Every finding on record at Clarence Nursing Home

Based on observation, staff interview, and facility policy review, the facility failed to ensure staff performed proper hand hygiene and maintained infection control practices during meal preparation and beverage service. This affected 2 of 2 residents receiving pureed diets and meal tray service for 1 of 1 dining observation.Findings include:Observation of puree prep and meal service on 08/25/2026 revealed the following:On 08/25/2026 at 10:13 AM, Staff B, Dietary Manager, prepared pureed meals for 2 residents. During the prep of yams, Staff B performed hand hygiene and donned gloves to remove 3 yams from aluminum foil into the puree machine. She then removed her gloves and touched a spatula and a #8 scoop without performing hand hygiene.Continuous observation on 08/25/2026 from 10:41 AM to 11:05 AM revealed Staff C, Dietary Worker, performed hand hygiene and prepared ice water glasses. While wearing gloves, she touched tray nameplates and proceeded to the ice machine with a cart holding over 20 glasses. Wearing the same gloves, she filled cups with ice using an ice scoop while using her bare opposite hand to directly touch and guide ice into the cups. She poured ice from one filled cup directly back into the ice machine. Wearing the same pair of gloves, she turned on the sink, filled a water pitcher, filled glasses, and guided additional ice into cups with her hand. She then placed lids on the cups, touched the kitchen door handle, exited to pass waters, returned to the kitchen, applied more lids, and gathered soiled silverware from a dining room table. She removed her gloves, failed to perform hand hygiene, and placed name cards on room trays. She performed hand hygiene only after completing the tray prep.On 08/25/2026 at 11:29 AM, Staff D, Server, obtained a piece of yam on her left thumb nail while preparing food trays. She continued serving plates without stopping to perform hand hygiene.In an interview on 08/25/2026 at 11:06 AM, Staff B stated she did not expect staff to wear gloves while serving or preparing water.In an interview on 08/26/2026 at 11:05 AM, Staff B stated staff should remove gloves after clean tasks, perform hand hygiene, and put on new gloves. She stated staff should not touch ice directly with gloved hands or pour used ice back into the machine, noting contaminated ice should be dumped into the sink. She acknowledged staff are expected to wash their hands immediately if food spills onto their hands or gloves during tray line assembly.The facility policy titled Handwashing revised 1/09 instructed personnel to wash their hands before and after resident contact, before handling food, when hands become obviously soiled, and after removing gloves. The policy noted that gloves should be used for hand-contaminating activities and that gloves should be removed and hands washed when the activity is completed. The policy further specified that gloves should be used as an adjunct to and not a substitute for hand washing.The facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices revised October 2017 instructed employees to wash hands after handling soiled equipment or utensils, during food preparation as often as necessary to remove soil and contamination, to prevent cross contamination when changing tasks, and after engaging in other activities that contaminate the hands. The policy further prohibited contact between food and bare hands, required training on proper use of utensils as tools to prevent foodborne illness, and specified that gloves are single-use items that must be discarded after completing the task for which they are used.

Based on clinical record review, resident interview, and staff interview, the facility failed to develop a baseline care plan that included diabetic monitoring and management for 1 of 3 resident reviewed for care planning (Resident #46).The facility reported a census of 43 residents.Findings include:Resident #46 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease.The Physician Orders dated 08/20/2026 documented an active order for Insulin Glargine Subcutaneous Solution, inject 15 units subcutaneously in the morning related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease.The Baseline Care Plan initiated on 08/19/2026 lacked interventions and daily monitoring for the management of Type 2 Diabetes Mellitus and insulin administration.In an interview on 08/24/2026 at 1:01 PM, Resident #46 stated he arrived at the facility the previous Wednesday afternoon for therapy services, and the facility staff manage his daily insulin and medications while he is there.In an interview on 08/26/2026 at 11:24 AM, Staff A, MDS Coordinator, stated that a baseline care plan includes mobility, hygiene, dentures, goals, oxygen/CPAP, therapy, and catheters. When asked about diabetics, Staff A stated a separate task and focused problem should be added at the same time as the baseline care plan. Staff A acknowledged the baseline care plan for Resident #46 did not include diabetic care interventions and stated she likes to have it in on the first day, but had not added it yet.

Based on clinical record review, observation, resident interview, and staff interview, the facility failed to ensure a comprehensive care plan was developed and updated to include measurable objectives, specific interventions, and monitoring for active antibiotic therapy, urinary tract infection (UTI) management, and antidepressant medication therapy for 2 of 14 residents reviewed for care planning (Residents #9 and #20). The facility reported a census of 43 residents. Findings Include: 1. Review of Resident #9's Minimum Data Set (MDS) quarterly dated 7/30/26 recorded a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated cognition intact. In an interview on 8/24/26 at 12:45 PM, Resident #9 stated he was taking an antibiotic started the previous Sunday. The resident stated he had been on and off antibiotic therapy for a month or two, beginning sometime in July. Clinical record review of the Medication Administration Record (MAR) and Physician Orders revealed the resident received a course of Levaquin in July 2026. The MAR for August 2026 documented orders for Ciprofloxacin 250 mg twice daily started on 8/21/26 for 5 days due to a positive urinalysis and hematuria, and Augmentin (Amoxicillin-Pot Clavulanate) 875-125 mg twice daily started on 8/24/26 for 10 days for a UTI. Review of Resident #9's Care Plan updated through 8/21/26 revealed the care plan lacked goals, interventions, or monitoring parameters regarding antibiotic treatment, UTI management, hematuria monitoring, or tracking potential side effects of antibiotic therapy. In an interview on 8/25/26 at 10:15 AM, Staff A, MDS Coordinator, acknowledged the Care Plan was not updated to reflect the resident's acute UTI, symptoms of hematuria, or active antibiotic therapy and stated that it should have been updated as soon as the UTI was known and that she didn't get around to updating it yet. 2. The MDS for Resident#20 dated 7/30/26 listed diagnoses of Parkinson's disease, general anxiety, and high blood pressure (HTN). The MDS Brief Interview for Mental Status (BIMS) showed a score of 9 out of 15, moderate cognitive impairment. The Care Plan for Resident#20 failed to address the antidepressant used, adverse effects of the medication and or signs or symptoms the medication worked or not. The Care Plan dated 6/11/26 identified Resident#20 very sad due to he lost his wife. The Medication Administration Record (MAR) for Resident#20 dated 8/2026, directed escitalopram oxalate (antidepressant) 20 milligrams (MG) daily for depression. started on 4/29/26. The Tasks for Resident#20 failed to address the adverse effects of the antidepressant. On 08/24/2026 at 2:02 PM Resident #20 sat in his room, asleep in the chair. On 08/27/2026 11:56 AM Staff A MDS Coordinator reported she failed to address the antidepressant on the Care Plan. On 08/27/2026 12:30 AM Staff A MDS Coordinator confirmed the MDS drives the Care Plan and what's addressed on the Care Plan.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to complete and sign admission, quarterly, and discharge resident assessments within the required time frames for 3 of 3 residents reviewed (Residents #27, #42, and #197). The facility reported a census of 42 residents.Findings include:1. Review of the Admission/Medicare - 5 Day Minimum Data Set (MDS) for Resident #197 dated 6/24/25 revealed an admission date of 6/17/25. Section Z, Assessment Administration, indicated all sections of the MDS were signed except Sections GG and V.The MDS section of the resident's electronic health record documented the Admission/Medicare - 5 Day assessment was in progress. A red box titled Complete MDS listed a date of 6/30/25. A yellow box titled Sign indicated 98 items were unsigned. A grey box titled Care Plan Decisions listed a complete by date of 7/7/25.During an interview on 7/9/25 at 9:34 AM, the MDS Coordinator confirmed she was responsible for completing and submitting MDS data. She stated she would have to look at the Resident Assessment Instrument (RAI) Manual to determine due dates for admission and discharge MDS. She stated she had always gone 14 days from the Care Plan date for submission and acknowledged the Complete MDS date in the red box was past due. She stated she still needed to complete Section GG.2. Review of the Discharge, Return Not Anticipated MDS for Resident #27 dated 6/20/25 revealed an admission date of 5/28/25 and a discharge date of 6/20/25. Section Z included signed sections C, D, and E by the social worker.The MDS section of the resident's electronic health record documented the Discharge MDS was in progress. Sections A, B, GG, H, I, J, K, M, N, O, P, and Q were in red or yellow and listed as In Progress. A red box titled Complete MDS had a complete by date of 7/4/25. A yellow box titled Sign listed 284 items as unsigned. During the interview on 7/9/25 at 9:34 AM, the MDS Coordinator confirmed the red box in Resident #27 electronic record meant the completion was past the expected date. An email from the Administrator on 7/9/25 at 9:59 AM communicated the facility did not have an MDS policy and included a document titled Scheduling MDS Assessments as the closest thing the facility had. Review of the Scheduling MDS Assessment document revealed, in part:2. OBRA (Omnibus Budget Reconciliation Act) Assessments: to be completed on ALL residents in the facility. A. admission assessment: This is a comprehensive item set (assessment), including CAAS (Care Area Assessments). To be completed by day 14 of the stay.3. PPS (Prospective Payment System) (Medicare) assessments- particularly important that these assessments are completed on time, or facility is at risk of receiving the default Medicare rate for days unaccounted for. A. Medicare 5-day: To be completed by day 8 of the stay (5 days plus three grace days). May be combined with an admission or significant change in status assessment.D. PPS discharge assessment: Required to prove that Medicare part A services have ceased. To be completed with an ARD (Assessment Reference Date) on the last day the resident receives Medicare Part A services. 3. Review of the Clinical-MDS list of assessments, dated 7/9/25, revealed a Quarterly MDS for Resident #42 dated 6/12/25. The Clinical-MDS list indicated a status of In Progress. Review of the MDS revealed sections A, B, GG, H, I, J, K, L, M, N, O, P, Q were not completed in the required timeframe. The MDS Summary screen undated, showed 222 errors on the MDS dated [DATE].During an interview on 7/09/25 at 11:30 AM, the MDS nurse confirmed the MDS for Resident # 42 is late.During an interview on 7/09/25 at 11:32 PM, the Director of Nursing (DON) reported the facility kept the MDS Coordinator busy. Review of the RAI Manual, dated October 2023, page 2-17 revealed in part: a. admission Assessment due no later than the 14th calendar day of the resident's admission (admission date plus 13 calendar days).b. Discharge Assessments-return not anticipated must be completed no later than the discharge date plus 14 days.

