Every finding on record at Community Care Center

Based on staff interviews, facility investigation review, and facility policy review the facility failed to notify DIAL (Department of inspection, appeals and licensing) and the law enforcement of an allegation of abuse for Resident #1 that was reported on 1/6/25 at approximately 4:15 PM. The facility reported a census of 53 residents. Findings include: The facility form titled Complaint Investigation dated 1/6/26 documented Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA reported to the Administrator that Staff C, CNA told them she slapped Resident #1 when he had his hands down her sweater and she said she told him to keep his fucking hands off her. Review of the document titled Self Report List from January 2025 to January 2026 revealed the facility failed to file the allegation of abuse with DIAL. On 1/26/26 at 11:45 AM, Staff A reported she was in toileting Resident #2 and Staff C came in and said Resident #1's call light was going off and that she was not comfortable answering the light on her own. Staff A said Staff C reported on Christmas she was wearing an ugly grinch sweater and Resident #1 reached down her shirt, grabbed her breast and she smacked him across the face. Staff A reported she told Staff D, Registered Nurse (RN) since she was a mandatory reporter and Staff D told her that she would have throat punched him. She said she then went to the Administrator about it and the Administrator told her that she was not believable since she was showing emotion.On 1/26/26 at 3:44 PM, Staff B reported she was taking Resident #2 to the toilet. She said Staff A came into the room with Staff C. Staff B said she asked Staff C if she took a second person in Resident #1's room and Staff C said yes, that she refused to go in the room by herself. Staff B said Staff C told her on Christmas she was wearing a lighted Christmas sweater and Resident #1 reached down her shirt, grabbed her boob and she slapped him across the face. She said Staff C used the F word and B word to describe what happened. Staff B said she did not know if Staff C said those words to Resident #1 or not.The facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy revised 9/29/21 documented all resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse was responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections, Appeals & Licensing Health Facilities Division not later than two hours after the allegation was made. If there is a reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement. While the federal regulations require all abuse allegations to be reported to DIAL within 2 hours, the Elder Justice Act has a different time frame for reporting to the police/sheriff. If an allegation of abuse that results from a crime results in serious bodily injury to a resident, a report must be made to law enforcement not later than two hours after the allegation was made. If the allegation of abuse does not result in serious bodily injury, a report to law enforcement must be made not later than twenty four hours. On 1/26/26 at 1:15 PM, the Administrator said she did not file a report to DIAL as she did not believe there was a potential for abuse.On 1/27/26 at 3:17 PM, the Administrator reported she did not notify the police of the allegation of abuse.

Based on staff interviews, facility investigation review, facility payroll review and facility policy review the facility failed to separate a staff member from dependent residents accused of alleged abuse that was reported on 1/6/26 at approximately 4:15 PM for Resident #1.The facility reported a census of 53 residents.Findings include: The facility form titled Complaint Investigation dated 1/6/26 documented Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA reported to the Administrator that Staff C, CNA told them she slapped Resident #1 when he had his hands down her sweater and she said she told him to keep his fucking hands off her. On 1/26/26 at 11:45 AM, Staff A reported she was in toileting Resident #2 and Staff C came in and said Resident #1's call light was going off and that she was not comfortable answering the light on her own. Staff A said Staff C reported on Christmas she was wearing an ugly grinch sweater and Resident #1 reached down her shirt, grabbed her breast and she smacked him across the face. Staff A reported she told Staff D, Registered Nurse (RN) since she was a mandatory reporter and Staff D told her that she would have throat punched him. She said she then went to the Administrator about it and the Administrator told her that she was not believable since she was showing emotion.On 1/26/26 at 3:44 PM, Staff B reported she was taking Resident #2 to the toilet. She said Staff A came into the room with Staff C. Staff B said she asked Staff C if she took a second person in Resident #1's room and Staff C said yes, that she refused to go in the room by herself. Staff B said Staff C told her on Christmas she was wearing a lighted Christmas sweater and Resident #1 reached down her shirt, grabbed her boob and she slapped him across the face. She said Staff C used the F word and B word to describe what happened. Staff B said she did not know if Staff C said those words to Resident #1 or not.Review of the Employee Time Cards Report from 1/6/26 to 1/27/26 revealed Staff C worked full shifts on the following dates: 1/6/26, 1/8/26, 1/9/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/17/26, 1/18/26, 1/21/26, 1/22/26, 1/23/26, and 1/26/26. On 1/27/26 at 4:30 PM, the Administrator verified the staff member was not separated from Resident #1 and acknowledged the abuse policy was not followed.The facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy revised 9/29/21 documented upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances (3) separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents. The policy further documented following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee may be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the Department concludes its investigation and issues the written results of its investigation.

