheek and said yes when asked if the other resident kissed him/her on the lips. The surveyor then asked Resident #2 if Resident #1 touched him/her inappropriately and the resident stated yes. The resident said yes when asked if the other resident touched the resident's breast and yes when asked if the other resident touched between the legs. The resident replied no that he/she did not like it and yes that he/she would rather the other resident was not around him/her. Review of 15 minute check sheets showed that the facility started 15 minute checks on Resident #1 on 9/19/16 at 6 a.m. Resident #1's Care Plan contained the 15 minute check intervention on 9/20/16. In a follow up interview with Resident #2, on 9/28/16 at 2:18 p.m. the resident again stated yes that he/she was touched inappropriately by the other resident. The resident stated yes that it made him/her feel bad and no that it did not make him/her feel happy. The resident agreed that he/she did not want it to happen again. The facility did not assess the resident for injury until 9/19/16. According to a shower/bath sheet, the resident did not sustain injury. The facility policy and procedures titled Abuse & Neglect, revised on 9/1/14, identified each resident had the right to be free from abuse, neglect and misappropriation of resident property. The abuse policy did not address assessment of the victim or notification of physician and family until 9/29/16 when the facility added an addendum that directed staff to make immediate notification and conduct an assessment immediately.

Based on clinical record review, staff, resident and State Climatologist interviews and observations the facility failed to provide adequate supervision for 1 of 6 residents observed (Resident #1). The facility reported a census of 33 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 ' s Brief Interview for Mental Status (BIMS) score of 13 indicated, intact cognitive ability with disorganized thinking. Resident #1 exhibited hallucination and delusions that could put him/her at significant risk for physical illness or injury. Resident #1 was independent with bed mobility, transfers, ambulation, dressing and toilet use and required no assistive devices. Resident #1 ' s [DIAGNOSES REDACTED]. Review of the Care Plan initiated10/28/15, identified Resident #1at risk for wandering/elopement related to Dementia and exit seeking behaviors. The care plan directed the staff of the following interventions: a. Know Resident#1 ' s whereabouts. b. Maintain alarms on exit doors. c. On 10/29/15, to perform 30 minute checks when Resident was awake and 1 hour checks when asleep. d. Updated on 12/19/15 staff members directed to remove window cranks from Resident#1's bed room windows. e. On 12/30/15, the care plan directed the staff to complete 5 minute checks while awake and 30 minute checks while asleep. Review of the Progress Notes dated 12/19/15 starting at 12:37 a.m. Staff A Licensed Practical Nurse (LPN) documented she received a phone call from Resident #1's son at 6:50 p.m. on 12/18/15. The son stated Resident #1called telling him that he/she just escaped and was by the Red Barn. Staff A LPN immediately went to Resident #1's room and found the window open, the screen removed and Resident #1 gone. Staff A LPN sent Staff B Certified Nursing Assistant (CNA) to the Red Barn and retrieved Resident #1, bringing him/her back to the facility. Upon return to the facility Staff B CNA had difficulty coaxing Resident #1 out of her car but Resident #1 returned to the building after 30-40 minutes. Staff A LPN assessed Resident #1 and documented complaints of chest pain. Staff A LPN received an order to transfer Resident #1 to a local hospital for evaluation of chest pain. According to the progress notes Resident #1spent the night in the hospital prior to returning to the facility. Review of an Incident/Accident Report dated 12/18/15 revealed Resident #1 opened his/her bedroom window, removed the screen and climbed out with his/her suitcase. At 6:50 p.m. the Charge Nurse Staff A LPN received a phone call from Resident #1's son, reporting Resident #1left the building and where staff members could locate Resident #1. The report form indicated Resident #1 left the building at 8:20 p.m. for a local hospital. The Incident Report indicated Resident #1 was on 15 minute checks when he/she eloped from the facility. Review Resident #1's hospital summary dated 12/18-12/19/15 revealed Resident #1 came to the hospital on [DATE] at 8:52 p.m. after he/she eloped from the facility, stumbled and fell while out. Resident #1 fell forward and knocked his/her glasses off and skinned his/her right knee. The hospital reports revealed Resident #1 fractured the 5th rib and possibly 6th rib and suffered secondary chest pain due to the rib fractures. Resident #1 returned to the facility on [DATE]. During an interview with Staff A-LPN Charge Nurse on 12/29/15 at 11:30 a.m., Staff A stated she last saw Resident #1 in his/her bedroom at 6:00 p.m. when Staff A administered medications. Staff A stated at approximately 6:45 p.m. she received a phone call from Resident #1's son, the son stated Resident #1 called and stated he/she escaped and was at the Red Barn. Staff A went to Resident #1's room, found the window open and Resident #1 gone. Staff A LPN sent Staff B CNA to retrieve Resident #1. During an interview with Staff B-C.N.A. on 12/29/15 at 10:55 a.m., Staff B stated she went at approximately 6:45 p.m. to the Red Barn and picked Resident #1 up to return to the facility. Staff B stated when they arrived at the Red Barn she observed Resident #1 sitting on the ground, with his/her legs out. Resident #1 asked Staff B to help him/her up. Resident #1 commented he/she was waiting for his/her daughter to come and pick him/her up. Staff B stated she helped Resident #1up and Staff B assisted Resident #1 to ambulate to her car without apparent difficulty. Upon return to the facility Resident #1 refused to get out of Staff B's car for about 45 minutes but eventually exited to use the bathroom. Staff B stated when Resident #1 returned from the hospital on [DATE] he/she was placed on 5 minute checks. Staff B stated staff members worked as a team at the facility so everyone was responsible for Resident #1's 5 minute checks. Review of the 5 minute safety checks form for Resident #1 dated 12/29/15 at 8:30 a.m. revealed the staff failed to sign off the 5 minute checks from 6:30 a.m. to 8:30 a.m. Interview with Staff C on 12/29/15 at 8:22 a.m., Staff C CNA stated Resident #1 had been awake and moving about the facility since 6:30 a.m. Staff C stated Resident #1 walked up and down the hall, out to the lobby area and sat in a chair. Interviews with Staff C, D, E and Staff F on 12/29/15 from 8:11 a.m.-8:34 a.m., all staff interviewed stated they work as a team to watch Resident #1, there isn't any one staff assigned to do the 5 minute checks, and stated whoever is around will check on Resident #1 and document the checks. During an interview with the Administrator on 12/29/15 at 9:00 a.m., the Administrator stated after Resident #1's elopement they checked every window in the facility, finding 11 window cranks, one crank found in Resident #1's bedroom. The cranks were removed from all facility windows. During an interview with Resident #1 on 12/29/15 at 8:00 a.m., Resident #1 stated the window crank was on the window, he/she cranked open the window, removed the screen and crawled out of the window. Resident #1 stated it was easy to do because the windows are low and the crank was on the window. According to Resident #1the facility has since the elopement removed all window cranks now from the windows. Resident #1 stated he/she fell at the Red Barn and broke 2 ribs. Observations of Resident #1 on 12/29/15, 1/4/16 and 1/5/16 revealed he/she was ambulating about the facility halls with his/her coat on. Interview with the State Climatologist on 1/7/16 at 8:21 a.m. revealed weather conditions on 12/18/15 at 6:00 p.m. as follows: temperature of 24 degrees with a wind chill of 10 degrees, wind from 20-30 miles per hour and a light snow falling. Clinical records revealed the facility has 8 residents who wander about the facility with Wander Guards utilized. The facility identified 8 residents who ambulate about the facility independently and the staff members utilize Wander Guards on 3 of 8 of those independent residents Note: At the time of the onsite investigation the deficiency was coded at a J level for immediate and serious jeopardy. By December 29, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to a D level. The facility removed the window cranks from the facility resident bedroom windows and implemented an assignemtn sheet for 5 minute checks for required residents.