Based on staff interviews, facility record review and facility policy review the facility failed to have the required Infection Preventionist (IP) at 2 of 2 Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 45 residents. Findings included: The QAPI sign-in sheet dated 3/21/24 and 6/6/24 failed to reflect the signature of the Infection Preventionist. The sign-in sheet reflected Staff A, Licensed Practical Nurse, Facilitator of the QAPI. The facility provided a QAPI Members list undated, that identified Staff A as the QAPI Coordinator and included the Infection Preventionist name which was not listed on the QAPI sign-in sheet as referenced above. On 8/22/24 at 11:10 AM, Staff A, reported the IP is required at the QAA/QAPI meetings On 8/22/24 12:30 PM, Staff A and the Director of Nursing (DON) reported the QAA and QAPI meeting are the same meeting. The facility provided a policy titled QAPI Plan Guidelines dated 5/21/18, included direction under Guidelines for Governance and Leadership that the CEO has responsibility and is accountable to the Board of Directors for ensuring that QAPI is implemented throughout our organization. QAPI will contain the following resources: The administrator will be responsible for QAPI and designating assignments. The administrator will educate or assign a designee to provide training. The QAPI committee will provide adequate resources for the PIP. The QAPI committee will assess the plan to provide the resources. Staff will be utilized in the development and execution of our QAPI process. Through training and evaluation we will monitor their proficiency. QAPI Leadership: The QAPI committee will be comprised of Department Heads and volunteers from direct care staff, our facility Medical Director and a member from the Board of Directors. The QAPI committee will meet monthly with the Medical Director quarterly.

Based on observation, policy review and staff interview the facility failed to wear appropriate Personal Protective Equipment (PPE) to follow Enhanced Barrier Precautions (EBP) while administering a tube feeding for 1 of 1 residents (Resident #38) reviewed for EBP. The facility reported a census of 45 residents. Findings include: Physician's orders for Resident #38 include an order dated 6/28/24 for Jevity 1.2 calorie/fiber oral liquid, give 300 milliliters (ml) via g tube. The Care Plan intervention dated 8/19/24 for Resident #38 directed staff to use EBP with high contact care. The undated facility policy titled Enhanced Barrier Precautions directed staff to use gown and gloves as the minimum level of PPE for high contact activities. The policy defines feeding tube as a high contact activity. During an observation on 8/21/24 at 12:57 PM Staff A, Licensed Practical Nurse (LPN) entered Resident #38's room to administer her tube feeding. Staff A performed hand hygiene and applied gloves. She failed to don a gown. She administered the tube feeding and water flushes through the tube. During a interview on 8/21/24 at 1:07 PM Staff A approached the surveyor and explained she forgot to don a gown while administering the tube feeding. During an interview on 8/21/24 at 1:46 PM the Director of Nursing (DON) explained she would expect gown and gloves to be worn and they (the staff) all know that.

Based on clinical record review, observations, staff interviews, and facility document review, the facility failed to follow Physician's Orders for insulin administration (Resident #29). The facility further failed to follow sanitary practice when staff placed medication directly into ungloved hands then into the residents' mouths (Resident #19, #25, #33, #36) for 5 of 5 medication administrations observed. Findings Include: 1. The Minimum Data Set (MDS), for Resident #29, dated 12/07/23, revealed a Brief Interview for Mental Status (BIMS), score of 11 out of 15, indicative of moderate cognitive impairment. Diagnoses included: Diabetes Mellitus, Type 2, with long-term and current use of insulin, and non-Alzheimer's dementia. Resident #29 required insulin injections all 7 days of the MDS reference period. The Care Plan, revised on 6/19/23, revealed a focus area for the diagnosis of Diabetes Mellitus with an intervention that indicated Resident #29 required insulin to help regulate blood sugars and instructed to refer to medication record. The Administration Record (MAR), dated January 2024, revealed an order for Novolog (Insulin Aspart) Injection Solution 100 Unit/milliliter with instruction to inject 10 Units before meals, scheduled to be given at the following times: 7:30 AM, 11:00 AM, and 4:00 PM. Review of Resident #29's health record lacked a Progress Note or documentation of insulin given after breakfast instead of before meals as ordered. On 1/03/24 at 8:32 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #29's room upon resident's return from breakfast and administered 10 units of Novolog insulin. On 1/04/24 at 12:40 PM, Staff A reported they typically would give Resident #29's morning insulin between 7:00 AM and 8:00 AM. Staff A stated Resident #29 had gone to breakfast before insulin had been administered during observation on 1/03/24. On 1/04/24 at 12:47 PM, Director of Nursing (DON), informed the expectation of documentation in the health record when insulin is given outside of Physician's Orders and stated medication scheduled at a certain time should be administered between an hour before and an hour after the scheduled time. The facility document titled, Charge Nurse Orientation Checklist, signed by both Staff A on 7/19/23 and Director of Nursing, included initials that indicated Staff A orientation covered the following topics: Correction insulin schedules, Insulin storage, administration, and documentation. 2. The Medication Administration Record (MAR), dated January 2024, revealed Resident #19 with orders for Aspirin 81 milligrams (mg) once per day and Tylenol 500 mg twice per day. On 1/02/24 at 2:50 PM, Staff B, Registered Nurse (RN) applied hand sanitizer and prepared Resident #19's medications, pills popped out of packaged medication card directly into Staff B's bare hand and then dropped into a medication cup, Staff B then applied gloves, took one pill out of medication cup and placed directly into Resident #19's mouth, the second pill given by mouth via medication cup. Staff B then removed gloves and applied hand sanitizer. 3. The Medication Administration Record (MAR), dated January 2024, revealed Resident #25 had an order for Tylenol 500 mg twice per day. On 1/02/24 at 2:40 PM, Staff B applied hand sanitizer and prepared Resident #25's evening medications, pill popped out of packaged medication card directly into Staff B's bare hand and then dropped into a medication cup. Staff B then applied gloves, took one pill out of medication cup and placed directly into Resident #25's mouth. Following medication administration, Staff B removed gloves and applied hand sanitizer. 4. The Medication Administration Record (MAR), dated January 2024, revealed Resident #33 had orders for Eliquis 5 mg twice per day, Metoprolol 100 mg twice per day, and Senna Plus-Docusate 8.6-50 mg daily. On 1/03/24 at 2:40 PM, Staff B applied hand sanitizer and prepared Resident #33 medications, pills popped out of packaged medication card directly into Staff B's bare hand and then dropped into a medication cup, Resident #33 given the pills by mouth. Staff B then applied hand sanitizer. 5. The Medication Administration Record (MAR), dated January 2024, revealed Resident #36 had orders for Tylenol 500 milligrams (mg), 2 tablets, twice per day and Hydrocodone-Tylenol (Lortab) 5-325 mg half tablet three times a day. On 1/02/24 at 2:33 PM, Staff B, Registered Nurse (RN) prepared Resident #36's evening medications, pills had been popped out of a packaged medication card directly into Staff B's bare hand and then dropped into a medication cup, Resident #19 given the pills by mouth. Staff B then applied hand sanitizer. On 1/03/24 at 8:40 AM, Staff A reported medications should not be placed in ungloved hands at any time during medication preparation or administration. On 1/04/23 at 11:40 AM, Facility Administrator notified the facility lacked policy related to medication administration. On 1/04/24 at 12:47 PM, Director of Nursing (DON), indicated a gloved hand must be used to directly handle medications. A facility document, titled Charge Nurse Job Description, signed and dated by Staff B on 4/26/22 revealed the Nurse duty and responsibility to administer medications and treatments ordered by the care provider with proper technique.