Based on clinical record review, staff interviews and facility policy review, the facility failed to notify the Physician and family of an allegation of abuse for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 53 residents.Findings include: The Minimum Data Set (MDS) for Resident #1 dated 12/28/25 identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #1's MDS included diagnoses of Alzheimer's, Non-Alzheimer's disease, anxiety, and depression.A facility form titled Complaint Investigation dated 1/6/26 documented Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA reported to the Administrator that Staff C, CNA told them she slapped Resident #1 when he had his hands down her sweater and she said she told him to keep his f***ing hands off her. Review of the Clinical Record lacked documentation the allegation of abuse was reported to Resident #1's Physician or family. On 1/27/26 at 10:58 AM, the Director of Nursing (DON) verified the family had not been called regarding the allegation of abuse on 1/6/26. On 1/28/26 at 10:55 AM, the Administrator verified Resident #1's Physician was not notified of the allegation of abuse on 1/6/26.The facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy revised 9/29/21 revealed the Administrator would complete documentation of the allegation of Resident abuse and collect any supporting documents relative to alleged incident which included providing proper notification to the primary care provider and responsible party.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access by leaving 16 residents' information accessible when staff walked away from the Electronic Health Record (EHR) laptop. The facility reported a census of 52 residents. Findings include:On 12/08/25 at 2:59 PM, an open laptop was observed in the dining room area with 16 residents' EHR information accessible. There were three (3) residents in the dining room and no staff present.At 3:00 PM, Staff F, Registered Nurse (RN) stated she thought she locked the laptop when she walked away. She said they do not leave the resident information open when they leave the computer.At 3:02 PM, Staff G, Certified Nurse Aide (CNA) stated two (2) of the three (3) residents were ambulatory.On 12/11/25 at 8:34 AM, the Director of Nursing (DON) stated the laptop should be locked when staff aren't present.A policy titled Dignity, Privacy, and Confidentiality revised 5/29/18 indicated resident records are limited to the use of the staff and will be safeguarded at all times to ensure confidentiality.

Based on observation, staff interview and policy review the facility failed to ensure that kitchen staff used adequate hand hygiene practices to mitigate cross contamination during the meal service. The facility reported a census 52 residents. Findings include:On 12/9/25 at 10:20 AM, Staff A, Dietary Aid, prepared one pureed and 7 ground meat servings for the lunch meal. At 10:30 AM, Staff A removed a pan of stew from the oven and stirred it with a large serving spoon. She then laid the spoon directly on the counter without a barrier. She scooped out the number of servings needed for the ground menu into the mixer, between the scooping, she laid the spoon on the counter. At 10:45 AM she pulled the meat balls out of the oven and prepared 5 mechanical soft and one pureed. Several times during the pureed and ground meat process, she laid the scoop on the counter alongside the large oven mitts that are very stained and soiled. In an observation of the lunch service at 12:20 PM, Staff A donned gloves, grabbed a bag of bread, reached in and got 2 pieces of bread, buttered them and put them on the grill for a grilled cheese sandwich. With the same gloved hands, she grabbed a meal ticket from a staff member, touched several surfaces, opened the refrigerator and got a bag of cheese slices. She then reached in the bag and got a couple of slices of cheese and put them on the bread on the grill. Staff A then took the disposable gloves off and failed to wash her hands before going back to serving up the plates of food. On 12/10/2025 at 7:11 AM, the Dietary Manager (DM) said that she did witness the hand hygiene issues during the lunch service, and she had a conversation with Staff A about placing utensils on the counter between scoops of stew, and regarding the use of gloves and cross contamination concerns. She said they have worked on education with Staff A on some of these issues and having difficulty getting her to understand. According to a facility policy titled: Hand Hygiene, last reviewed on 8/30/2021, the purpose of the hand hygiene education was to reduce the spread of potential pathogens on the hands, and to protect residents and staff. The use of gloves should be used as an adjunct, not a substitute for hand washing. Gloves should be used for hand contaminating activities, should be removed and the hands washed after such activity. Gloves may need to be changed between procedures, and disposable gloves should only be used once and should not be washed for reuse.