Based on record review and interviews with staff and the ARNP (Advanced Registered Nurse Practitioner), the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care (Resident #13). The sample consisted of 9 residents and 2 closed records. The facility reported a census of 24 residents and identified 3 of the 24 requested (advanced directives) CPR (Cardiac [MEDICAL CONDITION] Resuscitation) which was not performed when Resident #13 was found with no heartbeat, not breathing and cold to touch. Findings include: 1. Resident #13 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident with a brief interview for mental status score of 13. A score of 13 to 15 identified the resident to not have a cognitive problem. According to the MDS, the resident required extensive assistance with transfers, dressing and toilet assistance. Review of the Iowa Physician Orders for Scope of Treatment dated [DATE] identified advanced directives. The advanced directives, directed the staff to provide CPR (cardiopulmonary resuscitation) and full treatment as needed. The Iowa Physician Orders for scope of Treatment (POST) directed staff to follow these orders, and then contact the physician, nurse practitioner or physician ' s assistant. This document is a medical order sheet based on the person ' s current medical condition and treatment preferences. Everyone shall be treated with dignity and respect. Review of the Progress Notes dated [DATE] at 9:35 PM reflected a CNA (certified nursing assistant) completed rounds and found the resident sitting in the wheelchair and very cold with cyanosis of the hands, face. The assistant alerted the nurse and the nurse responded. The resident had no blood pressure, pulse or respirations present. The resident was transferred to the bed with the assistance of 2 staff. The nurse telephoned the DON (Director of Nursing) at 9:37 PM and the Administrator at 9:40 PM. The nurse notified the family at 9:52 PM. The note reflected the CNA checked on the resident and the resident had been alright and the resident was waiting for a telephone call. The CNA checked on the resident again at 9:35 PM and the resident showed no signs of life and had been cold and very cyanotic in the lips, face and hands. The nurse notified the on-call Physician at 10:00 PM. The on-call physician gave the nurse an order to release the body to the funeral home. The Care Plan for Resident #13 dated [DATE] identified the resident had a request for a full code and the intervention directed the staff to initiate CPR per the advanced directive choices on [DATE]. Review of the policy and procedure titled Death of a Resident, dated [DATE] directed staff to do the following: a. When a resident is found to be without heartbeat or respirations the nurse on duty identifies the code status. b. If the resident is a "full code" status, CPR is started and emergency 911 services are activated. c. If the resident is a "do not resuscitate" status, the following procedures are followed if permitted by state laws. Contact the attending physician, nurse practitioner or physician ' s assistant. If unavailable, the staff can contact an alternate physician, medical director and then county coroner. Review of the facility policy and procedure titled Cardiopulmonary Resuscitation (not dated) reflected the facility will provide basic life support including the initiation of CPR to an individual who experiences [MEDICAL CONDITION] (defined as the cessation of respirations and/or pulse) in accordance with the resident's advanced directives or in the absence of advanced directives or a DNR order or who do not show AHA (American heart Association) signs of a reversible clinical death as defined in the AHA guidelines for CPR and emergency cardiac care.(e.g. Rigor mortis, dependent lividity (pooling of the blood that occurs after death and may look blue, purple or black and is similar to bruising), decapitation, transection, or decomposition). During an interview on [DATE] at 6:00 PM with Staff H, LPN (Licensed Practical Nurse) she stated that the CNA did rounds at about 9:35 PM and found the resident sitting next to the table in the wheelchair. The resident had been very blue, cold and clammy and there were no vital signs at all. Staff transferred the resident to bed. She then called the DON, Administrator and the family. She further stated the resident had been a full code and she asked the DON, when she called her, if the resident had been blue if she was right to not start CPR. She stated that she had not been aware of a change in the CPR policy and it was alright for no CPR. During an interview with the DON (Director of Nursing) on [DATE] at 7:45 AM she stated that she had been verbally told by a corporate staff member that if staff finds a resident with obvious stiffness, cold, mottling or cyanotic, then staff did not need to perform CPR. The DON stated she did not have a written policy for this and did not put it out to the nurses nor provides education. She further stated Staff H, LPN called her at home and said she thought the resident had passed away and had been a full code and not sure what to do. She asked staff if the resident was cold, stiff, blue and asked if CPR could help. During an interview with Staff F, LPN on [DATE] at 9:15 AM she stated the advanced directives are posted in the resident's chart. If the resident wanted CPR staff are to initiate it. She also stated she would not do CPR if the resident requested DNR (Do not Resuscitate). During an interview with Staff G, CNA on [DATE] at 10:35 AM he stated he had been to the resident's room at 8:30 PM and moved the resident ' s wheelchair to the table so the resident could be by the phone. The resident usually went to bed around 9:00 p.m. He did rounds and found the resident slumped over in the wheelchair. The resident had been mottled, had no respirations and no pulse. Staff G stated he called the nurse to the room. The nurse then ran to get the blood pressure cuff. They had tried to check the resident's vital signs 2 to 3 times. He stated that he had asked the nurse if they were to start CPR and the nurse stated no, he/she's gone. On [DATE] at 9:45 AM, the ARNP (Advanced Registered Nurse Practitioner) was interviewed and stated she would expect staff to start compressions and call 911 for a resident that had a full code status. She further stated it is the resident and family's choice. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By [DATE], the facility had implemented measures to adequately address the jeopardy and the grid placement was lowered to the "D" level. The facility provided an in-service to nursing personnel for the policy titled Cardiopulmonary Resuscitate and for the policy titled Do Not Resuscitate. As of the [DATE] exit conference, the facility continued to need to: · Finish in-servicing all nursing staff regarding the facility policy for Cardiopulmonary Resuscitate and Do Not Resuscitate. · Continue to monitor nursing staff to assure resident's advance directives are being followed and as ordered by the physician.