Based on clinical record review, observations, staff interviews and facility policy review the facility failed to report injuries of unknown origin to the State Agency (SA) for 1 out of 1 residents reviewed (Resident #10). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident # 10 dated 12/9/23, listed diagnoses of Alzheimer's disease, and hypertension. The MDS identified Resident #10 with short and long-term memory problems and severely impaired daily decision-making skills. The MDS reflected Resident #10 dependent on staff for transfers, positioning, dressing, eating and personal hygiene. The Care Plan for Resident #10 dated 6/20/23, directed stop & watch, report any changes in my skin when helping with my cares, discoloration, redness, swelling, open areas, drainage, odor, pain/tenderness, and so on. The Care Plan continued, notify provider with changes or concerns. The Care Plan reflected Resident #10 required a full body lift to transfer to and from her wheelchair. On 1/02/24 at 11:00 AM, Resident #10's right exterior side of her eye appeared purple in color approximately the size of a quarter. On 1/03/24 at 11:02 AM, Staff A, Certified Nurses Aid (CNA) reported she noticed Resident #10's bruised eye on Monday 1/1/24. The right eye exterior side looked purple in color. Staff A, said she thought someone poked her with her glasses. On 1/03/24 at 11:04 AM, the Director of Nursing (DON) reported the Incident Reports (IR) are in Electronic Health Records (EHR). On 1/03/24 at 11:07 AM, the Director of Nursing (DON) confirmed she failed to see an Incident Report (IR) for Resident #10's bruised eye. The DON stated she noticed the bruise this morning with dry crusty substance at the corner of her eye and thought the resident may have rubbed or scratched at her eye. On 1/03/24 at 11:11 AM, the DON reported the nurse told her over the weekend the CNA's reported they bumped her eye/face with the arm of the full body lift. On 1/04/24 at 9:36 AM, Staff B, Licensed Practical Nurse (LPN) reported Staff D, CNA told her about the bruise on Friday 12/29/23. Staff B revealed she assumed the injury resulted from staff bumping her with a full body lift arm. On 1/04/24 at 9:40 AM, Staff E, CNA stated she first saw the red bruise on 12/30/23 on the day shift. She indicated the nurse knew about it. On 1/04/24 at 10:16 AM, Staff C, CNA stated she failed to see a bruise on Resident #10 on Friday when she worked the day shift. She reported she noticed the bruise on Monday 1/1/24. On 1/04/24 at 11:20 AM, the DON reported she's confident the injury on Resident #10's eye developed from her rubbing it. The DON reported she knew of the eye bruise on 1/2/24. The DON reported, Staff B told her the CNA told her the cause resulted from when the full body lift bumped Resident #10. The DON denied she completed an investigation into eye injury. When questioned if she's expected to report and investigate all the small bumps and bruises that are found on the resident, she let out an exasperated sigh. The facility provided a policy titled Abuse Prevention, Identification, Investigation and Reporting policy dated 4/1/2017, directed under Identification, Investigation and Reporting: At point #12 Injuries of unknown Source An injury should be classified as an Injury of Unknown Source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, b. The injury is suspicious because of the extent of the injury or location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Reporting: All allegation of resident abuse, neglect, exploitation, mistreatment, injuries ok unknown origin and misappropriation should be reported to immediately to the chare nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegation of Resident Abuse shall be reported to the State Agency not later than 2 hours after the allegation is made, if the events that cause the allegation results in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Based on clinical record review, observations, staff interviews, and facility policy review the facility failed to investigate injuries of unknown origin for 1 out of 1 residents reviewed (Resident #10). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident #10 dated 12/9/23, listed diagnoses of Alzheimer's disease, and hypertension. The MDS identified Resident #10's short and long-term memory problems and severely impaired daily decision-making skills. The MDS reflected Resident #10 dependent on staff for transfers, positioning, dressing, eating and personal hygiene. The Care Plan for Resident #10 dated 6/20/23, directed stop & watch, report any changes in my skin when helping with my cares, discoloration, redness, swelling, open areas, drainage, odor, pain/tenderness, and so on. The Care Plan continued, notify provider with changes or concerns. The Care Plan reflected Resident #10 required a full body lift to transfer to and from her wheelchair. On 1/02/24 at 11:00 AM, Resident #10's right exterior side of her eye appeared purple in color approximately the size of a quarter. On 1/03/24 at 11:02 AM, Staff A, Certified Nurses Aid (CNA), reported she noticed Resident #10's bruised eye on Monday 1/1/24. The right eye exterior side looked purple in color. Staff A, said she thought someone poked her with her glasses. On 1/03/24 at 11:07 AM, the Director of Nursing (DON), stated she noticed the bruise this morning with dry crusty substance at the corner of her eye and thought the resident may have rubbed or scratched at her eye. On 1/03/24 at 11:11 AM, the DON reported a nurse told her over the weekend the CNA's reported they bumped her eye/face with the arm of the full body lift. On 1/04/24 at 9:36 AM, Staff B, Licensed Practical Nurse (LPN) reported Staff D, CNA told her about the bruise on Friday 12/29/23. Staff B revealed she assumed the injury resulted from staff bumping her with a full body lift arm. On 01/04/24 at 10:16 AM, Staff C, CNA stated she failed to see a bruise on Resident #10 Friday when she worked day shift. She reported she noticed the bruise on Monday 1/1/24. On 1/04/24 at 11:20 AM, the DON reported she's confident the injury on Resident #10's eye developed from her rubbing it. The DON confirmed, Staff B told her the CNA told her the cause resulted from the full body lift bumped Resident #10. The DON denied she completed an investigation into eye injury. The DON confirmed the facility failed to complete an Incident Report (IR) for the bruise. The DON stated she failed to obtain statements from staff and failed to have an investigation documented related to the development of the bruise. When the DON questioned if she's expected to investigate all the small bumps and bruises that are found on the resident, she let out an exasperated sigh. The facility provided a policy titled Abuse Prevention, Identification, Investigation and Reporting policy dated 4/1/2017, directed under Identification, Investigation and Reporting: At point #12 Injuries of unknown Source An injury should be classified as an Injury of Unknown Source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, b. The injury is suspicious because of the extent of the injury or location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Investigation: Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed the Administrator or his /her designee will designate a member of management to investigate the alleged incident the Administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the incident: a. Review documentation in resident record (including review of the assessment if resident injury). b, Assess the resident for injury if the allegation involves physical or sexual abuse; c. Provide proper notification to primary care provider, responsible party, etc; d. Attempt to obtain witness statements (oral, and/or written) from all known witnesses. f. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with. Following the investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the State Agency (SA). This written report shall be forwarded to the SA within five days of the initial report.