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to lock the wheelchair during a resident transfer for 1 of 1 residents (#17) reviewed for safe transfers. The facility reported a census of 52 residents. Findings include:The Minimum Data Set (MDS) for Resident #17 dated 11/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of thyroid disorder, Parkinson's Disease, hallucinations, and multiple right rib fractures. It indicated he required setup assistance with eating, supervision with oral and personal hygiene, moderate assistance with toileting and dressing, maximal assistance with bathing, and was dependent with footwear. It also indicated he required moderate assistance with sit-to-stand, was dependent with toilet, tub, and car transfers and used a walker or wheelchair for mobility. It further indicated other forms of bed mobility or transfers were not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.The Care Plan dated 11/23/25 indicated the resident required one-person assistance with transfers. It also directed staff to keep the wheelchair brakes locked next to the resident's bed and indicated the resident would sometimes try to self-transfer.The Progress Notes indicated the resident fell on [DATE] during a self-transfer attempt.On 12/10/25 at 10:38 AM, Staff B, Certified Nurse Aide (CNA) and a CNA nursing student transferred Resident #17 in the dining room from a recliner to a wheelchair. The wheelchair was unlocked throughout the transfer process.At 10:49 AM, Staff B, CNA and Staff C, Certified Medication Aide transferred Resident #17 from a wheelchair to a recliner. The wheelchair was unlocked until the resident stood up with staff assistance and a CNA student locked the right wheel.At 10:50 AM, Staff A stated she forgot to lock the wheelchair before transferring Resident #17.At 10:52 AM, Staff C stated she left it unlocked so she could move it out of her way when she got the resident to shuffle to the recliner. She also stated it would normally be locked, but there was a CNA student who was holding the wheelchair.At 10:59 AM, the CNA Clinical Instructor stated students can help if they were comfortable.At 12:50 PM, Staff D, Licensed Practical Nurse (LPN) stated when transferring a resident from or to a wheelchair, the wheels should be locked.At 1:56 PM, Staff E, Registered Nurse (RN) stated the wheels should be locked when transferring a resident to or from a wheelchair.On 12/11/25 at 8:34 AM, the Director of Nursing (DON) stated staff should have locked the wheelchair during the transfer.A policy titled Mobility: Assisted Transfer revised 11/18/17 directed staff to lock the wheels during transfers involving a wheelchair.

Based on electronic record review (EHR), staff interviews, and policy review the facility failed to develop a comprehensive care plan related to a resident with a diagnosis of dementia for 1 of 5 residents reviewed (Resident #3). The facility reported a census of 52 residents.Findings include: Review of Resident #3's Minimum Data Set (MDS) date 11/5/25 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS further revealed a diagnosis of non-Alzheimer's dementia. Review of Resident #3's Care Plan with a revision date of 12/2/25 revealed no goals, focus, or interventions related to Resident #3's diagnosis of dementia. Interview on 12/9/2025 at 12:36 PM with the Director of Nursing (DON) confirmed there was no implementation of a care plan concerning dementia with the interventions to assist resident #3. The DON further revealed she would expect more to be on the care plan concerning dementia for Resident #3. Review of a facility provided policy titled, Care Plan Creation with a revision date of 9/27/25 revealed:a. Identify needs and problems of resident based on nursing history and assessment, physician's orders, inter-facility transfer forms (when available), past history and physical examination, and any other available information.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 1 out of 5 residents reviewed (Resident #3). The facility reported a census of 52 residents.Findings include: Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS showed Resident #3 also took antipsychotropic medication during the review period. The MDS further revealed diagnoses of non-Alzheimer's dementia, depression, and hallucinations. Review of Resident #3's Electronic Healthcare Record (EHR) page titled, Physician's Orders revealed an order dated 10/29/25 for Quetiapine (antipsychotic) 50mg 1 tablet at bedtime for dementia. Further review revealed another order for Quetiapine 25mg 1 tablet in the morning for dementia with a start date of 11/24/25. Review of the Care Plan with a revised date of 12/2/25 lacked non-pharmacological interventions and targeted behaviors with antipsychotic medications. Interview 12/09/2025 at 12:05 PM with the Director of Nursing (DON) revealed that she would expect nonpharmacological interventions to be placed in the care plan for residents with psychotropic medications. The DON further acknowledged there were no nonpharmacological interventions currently on Resident #3's care plan. Review of a facility provided policy titled, Care Plan Creation with a revision date of 9/27/17 revealed: a. To provide a documented interdisciplinary plan of care that focuses on attaining or maintaining physical, social, mental health of the resident. b. To increase and make more comprehensive communication to all care givers to improve continuity of resident care.