Based on clinical record review and staff interviews, the facility staff failed to provide accurate assessment and intervention for 1 of 4 residents reviewed (Resident #1). Record review and staff interview established Resident #1 fell during a transfer and staff picked up the resident without allowing the nurse to assess the resident. In addition, the staff transferred the resident via "cradle carried" after the fall. Resident #1 sustained had a right fractured ankle and increased pain after the incident. Staff interview revealed the nurse failed to document the fall or failed to notify the physician after the incident. The facility reported a census of 28 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS score of 3 which indicated the resident had severe cognitive ability. The MDS indicated Resident #1 required limited assistance of 1 staff for transfers, walking and toilet use. Since the resident's admission of 8/22/13 the resident sustained [REDACTED]. Review of the Care Plan dated 6/10/14 indicated Resident #1 had a potential for falls due to their unsteady gait. The Care Plan indicated the resident required assist of 1 staff to assist with ambulation and transfers. The Care Plan updated 8/19/14 directed the staff to use 2 staff to transfer or ambulation, pressure alarms in their bed and gripper strips in front of their bed, chair and in front of the toilet. Review of a Fall Investigation/Follow up sheet dated 8/19/14 at 7:00 p.m. indicated one staff member ambulated Resident #1 to the bathroom, during the walk back the resident experienced jerking of their legs, they bent at the knees and the staff member lowered the resident to their knees. The aide assisted the resident up and back to their bed. The Fall Investigation indicated the resident complained of pain to their right heel upon RN assessment after the fall. Review of the Nurses Notes dated 8/19/14, the Nurses Notes failed to reveal Resident #1 sustained a fall on 8/19/14. The Nurses Notes dated 8/20/14 at 7:27 a.m. and 10:46 a.m. indicated the resident complained of pain and the staff administered Tylenol for pain. Further review of the Nurses Notes on 8/20/14 (late entry) at 7:50 a.m. indicated Resident #1 complained of pain during a transfer to their chair with 2 staff. The resident complained of pain and would not bear weight on their right foot during the transfer. The Director of Nurses contacted the resident's physician and received an order for [REDACTED]. Review of a local emergency room X-ray report dated 8/20/14 indicated the resident sustained [REDACTED]. The emergency room physician placed a cast to the resident' right lower leg. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During an interview with Staff A, RN on 9/9/14 at 2:30 p.m., Staff A stated they worked on the evening of 8/19/14, the staff called them to Resident #1's room after the staff lowered the resident to the floor and then transferred the resident back to their bed alone. Staff A stated they completed range of motion and the resident yelled out in pain when Staff A palpated their right heel area. Staff A stated the heel area appeared red and they thought the resident had pain from a developing pressure area on the heel. Staff A directed the staff to elevate the resident' heel off the bed for the rest of their evening shift. Staff A stated they failed to document the incident, failed to notify the physician and the resident's family of the incident and failed to make out a skin sheet for the noted red heel. Staff A stated they worked again in the morning of 8/20/14, the resident continued to complain of pain to the right heel and the nurse administered pain medication. Staff A stated they looked at the resident's heel the morning of 8/20/14 and noted the resident's heel still red and now bruises noted around the right ankle. Staff A stated the aides reported to them that morning the resident would not put weight on their right ankle. Staff A stated they sent out a fax to the resident's physician but did not receive a response back as of noon on 8/20/14. The C.N.A. staff continued to get the resident up for meals and toileting the morning of 8/20/14, each time noting the resident could not bear weight on their right foot. Staff A stated they received a 3 day suspension for their failure to document the 8/19/14 incident in the nurses notes. A review of the Correction Action documented on 8/19/14- 8/20/14, identified after the fall, Staff A did not document in the nurse's note, or enter on the 24 hour report or create a hot chart; and then failed to reassess on the following day 8/20/14. During an interview with Staff C, C.N.A. on 9/914 at 3:00 p.m., Staff C stated they worked the evening of 8/19/14 and gave care to Resident #1. Staff C stated after the evening meal they walked the resident from their bathroom to their bed when the resident's knees buckled. Staff C stated the resident started to go down at which point the staff could not assist the resident to stand up and lowered them to the floor. Resident #1 had their knees on the floor and their ankles bent. Staff C raised the resident up and placed them in their bed, the resident said "ouch, ouch" at this time. Staff C summoned help and Staff B RN entered the room. Staff C told Staff B that the resident had to be lowered to the floor. Staff B began to poke around on the resident's heels which made the resident yell out in pain. According to the Member Communication Statement, dated 8/20/14, Staff C had stated she lowered Resident #1 to the ground when the resident lost his/her balance. Staff C then cradle carried Resident #1 to the bed before she got a nurse. Staff C documented she had been trained on proper transfer technique and she should have left the resident in-place instead of cradle carry. Review of the Fall Policy dated 7/1/11 directed the Nurse to make a physical assessment and make recommendations for immediate safety interventions or immediate medical interventions, notify the physician and the family, initiate and complete the Fall Report Process and revise the Plan of Care. During an interview with Staff B, Director of Nurses on 9/10/14 at 9:30 a.m. revealed the Physician Notification Fax which had a date on it of 8/19/14 did not actually get faxed to the Physician until 8/20/14, the day after Resident #1 lowered to the floor. Staff B stated they found about the staff lowering the resident to the floor abound 12:00 p.m. 8/20/14 and contacted the resident's physician and obtained an order for [REDACTED]. Staff B stated they touched Resident #1's right ankle and the resident screamed out in pain. The progress notes dated 8/21/14 documented Resident #1's family member had been informed of his/her fracture, cast, and pain medication. The progress notes dated 8/22/14 identified the podiatrist at the facility to visit with him/her. The Podiatrist Progress Notes 8/22/14 documented the resident had fractured his/her right ankle in a fall. The resident's left foot was extremely swollen and staff reported the left foot was not examined. The resident's left foot was extremely swollen and staff reported the left foot was not examined. A progress note dated 8/22/14 identified x-rays to left foot and ankle. Resident #1 screaming out in pain. The x-rays revealed no fracture to left ankle. A progress note dated 8/23/14 identified the resident had increasing pain in his/her right hip. The resident had been sent to the hospital to assess his/her right hip and increased pain. The resident returned from the emergency roiagnom on [DATE] at 11:38 p.m., with the physician reporting no fractures or abnormalities noted. The MAR indicated [REDACTED]. Review of a Nursing Staff In-service dated 8/21/14 re-educated the staff on fall protocol. The in-service directed the staff to assess vital signs, assess for obvious injury, do a full body skin check, assess all range of motion and notify the family and physician.