Based on clinical record review, observations, staff and resident interviews, the facility failed to accurately complete resident assessments in the Minimum Data Set (MDS) for 1 of 12 residents reviewed (Resident #42). The facility reported a census of 46 residents. Findings Include: An Admission assessment dated [DATE] indicated the resident experienced shortness of breath with exertion and required the use of a continuous positive airway pressure device (CPAP) at night for obstructive sleep apnea. An MDS titled Admission/Medicare - 5 Day dated 11/15/23, documented diagnoses of atrial fibrillation, orthostatic hypotension, and sleep apnea. The MDS identified the resident required partial assistance with self care from another person to complete any activities. The MDS failed to include the use of a CPAP. An MDS titled End of PPS Part A Stay dated 11/30/23 failed to include the use of a CPAP. A Care Plan printed 1/3/24 failed to include the use of a CPAP. The Medication Administration records for November 2023 indicated the resident used the CPAP daily. On 1/04/24 at 9:48 AM observed the resident rested in their recliner with both feet up. They did not have the CPAP on. An interview with the resident confirmed they used their CPAP daily at bed time, and staff put it on for them because it is easier. An interview on 1/3/24 at 3:18 PM, the Director of Nursing (DON) indicated the MDS Coordinator completed the Care Plan and MDS documentation for this facility. She wanted to talk to them before determining if the CPAP should be on the Care Plan and MDS. At 3:41 PM the DON confirmed that the CPAP was not on the Care Plan and was added. An interview on 1/4/24 at 10:37 AM, the MDS Coordinator revealed the resident's MDS required a correction to reflect the CPAP. On 1/4/23 at 11:45 AM, the Administrator stated the facility lacked a policy that included comprehensive assessments.

Based on Minimum Data Set Assessment Tool review, Care Plan review and staff interviews, the facility failed to update residents' Care Plans for 6 of 12 residents reviewed (Residents #1, #14, #18, #24, #38 and #95). The facility reported a census of 43 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15, independent with Activities of Daily Living (ADL's) and with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan revealed marked as overdue for review which had been due 6/30/22 and identified the resident with the following problems: a. At increased risk for respiratory complications such as COVID. b. Diabetic. c. Visual deficits due to [CONDITION(S)]. d. Chest pain with elevated heart rate. e. Vision and hearing are poor. 2. The MDS dated [DATE] identified Resident #24 as cognitively intact with a BIMS of 12, required limited assist with ADLs and with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan with the last revision date of 7/5/22 failed to identify the resident had the order for [MEDICATION(S)] (a blood thinner used to treat [CONDITION(S)]) and identify interventions required with the care of residents on blood thinners. 3. The MDS dated [DATE] identified Resident #38 as cognitively impaired with a BIMS of 0, required extensive staff assistance with most ADLs and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan showed the Care Plan with the review date due 4/28/22 and identified the resident with the following problems: a. I have Alzheimer's disease. b. I need help with ADLs. c. Increased risk for respiratory complications due to possible exposure to COVID. d. I have difficulty saying what I mean. 4. The MDS dated [DATE] identified Resident #95 as cognitively intact with a BIMS of 14, required extensive staff assistance with most ADLs and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . She had an admitted to the facility of 6/15/22. A review of the Care Plan showed the Care Plan not reviewed and updated until 7/11/22 (end date of the Survey) and identified the resident with the following problems: a. I take blood thinners. b. Left side weakness. c. Pain in hips from [CONDITION(S)]. During an interview on 7/11/22 10:48 AM, the Director of Nursing (DON) reported the MDS Coordinator is responsible for updating Care Plans and the DON can also update. The MDS Coordinator updates the majority of the Care Plans. She also reported she would expect the Care Plans to be updated quarterly or with any changes in condition. Residents who are new admissions, should have a working Care Plan finalized within 3 weeks of admission. If there are no changes in condition, Care Plans should be updated quarterly. 5. A Minimum Data Set (MDS) Quarterly assessment dated [DATE] identified Resident #14 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicated cognitively intact. A record review on 7/11/22 indicated Resident #14's Care Plan was outdated as of 6/15/22. Problem areas addressed on the care plan included: personal care, remain free of signs and symptoms of respiratory changes related to COVID-19, choose preferred activities everyday, and remain free of bleeding or bruising related to a blood thinner. 6. A MDS Annual assessment dated [DATE] identified Resident #18 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also indicated the resident is independent with bed mobility, transfers, ambulation, eating, toilet use, personal hygiene, and dressing. A Brief Interview for Mental Status (BIMS) score of 15 of 15, indicated cognitively intact. A record review on 7/11/22 indicated Resident #14 care plan was outdated as of 5/25/22. Problem areas addressed on the Care Plan included: Free of changes to well being, staff provide activities of interest, remain free of signs and symptoms of COVID -19, ask for help and support as needed, minimize incontinence, free of injuries, participate in personal cares, lose weight, monitor for signs and symptoms of depression and/or anxiety, and receive psychiatric care During an interview on 7/11/22 at 1:01 PM, the MDS Coordinator stated she is responsible for completing Care Plan updates. She stated she would complete the updated Minimum Data Set (MDS), and then the Care Plan should be updated as soon as possible. The MDS Coordinator stated if a resident is taking a blood thinner she would address this on the Care Plan

Based on observations, staff interviews and policy review, the facility failed to maintain safe food storage in the kitchen. The facility reported a census 43 of residents. Findings Include: An observation of food storage in the first white Whirlpool refrigerator on the right hand side of the kitchen on 7/5/22 at 12:20 PM revealed the following: a. A container of leftover tortellini dated 6/22/22. The Dietary Food Supervisor immediately disposed of the item. b. An open bottle of Sprite with no date. The Food Services Supervisor (FSS) stated the soda belonged to a Dietary Staff. An observation of food storage in the first white Whirlpool refrigerator on the right hand side of the kitchen on 7/6/22 at 10:50 AM revealed the following: a. An uncovered half- full glass of ice water with a staff name on the glass. The Dietary Food Supervisor immediately disposed of the item. During an interview on 6/29/22 at 10:57 AM, the FSS stated she would expect all leftover food to be put in a closed container, dated, cooled and then put in the refrigerator for a maximum of three days. She stated that tortellini dated 6/22/22 should have been discarded on 6/25/22. The FSS stated she would expect staff to take a drink of water and then put the glass in the dirty dish area. She stated that staff should not put any drink in the refrigerators where resident food is stored. During an interview on 07/11/22 at 12:46 PM, Staff E, Cook stated leftover food should be labeled with the date the item is prepared or opened. If the food is not used within three days of the label date the item should be discarded. Staff E stated staff drinks would be covered and dated prior to being placed in the kitchen refrigerator. During an interview on 07/11/22 at 1:10 PM, Staff F, Dietary Aide stated she would label her drink with the date and her name before placing it in the kitchen refrigerator. Staff F stated if she puts a drink in the break room refrigerator someone would take it. Staff F stated she would throw out any left over items that are three days or more past the date written on the container. A review of an undated facility policy titled Labeling and Storage of Prepared and Opened Foods, directed Dietary Staff to write the date a food item is opened or prepared on the container, and either use or discard by the end of the third day.

Based on observation, staff interviews and policy review, the facility failed to follow professional standards during the medication administration and storage review for 1 out of 1 medication carts reviewed. The facility reported a census of 46 resident. Findings Include: 1. On 07/22/21 at 7:57 AM, observed the Medication Cart drawers held 6 medication cups of pre popped medications and 8 medication cups in the bottom right drawer held white powder. Interview on 07/22/21 at 8:00 AM, Staff A, Licensed Practical Nurse (LPN) reported the 1st resident's medication is set up because she is normally up by now, but she's not. The other medications are ready for administration. Staff A confirmed the 8 cups that held white powder is [MEDICATION(S)] (bowel medication). Interview on 07/22/21 at 8:11 AM, the Director of Nursing (DON) reported she expected the nurses to get medications set up and administer them, not pre-set them up and leave in the Medication Cart. The facility provided policy titled Unit Dose System dated 11/19/2008, directed at point #11: Should a dose be offered and subsequently refused or not given for any reason after it has been taken out of the cassette, note on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff will destroy this medication. The policy continued to direct at point #17: Only the nurse dispensing medications from the cassette is to administer to the resident. NO PRE-SETTINGS!

