Every finding on record at Anamosa Care Center

Based on clinical record review, Notice of Transfer forms, and interviews the facility failed to submit hospitalizations to the Office of the Long Term Care Ombudsman (OLTCO) for Resident #6. The facility further failed to submit any hospitalizations to the OLTCO in April, May, or June 2026. The facility reported a census of 54 residents. Findings include:The Minimum Data Set (MDS) for Resident #6 dated 5/24/26 documented diagnoses of deep venous thrombosis (blood clot in a deep vein), retention of urine, and hypertension (high bood pressure). A document titled eINTERACT Transfer Form effective 6/02/26 at 9:16 AM indicated the resident transferred unplanned to the local hospital for edema. A General Progress Note dated 6/06/26 at 9:22 PM revealed Resident #6's son took him to the hospital for chest pain and blood clot concerns. A document titled eINTERACT Transfer Form effective 6/07/26 at 11:16 AM documented Resident #6 transferred unplanned to a different hospital for urinary retention, straining to void, and pain.A General Progress Note dated 6/16/26 at 11:42 PM documented the resident reported chest pain while he was out of the facility with his family who then took him to the emergency department (the resident remained at the hospital for 2 days). Notice of Transfer Form to Long Term Care Ombudsman forms dated April 2026, May 2026, and June 2026 did not include any hospital transfers. On 7/29/26 at 1:37 PM, the Administrator stated Staff F, Social Services was responsible to submit the report including the resident's name, discharge date , whether the transfer or discharge was voluntary or involuntary, or if the resident passed away. She stated they did not include hospitalizations.On 7/29/26 at 1:43 PM, Staff F confirmed they sent the transfer form to the OLTCO once a month. She reviewed her binder and stated they were not reporting hospitalizations. Staff F reported they were sent in October so it appeared some months they sent hospitalizations and some they did not.

Based on clinical record review, interviews, and the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1 dated October 2025, the facility failed to complete a significant change assessment on a resident who discharged from hospice services for 1 of 1 resident reviewed for a change in condition (Resident #10). The facility reported a census of 54 residents.Findings include:The Minimum Data Set (MDS) assessment for Resident #10 dated 4/29/26 documented diagnoses of malnutrition, non-Alzheimer's dementia, and cerebrovascular accident (stroke). Section O of the MDS assessment indicated the resident received hospice care. A progress note dated 5/11/2026 at 4:21 PM titled General Progress Note: Late Entry documented the resident was discharged from hospice services and would transition to ICF (Intermediate Care Facility) level of care as of 5/11/26. A physician's order in the Electronic Health Record (EHR) dated 5/26/26 confirmed hospice was discontinued. Review of the MDS tab in the EHR revealed the list of completed assessments did not include a significant change assessment at the time hospice services were discontinued. On 7/28/26 at 3:24 PM the Administrator stated the MDS assessments were centralized and completed off site. She stated the facility held meetings on Wednesdays to discuss changes in resident care. On 7/29/26 at 1:02 PM Staff B, MDS Coordinator stated she received the necessary information to complete significant change assessments through quarterly 'bundles.' This was explained as information from the EHR, nursing, social services, activities, the Certified Nurses Aides (CNAs), and other departments used to complete each section of the MDS. Staff B stated significant change MDS assessments should be completed when residents had a change in two or more areas and included when a resident started or stopped using hospice services. She said this assessment should be completed within 14 days and added that she missed the assessment for Resident #10 when they went off of hospice. Review of the RAI 3.0 User's Manual page 2-17 documented the MDS completion date for a significant change in status shall be completed no later than the 14th calendar day after determination that a significant change in the resident's status occurred.

Based on observation, staff interviews, clinical record review, and policy review the facility failed to follow professional standards of medication administration when an extended-release medication was crushed and administered to a resident for 1 of 5 observed during medication observation (Resident #9). The facility reported a census of 54 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed the resident had difficulty or pain with swallowing and required mechanically altered diet. Review of the resident's Care plan, admission date 10/11/25, documented the following per special instructions: Meds crushed in applesauce. The Profile Page of Resident #9's Electronic Health Record relayed, Special Instructions: Meds crushed in applesauce. A Physician Order dated 10/9/25 directed, in part, may crush medications if not contraindicated. The Medication Administration Record dated July 2026 for Resident #9 directed to give Myrbetriq, 25 milligram Extended Release (ER) 24-hour tablet one time a day related to incontinence and to Dispense as Written ([NAME]). During a continuous observation on 7/29/26 from 8:50 AM to 9:05 AM Staff E, Licensed Practical Nurse (LPN) dispensed Resident #9 morning pills into a medication cup then proceeded to add the pills to a plastic sleeve and crushed all the medications in the crushing device. Staff E added the powdered mixture to a medication cup, added apple sauce and spooned the mixture into Resident #9's mouth. On 7/29/26 at 9:45 AM, Staff E, LPN queried and responded Resident #9 had an order authorizing medications to be crushed and referred to the Resident #9 profile page directive. Staff E then referred to the original physician's order that documented, may crush medications unless contraindicated, and voiced had felt the direction was not clear. On 7/29/26 at 3:50 PM the Director of Nurses (DON) relayed nurses should know an extend release medication was not to be crushed. The DON further explained pharmacy did a review when there was a change for crushing medications in addition to the usual pharmacy monthly reviews. A Policy titled Medication Administration dated 2025 directed to crush medication as ordered, and included, not to crush medications with do not crush instructions.

Based on observations, interviews, clinical record review, staff orientation checklist review, and policy review the facility failed to ensure appropriate infection control practices including proper hand hygiene and glove use during cares, failed to ensure disinfection of the glucometer after use, and failed to ensure the tubing including nasal cannula for supplemental oxygen use remained off of the floor for 2 of 18 residents reviewed (Resident #25 and Resident #50). The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed diagnosis of diabetes. Per the MDS assessment, the resident required insulin injections. The Care Plan focus area dated 5/6/26 for Resident #50 documented a diagnosis of diabetes. The Care Plan focus area revealed, in part, Resident #50 was at risk for frequent infections. The intervention dated 5/6/26 revealed to check blood glucose levels as ordered. During an observation on 7/28/26 at 9:25 AM, Staff A, Licensed Practical Nurse (LPN) took a glucometer (device to check blood glucose) from the medication cart, placed it on a paper towel barrier, retrieved a blood sample from Resident #50, discarded the test strip, and returned the glucometer back to the medication cart. During an interview on 7/29/2026 at 10:09 AM, Staff A relayed had not sanitized the glucometer before or after used it to obtain Resident #50's blood sugar. Staff A explained should have used alcohol wipes to clean the glucometer and did not. During an interview with the Director of Nurses (DON) on 7/29/26 at 3:52 PM, the DON relayed would expect all nurses to follow the training conducted at hire, and revealed the training sheet included instructions for glucometer disinfecting. A Document titled Licensed Nurse Orientation included the directive to disinfect glucometer using an approved Environmental Protection Agency (EPA) registered disinfectant per manufacturer instruction prior to using. The Licensed Nurse Orientation document further revealed to disinfect after obtaining the blood sample, prior to placing in container. 2. The MDS dated [DATE] for Resident #25 revealed a diagnosis of Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease. The MDS further revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of Resident #25's Care Plan focus area dated 2/12/26 documented a diagnosis of COPD/Asthma, and revealed Resident #25 was at risk for shortness of breath, impaired breathing, and respiratory infections. The Intervention dated 2/12/26 included to administer supplemental oxygen as ordered by the physician. a. On 7/27/2026 at 10:18 am, Resident #25 observed in bed with oxygen on via nasal cannula (NC) and an oxygen concentrator at 2 liters (L). On 7/28/26 at 8:43 am and 1:44 pm, observed the oxygen tubing, including the NC, lying on the floor in Resident #25's room on the right side of the bed. On 7/29/26 at 8:04 am, the oxygen tubing, including the NC, was lying on the floor in Resident #25's room on the right side of the bed. Staff D stood on the right side of the bed and provided care. At 8:22am, the resident's oxygen tubing and nasal cannula observed in the same position. At 9:28 am, Resident #25 relayed that she didn't take her oxygen off or put it on herself. On 7/29/26 at 10:42 am, Staff D, Certified Nursing Assistant (CNA) acknowledged if resident oxygen tubing was found on the ground she would pick it up and wipe it off with alcohol. On 7/29/26 at 10:55 am Staff C, CNA revealed if she noticed resident oxygen tubing on the floor she would pick it up. On 7/29/26 at 10:58 am the DON acknowledged she expected the CNA to report to the nurse that the oxygen tubing, including the NC, was on the floor. The policy titled Oxygen Administration revised October 2010 directed staff to report other information in accordance with facility policy and professional standards. b. The Care Plan focus area dated 2/12/26 revealed Resident #25 was incontinent of bladder and was at risk for impaired skin, urinary tract infections (UTI), and irritation in the peri-area. The intervention dated 2/12/26 included to monitor/document/report as needed (PRN), any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, and medication side effects. During an observation on 7/29/2026 at 8:04 am, Staff C, CNA and Staff D, CNA provided incontinence care for Resident #25. Staff C washed her hands before she put on gloves to perform care. Staff C used a gloved hand to touch the radio (walkie-talkie) when requested incontinence products; gloves were not changed after. Staff D put on gloves without first washing their hands. Staff D removed gloves and applied new gloves without hand washing or alcohol-based hand sanitizer use. Staff D removed gloves at the end of care and failed to wash her hands. During an interview on 7/29/26 at 10:42 am, Staff D relayed should wash your hands every time enter a resident room, before providing care, and after care was completed. During an interview on 7/29/26 at 10:55 am, Staff C relayed should wash your hands before and after got residents ready. On 7/29/26 at 10:58 am, the DON acknowledged CNAs would be expected to wash their hands before and after providing care, and whenever their hands were soiled. The policy titled Handwashing/Hand Hygiene revised August 2019 directed staff to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .before and after direct contact with residents .after removing gloves.