Based on record review, staff interviews and review of facility policy/procedures, the facility failed to prevent the development of pressure ulcers, adequately assess the pressure sores and provide timely interventions to promote healing for 3 of 4 residents reviewed with pressure ulcers (Resident #1, #3 & #6). The facility identified a census of 31 residents. Findings include: 1. Resident #6 had an admission MDS (Minimum Data Set) assessment with a reference date of 12/21/13. The MDS identified the resident had [DIAGNOSES REDACTED]. The assessment reflected the resident had a risk for the development of pressure ulcers and currently did not have pressure or venous ulcers. The MDS reflected the facility had implemented a pressure reducing device for the bed and chair. The facility did not have a turning or repositioning program. The MDS reflected the resident required extensive assistance from staff for bed mobility and needed assistance with the activities of daily living. The resident required extensive assistance from staff for urinary incontinence. The MDS assessment with a reference date of 3/7/14 identified the resident had developed a Stage 2 pressure ulcer on 1/23/14. The facility continued to use pressure reducing devices on the chair and bed. The facility did not have a turning/repositioning program. Resident #6 had a MDS assessment with a reference date of 4/4/14 which identified the resident had a Stage 2 pressure ulcer and a nonstageable ulcer (unable to see wound bed). The facility continued to have pressure reducing devices for the chair and bed and the facility applied medication to the resident's feet. The facility did not have a repositioning or turning program. The [DIAGNOSES REDACTED]. Review of the care plan dated 4/9/14 identified the resident with the potential/actual impairment to the skin integrity related to diminished independent mobility, altered mentation, failure to thrive in an adult, and age related skin changes and incontinence. The interventions included: a. Float the resident ' heels off of the bed when in bed. b. The resident should never wear Croc shoes. c. To be the last one up for meals/activities and then the first one (person) back to bed to limit the amount of time sitting on bottom. d. To wear blue boots at all times except when bathing. e. Pressure relieving/reducing mattress to protect skin while in bed. f. Perform treatments per the physician ' orders. A Braden Scale dated 12/20/13 identified Resident #6 at risk for pressure ulcer development. Left heel pressure ulcer: (The facility did not have interventions in place to prevent the development of the heel ulcer) The Skin Assessment form dated 3/27/14 reflected the staff identified a pressure ulcer located on the left heel on 3/25/14. The assessment identified the wound to be a facility acquired pressure ulcer. The wound stage was identified as unstageable and measured 4 cm (centimeters) by 4 cm. The surrounding skin color appeared pink with [MEDICAL CONDITION] (swelling) and induration present (reddened, thickened, painful). The Skin Assessment form dated 3/27/14 identified the left heel ulcer measured 3 cm by 3 cm. and on 3/28/14 the left heel measured 4 cm by 4 cm. The Skin Assessment form identified on 4/4/14, the left heel measured 5 cm by 4 cm. and unstageable. The Skin Assessment form. The Skin Assessment form dated 4/18/14 identified the wound has 4.1 cm by 4 cm and unstageable (2 weeks later). Coccyx pressure ulcers: (The facility did not have an intervention for turning and repositioning) Review of the Skin Assessment form dated 4/2/14 identified the resident with an open area on the coccyx area which measured 1.5 centimeters (cm) by .5 cm. Review of the Skin Assessment Form dated 4/4/14 revealed the resident with an open area, Stage 2, distally from the direct coccyx, which measured .4 cm by .4 cm by .1 cm. The treatment directed staff to cleanse the area with normal saline, use a skin prep and apply [MEDICATION NAME] and as needed if soiled. The assessment directed staff to have the resident repositioned from side to side only and up only for short amounts of time. Stage 1: An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperatures, tissue consistency, sensation and or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage 2: Partial thickness of skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous that may extend down to, but not through, underlying fascia. The ulcer clinically presents as a deep crater with or without undermining of adjacent tissue. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Observation on 4/22/14 at 9:21 a.m., revealed the resident sitting in the wheelchair in the therapy room while staff encouraged the resident to do exercises Observation on 4/22/14 at 9:50 a.m., revealed staff transferred the resident from the wheelchair to bed. Staff positioned the resident in a supine position (on back). On 4/22/14 at 11:55 a.m., Staff C (RN) was interviewed and stated to her knowledge, the resident had no treatments to their bottom and the only area to be measured or a dressing change would be to the resident's heel. Observation on 4/22/14 at 1:30 p.m. revealed Staff C and Staff H (certified nursing assistants) provided incontinent cares to the resident. When the resident was positioned onto the right side, Staff C stated there was a dressing on the resident's coccyx area and they would go obtain the dressing supplies to change the dressing and measure the area. Staff C proceeded to remove the dressing and cleanse the area. Upon measuring the area, she stated the area measured .8 cm by .2 cm and that this is a change from prior assessments (enlarged). The facility policy and procedure titled Pressure Ulcer and Wound treatment (not dated) directed staff the ulcer/wound would be reviewed weekly. The ulcer/wound ' response to a treatment plan will be documented in the resident's clinical record no less often than weekly. On 4/21/14 at 3:01 p.m. the Interim Director of Nursing (DON) was informed that the clinical record revealed the pressure ulcers were not routinely assessed. The DON stated Staff C had a green notebook with documentation which needed to be put into the computer system. The DON did not allow the notebook to be viewed. The Director of Nursing provided dated measurements of the pressure ulcers onto a scratch paper from the information obtained from the green book. The information did not identify assessments of the wound. 2. Resident #1 had an MDS with a reference date of 3/7/14 which identified [DIAGNOSES REDACTED]. The MDS reported the resident had a severe cognitive impairment. The MDS revealed the resident required total staff assistance for transfers and dressing. A review of the resident's care plan, identified a problem with the resident experienced a self- care deficit due to profound mental [MEDICAL CONDITION], depression, catheter, and risk for skin alterations. An intervention for the care plan directed staff to monitor the resident's skin with cares and bathing. A review of the resident's Skin Assessments revealed the facility lacked routine documentation of an open area on the resident's right shin. Documentation revealed the following assessments: On 2/12/14, the area measured 2 cm by 1 cm with a scant amount of serosanguineous exudate. On 2/14/14, the area measured 0.75 cm by 0.5 cm area with a scant amount of serosanguineous exudate. On 3/7/14, the area measured 1.75 cm by 0.75 cm with no exudate. On 3/21/14, the area measured 1.9 cm by 0.9 cm with no exudate. On 4/23/14, at 4:00 PM, Staff F was interviewed and reported the area on Resident #1's right shin had been completely healed. An observation on 4/24/14, at 10:30 am., with Staff F revealed a small area on the resident's right shin as red and shiny. 3. Resident #3 had a Minimum Data Set (MDS) assessment, with a reference date of 3/14/14. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident had a Stage 2 pressure ulcer. The resident's Care Plan identified the resident at risk for skin impairment. Review of the care plan did not include specific interventions for assessment and treatment of [REDACTED]. Review of the resident's pressure ulcer forms revealed the following documentation: On 1/17/14, the facility acquired pressure ulcer measured 1 cm in length by 1 cm in width. On 1/24/14 the coccyx pressure ulcer measured 2 cm in length by 2 cm in width by .25 cm in depth. On 2/7/14, the coccyx pressure ulcer measured 2 cm in length by 1.5 cm in width by .25 cm in depth. On 2/14/14 the coccyx pressure ulcer measured 2.5 cm in length by 2 cm in width by .5 cm in depth. On 2/27/14 the pressure ulcer coccyx wound measured 1 cm in length by .5 cm in width. On 3/7/14 the pressure ulcer coccyx wound measured 2 cm in length by 2 cm in width, and .5 cm in depth. On 3/14/14 the coccyx pressure ulcer measured 2.4 cm in length by 1.4 cm in width, and .2 cm in depth. On 3/21/14 the coccyx pressure ulcer measured 1.2 cm in length by 1.5 cm in width, and .2 cm in depth. On 3/28/14 the coccyx pressure ulcer measured 1 cm in length by .8 centimeter in width and .1 cm in depth. On 4/4/14, the Stage 2 coccyx pressure ulcer measured 1 centimeter (cm) in length by .5 cm in width, and .1 centimeter in depth. The wound had 100 percent granulation present. A review of the clinical record on 4/23/14, did not reveal documentation of the wound measurements from 4/4/14 to 4/23/14. On 4/23/14 at 9:20 am, the interim Director of Nursing and Staff C (Registered Nurse), was interviewed and stated the wounds had been measured on 4/11/14 and 4/18/14, but had not been entered in the clinical medical record. Staff C reported she had documented them in a personal notepad for those dates. During an interview on 4/23/14 at 4:40 PM, Staff C verified she had completed the pressure ulcer forms documentation for the measurements completed on 4/11/14 and 4/18/14 in the clinical electronic medical record today. A review of a pressure ulcer form dated 4/18/14, reflected the resident's coccyx wound measured .5 cm in length by .5 cm in width, and no depth. According to the MDS assessment, with a reference date of 3/7/14, documented Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive to total assistance with bed mobility, transfers, toilet use and personal hygiene. The MDS documented an unstageable pressure ulcer and applications of ointments and creams. The care plan dated 3/25/14 identified the resident at risk for skin integrity impairments due to diminished independent mobility, [MEDICAL CONDITION], multiple other co-morbidities. The interventions directed staff to administer treatments per the physician's orders [REDACTED]. Review of the Pressure ulcer Evaluation weekly form dated 1/31/14, documented an unstagable pressure ulcer on the right heel which measured 0.5 cm by 0.25 cm by 0.25 cm. Further review of the Pressure ulcer Evaluation Weekly form revealed measurements completed on the following dates: 2/7/14, 2/14/14, 3/7/14, 3/14/14, 3/21/14, 4/18/14. The clinical record lacked documentation from 2/14/14 through 3/7/14 and 3/21/14 through 4/18/14. Review of the Pressure Ulcer Evaluation Weekly form dated 3/12/13, documented an intact blister to the residents left big toe which measured 1.0 cm by 0.5 cm. Further review of the Pressure Ulcer Evaluation Weekly form revealed measurements and assessments completed on the following dates: 3/15/14,. 3/21/14 and 4/11/14. The clinical record lacked documentation from 3/21/14 through 4/11/14.