Based on observations, record review, family and staff interviews, the facility failed to identify the resident's window as a potential exit with which the resident eloped through for one of five residents reviewed for supervision (Resident #1). The facility reported a census of 41 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) Admission Assessment completed 12/25/21 documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively intact with a Brief Interview for Mental Status) score of 12 out of 15, required limited staff assistance with walking and personal hygiene. The Care Plan with the target goal date of 1/6/21 identified the resident with the problem of being at risk for falling as he is constantly walking, has exit seeking behaviors without safety awareness (date initiated 12/18/20) Interventions included: a. Arrange for male staff to accompany, 1:1 with him as less suspicious of men. Topics of interest: farming and golfing. b. He enjoys a cup of coffee with a snack. He likes to look at the phone book. c. Be alert to him wearing his coat and hat in the facility, as a cue he intends to leave. Attempt to engage with visiting with wife, with activity board, sorting nuts and bolts, offer a cup of coffee and snack. d. If he becomes fatigued or dizzy, allow him to rest. e. Keep his room door open (even with quarantine) so he has supervision of his activities so he is safe f. Prompt him to change positions slowly as he can become dizzy with initial standing g. Redirect him to his room for less stimulation when he is angry. He often tires himself and needs to nap to change his mood. h. Secure Care Wander Bracelet applied to ankle to alert staff to presence at exit doors. Join to assist with redirection from leaving facility (date initiated 1/8/21). A review of the Incident Report dated 1/12/21 at 5:00 a.m. had documentation of the following: The resident had been observed laying outside in the parking lot, groaning and laying on his left side, alert and responsive but unable to state what he was doing or what happened. Immediate action taken: Lifted into a wheelchair with the assistance of three staff members and returned to the facility and his room with transfer to bed Interventions: Comfort care for right [MEDICAL CONDITION] at the facility. Family decision for Hospice care and pain management Mental status: Oriented to person, situation and place Notes: Small irregular lacerations to back of the head. Previous laceration opened at back of the head. Right elbow with 2 cm (centimeters) irregular shaped laceration and right wrist with 2.5 cm C shaped skin tear. Lacerations cleansed and dressings applied for comfort. Complained of right hip and thigh pain, rubbing his upper thigh area and demonstrated area of pain. Right leg is shorter than the left leg and foot rolled outward. The resident complained of pain when he moved his right leg. Injury type: Right trochanter fracture (hip). Other info: Last visual check at 4:30 a.m. sitting on his bed. In response to hearing a voice calling out, found his room door closed and over-the-bed table in front of door. Upon entering the room, noted window open and resident not present in his room at 4:50 a.m. He had removed the screen of the window to exit through the window. Temperature 26 degrees outdoors. A review of radiology report dated 1/12/21 of the right hip revealed an acute lower femoral neck/intertrochanteric fracture is noted with increased angulation deformity. A review of the nurse's notes revealed the following: a. On 12/20/20 at 10:21 p.m., Needs reminding to ask for assistance when up. Ambulated to front lobby from room without assistance. Joined and assisted back to room. I'm just going to walk out of here sometime and go home. b. On 1/2/21 at 3:31 p.m., Resident wearing coat and stocking hat wandering about the nursing facility, stated he is tired of sitting around and wants to leave. c. On 1/7/21 at 4:08 a.m., Resident very agitated and determined to go home this shift. Going to doorways and attempting to go out. Had hat and coat on and insisted on leaving. d. On 1/8/21 at 10:02 a.m., Exited facility, staff joined and accompanied back to the facility. Secure Care Wander Bracelet (anklet) applied to help with exit seeking behavior. e. On 1/8/21 at 5:00 p.m., Wearing his coat & cap with and heading to the north exit door stating needed to go get his golf cart to service it. f. On 1/8/21 at 8:00 p.m., Attempted to exit front lobby door. Agitated and very hard to redirect back into building. Attempted to bite and did hit Certified Nurse Aide (CNA). Finally able to get resident back into the lobby. g. On 1/9/21 at 3:16 p.m., The resident exited the north door followed by staff to the parking lot. Staff able to convince him to return to the building with extensive prompting and cueing at 12:00 p.m. h. On 1/10/2021 at 9:30 a.m., Reportedly tore Secure Care band from leg overnight and up most of the night, drank 5 cups of coffee and had chips and dip, as well as verbalizing he was wanting to leave today. Around 8:10 a.m., resident attempted to leave, difficult to redirect, and staff able to return him back to his room & setup with a book to distract him. He returned to lobby & attempted to exit front door with CNAs diverting him, he then quickly turned & headed toward north door to exit. i. On 1/12/21 at 6:02 a.m. an entry stated at 4:15 a.m. the resident came to the front lobby with walker. Gait steady with ambulation. Asked if the doors were unlocked so he could go home. Informed the doors would not be unlocked until 6:00 a.m. At 4:30 a.m., Room check and observed him sitting on his bed. Content. At 4:50 a.m. Heard a faint calling out. On room check, room door closed and over bed table in front of door. Upon entering room, noted window open and resident not present. Observed him laying outside & in the parking lot. Staff joined the resident to support outside of facility. Alert and responsive but unable to state what he was doing or what happened. Groaning and laying on his left side. Lifted into a wheelchair with assist of 3 staff and returned to facility and his room. Small irregular lacerations to back of head. Previous laceration opened at back of head. Right elbow with 2 cm (centimeters) irregular shaped laceration and right wrist with a 2.5 cm C shaped skin tear. Lacerations cleansed and dressings applied for comfort. The resident complained of right hip and thigh pain, rubbing his upper thigh area with his right leg shorter than the left leg and right foot rolled outward. During an interview on 1/19/21 at 7:04 p.m., Staff A, Registered Nurse (RN) reported the resident did have a history of attempts to elope from the facility two or three times before this, and that he had been independent with ambulation using his walker and he did have a Wander Guard bracelet that he wore on his ankle. If he refused the interventions to distract him, we would try to engage him in another activity. In an interview on 1/19/21 7:17 p.m., Staff B, RN reported the resident had a history of [REDACTED]. If the staff attempted interventions to redirect and he refused, the staff would need to attempt other interventions such as taking him to visit his wife, read the newspaper, offer snacks or walk with him to other parts of the facility, provide one on one to keep him engaged. She also reported Staff E, CNA checked on him 1/12/21 last at 4:30 a.m. At 4:50 a.m. they heard someone calling out, checked his room, found the window open and the screen popped out. They found his Secure Care band in the garbage can. They found him lying on the concrete on the parking lot. There was no snow on the parking lot, just the piles on the corners. He wore his jeans, flannel shirt, socks, and shoes without a coat, gloves or hat on. The temperature had probably been 22 degrees out. The staff assisted him to bed, Staff B did not notice any outward rotation of his legs. When she notified the family, they chose to keep him at the facility and not send him out to the hospital. During an interview on 1/20/21 at 4:56 a.m., Staff C, CNA reported the resident had a history of [REDACTED]. He did have a Wander Guard bracelet on his ankle which he had been able to remove. He had been independent with ambulation using a walker. The staff had to make rounds on the residents every 45 minutes during the night. Staff C and Staff E, CNA's had taken turns checking on the resident and Staff C saw him last at 3:30 a.m. When Staff E checked on him, she said his window was open and screen popped out. They found him on the concrete in the parking lot. She reported he did not have a coat or gloves on, laid on his left side and had some bleeding up on his arm and some on the back of his head. The staff assisted him to a wheelchair and back to his bed. She noticed the Wander Guard alarm bracelet in the garbage can. At that point, she left the room to tend to other residents. In an interview on 1/20/21 at 9:14 a.m., Staff D, CNA reported the resident had a history of [REDACTED]. He had been able to walk outside to the dumpster using his wheeled walker. He had been care planned to be independent with wheeled walker. When they applied the Wander Guard bracelet on his ankle, he told her that's not going to stop me from leaving The staff had to check on him every 10 minutes, distract him, re-orient him or talk about his hobbies. He had dementia and refused interventions and when he did, Staff D reported would walk with the resident. During an interview on 1/20/21 9:57 a.m., Staff E, CNA reported the resident had a history of [REDACTED]. The night shift staff had to check on him during the night every hour, and every 20 minutes if he had been awake. He always talked about wanting to go home or go to the store. He had a Wander Guard bracelet put on soon after he had been admitted . On 1/12/21 she went to his room at 4:30 a.m. where she found him sitting on his bed. Later he came out to the hall to ask the staff to unlock the front door. They told him no and helped him back to bed. At 4:50 a.m. Staff B, RN and Staff E, CNA heard someone moaning. Staff E went to his room, found the bedside table behind the door and had a hard time opening it. She found the window open and the screen pushed out. She ran outside and found him lying on the concrete near the dumpsters. He did not have a coat on. It was 15 or 20 degrees outside that night. The staff helped him up into a wheelchair and back into his bed. She saw blood on his right forearm on the right side and a laceration from a previous head wound from a fall earlier that day. Upon returning him to the facility, she noticed the Wander Guard alarm did not sound when they came through the door and later found his Wander Guard bracelet in the trash can. The resident and family chose not to have him go to the hospital. In an interview on 1/20/21 10:25 a.m., Staff F, RN reported the resident had a history of [REDACTED]. The week before that fall, the attempts were frequent, he would keep trying to leave and put on his coat and hat when he did. A Secure Care bracelet had been placed on his ankle in early January 2021. He had been care planned to be independent with ambulation using his walker. In an interview on 1/21/21 12:10 p.m., the Social Worker reported the resident's family chose to keep him at the facility as his wife also resided there and they wanted to keep them together. During an interview on 1/21/21 12:34 p.m., the Director of Nursing (DON) reported when a Secure Care bracelet is applied on a resident, all of the exit doors are alarmed and will all trigger when the resident goes out. When this resident had first admitted to the facility, his family reported he did not have exit seeking behaviors prior to this. After January 1st, his behavior changed drastically. After the incident with his elopement from his window, the administrator purchased a window alarm that would sound if the window had been opened. The staffing had changed to assign one aide to stay on each hall to keep a closer eye on the residents. When asked for the facility's policy on falls, the DON provided a copy of the protocol which had documentation of the following instructions: 1. When you see a resident who has fallen, do the following: a. Immediately go the resident, stay with the resident. b. If you are not a nurse, call for a nurse. c. Encourage the resident not to move. d. Ask them, what were you doing just before you fell ? or what were you trying to do just before you fell ? e. Begin getting answers to the 10 questions. f. Stay for the fall huddle, assist in getting a fall huddle started. 2. Fall Scene Investigation: a. Post fall investigation form. b. Data collection tool used to assess clues and evidence to determine Root Cause Analysis (RCA). c. Completed soon after the fall occurs and/or during the fall huddle. d. Completed by nurse in charge on duty at time of fall. 3. Causation Findings Identified from the Fall Prevention Program: a. External causes: noise, busy activity, lack of environment contrasts, placement of furniture, equipment and personal items, floor surfaces. b. Internal causes: poor balance, sleep deprivation/sleep fragmentation, need for the 4 Ps, medications (type and amount), orthostatic blood pressure, lack of endurance. c. Systemic causes: time of day, shift change/times, break times, day of week, location of fall, type of fall, routine staff assignments, staffing levels.