Based on observations, staff and family interviews, and facility policy review the facility failed to treat 1 out of 1 residents reviewed with dignity telling them to be incontinent in the bed after they asked to use the restroom (Resident #47). The facility reported a census of 55 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of Parkinson's disease, non-Alzheimer's dementia, and anxiety. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 5 (severely impaired cognition). The MDS identified Resident #47 as dependent on staff for toileting, transfer, and toileting hygiene. The Care Plan for Resident #47 date initiated 04/19/2024, directed staff to assist to toilet, before and after meals, at bedtime, and as needed. The Care Plan directed staff to provide incontinence (the inability to control bodily functions, specifically urination) care after each incontinent episode. The Care Card undated, hung on the wall in Resident #47's room marked T for toilet. On 6/09/25 at 1:06 PM, Resident #47's family reported on 6/8/25 at bedtime after the Certified Nurses Aids (CNA) put Resident #47 in the bed, Resident #47 told Staff C, CNA he needed to use the restroom. Staff C directed Resident #47 be incontinent in the bed and told him she would come back later and clean him up. The family reported being very upset with that direction from Staff C. On 6/11/25 at 1:00 PM, Resident #47's family reported she talked to the facility about her concern and the Director of Nursing (DON) told her it will be addressed. On 6/11/25 at 4:51 PM, the Director of Nursing (DON) reported she expected the staff to take a resident to the bathroom before they are put to bed at night. She confirmed telling a resident to go to the bathroom in the bed is unacceptable. On 6/11/25 on 7:51 PM, Staff B CNA, reported the Care Card on the wall in the residents room tells the staff how to care for the residents. How the resident transfers if they are toileted or check and change and other key care needs. Staff B stated the normal bedtime routine included taking the resident to the bathroom before bed, oral cares and getting them in bed safely. On 6/12/25 at 7:18 AM, the Restorative Nurse reported the T on the Care Sign indicated the residents use the toilet, or a bed pan, or a urinal. On 6/12/25 at 7:44 AM, Staff D, CNA reported if a resident is in bed and tells someone they need to go to the bathroom, you get them to the bathroom. She confirmed you don't tell them to go in the bed and clean them up after. On 6/12/25 at 9:38 AM Staff E, CNA reported why would you ever tell a resident to go to the bathroom in their bed, you take them to the bathroom, or use a bedpan or a urinal. She said that's not treating them right to tell them to go in the bed. The facility provided a policy titled Residents' [NAME] of Rights dated 12/2023, the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observations, staff and family interviews, and facility policy review the facility failed to provide staff assistance in a timely manor for 2 out of 2 residents reviewed (Residents #32 and #47). The facility reported a census of 55 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of Parkinson's disease, non-Alzheimer's dementia, and anxiety. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 5 (severely impaired cognition). The MDS identified Resident #47 as dependent on staff for toileting, transfers, and toileting hygiene. The Care Plan for Resident #47 date initiated 04/19/2024, directed staff to assist to toilet, before meals, after meals, at bedtime, and as needed. On 6/09/25 at 1:06 PM, Resident #47's family reported last night 6/8/25 Staff C, Certified Nurses Aid (CNA) walked by his room when his call light was on. The family revealed 35 minutes later she went to the lobby area to finds a staff to help Resident #47. 2. The MDS assessment for Resident #32 dated 4/23/25, included diagnoses of heart failure and diabetes mellitus (DM). The MDS reflected the BIMS score of 2 (severely impaired cognition). The Care Plan dated 1/20/25, directed staff to provide toileting assistance before and after meals, at bedtime, and as needed. On 06/11/25 at 4:13 PM, Resident#32 called out she needed to go to the bathroom. Two nurses were in and out of the area and two CNAs were in and out of the area helping other residents. Staff F, CNA's told Resident #32 they were busy, but would help her in a few minutes. Resident #32 continued to call out for help until 4:34 PM Twenty-one minutes later the Staff F helped Resident #32. On 6/10/25 at 4:38 PM, Staff A, CNA stated some residents do complain about the time it takes to get to the call light. She revealed they are checking the call light and are helping other residents. On 06/11/25 at 7:51 PM Staff B, CNA reported the time to get to the call lights are 15 minutes or sooner. She reported they try to make that happen. She reported at times they do tell the resident they will be right back, because they are helping another resident. On 6/11/25 at 4:51 PM, the Director of Nursing reported the expected call light maximum time is 15 minutes. She reported when a resident is calling out for help she expected the staff to immediately help them. The DON confirmed when a resident called out for help in the lounge without a call light she would expect the resident be taken care of within 15 minutes like a call light. On 6/12/25 10:59 AM the Assistant Director of Nursing (ADON) reported she completed a job fair that included going over the CNA Competency with the staff and they signed a paper acknowledging the expectation to answerer call lights in 15 minutes. The ADON revealed she thought Staff C failed to complete that training. Staff C's employee file lacked the CNA Competency. The Facility provided a copy of the CNA Competency that included call light response time. The facility provided a Preceptor Checklist for Staff C dated 12/7/2024, that identified training for call light response and toileting. The facility provided a Preceptor Guidance undated, that directed call lights must be answered in 15 minutes.

Based on clinical record review, facility incident investigation review, policy review, and staff interviews, the facility failed to assess a resident after spilling hot thickened coffee during meal service which resulted in a second degree burn (tissue damage to the top and middle layers of skin in which blisters can develop). She required antibiotics and treatments at the wound care clinic for injury 1 of 1 residents reviewed (Resident #14). The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) for Resident #14 dated 4/24/24 documented a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. The MDS documented Resident #14 had diagnoses including hypertension, stroke, dementia, dysphagia, and hemiplegia to the left side. It further documents that the resident required supervision with eating (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) The Care Plan for Resident #14 revised 2/07/24 with a focus area for Nutritional Status related to diabetes, altered textures, and need for supplement. Interventions listed to use plastic dinnerware due to behaviors and to monitor for chewing, swallowing problems. Review of the facility incident report investigation dated 6/01/24 documented Resident #14 was seated in the dining room for supper (supper meal served at 6 PM). She was served her thickened coffee in a styrofoam cup with a lid per her Care Plan. Staff laid her blanket on the table (the resident likes a blanket for her shoulders during the meal). Staff observed her grabbing onto her blanket and pulling it toward herself. When she pulled the blanket she spilled her hot coffee and juice on the table. Staff noted the spill and got rags to clean up the spill. They removed the wet blanket and rags from the table. The incident investigation lacked any documentation of the resident being assessed to make sure the hot coffee didn't spill on the resident. It documented it wasn't until staff was providing bedtime care that staff noticed the resident's thigh areas were red and had blisters. Staff then notified the nurse. The nurse then assessed the skin, tried to notify the resident representative and sent a message to the physician. The intervention done at the time was staff education to assess the resident right away after a spill of hot liquids. Review of the CNAs working the day of the incident lacked any documentation of assessing Resident #14 after the spill of the hot coffee to make sure it did not spill on the resident. Review of the Progress Note, Health Status Note dated 6/01/24 at 9:39 PM Staff G, LPN documented Resident #14 spilled her hot chocolate on the table and herself and it wasn't found until HS (bedtime) cares noted blisters and red areas. It documented the left inner thigh with two blisters, the red area measured 12.7 centimeters (cm) by 7.6 cm. One of the fluid blisters measuring 2.4 cm by 1.2 cm. A Progress Note, Health Status Note dated 6/04/24 at 9:00 AM documented Resident #14 was seen by the Advanced Nurse Practitioner (ARNP) and she assessed the bilateral thigh burns. The ARNP ordered Cephalexin (antibiotic) four times a day for seven days. Review of the non-pressure skin condition report for 6/01/24 documented the resident had 12.7 cm by 7.6 cm burn area to left thigh with one blister measured 2.4 cm by 1.2 cm and the other blister 1 cm around. The right thigh burn measured 3.1 cm by 1.5 cm. A Progress Note, Health Status Note dated 6/22/24 at 5:32 AM documented the physician ordered a referral for Resident #14 to be seen at the wound clinic. The Wound Clinic Provider note dated 6/26/24 documented the resident's left thigh burn noted to have necrotic; partial granulation to the site. The physician debrided the wound (removal of the dead, damaged or infected tissue). During an interview on 7/22/24 at 4:58 PM Staff G, Licensed Practical Nurse (LPN) reported she was the nurse working the evening of the incident. She verbalized she was at the kitchen window when staff came up to get towels to clean up the spill but did not report any of the spill landing on the resident. She reported she did not assess the resident to make sure. She reported Staff I, Certified Nurse Aide (CNA) was sitting with the resident at the time of the incident. She reported it was not until Staff H, CNA came up at bedtime after 9 PM and reported the resident had a red area with blisters to the thighs. Staff G went to the residents room and assessed her. During an interview on 7/23/24 at 10:59 AM, the Administrator reported the staff failed to assess the resident to make sure the hot coffee did not spill on the resident. She reported Staff I, CNA was sitting at the table when the incident occurred. During an interview on 7/25/24 at 9:15 AM, Staff K, Dietary reported prior to the incident for Resident #14 staff had not been temping the coffee or hot chocolate. During an interview on 7/25/24 at 09:59 AM, the Dietary manager reported there was no policy in place prior to the incident to temp the coffee and hot chocolate.