Based on observation, record review and staff, resident and family interviews, the facility failed to ensure a resident who enters the facility without pressure sores does not develop pressure sores and failed to provide the necessary care and services to promote healing and prevent new sores from developing (Resident #1, #3) The sample consisted of 9 residents with facility acquired pressure ulcers and the facility identified a census of 23 residents. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment, with a reference date of 7/26/13, which reflected the resident required extensive assistance with bed mobility, dressing, personal hygiene and total assistance for transfers and toilet use. The MDS revealed this resident did not walk and had a retention catheter for urine collection. The MDS cognitive testing identified Resident #1 scored a 3 out of 15, indicating cognitive impairment. The resident had memory loss and disorganized thinking. The MDS also identified this resident exhibited no behaviors and did not refuse care during the seven-day assessment period. The resident required staff assistance to stabilize when moving from a seated to standing position and bed to chair. The resident was at risk for pressure ulcers and did not have any pressure ulcers at the time of this assessment. A Braden Score (a test to determine pressure ulcer risk) dated 7/26/13 assessed this resident at a moderate risk for pressure ulcers due to limited sensory perception, occasionally moist skin, chair fast, very limited mobility and a potential problem with friction and shearing forces. The Care Plan, dated 5/14/13 included this resident's risk for impairments to skin integrity due to [MEDICAL CONDITION], decreased mobility and multiple other co-morbidities. The Care Plan directed staff to keep the skin clean and dry. The Care Plan addressed a problem with self-care deficit and noted the resident required the assistance of two persons and the Hoyer Lift for transfers due to weakness of the resident ' s legs. The plan of care also instructed the staff to monitor/document/report any signs and symptoms of [MEDICAL CONDITION], including poor wound healing. Hand written updates to this plan of care on 9/18/13 directed staff that the resident is to be up only for meals and to lie on side while in bed. The resident has a pressure ulcer to the inner buttocks area. The Care Plan reflected on 9/23/13 to keep the resident ' s heels off of the mattress. A Physician's note dated 5/2/13 noted Resident #1 had [MEDICAL CONDITION] with the inability to walk. The Chronic Illness list included 20 medical [DIAGNOSES REDACTED]. Hospital Laboratory blood work records revealed this resident's A1C (long-term blood sugar testing) tested elevated on 9/17/13 at 7.9 with the reference normal range listed 4.5 to 6.2. This resident's [MEDICATION NAME] tested low on 6/11/13 at 2.9 with the reference range of 3.4 to 5.0. When interviewed on 9/25/13 at 1:20 p.m. this resident's spouse stated this resident had a history of [REDACTED]. Observation on 10/3/13 at 11:30 a.m. revealed Staff C (staff nurse) performed a wound treatment to the resident's right foot/toes. The resident laid on the new bariatric bed with an alternating air mattress and wore new heel floater boots. The nurse removed the boot to the right foot and removed a soiled dressing from the right heel. The old dressing contained dried bloody drainage. The now open wound was unstageable due to the center was filled in with dried blood. Staff C, the facility's staff nurse assigned to routinely assess wounds, stated at this time this wound was probably a Stage IV due to it was deeper than a Stage III. Staff C stated as of yesterday, this resident continued to have three open areas on the coccyx area, including one full thickness wound and two partial thickness wounds. Pressure Ulcer Evaluation Weekly Records printed from the facility computer for this resident included: 1. New Pressure Ulcer to right buttock: facility acquired, Stage II, measured 3 cm (centimeters) long by 1 cm wide with no depth, pink wound bed, and plan of care not updated. 2. New Pressure Ulcer to right heel, facility acquired on 9/22/13, Stage I, measured 3 cm long by 3 cm wide and no depth. Skin pink and shiny. Pain during turning and repositioning. Current treatment: feet elevated, heels floated. Plan of Care not updated. 3. New Pressure Ulcer on coccyx, facility acquired on 9/25/13, Stage II measuring 2 cm long by 0.5 cm wide and 0.025 cm deep. Tissue description: dark pink with a red wound bed. Surrounding skin: maceration. Pain present. Plan of Care not updated. 4. New Pressure Ulcer to this resident's coccyx, facility acquired on 9/25/13 measuring 1 cm long by 1 cm wide and 0.25 cm deep. Tissue description: dark pink/red wound base with macerated surrounding skin. Pain present. A Nursing Communication sheet dated 9/19/13 instructed staff the resident to be up out of bed for meals only. This communication also instructed staff to position resident on side while in bed. This communication sheet instructed staff to lay the resident down after meals, and to be last resident up for meals and the first one down after meals due to pressure ulcer. A Shower/skin assessment sheet documented the resident's skin was ok (all right) without skin concerns on 9/6/13, 9/13/13, 9/17/13 and again on 9/20/13. The shower skin assessment sheet dated 9/28/13 documented skin inspected and ok. The skin/shower inspection sheet documented 10/1/13 identified no skin issues/concerns. Facility Progress Notes printed from this facility's computer included: 9/18/13 at 2:44 p.m. noted a 3 cm by 1 cm Stage II open lesion to inner right buttock. Denies pain. Area cleansed and covered with [MEDICATION NAME] (transparent dressing) 9/19/13 at 12:32 p.m. notified Nurse Practitioner of resident's new pressure ulcer with new skin treatment received. Facility informed this resident's spouse of wound and new treatment. Spouse asked if new area is due to resident liked to stay in wheelchair. Nurse informed spouse it was very possible that sore was from resident refusing to turn while in bed and also from refusing to get out of the wheelchair. 9/21/13 at 6:56 p.m. increased confusion noted in the afternoon; resident face flushed, poor appetite 9/22/13 at 12:33 p.m. resident assisted to bed between meals; resident refused to stay on side while in bed. Very unhappy that he/she had to lie down between meals; was easily redirected after spouse arrived for visit. 9/22/13 at 8:43 p.m. 3 cm circular fluid filled blister found on right heel while doing cares before lying down. 9/23/13 at 9:27 a.m. bariatric bed ordered today 9/23/13 at 10:36 a.m. nurse practitioner informed of new area on heel, with new order to paint heel with [MEDICATION NAME] (providone-iodine (PVPI) topical antiseptics) 2 times daily. 9/23/13 at 8:59 p.m. resident non-compliant about staying in bed until right before supper; also non-compliant about lying on side to side while in bed; resident lying on back right now. Increased confusion noted-tried to go out front door several times, even after spouse instructed him/her, he/she could not. 9/24/13 at 2:10 p.m. resident continued to have increased confusion and refused to lie down. Facility Prevention of Pressure Ulcers policy and procedure dated 10/2010 included: 1. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. 2. For a person in a chair, change position at lease every hour, use foam, gel or air cushion as indicated to relieve pressure. 3. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging. 4. Refer resident to a restorative program. 