Based on observation, review of the facility's COVID Screen-In Sheets, staff, physician, Public Health personnel interviews and Center for Disease Control and Prevention (CDC) COVID guidelines, the facility failed to follow CDC Infection Control Guidelines for COVID-19 allowing staff to work while presenting signs and symptoms consistent with the COVID-19 infection. The situation resulted in 32 of the 44 residents positive for COVD-19 as of 10/17/20 and by 10/21/20, all 44 residents were positive. The facility reported a census of 44 residents. During an observation on 10/19/20 at 1:10 p.m. , the facility has established a screened-in process for staff to be checked for temperature and asked whether they exhibit signs or symptoms including: cough, sore throat, new shortness of breath, headache, new loss of taste or smell, fever or chills, or gastrointestinal symptoms such as vomiting or diarrhea. Each staff member must fill this out before entering the facility for each shift and at the end of each shift. Review of the facility's screened-in sheets for 10/15/20 revealed the Staff A, Certified Nurse Aide (CNA), circled yes to the following symptoms: cough, new shortness of breath, headache, new loss of taste or smell, and chills. Staff A's temperature upon entering the facility was 97.7 degrees Fahrenheit (F). On 10/16/20, the screened sheet revealed Staff A circled yes to cough, sore throat, new shortness of breath, headache, and new loss of taste or smell. Staff A's temperature was 97.5 degrees F. On 10/17/20, Staff A circled yes to the following symptoms: cough, sore throat, new shortness of breath, headache, and new loss of taste or smell. During an interview on 10/22/20 at 11:12 a.m., Staff A, CNA, recalled working the following dates 10/15/20, 10/16/20/ and 10/17/20. Staff A commented she thought she should have stayed home those days and not worked. Staff A stated on 10/15/20 she had a runny nose, cough, sore throat, loss of smell and a headache. Staff A called into the facility on [DATE] and explained to the Director of Nursing (DON) she was not feeling well. She stated the DON asked her to come in to be tested for COVID 19 and to have her temperature taken. Staff A recalled being told her test would come back in about 15 to 20 minutes and she would know whether she could work. Her [MEDICATION NAME] test showed she was negative for COVID-19 and had her temperature taken which showed she did not have a fever. Staff A recalled being screened in by Staff B, CNA, who asked her why Staff A was at the facility if she wasn't feeling well. Staff A replied she was cleared to work because her test came back negative for COVID 19 and she did not have a fever. During her shifts, staff were concerned she worked because she told staff she did not feel well. Staff A stated on Thursday she lost her sense of taste. Staff A reported she was tested on [DATE] and on 10/19/20, she found her Polymerase Chain Reaction (PCR) test (one test process utilized to ascertain if a person is positive or negative COVID) showed she was positive with COVID 19. Staff A reported the facility was short staffed and recalled at least three staff members quitting in the last two to three months. During an interview on 10/27/20 at 11:02 a.m., Staff B, CNA, recalled screening Staff A, CNA, before her shift. She recalled asking Staff A, why she was there at the facility if she was not feeling well. Staff B reported Staff A had said she was cleared to work by the DON because she did not have a fever and her COVID-19 test came back negative. Staff B took Staff A at her word and did not report the screen to the DON. Staff B recalled Staff A did not look like she felt well. Staff B reported she worked evening shifts with Staff A. Staff B then reported on 10/19/20. She did not feel well and went to the doctor, where she tested for COVID-19 and received a letter from the physician to not work. Staff B reported she felt the facility would not take no for an answer, which is why she went to the physician to receive a doctor's note to not work. During an interview on 10/26/20 at 11:20 a.m., the DON reported she usually checked screen-in sheets daily but she did not check the screen-in sheets for 10/15/20. She reported Staff A, CNA, called her and reported runny nose and cough but Staff A had wondered if it was due to the mask. The DON reported Staff A's [MEDICATION NAME] test came back negative for COVID-19, so she allowed Staff A to work but only with residents who were positive and residents suspected of COVID 19. The DON reported residents who tested positive or showed symptoms of COVID-19 were quarantined down the North and North West halls. The DON stated Staff A did not work with any other residents other than those residents. The DON reported there was one resident and one staff member who were positive with COVID-19 on 10/14/20. On 10/15/20, one additional staff member tested positive with COVID-19, however, there were multiple residents suspected of having COVID 19 because of their symptoms. The DON reported everyone in the facility was tested on [DATE] and the results for 10/16/20 showed 31 residents were positive with COVID-9. During an additional interview on 10/27/20 at 12:15 p.m., the DON reported during the week of 10/12/20 through 10/16/20, she did not feel the facility was short staffed. She reported it was the weekend and week after the facility was short. She reported the Administrator reached out to resources around but could not get staffing. During an interview on 10/22/20 at 12:50 p.m., the Administrator explained he tried to get additional staff by contracting with a Nursing Agency for staffing on 10/16/20. He reported he reached out to the Iowa Department of Public Health (IDPH) awaiting for COVID testing results and was told to use his best judgement for staffing and reach out to the Department of Inspections and Appeals (DIA). He reported discussing utilizing the facility's own staff who were positive for COVID 19 but asymptomatic. The Administrator reported on 10/19/20 he reached out to the Iowa Health Care Association (IHCA) for clarification about having asymptomatic staff work at the facility with positive residents. During a follow-up interview on 10/26/20 at 11:00 a.m., the Administrator reported he utilized a website called IServe for local area Nursing Staff and had reached out to a Staffing Consultant. He reported the staffing consultant told him to contact DIA to see what other resources he could use. He reported most of the staffing shortage was on the evening shift and day shift staff helped by staying an extra shift. The Administrator reported he was unaware of Staff A working while exhibiting signs of symptoms and commented he didn't check the screen in logs. During an interview on 10/21/20 at 3:46 p.m., the Medical Director reported having multiple discussions with the facility in regards to staffing. She explained the facility were in crisis mode and attempted to get staffing. The Medical Director stated she hoped the facility would not allow a staff member exhibiting symptoms of COVID-19 to work, but instead to turn them away. During an interview on 10/21/20 at 3:24 p.m., a Consultant with the Health Department stated the facility should not have allowed staff to work who were symptomatic. Review of the facility's undated Emergency Preparedness Staffing showed an addition from the CDC for strategies to mitigate healthcare personnel staffing shortages, dated July 17, 2020 but not made effective by the facility until 10/18/20. The policy showed if there were a shortage, the facility could have a COVID positive or suspected COVID positive asymptomatic staff member work who are well enough and willing to work. However, the staff member can either perform job duties where they don't interact with others, or provide care only for residents with or suspected of COVID 19.