Based on personnel record review and staff interviews, the facility failed to do an annual performance evaluation for 5 of 5 employees reviewed (Staff B, Staff C, Staff D, Staff E, and Staff F). The facility identified a census of 60 residents. Findings include: 1. Personnel record review documented Staff B, Certified Nurses Aide (CNA) had a hire date of 10/22/19. A performance review dated 10/27/2020 signed and dated by Staff B, CNA. Further review lacked any annual performance reviews completed in 2021, 2022, and 2023. 2. Personnel record review documented Staff C, CNA had a hire date of 12/04/22. Further review lacked documentation of an annual performance review completed for Staff C since hire. 3. Personnel record review documented Staff D, CNA had a hire date of 9/11/22. Further review lacked documentation of an annual performance review completed for Staff D since hire. 4. Personnel record review documented Staff E, CNA had a hire date of 6/15/20. Further review lacked documentation of an annual performance review completed for Staff E since hire. 5. Personnel record review documented Staff F, CNA had a hire date of 18/20/2014. A performance review dated 6/15/2020 signed and dated by Staff F, CNA. Further review lacked any annual performance reviews completed in 2021, 2022, and 2023. During an interview on 7/24/24 at 12:52 PM, the Director of Nursing (DON) reported the annual reviews should be done yearly for the CNAs by the DON. She reported the Admin. Assistant is in charge of keeping track of when those are due and who is due. She reports she started the DON position in November of 2023 and has not done any reviews since starting. During an interview on 7/24/24 at 12:56 PM, Admin. Assistant reported she has a spreadsheet of when annual evaluations are due and sends an email to the department heads when one is due but there is no follow up for making sure they are done. She reported she does not have a system in place to get them back completed. During an interview on 7/24/24 at 01:39 PM, the Administrator reported the annual evaluation's have not been consistently getting done. They are trying to get consistency in place but there hasn't been.

Based on observations, pest control receipt review, resident interview, staff interviews, and policy review the facility failed to maintain an effective pest control program in the facility. The facility reported a census of 60 residents. Findings include: During an observation on 07/22/24 at 08:29 AM two flies were flying in circles in the kitchen. During food service one fly landed on the brown sugar topping a bowl of crispy rice cereal. It crawled from the sugar to the cereal, sat for about 10 seconds, and flew away. At 08:33 AM a fly landed on bowl of cheerios with brown sugar on it, crawled over the top of the sugar and into the hole of one of the cheerios, then crawled back on top of the sugar. The fly remained in the bowl 07/22/24 08:36 AM. On 07/22/24 at 12:24 PM observed Resident #58 shooing away a fly at his table. He attempted three separate swats to get it away from his food. At 12:26 PM the fly landed on the residents back and crawled on his neck. He shook his head and it flew away. He stated there are too many flies in this place. During continuous observation on 07/23/24 from 9:12 AM to 9:28 AM flies landed on the table, the chair, 4 residents, and a laptop 9 times. At 9:25 AM two flies landed on the table at the same time and then one flew to a resident's back and crawled onto her hair. At 9:26 AM a resident seated at the table next to the 100 hall was observed moving her hand back and forth in front of her face while staff were sanitizing tables and putting out fresh tablecloths. After she waived her hand observed flies land on 2 freshly cleaned tables and tablecloths 3 additional times. At 12:54 PM on 07/23/24 observed a fly land on a table in the common area next to a resident doing a puzzle. The fly flew upwards and landed on his head, flew to a resident asleep in her wheelchair next to him, and landed on her cheek. The fly crawled on her face just over a minute before flying towards the dining room. While observing a resident transfer on 07/23/24 at 02:52 PM Staff L, Licensed Practical Nurse (LPN) attempted to get flies away from a resident sleeping in the common area next to the dining room. She stated they needed to get a fly swatter around here. On 07/24/24 at 09:37 AM two flies landed on common area table. One crawled on the table top until 09:42 AM, the other landed on a resident's hair. She slept in one of the recliners next to the table. The fly crawled around on her head for about a minute and a half according to the clock on the wall. During an observation on 07/24/24 at 10:14 AM flies were in the 200 hallway by rooms [ROOM NUMBERS]. They landed on a wheelchair and the handrail. One then flew into room [ROOM NUMBER]. During an interview with Resident #58, who had a Brief Interview for Mental Status score of 13/15 indicating intact cognition, on 7/25/24 at 9:28 AM he stated flies were everywhere in the building. He indicated he was swatting at them all the time and mentioned they landed on him and his food. They were also in his room. An interview with the Administrator on 7/23/24 at 1:30 PM determined flies have been more of an issue recently. She stated the pest control company came once a month. Staff J, Cook, revealed during an interview on 7/24/24 at 12:44 PM that flies were not usually a problem but had been bad for the past week or so. An interview with Staff M, Maintenance, at 8:12 AM on 7/25/24 revealed he had not really noticed the flies. The facility had addressed spiders but he was not aware of the flies. He stated the pest control company came once or twice a month to spray the baseboards with an all natural chemical. A pest control receipt dated 7/11/24 indicated pest control was performed. It lacked documentation of the types of pests that were addressed. A policy titled Insect and Rodent Control dated 8/1/2002 documented insects and rodents carried harmful bacteria and the elimination or reduction of pests enhanced the facilities ability to prevent the spread of infection.

Based on observation, staff interviews, and policy review the facility failed to maintain sanitary conditions for 1 of 1 residents when staff used their bare hand to clean the top of a pepper shaker before putting the pepper on a resident's food (Residents #58). The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) assessment for resident #58 documented a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. Resident diagnoses included hypertension, respiratory failure, and diabetes mellitus. The MDS revealed the resident required supervision or touching assistance for eating meaning the helper provided verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed the activity. Assistance might be provided throughout the meal or intermittently. On 07/22/24 at 12:24 PM observed Resident #58 seated at a table in the main dining room with two other residents. He added salt and pepper to his food from the shakers on the table. At 12:26 PM the resident called Staff A, Dietary aide, over from assisting another resident to help with the salt and pepper shakers. The resident explained the shaker was almost out of pepper and they needed more. Staff A took the shaker from the resident, held it up to look at it, and shook it. She told the resident there was enough pepper in the shaker, and then used the heel of her left hand to rub over the holes on the top of the shaker. She then sprinkled pepper on the resident's salad. During an interview with Resident #58 on 7/25/24 at 9:28 AM he stated he was not aware the staff member cleaned the top of the shaker with her bare hand before she put the pepper on his food. He said, Ewww. He added he would have said something to the staff person if he had known. An interview with Staff J, Cook, on 7/24/24 at 12:44 PM revealed the condiment containers on the tables in the main dining room were wiped out, run through the dishwasher, and refilled at meals. The shakers were only put in the dishwasher when they got low. A follow up interview with the Dietary Supervisor on 7/24/24 at 12:50 PM determined the shakers were usually cleaned when they were empty, as needed, or every other week. She confirmed the top of the shakers should not be cleaned off with a bare hand. She stated staff would need to be reeducated. A policy titled Infection Prevention and Control Plan effective 8/1/17 documented a goal of preventing food-borne illness and surveillance activity that included monitoring food safety.