5. Place resident on a minimum of a every two hour check and change program. Policy and Procedure Manual for Wound Documentation dated July 2012 instructed staff on accurate assessment and documentation of wounds regardless of etiology. This policy described a Stage 3 (Stage III) wound as a full thickness wound. This policy also instructed staff to stage and unstageable wound as a Stage 4 (Stage IV). A physician progress notes [REDACTED]. The physician noted this resident remained wheelchair bound. A Nurse Practitioner's note dated 6/7/13 assessment included diabetes with diabetic [MEDICAL CONDITION], dementia, [MEDICAL CONDITIONS] and the use of an indwelling urinary catheter. A Care Conference Summary Sheet dated 8/8/13 noted the conference reviewed assessment sheets including bowel and bladder, skin, fall risk, pain, side rail, and nutrition. The document revealed the Care Conference failed to review Braden Scale (pressure ulcer risk assessment) as directed in their Policy and Procedures. The resident's long term goal was to stay as well as he/she was at the time of the conference. Observations included: 9/18/13 at 11:40 a.m. resident up in wheelchair in the chapel for an activity. Staff F (C.N.A.-Certified Nursing Assistant) brought the resident from the chapel to his/her bedroom to check and change due to incontinency prior to the noon meal. The C.N.A. emptied the urine from the retention catheter bag prior to transferring the resident from the wheelchair to the bed with the assistance of a registered nurse, Staff G and a Hoyer (mechanical) lift. After positioning the resident on the bed, the staff performed incontinency care due to feces present. The skin had a dull maroon color present with a full thickness open area observed. Both R.N. and the C.N.A. denied the resident had any skin problems or open areas. The surveyor instructed the R.N. and C.N.A. to examine the resident's coccyx at which time both staff verified a new full thickness open area on the resident's inner buttock. When interviewed on 9/18/13 at noon, Staff F stated two people cannot adequately reposition and provide care, including incontinent cleansing for this resident when in bed due to the resident's size. The resident took up most of the bed and is not able to roll over fully due to size and the wedges in the bed. Observation on 9/18/13 at noon revealed the resident had a worn, two inch pad in the seat of the wheelchair (does not adequately provide pressure reduction). Observation on 9/18/13 at 12:02 p.m. revealed Staff G measured the resident's new open area. When staff attempted to roll the resident onto side (in order to allow thorough cleansing and wound dressing application), the resident laid up against the side rail and staff was unable to roll resident fully onto his/her side. When interviewed on 9/18/13 at 12:13 p.m. the resident described his/her buttock pain as not too bad. When asked to rate his/her pain on a scale of one to ten with one being very mild to ten being severe, the resident assessed his/her current pain as a four or five. When interviewed on 9/18/13 at 4:30 p.m. the resident's spouse and two children expressed concern regarding the resident's bed being too small for the resident. The family expressed concern due to the resident was unable to turn to his/her side due to lack of space in the bed. Observation on 9/19/13 at 6:10 a.m. revealed the resident in bed. Bed in low position. Eyes closed and respirations easy. Both side rails in an up position. The resident laid supine (on back) with the head of the bed elevated. On 9/25/13 at 7:15 a.m. the resident laid supine in bed. Observation revealed no positioning pillows in place under legs to float heels. The resident ' s heels rested directly on the bed. No pillows noted on the floor or in the bed near this resident's feet. Observation noted resident in bed supine with shoulders and hips touching the wedge cushions along both sides of the bed. There was no space between the resident and the wedge cushions in this resident's bed. When interviewed on 9/25/13 at 8:50 a.m. a C.N.A. (Certified Nursing Assistant) Staff F stated when she came on duty at 6:00 a.m. the resident laid in bed with his/her heels directly on the bed. On 9/25/13 at 8:45 a.m. the resident sat in a wheelchair. Observation revealed a sock and a slipper sock on the resident's right foot. Observation at this time revealed no pressure devices under the resident's right foot/heel. The resident's right heel rested on the metal foot rest. When interviewed on 9/25/13 at 8:55 a.m. the D.O.N. (Director of Nursing) verified the lack of any pressure relief to the resident's right heel. She stated she wanted to order special heel protectors for this resident. The DON stated the only planned pressure relief planned at this time for the resident's right foot was to float heels off the bed. She denied implementing any pressure relief/protection for the pressure ulcer on this resident ' s right heel while up in the wheelchair. On 9/18/13 at 7:10 p.m. two C.N.A.'s, Staff I and Staff H transferred the resident from the wheelchair to bed with the use of the Hoyer lift. Staff removed the resident ' s pants and brief, revealing soiling of unformed feces. The staff stated they noticed this new open area last Saturday. Staff then summoned the nurse, Staff J to treat the resident's open area. When interviewed on 9/18/13 at 7:40 p.m. the licensed practical nurse, Staff J identified the resident's open area as new. On 9/24/13 at 6:47 a.m. observation noted the resident in bed. Staff A and Staff C (both certified nursing assistants) prepared to provide cares for the resident. The resident's heels rested directly on the bed. Observation revealed the lack of positioning pillows or any type of devices to float this resident's heels off the bed. Observation revealed a large blister on the right heel. The nurse informed the resident she was going to put medicine on his/her bottom. Staff encouraged resident to assist with turning to the left. Staff A stated it was hard to roll this resident in bed due to the cushion prevented him/her from rolling the resident to the side. Staff verified the lack of extra room in the bed to allow the resident to roll onto his/her side. Observation revealed staff unfastened the resident's brief revealing unformed feces. After cleansing the area, observation revealed a full thickness open area on the buttock. Staff had unfastened the resident's brief and tucked the sides of the brief down under the resident's side, the nurse then rolled the edge of the brief and pulled on the brief, pulling it out from under the resident, using several pulls. Both the nurse and the nursing assistant verified the size of the resident along with the size of the bed, prevented them from positioning the resident to the side to allow for thorough cleansing. Observations on 9/25/13 at 1:20 p.m. revealed two staff, Staff C and Staff F transfer the resident from the wheelchair to the bed with the use of the Hoyer lift. Staff stated they last provided care for this resident before breakfast when they assisted the resident out of bed and into the wheelchair. Staff denied lying the resident down in bed after breakfast and denied providing any check and change of this resident's brief. Staff denied checking the resident for incontinence of bowel or providing pressure relief or position change since before breakfast that morning. The nurse stated she offered to lay the resident down, however the resident refused. After transferring the resident to bed, the staff removed the resident's pants and unfastened the resident's brief. The nurse then pulled the brief out from under the resident. As the nurse pulled on the brief, observation revealed the resident's skin pulled along with the brief. The Nutrition update dated 9/18/13 addressed a new Stage II area on this resident's coccyx. Wound attributed to spending much time lying on his/her back. The Nutrition update dated 9/25/13 addressed a Stage III area on the coccyx and an unstageable area on the heel. The dietician recommended giving the resident one scoop of protein powder to his/her juice at breakfast and lunch to increase protein intake. Although this resident was at risk for the development of pressure ulcers, the facility did not follow their own policy and procedures and did not provide a large enough bed to allow proper positioning for pressure relief. The facility did not provide the resident adequate pressure relief while seated in the chair and allowed this confused resident to sit from before breakfast until after lunch. The