Based on record review and staff interview, the facility failed to update resident Care Plans for 2 of 12 residents reviewed (Resident #7 and #8). The facility reported a census of 44 residents. Findings include: 1. Resident's #7's Minimum Data Set (MDS) quarterly assessment completed [DATE] documented the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 out of 15 and required extensive staff assistance only with moving in and out of her room and bathing. A review of the resident's Care Plan revealed the last revision date as [DATE] and the next revision date to be due on [DATE]. A review of the Nurse Practitioner note dated [DATE] documented the staff reported the resident with a weight loss of ten pounds since (MONTH) 2019 after her husband's passing. Weight was 181 in October/November and now weighs 156. A review of the Social Services notes revealed the following entries: a. On [DATE] at 2:55 p.m. the resident's husband passed away this past quarter. b. On [DATE] at 11:02 a.m. isolated episodes of anger, but generally accepting of staff assistance. During an interview on [DATE] at 7:51 a.m., the Director of Nursing (DON) reported she would expect Care Plans to be updated with care conferences, quarterly and as needed when changes in condition arise, that when a new problem is identified, she would expect it to be addressed on the Care Plan within 2 weeks. She would have expected the fact the resident's spouse expired to be addressed on the Care Plan if it had been a problem. In an interview on [DATE] at 9:04 a.m., the MDS coordinator reported Care Plans should be updated with any changes and quarterly and possibly she failed to update this resident's care plan when due as she had other responsibilities. During an interview on [DATE] at 10:00 a.m., the DON reported the facility did not have a policy on Care Plans. 2. Resident #8's MDS quarterly assessment completed [DATE] documented the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively intact with a BIMS score of 12 out of 15, required extensive staff assist only with dressing, eating (as the resident had a feeding tube which provided at least 51% or more of his total calories) and bathing. The MDS also identified the resident had been at risk for developing pressure ulcers. A review of the admission MDS completed [DATE] shown the Care Area Assessment triggered the problem of pressure ulcer as the resident required activities of daily assistance for bed mobility and had frequent bowel incontinence. A review of the treatment administration records and physician orders [REDACTED]. At the time of record review completed on [DATE] the care plan identified the resident with the problem of a sore to his left buttock on [DATE] with the following interventions added: a. Help me with my position changes and walking. I am able to alert staff to my need for changes and I am independent with slight position changes for comfort. b. Notify my provider with changes in my wound. c. Nursing to monitor and assess my wound weekly, often following my bath. During an interview on [DATE] at 11:21 a.m., Staff A, Licensed Practical Nurse (LPN), reported the current pressure ulcer opened up in (MONTH) 2019. If the resident had been identified as a high risk for developing a pressure ulcer, she would expect that to be addressed on the Care Plan. In an interview on [DATE] at 7:51 a.m., the Director of Nursing (DON) reported she would expect Care Plans to be updated quarterly and as needed with any change of condition be addressed within 2 weeks on the Care Plan. If a resident triggered for pressure ulcers on the MDS Care Area Assessments, she would expect that to be addressed on the Care Plan During a interview on [DATE] at 9:04 a.m., the MDS Coordinator reported if a resident triggered on the MDS Care Area Assessment for pressure ulcer, she does not always add this to the Care Plan. If a new problem had been identified, she would ensure it had been addressed on the Care Plan as soon as possible, however, did not provide a time frame when it should be completed. She also reported the pressure ulcer initially opened up in (MONTH) 2019 and should have been addressed on the care plan. In an interview on [DATE] 10:00 a.m., the DON reported the facility did not have any policies on care plans.

Based on observation, record review and staff interview, the facility failed to provide complete documentation of the assessment of a pressure ulcer identified for the only resident in the facility identified with a pressure ulcer. (Resident #8) The facility reported a census of 44 residents. Findings include: Resident #8's Minimum Data Set (MDS) quarterly assessment completed 5/23/19 documented the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 12 out of 15, required extensive staff assist only with dressing, eating (as the resident had a feeding tube which provided at least 51% or more of his total calories) and bathing. The MDS identified the resident at risk for developing pressure ulcers. A review of the admission MDS completed 11/19/18 Care Area Assessment triggered the problem of a pressure ulcer as the resident required activities of daily assistance for bed mobility and had frequent bowel incontinence. A review of the treatment administration records and physician orders [REDACTED]. At the time of record review completed on 9/4/19 the Care Plan identified the resident with the problem of a sore to his left buttock on 9/3/19 with the following interventions added: a. Help me with my position changes and walking. I am able to alert staff to my need for changes and I am independent with slight position changes for comfort. b. Notify my provider with changes in my wound. c. Nursing to monitor and assess my wound weekly, often following my bath. During an observation of wound care on 9/4/19 at 10:13 a.m. Staff B, Registered Nurse (RN) washed her hands, donned new gloves, and removed the dressing from the left gluteal (buttocks) wound which appeared without any signs of infection. Staff B measured the wound with the length of 0.3 centimeters (cm) width of 0.1 cm and no depth. Staff B then cleansed the wound area with a soapy wet cloth inward out and dried and applied the [MEDICATION NAME] dressing to there pressure ulcer, removed gloves and pulled up resident's pants. A review of the nurse's notes revealed the following entries: a. On 6/24/19 at 2:59 p.m., resident's left buttocks cheek is healed, scab remains, continue to apply barrier cream for moisturizer. b. On 8/19/2019 at 2:31 p.m., left buttocks open area has returned. Size 1 cm x 1 cm x 0.1 mm. Applied [MEDICATION NAME] for comfort. c. On 8/26/2019 at 10:20 a.m., after whirl pool bath opening to left buttock is 1.2 cm x 0.7 cm x 0.2 mm depth. Applied [MEDICATION NAME] for comfort. d. On 9/3/2019 at 9:30 p.m., assessed open area on left buttock- area has decreased in size. Area measures 1 cm x 0.5 cm x 0.1 mm depth. Denied pain to the area. Area without active drainage, wound bed dry & intact. Periwound skin light pink with wound bed dull redness. Refused to have [MEDICATION NAME] applied to area. e. On 9/4/2019 at 10:23 a.m., open area left buttocks cleansed and Mepelix dressing reapplied. Measures 0.3 cm x 0.1 cm, no depth, no drainage and skin circumference without redness or warmth. During an interview on 9/4/19 at 11:21 a.m., Staff A, Licensed Practical Nurse (LPN), reported the current pressure ulcer for Resident #8 opened up in August, and when a new pressure ulcer develops, she would expect the nurses to document on a weekly basis, the length, diameter and depth, the presence of any redness, and drainage which should be documented in the progress notes in the electronic record. In an interview on 9/5/19 at 7:51 a.m., the Director of Nursing (DON) reported she would expect nurses to document on pressure ulcers the appearance of the wound, an assessment of the dimensions, surrounding skin, presence of drainage and notify the doctor and there family. She also reported she would expect this to be addressed on the Care Plan During a interview on 9/5/19 at 9:04 a.m., the MDS Coordinator reported if a resident triggered on the MDS Care Area Assessment for pressure ulcer, she does not always add this to the Care Plan. If a new problem had been identified, she would ensure it had been addressed on the Care Plan as soon as possible, however, did not provide a time frame when it should be completed. She also reported the pressure ulcer initially opened up in (MONTH) 2019 and should have been addressed on the Care Plan. In an interview on 9/5/19 10:00 a.m., the DON reported the facility did not have any policies on pressure ulcers.