Based on record review, staff interview and facility policy review the facility failed to process a complete background check as required by the state of Iowa for 1 out of 1 record reviewed (Staff A, Certified Nurse Aide). The facility reported a census of 59 residents. Findings include: The Daily Assignment Sheet dated 1/5/24 indicated Staff A, Certified Nurse Aide (CNA) worked 6 AM to 2 PM shift on the brown hall. Staff A's Single Contact License and Background Check (SING) printed on 3/18/23 listed the criminal history section as further research required. The status listed the research complete on 3/4/24 as no criminal history record found. Review of the Iowa Department of Human Services Authorization for Release of Child and Dependent Adult Abuse Information completed 3/21/24 for Staff A, CNA indicated information requested is not listed on the Dependent Adult Abuse Registry as having abused a dependent adult. On 3/21/24 at 10:58 A.M. the Administrator explained she expected to have all of the background checks completed before the staff worked at the facility. She reported that they have access to the Agency staff records, it shows completion but not the specific information. The Administrator said if the paperwork says complete valid, then nothing should prevent them from working in long term care. She added that she knew the state of Iowa required a completed SING. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 instructed the facility to screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. The facility will accomplish it through the following (including maintaining documentation of such results): a. Conduct an Iowa Criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code 58.11(3). b. The facility will conduct a criminal record check and dependent adult/child abuse registry check on all current employees and other individuals engaged to provide services to residents who have criminal convictions or founded abuse determinations after hire, or where the facility received credible information that an employee has had criminal conviction or a founded abuse determination subsequent to hire.

Based on clinical record review, staff interview and the Resident Instrument Assessment (RAI) manual the facility failed to accurately code anticoagulant use on the Minimum Data Set (MDS) assessment for three of four residents reviewed (Resident #14, #38, and #49) for MDS accuracy. The facility reported a census of 54 residents. Findings include: 1. The MDS assessment for Resident #14 dated 5/3/23 revealed the resident scored 15 out of 15 possible points on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS documented the resident received anticoagulant medication for seven of the last seven days. The Care Plan revised on 9/2/22 documented Resident #14 received anticoagulant/antiplatelet therapy related to paroxysmal atrial fibrillation and a history of pulmonary emboli. The Medication Administration Record (MAR) dated April 2023 and May 2023 documented the resident received clopidogrel bisulfate oral tablet 40 milligrams one time a day. The MAR's lacked any documentation the resident had an order for anticoagulation medication or received anticoagulation medication. 2. The MDS assessment for Resident #38 dated 5/31/23 revealed the resident scored 4 out of 15 possible points on a BIMS exam, which indicated severe cognitive impairment. The MDS documented the resident had received anticoagulant medication for seven of the last seven days. The Care Plan revised on 5/6/21 documented Resident #38 received anticoagulant therapy related to a history of cerebrovascular accident. The Medication Administration Record (MAR) dated May 2023 documented the resident received clopidogrel bisulfate oral tablet 75 milligrams one time a day. The MAR lacked any documentation the resident had an order for anticoagulation medication or received anticoagulation medication. 3. The MDS assessment for Resident #49 dated 4/19/23 revealed the resident scored 00 out of 15 possible points on a BIMS exam, which indicated severe cognitive impairment. The MDS documented the resident had received anticoagulant medication for seven of the last seven days. The Care Plan revised on 11/8/22 documented Resident #49 received anticoagulant therapy related to a history of trans ischemic attack and supraventricular tachycardia. The Medication Administration Record (MAR) dated April 2023 documented the resident received clopidogrel bisulfate oral tablet 75 milligrams one time a day. The MAR lacked any documentation the resident had an order for anticoagulation medication or received anticoagulation medication. On 6/15/23 at 11:12 AM, the MDS Coordinator, acknowledged they had coded plavix as an anticoagulant. The MDS Coordinator stated the facility did not have a separate policy and followed the RAI manual. The RAI Manual dated October 2019 documented to not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel.

Based on record review, staff interview and facility policy review the facility failed to ensure a staff member certified in Cardiopulmonary Resuscitation (CPR) present at the facility for the complete evening/overnight shift on [DATE]. The facility reported a census of 55 residents. Findings Include: The Nursing Schedule for [DATE] revealed Staff A, Registered Nurse (RN) worked the P shift on [DATE]. Review of the CPR certification information for Staff A provided by the facility revealed Staff A certified on [DATE] and recommended renewal date was ,d+[DATE]. The Nursing Schedule revealed Staff B, RN worked 6:00 PM through 10:00 PM on [DATE]. The list of current CPR certified staff provided by the facility included Staff B. A CPR certified staff member was not observed to be present on the schedule on [DATE] between 10:00 PM and 6:00 AM for [DATE]. On [DATE] at 11:20 AM, an interview conducted via telephone with the facility's Director of Nursing (DON). The DON explained the P shift was 6:00 PM to 6:00 AM, and the AM shift was 6:00 AM to 6:00 PM. The DON was queried if they had been able to identify a CPR certified staff member worked between 10:00 PM and 6:00 AM on [DATE], and the DON acknowledged unable to do so. The DON acknowledged all of the nurses at the facility should be CPR certified. The Facility Policy titled Cardiopulmonary Resuscitation (CPR), dated ,d+[DATE], documented at bulletin #3: If CPR is required, it will be immediately initiated by a Licensed Nurse currently certified to perform CPR, pursuant to current American Heart Association guidelines.

Based on clinical record review, policy review, and resident representative interview, the facility failed to ensure residents did not receive foods they had allergies to for 1 of 15 residents in the sample(Resident #26). The facility reported a census of 55 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 12/23/21, listed diagnoses for Resident #26 included diabetes, [CONDITION(S)] (stroke), and [CONDITION(S)]. The MDS stated the resident required supervision and setup assistance with eating, and extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 10 out of 15, indicating moderately impaired cognition. The Baseline Care Plan, dated 3/5/21, stated the resident had an allergy to eggs and mushrooms. A Care Plan entry, dated 3/10/21, stated the resident had an allergy to mushrooms and nuts. A 3/10/21 Nutrition/Dietary Note stated the resident had an allergy to eggs and mushrooms. The note stated the resident and her spouse stated she ate eggs but did not eat mushrooms or nuts. A Physician Progress Note, dated 10/5/21, stated the resident had allergies to tomatoes, egg whites, mushroom extract, and peanut-containing drugs. The note stated the resident had a reaction of [MEDICATION(S)] (a severe, potentially life-threatening allergic reaction) to tomatoes. The resident's Order Summary Report, dated 12/16/21, stated the resident had allergies to eggs and mushrooms. The HCI Nutritional Assessment/Reassessment v2, dated 12/22/21 did not include any allergies under the section Food Allergies. The facility policy Dietary Policies and Procedures, dated 9/21, stated a member of the Nursing Staff or the Dietician would obtain and clarify Diet Orders and stated the facility would honor special dietary needs. During a telephone interview on 10/4/22 at 10:43 a.m., the resident's spouse stated the resident had allergies to nuts and eggs and the facility served those to her. During an interview on 1/6/22 at 9:40 a.m., the Dietary Manager stated Resident #26 did not like tomatoes or chocolate, but not aware the resident had any allergies. She stated normally the nurses informed the kitchen if the resident had allergies. During an interview on 1/6/22 at 11:30 a.m., the Consultant Dietician stated she listed the resident's allergies on a board in the kitchen today.