facility also did not provide any pressure relief to the resident's right heel after the resident developed an unstageable black blister on the right heel. 2. Resident #3 had a MDS assessment with a reference date of 8/23/2013. The MDS reflected the resident required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident experience episodes of incontinency with bowel and bladder. The clinical record revealed the resident had a history of [REDACTED]. Observation on 9/19/2013 at 7:00 a.m., revealed 2 staff members, Staff A (certified nursing assistant) and Staff E(licensed practical nurse) enter the resident ' s room. Staff A turned the resident onto her/his side and then pulled the disposable brief out from under the resident (can cause shearing force). Observation on 10/1/2013 at 3:50 p.m., revealed Staff I providing personal care for the resident. Staff I removed the brief and the surveyor observed a new area on the resident ' s left buttock. The circular area was approximately ? centimeter (cm) with white edges and a black center. Staff I stated she noticed this new area on 9/30/13 at which time, she informed the charge nurse, Staff J, who treated the new skin area on 930/2013. On 10/1/13 at 4:05 p.m., the staff nurse, Staff J was interviewed and verified the Certified Nursing Assistants reported Resident #3 had a new area located on the buttock on 9/30/13. Staff J stated she treated the new area on 9/30/13 but failed to document the new pressure area in the resident ' s record and failed to notify the physician and family. Staff J stated she did not implement new pressure ulcer interventions to enhance healing and for the prevention of new ulcers. A Pressure Ulcer Evaluation Weekly Record, printed from the facility computer, identified the resident had acquired a new Stage I pressure ulcer on 9/30/2013. The ulcer measured 1.5 cm long by 1 cm wide.

Based on clinical record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and failed to revise the Care Plan to ensure the resident ' s needs are met for safety (Resident #6). The sample consisted of 6 residents and the facility reported a census of 24 residents. Resident #6 had a history of [REDACTED]. During interviews, the facility staff stated when residents remove their alarms or deactivate them, then the alarms are changed to wireless alarms. The wireless alarms had not been implemented and added as an intervention in the care plan. The resident fell , fractured a hip and died of complications of a hip fracture. Findings include: 1. A [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. A recertification order signed by a Nurse Practitioner for [DATE] directed staff to have an alarm on the bed and chair and to check placement and function every shift-every 8 hours every day (this order had been first ordered on [DATE]). A Nurse Practitioner Progress Note dated [DATE] documented this resident complained of left knee pain occasionally. He/she did grumble about having to have two people to help him/her into the bathroom. He/she stated sometimes this was a nuisance. The resident had a history of [REDACTED]. Examination of the left knee revealed the left knee was a little bit larger than the right knee. There was bony deformity consistent with DJD (degenerative joint disease), but no recent bruising, [DIAGNOSES REDACTED]. He/she had a hematoma that had resolved on his/her scalp due to a previous fall, with just a little bit of a black scab noted on the scalp. The Nurse's Progress Notes included: On [DATE], the night shift noted the resident constantly setting alarms off at the start of the shift and asking for a bed that did not have an alarm. The day shift noted this resident verbalized understanding of transfer assistance yet continued to attempt self- transfers in the room. The afternoon shift noted the resident propelled self to the bedroom. The staff removed the resident from his/her bedroom several times due to the resident's attempt to self-transfer. On [DATE], the day shift noted the resident continued to go to the room and attempt to self- transfer. On [DATE] at 5:15 p.m. the alarm sounding. Upon entering the room, resident found sitting on the floor by the bed. At 4:00 p.m. the resident had returned from an appointment with a new physician's orders [REDACTED]. On [DATE] at 10:39 a.m. the resident has had no increased confusion noted this shift. The resident has self -transferred this morning twice, shutting the alarms off both times. The resident reoriented to safety issues with transferring self and kept in line of sight of staff. On [DATE] at 12:30 p.m. the resident is at risk for falls due to a history of falls with a fracture, muscle weakness, a history of a stroke and left side weakness and difficulty with walking. Resident to wear brace to left knee while walking. Resident uses a wheelchair and needs one staff assist with all cares. Resident is incontinent and wears depends. Resident has impaired cognition. Interventions in place: anticipate resident needs, call light in reach, encourage to participate in activities, appropriate footwear to be on when walking, mobilizing in wheelchair, winged mat to bed, laser alarm by bed, floors to be free of spills and clutter free. Resident is checked every fifteen minutes. Alarms to bed and chair. Toilet every 90 minutes at night, and/or when awake and restless. On [DATE] at 1:35 p.m. care plan updated due to history of falls and resident needs staff assistance with transfers. Staff have been noticing resident going into his/her room and attempting to transfer self without assistance from staff. Alarm (attached) to outside of resident ' s door. (Alarm) put on to alert staff when resident attempts to enter room without assistance. On [DATE] at 12:40 p.m. discontinue resident fifteen minute checks due to no recent falls and alarm in place. [DATE] at 7:23 p.m., the staff found the resident on the floor. The resident bled from the nose. A Fall Report dated [DATE] at 6:15 p.m. noted the staff found the resident sitting on buttocks in room. The pressure alarm was on and sounding. On [DATE] at 9:25 a.m., the nurse called to the resident ' s room. The resident on the bathroom floor, had attempted to self-transfer and alarm not sounding. The resident ' s spouse activated the call light. The resident had a golf ball sized hematoma on the posterior scalp. The nurse applied ice pack. The staff were advised to keep the door closed when the resident is not in the room so the door alarm will alert staff when she/he goes into the room. A Fall Report dated [DATE] at 8:45 a.m. noted the resident left the dining room and went back to (his/her) room. The door to the room was open due to the roommate ' s request. Staff unaware that resident in room. While attempting to toilet self the resident fell in the bathroom striking head on wall. Pressure alarm not sounding. Resident had unhooked the alarm. The Fall Investigation/Follow-Up report dated [DATE] by the now Director of Nursing, documented New Intervention: Close door when resident not in room. On [DATE] at 6:53 p.m. resident has been admitted to the hospital for the treatment of [REDACTED]. On [DATE] at 1:50 p.m. resident has been slightly confused: has been asking for father and brother. On [DATE] at 3:26 a.m. resident alert to person only, resident incontinent of urine. Resident complained of left leg pain. On [DATE] at 1:50 p.m., resident alert to person only with some confusion noted. On [DATE] at 1:11 a.m. bruise found on left foot on outer area around ankle while assisting resident to bathroom. Resident stated had no knowledge of origin of bruise, denies discomfort, slightly swollen, ice applied to reduce swelling. On [DATE] at 3:11 a.m. resident assisted up with one person assistance, walked to bathroom with gait belt and walker, gait slightly unsteady, resident denied any pain, left ankle bruising lite purple in color. On [DATE] at 11:05 a.m. staff called nurse to room, resident on the floor in doorway of bathroom, resident received 1.5 centimeter laceration to forehead by left temple. At 12:10 p.m. resident removed from dining