Based on observation, dietary menu review, dietary policy review and staff interview, the facility failed to ensure dietary staff followed the menu as planned for three residents on a pureed diet and failed to ensure an alternate was available as required. The facility census was 44 residents. Findings include: 1. The Diet Spreadsheet for week 2 Sunday showed the puree noon meal included: a. Three ounces of glazed pureed ham b. Four ounces pureed Au Gratin potatoes c. One serving of a pureed roll with margarine. The Diet Spreadsheet showed hamburger steak with gravy and parsley mashed potatoes as an alternative to the main meal. Observation on 7/1/18 at 10:10 a.m., revealed Staff A, Cook, preparing the pureed foods. Staff A placed three number (#) 8-scoops of cooked Au Gratin potatoes plus milk to the blender. After blending the potatoes, Staff A poured the pureed mixture into a pan and placed it into the steam oven. Staff A did not measure the total amount of the blended potatoes. Observation revealed Staff A served three pureed meals, not using a full #8 scoop for the potatoes. The steam table did not contain hamburger steak with gravy and parsley mashed potatoes as the menu stated. Observation at 12:05 p.m., revealed the Food Service Supervisor checked the pureed potatoes leftovers. There was 2 full scoops leftover. The Food Service Supervisor reported three pureed potatoes were made therefore there should be no leftovers. During interview on 7/1/18 at 12:15 p.m., the Food Service Supervisor reported the alternative meal was not offered on weekends, even though it was on the menu. During interview on 7/2/18 10:30 a.m., the Food Service Supervisor reported the cook should have measured the total amount of the pureed potatoes and checked the conversion chart for scoop size. The Cook should have served a full scoop level of the pureed potatoes and there should have been no leftovers. The Food Service Supervisor noticed the pureed roll and butter was not served as listed on the menu. During interview on 7/2/18 at 10:30 a.m., the Dietician reported they have not served any alternative food choices on the weekends for a long time, as staff are busy doing a lot of food prep for the coming week. She did not believe it had to do with staffing or budget, just different tasks being performed. The facility's Puree Process, undated, (from the Distributing Company) included the following: Step 1: Measure out desired number of servings into container for pureeing. Step 2: Puree the food. Step 3: Add any necessary thickener or appropriate liquid of nutritive value and flavor to obtain desired consistently. Step 4: Measure the total volume of the food after it is pureed. Step 5: Divide the volume of the pureed food by the original number of portions (see puree scoop chart). Step 6: Heat or chill the pureed food to safe serving temperatures.

Based on clinical record review, review of medication administration and psychoactive medication flow records, and staff interview, the facility failed to utilize non-pharmacological interventions for 2 of 2 residents reviewed with anxiolytic medication use before administering the medication. (Resident #2, 7) The facility census was 43 residents. Findings include: 1. The Significant Change minimum data set (MDS) with the reference date of 3/20/14 documented Resident #2 had [DIAGNOSES REDACTED]. The MDS indicated the resident received an anti-anxiety medication 7 times out of the last 7 days. The Physicians Orders dated 3/2014 documented an order dated of 9/6/13 for [MEDICATION NAME] (anti-anxiety medication) 0.25 milligrams every 2 hours as needed. The residents Care Plan identified a focus area of shortness of breath initiated 3/12/13. The Care Plan directed staff to talk , redirect, and reorient the resident to help reduce the residents anxiety. The Care Plan also directed staff to join and support the resident during periods of shortness of breath. The Medication Record dated 1/1/14 to 1/31/14 revealed the resident received the as needed [MEDICATION NAME] 5 times (3/11/14, and 3/12/14). The Psychoactive Medication Monthly Flow Record dated 3/2014, lacked documentation of anxiety for the dates staff administered the as needed [MEDICATION NAME] for the dates 1/11/14 and 1/12/14. The Nurses Notes dated January 2014 lacked documentation of non-pharmacological interventions for 4 of the 4 times staff administered the as needed [MEDICATION NAME]. The Medication Record dated 2/1/14 to 2/28/14 showed the resident received as needed [MEDICATION NAME] once on 2/3/14. The Psychoactive Medication Monthly Flow Record dated 2/2014, lacked documentation of anxiety on 2/3/14. The Nurses Notes dated February 2014 lacked documentation of non-pharmacological interventions for that date. The Medication Record dated 3/1/14 to 3/31/14 revealed the resident received as needed [MEDICATION NAME] 5 times for the dates (3/4/14, 3/7/14, 3/10/14, 3/12/14, and 3/17/14). The Psychoactive Medication Monthly Flow Record dated 3/2014 lacked documentation of anxiety on the dates staff administered the as needed [MEDICATION NAME]. The Nurses Notes dated March 2014 lacked documentation of non-pharmacological interventions for 2 of the 5 times the resident had received the as needed [MEDICATION NAME]. During an interview on 4/24/14 at 9:25 a.m. the Director of Nursing reported that interventions should be completed prior to giving medications like as needed [MEDICATION NAME]. 2. Resident #7 had [DIAGNOSES REDACTED]. The MDS documented behaviors of physical behavior symptoms directed toward others and verbal behavioral symptoms directed towards others. Review of a re-admission form dated 1/10/14 revealed a physician's orders [REDACTED]. daily as needed. Review of the February 2014 Medication Administration Record [REDACTED]. Review of the PRN (as needed) administration record documented the medication as given on the respective dates for anxiousness. Review of the April 2014 Medication Administration Record [REDACTED]. Review of the PRN administration record documented the medication as given on the respective dates for increased restlessness and anxiousness. Review of the clinical record revealed no documentation in the clinical record for Non-pharmacological interventions (such as behavioral interventions) instituted before giving the anxiolytic medication to Resident #7. Review of psychoactive medication monthly flow sheets for February and April 2014 revealed no documentation of the target behavioral symptoms Resident #7 exhibited as they related to the need for the administration for the anxiolytic medication.

Based on observation, record review and staff interviews, the facility failed to prepare and serve 1 of 1 observed meals under sanitary conditions. The facility reported a census of 46 residents. Findings Include: Observation in the facility kitchen on 2/20/13 between 10:45 a.m. and 11:10 a.m., and on 2/20/13 between 11:20 a.m. and 12:02 p.m. revealed the trash receptacle located by the dishwasher intake (dirty side of the kitchen) and not near the hand wash sink (clean side of kitchen). The location required staff to cross into the kitchen area regarded as dirty. During an interview on 2/20/13 at 11:10 a.m., the facility dietician agreed that staff should not cross into the dirty side of the kitchen to discard paper-towels after hands washed and a trash receptacle should have been located in the clean side of the kitchen near the hand wash sink. Continuous observation on 2/20/13 revealed the dietary manager (DM) at the stationary steam table and plated meals for resident room trays between 11:20 a.m. and 11:32 a.m. Observation at 11:26 a.m. revealed the #8 scoop with handle laid in the container of rice on the steam table, the DM picked up the scoop and placed on the steam table near the rice without a glove on and had not washed his/her hands prior to the action. Continued observation revealed the DM continued to plate the noon meal for residents between 11:32 a.m. and 11:58 a.m. as 2 dietary aides delivered the meals to residents seated in the dining room on 2 utility carts that were transported into and out of the kitchen with each delivery, the DM touched the handles of the utility carts multiple times during the process, at 11:42 a.m. the #8 scoop with handle laid in the container of rice on the steam table, and the DM removed the scoop without a glove and did not wash his/her hands prior to the action, placed the scoop on the steam table near the rice and continued to use the scoop throughout the continued observation. During an interview on 2/20/13 at 1:10 p.m., the facility dietician concurred that the DM should have washed his/her hands or worn a glove to remove the scoop from the rice and replaced the scoop with a clean one.