Based on observation, record review and staff interview, the facility failed to provide an admission assessment and physician clarification for use of an ED boot (stabilizer boot) resulting in the development of a pressure ulcer for 1 of 4 residents (Resident #46). The facility identified a census of 58 residents. The Admission Record showed Resident #46 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status Score (BIMS) of 3 indicating severe memory impairment. The resident required extensive assistance with toileting, personal hygiene, dressing and had a Foley catheter. The MDS identified the resident at risk of pressure ulcers with a Stage IV pressure ulcer present upon admission and a Stage III pressure ulcer that developed after admission. A review of the Physician Transfer Order Report from the hospital, dated 10/16/19, did not address a physician order [REDACTED]. The Certificate of Care for Nursing Home Admission signed by the physician 10/16/19 documented the resident did not have chronic wounds. The Braden Scale for Predicting Pressure Sore Risk, completed 10/16/19, identified a score of 15, indicating the resident at risk of developing a pressure ulcer. The Admission Nursing Assessment, dated 10/16/19, failed to reveal any skin assessment documentation regarding a pressure ulcer to the right lateral foot or the presence of a ED boot to the right lower extremity. The Admission Progress Note, dated 10/16/19, identified the resident admitted with a bruise to the right hand, left antecubital and a wound to the left malleolus (ankle bone). The Admission Progress Note did not address any documentation of a wound to the right lateral foot or the presence of a ED boot to the right lower extremity. The Baseline Care Plan, dated 10/17/19, identified the resident had a stage 4 pressure ulcer to the left Malleolus (ankle) with treatment and would be seen at the wound clinic. The Baseline Care Plan did not identify the resident wore an ED boot to the right lower extremity when admitted on [DATE] or any wounds to the right lower extremity. A Nursing Home Rounds dictation, dated 10/18/19, by Resident #46 attending physician, documented the resident complained of pain with the ED boot. The physician documented that the resident would have the boot removed from the right lower extremity and protect his/her feet with boots on when he/she lays down. The dictation documented the resident had a fall the day prior to 10/1/19, had a boot placed to the lower extremity and the ankle is chronically deformed due to poor healing of a previous fracture in (YEAR). The Nursing Home Round dictation lacked documentation of the presence of a stage 3 pressure ulcer to the right lateral foot. A Physician Order, dated 10/18/19, instructed to discontinue all treatments, except the left ankle wound treatment. Physical Therapy Daily Treatment Notes dated 10/21/19 and 10/22/19 documented the resident required assistance with completing exercises to the right lower extremity due to the increased weight to the extremity from the resident wearing the ED boot. Resident #46 saw the attending physician at the wound clinic on 10/23/19. The Wound Clinic Provider Note, dated 10/23/19, documented a [DIAGNOSES REDACTED]. The subjective narrative, as dictated by the attending physician, documented the right foot wounds were healed, but unfortunately he/she developed a pressure injury from the ED boot. The attending physician dictated to remove the ED boot at this time due to causing more harm than helping. The wound to the right lateral foot presented as a black, unstageable wound that required debridement on 10/23/19. Post debridement the wound to the right lateral foot showed a stage 3 pressure injury measuring 1 cubic centimeter (CM) in length, by 0.8 cm in width, by 0.1 cm in depth. The physician documented the wound to the right lateral foot reopened 10/23/19 due to a deep tissue injury (DTI) resulting from the ED boot. A Wound/Skin Healing Record, dated 10/23/19, provided by the facility, documented a stage 3 pressure ulcer to the right lateral foot with an onset date of 10/23/19 per the wound clinic assessment. The facility Progress Notes dated 10/16/19-10/22/19 lacked documentation the condition of right lateral foot had been assessed, until the wound clinic appointment 10/23/19 when the Stage 3 to the right lateral foot received debridement. The facility progress note dated 10/23/19 documents a new wound site on the right lateral foot, a stage 3 pressure ulcer. The Care Plan, with an initiation date of 10/24/19, identified the resident had a stage 3 pressure ulcer to the right lateral foot. The Care Plan directed the following care: a. Prevalon boot on when in bed, initiated 11/7/19. b. Wound clinic appointment weekly as ordered, initiated 10/24/19. c. Assess the pressure ulcer for location, stage, size (length, width, depth), presence and absence of granulation tissue, epithelization and condition of surrounding skin weekly, initiated 10/24/19. d. Apply treatment as ordered, initiated 10/24/19. e Assist with repositioning, initiated 10/24/19. f. Monitor skin during cares. Report any further skin breakdown (sore, tender, red or broken areas), initiated 10/24/19. g. Provide incontinence care after each incontinence episode, initiated 10/24/19. h. Use pressure reduction cushion to chair, initiated 10/24/19. i. Use pressure reduction mattress when resident in bed, initiated 11/14/19. A Physician order [REDACTED]. During an observation on 11/25/19 at 1:33 p.m., Staff A, Certified Nursing Assistant (CNA) and Staff F, CNA, transferred the resident to bed utilizing a mechanical standing lift. The resident wore gripper socks in bed. Staff A and Staff F did not apply the Prevalon boots to both feet per the 11/7/19 physician order [REDACTED]. During an observation on 11/26/19 at 9:30 a.m., Staff K, Licensed Practical Nurse (LPN), set up a clean field and supplies. Staff K proceeded to complete Santyl treatment as ordered by the physician for Resident #46's Stage 3, right lateral foot pressure ulcer. The pressure ulcer measured 0.8 cm in length, 0.5 cm in width, and 0.1 cm in depth. The wound bed had a small amount of brown, tan slough present, no odor or drainage. The peri-wound area remained pink. The resident reported he/she did not have pain to the wound area. During an interview on 11/25/19 at 11:06 a.m., Staff B, CNA, reported if a resident wears a special boot, the CNA's would not remove the boot to look at the skin. The nurse would remove and look at the skin. During an interview on 11/25/19 at 11:09 a.m., Staff D, Registered Nurse (RN), reported nurses would only remove a immobilization boot to look at the skin if ordered to do so by a physician. During an interview on 11/25/19 at 3:00 p.m., The Director of Nursing (DON) stated the resident got the boot on 10/1/19 in the emergency room after a fall with fracture. The Don stated the resident did have the boot on until 10/23/19 after the wound clinic visit. During an interview on 11/25/19 at 1:57 p.m., Staff A, CNA, reported she remembered the resident admitted with a boot on the right lower extremity. During an interview on 11/25/19 at 4:05 p.m., Staff H, Physical Therapist Assistant (PTA), reported the resident did admit with a boot to the right lower extremity. She remember the team discussing the boot at the Medicare meeting on 10/23/19 as the resident did not have a physician order [REDACTED]. During an interview on 11/25/19 at 4:53 p.m. via phone, Staff I, Doctor of Physical Therapy (DPT), reported the resident admitted with a boot to the right lower extremity. The resident had a fall a few weeks before coming to the nursing home and needed the boot to stabilize the weight bearing of the right foot due to a fibula injury. She reported the resident wore the boot to the right lower extremity for about 1 and a half weeks and did report pain, but the pain came from the right knee and calf area, not the right foot. Staff I could not recall if the right extremity boot had been physician ordered. During an interview on 11/25/19 at 5:07 p.m., via phone, the Primary Care Physician and Wound Clinic Physician, stated the resident had a history of [REDACTED]. The resident had been place in a special boot on 10/1/19 at the hospital emergency department. He confirmed he saw the resident on 10/18/19 and addressed the ED boot to the right lower foot should be removed. He reported he may not have dictated to wait in his note because he wanted to talk to the resident's son before removing the boot. He stated the use of a stabilizer boot is the standard of care for a fibular fracture. He reported he would expect the nurses to remove the ED boot and assess the skin with admission. But as he did not order the boot, the facility should have clarified further instruction with the hospital regarding the use of the boot, if the boot had not been physician ordered. He stated the right foot,stage III pressure ulcer had reopened. The wound resulted from a fall with injury to the right fibula and the boot did not help the situation but does not feel the area would have been unavoidable. He stated he saw the wound when he did rounds 10/18/19 and assessed again on 10/23/19 when he saw the resident in the wound clinic. During an interview on 11/26/19 at 7:05 a.m., Staff K, Licensed Practical Nurse (LPN), stated resident did admit with a boot to the right lower extremity. She reported the resident admitted between 5:00 p.m. - 5:30 p.m. and it is a busy time of day. Staff K reported she didn't know if the ED boot had a physician order [REDACTED]. She reported the assessment did not have documentation the right lower extremity had been assessed. She stated she could not remember 100% if she did or did not remove the boot to assess the right lower extremity and foot. During an interview on 11/26/19 at 7:33 a.m., the Director of Nursing (DON), reported she doesn't know why the resident's boot to the right lower extremity did not get removed on 10/18/19. She stated the boot should have been removed if the physician dictated the boot to be removed on 10/18/19. The DON confirmed the facility did not have a physician order [REDACTED]. During an interview on 11/26/19 at 7:36 a.m., the ADON, reported she does not see the resident or assess the resident when they are admitted to the facility. She gets the physician orders [REDACTED]. The ADON reported she did not know resident #46 had admitted with a ED boot to the right lower extremity. She reported if the ED boot did not have a physician order, it should have been clarified with the physician. During an interview on 11/26/19 at 10:36 a.m., Staff C, Licensed Practical Nurse (LPN), reported she assisted Staff K with the assessment of Resident #46 on 10/16/19. Staff C reported she could not recall if they did or did not remove the boot, but thought they may not have removed the boot and assessed the right foot. She reported she did not know if the ED boot had a physician order [REDACTED]. During an interview on 11/26/19 at 10:15, the DON reported she would have expected the nurses to document the presence of an ED boot and to assess the skin condition of the right lower extremity upon admission. The Nurse Consultant reported 11/26/19 at 10:18 a.m., the facility did not have a pressure ulcer or admission skin assessment policy.