room due to vomiting. At 12:25 p.m. an on call physician gave a new order to send this resident to the hospital. On [DATE] at 8:34 p.m. the hospital telephoned the facility. The resident had a fractured hip and would undergo surgery on [DATE]. The Fall Report dated [DATE] at 9:20 a.m. noted the resident was self- transferring from toilet to wheelchair in the room. Alarms were on but did not sound. Resident found lying on floor on right side in bathroom doorway. Staff reported alarms were in place and on but not sounding. The resident was last toileted at 8:00 a.m. The resident was last observed at 9:10 a.m. and was sitting in a wheelchair in common area. The Every 15 Minute Check sheet noted Staff A, a Certified Nursing Assistant (Certified Nursing Assistant) observed this resident asleep in bed that morning at 9:00 a.m., 9:15 a.m., 9:30 a.m., 9:45 a.m. and 10:00 a.m.. The sheet indicated the resident remained in bed at 10:15 a.m., 10:30 a.m., 10:45 a.m. and 11:00 a.m. Staff A documented she observed this resident in bed asleep at 9:00 a.m. and at 9:15 a.m. When interviewed on [DATE] at 3:45 a.m. Staff A stated when she exited the dining room on [DATE], she was not aware of this resident's location. Staff A stated when she did not see this resident in the lobby, she went to look for this resident. Staff A found the resident lying on the bathroom floor. A Fall Investigation/Follow-up (undated and not signed ) and noted on [DATE] at 9:20 a.m. The resident propelled self in wheelchair to his/her bedroom and was found lying in bathroom. The resident had a history of [REDACTED]. Door alarm was in "on" position. Resident had been toileted three times after staff got him/her up and dressed for the day. Resident had pressure alarm to bed/chair as well. New Interventions/safety measures put in place included fifteen minute checks would be initiated as well as wireless alarm system for bed/chair. When interviewed on [DATE] at 11:50 a.m. the Director of Nursing denied knowing of this resident's history of turning off or removing his/her personal alarm. The Director of Nursing stated when a resident is able to remove or turn off their alarm; they (the facility) change to a wireless alarm. When asked why a wireless alarm was not used for this resident, the Director of Nursing stated due to she was unaware this resident had a history of [REDACTED]. When interviewed on [DATE] at noon, the Director of Nursing stated she was working in the facility as a staff nurse at the time of this fall. She denied knowing of the resident's history of disabling his/her alarms. She stated she completed the Fall Investigation/Follow-Up report dated [DATE]. This Fall Investigation/Follow-Up report noted the resident left the dining room after breakfast, wheeled self into room, attempted to transfer self to toilet, resident fell to floor, resident had unhooked his/her alarm. Review of the Care Plan, noted the facility identified this resident at risk for falls. One intervention dated [DATE] noted the resident uses a pad alarm in bed and chair. Ensure the device is in place and functioning every shift. Please make sure these devices follow me to where ever I am sitting. KEEP THE BOXES OUT OF MY REACH AS I TEND TO UNPLUG/SHUT OFF MY ALARMS. Review of this resident's plan of care revealed the facility failed to update this plan of care after the resident's fall on [DATE]. A Medical Review Consultants report noted the resident transferred to the hospital on [DATE] and expired at the hospital. On [DATE] at 3:45 p.m. Staff A (Certified Nursing Assistant) was interviewed and stated Resident #6 was confused at times and utilized alarms due to he/she would try and self-transfer. The resident was very impatient. Staff A had assisted getting Resident #6 out of bed that morning. The resident had a pressure alarm in the wheel chair and an alarm on the bedroom door. Staff A stated she last provided any care for Resident #6 when she assisted the resident up for the day and then pushed the resident's wheelchair to the lobby. After the breakfast meal she noted Resident #6 was not in the dining room or the lobby so she went to look for the resident. She then found the resident in his/her bathroom lying on the floor. The bedroom door alarm was not sounding. The wheelchair alarm was not sounding. The resident had a gash on the head. Staff A noted the brief she had applied to the resident that morning was in the trash can, the resident had a new brief wrapped around his/her legs and there was feces on the toilet seat. The resident was not wearing shoes. Staff A called for the nurse. The nurse assessed the resident and they transferred the resident from the floor to the wheelchair. The resident then was taken to the nurse's station where she/he sat for an hour to an hour and a half. Staff laid the resident down in bed. At lunch time, in the dining room (approximately 15minutes after arrival), the resident's head wound began to bleed again and the resident vomited. The resident remained in the wheelchair until the ambulance arrived. On [DATE] at 1:20 p.m. Staff B (Certified Nursing Assistant) was interviewed and stated Resident #6 was confused at times. This resident utilized an alarm on the bed, on the wheelchair and on the bedroom door. The resident had a history of [REDACTED]. The resident would unplug the pressure bed alarm and eventually was not able to unplug the chair alarm. Staff B witnessed this resident standing up trying to turn off the bedroom door alarm. On the day of this incident she had been in the resident's room to care for the resident ' s roommate while Staff A assisted Resident #6. Staff B had not cared for Resident #6 that day. Staff B stated this resident's roommate did not have the ability to turn off any alarms. Staff B stated she was unsure if this resident's bedroom door had been shut all the way. Staff B stated even if the alarm is turned on, if the door was not pulled tightly shut, it would not alarm when opened. Staff B stated usually if a resident would turn off an alarm, the facility would change the alarm to a call light alarm (automatically turns on the call light). On [DATE] at 5:35 p.m. Staff C (Licensed Practical Nurse) was interviewed and stated she had been employed at the facility only one month at the time of this resident's fall. Staff C worked a weekend package (worked weekends). Staff C stated the staff called her to the resident's room, where she observed the resident on the floor in the bathroom with a gash to the head. No alarms were sounding. They assisted the resident into the wheelchair and then took the resident to the nurse's station to monitor the resident. The resident then went to lunch. The staff then reported the resident bled through the bandage so they brought the resident from the dining room to the nurse's station. The resident told the nurse he/she was going to vomit. The nurse then kept the resident with her at the nurse's station until the ambulance arrived. When they stood the resident up to get on the ambulance gurney, the resident complained of leg pain. After this resident's fall, the resident had informed the nurse he/she needed to go to the bathroom and could not wait for the staff to come and help him/her. On [DATE] at 11:50 a.m. the Director of Nursing was interviewed and stated at the time of the resident ' s fall, the alarms did not sound. They were unable to determine why the alarms failed to sound. The Director of Nursing stated what may have happened was the door alarm only sounds for a short period of time and then goes off, so if the staff were in the dining room, they may not have heard the door alarm sound. The Director of Nursing stated she was not aware of this resident's history of turning off his/her own alarm and whenever a resident is able to turn off their own alarms, the facility changes to using a wireless alarm. A State of Iowa County Record, Certificate of Death for Resident #6, dated [DATE] documented this resident died on [DATE] at 2:35 a.m. The physician documented the immediate cause of death as complications from intertrochanteric fracture and fall.