Based on record review, observation and interview, the facility failed to secure a urinary drainage bag and tubing from contacting the floor to maintain acceptable infection control for 1 out of 3 residents (Resident # 46). The facility identified a census of 58 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident #46 dated 10/23/19 showed a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive loss. The resident required extensive assistance with toileting, personal hygiene, dressing and utilized a urinary catheter. The MDS documented [DIAGNOSES REDACTED]. A Physician Transfer Order Report, dated 10/16/19, ordered the resident to continue with a urinary catheter due to [MEDICAL CONDITION]. A physician order [REDACTED]. During an observation on 11/25/19 at 10:30 a.m., the resident sat in the lounge chair in the front lounge. The resident's catheter bag lay in a privacy bag on the floor underneath the lounge chair with the tubing laying directly on the floor. During an observation on 11/25/19 at 11:55 a.m., the resident sat in a lounge chair in the front lounge. The resident's catheter bag lay in a privacy bag on the floor under the chair with the tubing touching the floor and the resident's slipper shoes stepping on the top of the urinary drainage bag tubing. Staff A, Certified Nursing Assistant (CNA), talked to the resident on transferring to the wheelchair to go to the dining room for lunch. The resident refused to move from the lounge chair. Staff A did not pick the urinary drainage bag and tubing up off the floor and suspend from the chair. During an observation on 11/25/19 at 12:25 p.m., the resident sat in the lounge chair watching television. The resident's urinary drainage bag lay on the floor under the chair in the privacy bag with the drainage bag tubing laying on the floor and the resident stepped on the tubing with his/her slippers. During an observation on 11/25/19 at 1:45 p.m., Staff A and Staff F, CNA assisted the resident to lay down in bed and emptied the resident's urinary drainage bag. Staff A and Staff F did not put a privacy cover on the resident's urinary drainage bag after emptying the urinary drainage bag. Staff F lowered the electric bed to the low position causing the uncovered, urinary drainage bag to come into direct contact with the floor. During an observation on 11/25/19 at 1:54 p.m. the urinary drainage bag remained uncovered, dangling off the resident's bed touching the floor. No basin in place to keep the urinary drainage bag and tubing from laying on the floor. During an observation on 11/25/19 at 4:08 p.m. the urinary drainage bag remained uncovered, dangling off the resident's bed touching the floor. No basin in place to keep the urinary drainage bag or tubing from laying on the floor. The Care Plan, initiated 10/22/19, identified the resident would sit his/her catheter bag on the floor and directed the staff to encourage the resident not to do this and suspend the urinary drainage bag up off the floor when found. During an interview on 11/25/19 at 3:23 p.m., Staff G, (CNA) reported she had been trained that a urinary drainage bag should always be covered for privacy and the drainage bag/tubing should never come into contact with the floor. During an interview on 11/25/19 at 4:00 p.m., Staff C, Licensed Practical Nurse (LPN) stated a urinary drainage bag should always be covered for dignity and the bag or tubing should never come into contact with the floor. She reported the facility puts a basin under the urinary drainage bag when the bags are hung from the bed to keep the bag and tubing from contacting the floor. During an interview on 11/25/19 at 4:20 p.m., the Director of Nursing (DON) stated she would expect urinary drainage bags to be covered to protect the resident's dignity. She reported the urinary drainage bag and tubing should not come into contact with the floor for infection control. The Nurse Consultant reported on 11/26/19 at 10:18 a.m. the facility did not have a urinary catheter policy.

Based on observation, record review, resident and staff interviews, the facility failed to identify the resident with a pressure ulcer and document interventions on the Baseline Care Plan for one of three residents reviewed with pressure ulcers (Resident #261). The facility reported a census of 58 residents. Findings Include: A review of the Admission Record revealed the resident admitted to the facility on [DATE]. The facility did not have a completed Minimum Data Set (MDS) Assessment Tool on the medical record for reference. A review of the hospital discharge instructions dated 11/21/19 documented the following: a. Upcoming appointment with the wound clinic on 11/26/19. b. Dressing and wound orders to left foot two times daily. c. Remove packing. d. Flush with normal saline, may then irrigate with 3 milliters (ml) 1% [MEDICATION NAME]. e. Pack loosely with ¼ inch nugauze moistened with 0.125% Dakins's solution. f. Cover with 4x4 gauze folded in half, secure with [MEDICATION NAME] tape. An observation of wound care on 11/25/19 revealed the resident had a left plantar wound which measured 1.3 centimeters (cm) long, 2.0 cm wide and 0.5 cm deep. No signs of infection noted to wound bed or surrounding skin. A review of the Nurse's Notes revealed the following entries: 11/21/19 at 1:21 p.m., resident admitted for wound cares to the left foot, abrasion to left foot packed. During an interview on 11/25/19 at 10:53 a.m., the Director of Nursing reported the resident did have an open area to the bottom of her left foot upon admission and that she would expect that issue to be addressed on the Baseline Care Plan which all staff had the responsibility to develop. In an interview on 11/25/19 at 2:41 p.m., Staff E, Registered Nurse/ MDS Coordinator reported the resident admitted to have wound care for the open area she had to the bottom of her left foot. The Care Plan should have addressed this, and could not explain why it did not.

Based on clinical record review and staff interviews the facility failed to appropriately assess and provide interventions when one of four residents had a change in condition. (Resident #2). The facility reported a census of 50 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #2 identified with moderately impaired cognition, transferred and ambulated independently and had [DIAGNOSES REDACTED]. The Care Plan identified Resident #2 required assistance with Activities of Daily Living (ADL's) related to [DIAGNOSES REDACTED]. On 10/18/2018 the Care Plan initiated directives for staff to administer oxygen to keep oxygen sat's above 90% and report further deterioration in status to physician. The physician's orders [REDACTED]. The April, 2019 Medication Administration Record [REDACTED]. The April, 2019 Treatment Administration Record (TAR) revealed staff checked Resident #2's oxygen saturation levels one time on 4/17/2019. The resident's Progress Notes included: a. On 4/14/19 the resident requested [MEDICATION NAME] for post nasal drip and cough and cough drops. The resident stated the spray was ineffective. Staff requested a physician's orders [REDACTED].>b. On 4/15/19 [MEDICAL TREATMENT] informed the facility the resident tested positive for a respiratory virus, and sent the physician the information. c., On 4/17/19 at 4:28 p.m., staff checked the resident's oxygen saturation level and found it to be 82%. Staff applied oxygen at 2 liters with nasal cannula. The resident complained of shortness of breath (SOB). At 4:52 p.m., staff documented the oxygen was effective and the residents saturation level rose to 96%. d. On 4/19/19 at 8:20 p.m. staff documented the physician ordered to continue [MEDICATION NAME]. e. On 4/19/19 at 11:13 p.m. staff administered Tylenol for general aches and pain and it was effective. f. On 4/21/19 at 7:45 p.m. staff documented the resident complained of non productive cough, malaise, loss of appetite, stomach ache and back ache for the past 3 days. Vitals included oxygen saturation at 85% with 3 liters of oxygen, crackles heard on left posterior upper lobe, pulse 94, respirations 24, blood pressure 160/54. g. On 4/21/19 At 9:20 p.m. the physician ordered the resident be sent to the emergency room . h. On 4/22/2019 at 12:46 a.m. the hospital called the facility and reported the resident transferred to ICU (Intensive Care Unit) with a [DIAGNOSES REDACTED]. Review of The Weights and Vitals Summary included Resident #2's oxygen saturation levels: a. On 4/5/2019 - 90% on room air b. On 4/17/2019 - 90% c. On 4/22/2019 - 85%, oxygen via Nasal Cannula Review of The Weights and Vitals Summary included Resident #2's temperature recordings: a. On 4/17/2019 at 6:27 p.m. - 98.8 degrees Fahrenheit b. On 4/19/2019 at 3:31 p.m. - 98.2 c. On 4/26/2019 at 3:14 p.m. - 97.2 Review of the Hospital Respiratory Panel completed while the resident attending [MEDICAL TREATMENT], the nasopharyngeal swab results dated 4/15/2019 revealed Resident #2 tested positive for Human Metapneumovirus. Associated Diagnoses: [REDACTED]. The Emergency Department Notes dated 4/21/2019 at 9:45 p.m. revealed Resident #2 had [DIAGNOSES REDACTED]. The resident presented to the emergency department with fevers, shortness of breath and cough. The resident had oxygen saturation at 80% and was provided with 15 liters via non-rebreather to maintain saturations in the low 90's. The resident arrived febrile with a temperature of 39.3 degrees Celsius. (102.7 Fahrenheit), heart rate of 136 and respirations in the 30's. The Nursing Home to Hospital Transfer Form dated 4/21/2019 included Resident #2 had 85% oxygen saturation level, 98.2 degrees temperature. The Situation Background Appearance Review (SBAR) and Notify Communication Form reported the change in condition, symptoms, or signs started on 4/17/2019. During an interview on 5/28/2019 at 3:00 p.m., Staff A, Licensed Practical Nurse (LPN) reported working 4/21/2019 during the evening shift. Staff A reported Resident #2 stayed in his/her room during supper due to not feeling good enough to come to the dining room. Staff A checked the resident's vital signs and lungs and heard crackles. Staff A sent a message to the physician who did not respond immediately, so Staff A phoned the on call physician who ordered the resident be sent to the emergency room . Staff A sent the resident to the emergency room due to a low oxygen saturation level. During an interview on 6/3/2019 at 11:45 a.m. Staff B, LPN reported working during the day shift on 4/21/2019. Staff B indicated staff checked the resident's oxygen saturation levels daily in order to keep the levels at 90% or above. Staff B did not recall anything unusual and if he/she had checked the resident's saturation levels it would have been documented.

Based on clinical record review, staff, physician and resident interviews, the facility failed to complete an ongoing resident assessment after a fall for one of three residents (Resident #1) reviewed. The facility census was 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The Care Plan revealed Resident #1 had a fall risk related to a recent hospitalization and diagnoses. The Care Plan instructed staff to ambulate the resident with assistance of one outside of the room and could ambulate independently in the room. The Incident Report dated 7/22/2018 revealed Resident #1 fell in his/her room at approximately 6:50 a.m. Staff observed the resident lying on the floor on his/her left side. The resident indicated he/she intended to go to the bathroom. The report revealed the resident sustained [REDACTED]. Staff A, RN (Registered Nurse) assessed the resident, phoned and physician and family and administered first aide. Progress notes dated 7/22/18 at 6: 50 a.m., revealed Staff A, registered nurse, RN documented being called to the room by the roommate and found the resident on the floor on their left side. The resident stated she going to the bathroom. The resident complained of left back of head pain 10/10. Abrasion and hematoma noted to the right forehead measuring 3.3 by 1.8 centimeters with bruise. Staff A assessed pupils equal and reactive to light, grips strong, alert and oriented and applied ice. Staff A notified the physician and received no new orders and notified the resident's family member. Late entry for 7:00 a.m., documented Staff A applied ice to the residents shoulders and neck for complaint of pain and brought the resident to the lobby to continue to monitor. Late entry for 8:00 a.m., documented the resident ambulated with walker out to dining room for breakfast, ate without assistance and offered ice packs which the resident refused. Late entry for 12:30 p.m., documented the resident ate lunch in the dining room without difficulty. Brought back to the lobby after lunch to continue to monitor. Resident had cell phone and able to make calls. Offered ice packs and resident refused at this time for complaint of headache and neck ache. At 2:32 p.m., the resident worked with therapist and complained of neck pain 5-6/10. Ice packs offered, resident refused at this time. Therapy Notes dated 7/22/18, documented pain gel applied to the residents left ankle and cervical area to decrease pain with functional activities. Complained of severe pain in left ankle and neck. Nursing aware. Discussed with nursing staff recent fall and patient now assist of one due to increased confusion. At 6:32 p.m., Staff D, licensed practical nurse, LPN documented the resident's POA came and stated resident expressed wanting to go to the emergency room in regards to the fall this evening. Vitals checked, hematoma and purple bruise to right forehead. Complains of pain to head, neck and shoulders 10/10. Physician called and received order to send resident to emergency room . At 9:37 p.m., Staff D reported the resident was admitted with a C-2 (Cervical) fracture and a fracture to the back of the skull. During interview on 8/3/18 at 10:30 a.m., the resident reported falling in the room as she attempted to removed the sheets. The resident reported hitting her head on the floor and yelled for help. A nurse responded and three staff picked the resident up. The resident said her head hurt and everything else appeared fine. The resident stated her neck hurt all day and a friend came to the facility and she went to the hospital and returned to the facility with a neck brace. During interview on 8/7/18 at 10:30 a.m., the physician reviewed the notes from 7/22/18 and said the facility notified them at 7:30 a.m. and reported the resident had a significant goose egg on the back of the head related to a fall. The physician recommended they send the resident to the emergency room . The nurse said the resident had no pain and seemed fine. The physician reviewed the resident's findings and knew the resident did not receive blood thinners, had intact neuro's (neurological assessment) and had no complaint of head ache. The physician recommended staff continue neuro's according to protocol and call with any neuro changes. At 6:00 p.m., the facility called again and said they wanted to transfer the residents. During interview on 8/3/18 at 11:15 a.m., Staff A, RN recalled the resident on the floor and she reported pain at the back of the neck. The resident also had an abrasion on the forehead and a hematoma at the back of the head. Staff rolled the resident onto his/her back. The resident complained of pain the majority of the time, initially at 10 out of 10. When staff stood the resident up she had no pain. Staff A called the physician and reported the resident's neuro exam appeared normal. The physician directed Staff A to call with anything abnormal. The physician did not prescribe any medication at that time. Staff kept the resident at the front lounge for supervision and the pain eventually decreased to a 5 or 6 out of 10. At approximately 9:00 a.m., the resident asked to be seen at the emergency room . Staff A called Staff C, Licensed Practical Nurse, LPN and reported the fall and the resident's abrasion, hematoma, head and neck pain and the request to be sent out. Staff C told Staff A to go by her assessment. Staff A indicated she did not call the physician back again and the resident never asked again to be sent out. Staff A wished she would have notified the physician and asked for pain medication and gone by her gut instinct. During interview on 8/7/18 at 8:40 a.m., Staff D, LPN reported she learned the resident fell and had a hematoma on the right forehead and neuro exams had been started and the resident appeared fine during the day. After report, the resident's friend came and said the resident wanted to go to the hospital. Staff D assessed the resident and vitals and neuro's were normal. The resident did have a hematoma on the forehead and complained of neck and shoulder pain. The resident did not appear distressed but looked as though she did not feel well. Staff D called the physician and sent the resident to the emergency room .

Based on observation, clinical record review, review of resident bill of rights, resident and family interviews, the facility failed to ensure five residents observed were clean shaven and appropriately dressed and covered. The facility census was 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The Care Plan directed staff to provide morning and evening cares and baths. Observation on 11/27/18 at 12:15 p.m., revealed the resident seated at the dining room table with a moderate amount of facial hair present. At 1:30 p.m., staff provided toileting assistance and ambulated the resident to the lounge. Observation revealed the resident remained unshaven. Observation on 11/28/17 at 6:30 a.m., revealed the resident remained unshaven and was seated in the lounge chair. During interview on 11/27/17 at 8:30 p.m., the resident's family reported the resident had an electric razor for staff to use on the resident. 2. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The Care Plan identified the resident required assistance with activities of daily living due to physical issues. Observation on 11/27/17 at 1:35 p.m., revealed the resident in bed positioned on his back with their right leg exposed from the waist down. The room door remained open allowing staff, residents and visitors to observe the resident uncovered. Observation revealed two Staff assisted the resident's roommate to the bathroom leaving the door and curtain between the two resident's open. 3. The MDS assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The Care Plan identified the resident required assistance with activities of daily living related to [DIAGNOSES REDACTED]. Observation on 11/27/17 at 12:15 p.m., revealed the resident seated in the dining room eating lunch with a moderate amount of facial hair present. During interview on 11/27/17 at 8:40 p.m., the resident's family reported occasionally the resident required shaving and they shaved the resident. 4. The MDS assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had intact cognitive skills for daily decision making. The Care Plan revealed the resident required assistance with activities of daily living due to diagnoses, frequent incontinence and history of falls. The Care Plan directed staff to encourage the resident to sit in the recliner or lounge chair in the lobby, provide opportunities to walk when anxious, provide toileting before and after means and bed time and as needed, and transfer with assistance of two and a gait belt. The Care Plan instructed staff to provide incontinence products to maintain personal hygiene and dignity. Observation on 11/27/17 at 12:50 p.m., revealed two staff assisted the resident up from the dining room table and ambulate the resident to the bathroom. At 1:00 p.m., two staff came to assist the resident out of the bathroom and ambulated the resident to the lounge chair. The resident wore a white T-shirt and shorts that were loose fitting and required staff to hold the shorts in place and hold the gait belt while they ambulated the resident. While staff assisted the resident, the residents shorts dropped down at times, exposing the resident's undergarment and the resident's hip. At 5:45 p.m., Staff A, certified nurse aide, CNA and Staff B, CNA applied a gait belt and assisted the resident up from the lounge chair. Staff held onto the resident's shorts and gait belt and ambulated the resident towards the dining room table. Observation revealed the resident's cloth brief fall down from the resident's hips exposing it below the shorts and the resident's knees. The resident had a large amount of visible urine on the posterior shorts. Staff observed the urine and ambulated the resident to their room and to bed. The resident attempted to push the incontinent brief down. Staff provided incontinence cares and dressed the resident in a clean brief, shirt and jeans with a belt. Observation on 11/28/17 at 6:35 a.m., revealed the resident seated in a lounge chair with glasses reading the newspaper. The resident wore a long sleeved shirt, jeans with a belt and shoes. The resident reported he got help from staff, though not always fast enough. 5. The MDS assessment dated [DATE], documented Resident #7 had [DIAGNOSES REDACTED]. The Care Plan revealed the resident required assistance with activities of daily living due to [DIAGNOSES REDACTED]. The Care Plan directed staff to provide activities of daily living, morning and evenings cares, and allow extra time to complete them. Observation on 11/27/17 at 12:15 p.m., revealed the resident seated at the dining room table with a moderate amount of facial hair present. The facility Resident's Bill of Rights included: A. Residents Rights. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1). A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. E. Respect and Dignity. The resident has a right to be treated with respect and dignity, including: (3). The right to reside and receive services in the facility with reasonable accommodations of needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on clinical record review and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of four (4) residents reviewed. The facility reported a census of 53 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The assessment identified the resident had moderate impairment cognitive skills for daily decision making. The resident required assistance of two staff to transfer from one surface to another, ambulate, and use the toilet. The resident had unsteady balance during transitions and walking and required staff assistance to stabilize, and used a walker for mobility. The MDS also indicated the resident had two falls since admission or prior assessment with injury except major. The MDS dated [DATE] revealed Resident #1 did not ambulate and now used a wheelchair for mobility. The MDS reported the resident had no falls since admission/entry or prior assessment. The Care Plan revised on 5/30/14 identified Resident #1 had a high risk for falls related to being unsteady and only able to stabilize with human assistance. The care plan listed the following high risk factors: limitation in range of motion to all extremities, and taking antidepressant, opioid analgesic and pain management therapy as needed. The resident had a history of [REDACTED]. The resident prior fractures of the left hip & wrist. On 8/3/2013, the Care Plan instructed staff to not leave the resident unattended in a wheelchair, give first aide in the event of fall, bed alarm and pressure seat alarm on when up. On 10/11/2013 the Care Plan added: pressure floor alarm on when in bed. An Incident Report dated 11/4/2014 at 8:00 p.m. revealed staff found Resident #1 sitting on the bathroom floor with his/her back against the wall facing the toilet. Staff R reported being at the sink and noticed the resident stood, through the crack in the door. Staff R told the resident to sit down and the resident stepped backward, turned and fell on buttock and right hip. Staff E, LPN completed the assessment, notified the physician and family and transferred the resident to the emergency room . Nurse's Progress Notes dated 11/4/2014 at 8:00 p.m. revealed staff found Resident #1 sitting on the bathroom floor with his/her back against the wall facing the toilet. The resident sat underneath the upright walker. Staff R, CNA (Certified Nurse's Aide) reported he/she put the resident on the toilet, went to the sink, saw through the crack in the door that the resident got up. Staff R told the resident to sit down, the resident stepped back, turned and went down on the buttocks and right hip. Per Staff R, the resident did not hit his/her head, but complained of right hip pain and had been unable to move his/her right leg independently. The progress notes at 8:05 p.m., documented the staff called the ambulance. The Hospital Emergency Department notes included Resident #1 resided at a nursing home, ambulatory with the assistance of staff and used a walker. The report documented the resident had a fall and sustained a closed right intertrochanteric hip fracture. The resident had pain control with morphine. The resident had surgical repair of the right hip. Observation on 11/18/2014 at 9:15 a.m. revealed two CNA's transfer Resident #1 from the wheelchair to the bed using a green sling with no weight bearing. The resident used a bed pan for toileting. Observation revealed an incision on the right hip area with several intact staples. The resident had an alarmed mat placed on the floor near the bed. Staff R failed to return the surveyor's call for an interview. In a written statement dated 11/4/2014, Staff R reported she assisted Resident #1 to brush his/her teeth and was getting his/her wash cloth ready. The resident got up on his/her own, attempted to talk to Staff R without grabbing the walker. Staff R told the resident to turn around and sit back down on the toilet. The resident went to turn around and lost his/her balance and fell before Staff R could reach the resident. An Employee Counseling Form dated 11/5/2014 revealed Staff R received suspension until investigation completed. The form documented Staff R left a resident unattended. The resident required the assistance of one staff fell . During an interview on 11/18/2014, Staff E (Licensed Practical Nurse/ LPN) reported on 11/4/2014, when Resident #1 fell , Staff R called him/her to the room. Resident #1 sat on the bathroom floor. Staff R reported the resident sat on the toilet, and he/she went to the sink, but could see the resident through a crack in the bathroom door. Staff R observed the resident stand, and Staff R told the resident to sit and the resident turned and fell , and complained of right hip pain. Staff E reported basically the resident was within arm ' s reach but the door was in the way. Staff E stated Staff R was young and worked a lot of short shifts. Staff E reported the resident had alarms and staff should not leave a resident with an alarm alone on the toilet. The resident should be within reach. The bathroom door opened between staff and the resident. Resident #1 had a history of [REDACTED]. During an interview on 11/18/2014 at approximately 3:30 p.m., Corporate Nurse, Staff P, RN (Registered Nurse) stated we have a very rigorous orientation and that ' s company wide. Staff P stated she interviewed staff and planned to have all staff complete a preceptor ' s checklist again because they determined the facility failed to consistently, complete it. The facility failed to provide an orientation or preceptor checklist that Staff R completed upon hire. During an interview on 11/18/2014 at 3:15 p.m., Staff S, CNA reported working for three months, had three days of orientation. Staff S stated she learned that residents with alarms on the toilet should be within reach. During an interview on 11/18/2014 at 10:00 a.m., Staff T, CNA reported working at the facility for three years. Staff T revealed residents with alarms should not be left unattended on the toilet. Staff T reported if she needed a washcloth, she could call for one on the beeper. During an interview on 11/18/2014 at 9:30 a.m., Staff U, CNA reported working at the facility since February (2014). Staff U reported residents with alarms cannot be left alone on the toilet and staff should be within reach of the resident. Staff V, CNA stated on 11/18/14 at 3:30 p.m., residents with alarms cannot be left alone. Staff should be prepared or call on the walkie-talkie for help. History of falls prior to 11/4/14: a). An Incident Report dated 6/8/2014, revealed staff found the resident on the floor leaning on the recliner chair, ten feet from where he/she last sat. b). An Incident Report dated 6/20/2014, revealed Resident #1 had a fall with staff present. The incident report documented a Certified Nurse's Aide (CNA) transferred the resident with a gait belt, the resident began leaning and staff failed to stop the resident from falling. The resident hit his/her back on the bathroom door. The CNA transferred the resident to the recliner prior to allowing the nurse to assess the resident. The resident sustained [REDACTED]. The resident reported he/she had some vertigo and felt dizzy when he/she first got out of bed. c.) The progress notes dated 9/23/14 at 5:45 p.m. revealed the CNA called for the nurse. The nurse entered the room to find Resident #1 sitting on his/her bottom in the middle of the floor facing away from the bathroom. The resident ' s pants were on and up to hips. The resident reported he/she did not fall but crawled out of bed, which was in the low positon. An Incident Report dated 9/23/2014 at 5:45 p.m. revealed Resident #1 had a fall in the bathroom (unwitnessed incident). The CNA summoned Staff E, LPN to the room and he/she found the resident on the room, facing away from the bathroom with pants pulled up to the hips. The resident reported he/she was getting ready for supper, wanted out of bed and denied injury.