Based on record review, staff interviews, and policy review, the facility failed to complete a discharge summary and discharge Plan of Care for 4 of 4 residents (#1, #3, #4, #5) reviewed. The facility reported a census of 49 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #1 dated 6/27/25 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of anemia, hypertension, renal failure, malnutrition, and metabolic encephalopathy (improper brain functions due to a metabolism disorder). It revealed the resident was admitted on [DATE] and received Occupational Therapy (OT) and Physical Therapy (PT) services.The Physical Therapy Treatment Encounter Note(s) dated 6/30/25 indicated the resident was a fall risk but tolerated facility mobility without the use of an assistive device. It also indicated she was ready to discharge to her daughter's home the next day.The Transfer/Discharge Report dated 6/27/25 indicated the resident was alert and oriented x 3, ambulated without an assistive device, was continent of bowel and bladder, and was able to feed herself. It also indicated she met her level of functioning but did not include a summary of her OT or PT services.The Progress Notes dated 7/01/25 at 10:45 AM indicated the resident discharged home with her daughter who received and understood the discharge instructions.The resident's Medical Record lacked a Discharge Summary and Plan of Care.2. The MDS for Resident #3 dated 9/15/25 indicated Resident #3 had a BIMS of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, thyroid disorder, and displaced fracture of the lateral malleolus of the right fibula (right outer ankle bone). It revealed the resident was admitted on [DATE] and received OT and PT services.The Transfer/Discharge Report dated 9/29/25 indicated the resident was alert and oriented x 3, ambulated with a walker, was continent of bowel and bladder, and was able to feed herself. It also indicated she met her level of functioning but did not include a summary of her OT or PT services.The Progress Notes dated 10/03/25 at 10:30 AM indicated the resident was discharged home and accompanied by her daughter. It also indicated the discharge instructions were given and understood but did not indicate by whom.The resident's Medical Record lacked a Discharge Summary and Plan of Care.3. The MDS for Resident #4 dated 7/15/25 indicated Resident #4 had a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of atrial fibrillation (irregular heart rhythm), heart failure, chronic kidney disease, and fractured left hip. It revealed the resident was admitted on [DATE] and received Occupational Therapy (OT) and Physical Therapy (PT) services.The Physical Therapy PT Therapy Progress Report dated 7/21/25 indicated the resident had not met one (1) short-term goal (STG) and one (1) long-term goal (LTG). The Transfer/Discharge Report dated 7/21/25 indicated the resident was alert and oriented x 4, ambulated with a walker, was continent of bowel and bladder, and was able to feed himself. It also indicated he met his level of functioning, was discharged home with PT, nursing, and an aide but did not include a summary of his OT or PT services.The Progress Notes dated 7/26/25 at 10:58 AM indicated the resident signed the discharge instructions and stated his daughter would pick him up that afternoon to take him home.The resident's Medical Record lacked a Discharge Summary and Plan of Care.On 10/14/25 at 12:18 PM, Staff A, Physical Therapist (PT) stated the PT Home Evaluation for Resident #4 had been completed but not attached to his medical record. She confirmed the family did not get a copy of the Home Evaluation form upon discharge. A document titled Home Safety Checklist dated 7/22/25 indicated the resident was seen in his home with his son and was able to transfer in and out of the car and enter his home with a front-wheeled walker; both with stand-by assistance. It indicated no concerns limiting the discharge plan. It also indicated the resident was educated to manage the care needs for himself and allow others to assist his wife who will return home in 1-2 weeks.4. The MDS for Resident #5 dated 7/25/25 indicated Resident #5 had a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of heart failure, chronic kidney disease, and right shoulder replacement surgery. It revealed the resident began Medicare Occupational Therapy (OT) and Physical Therapy (PT) services on 7/18/25.The Physical Therapy Treatment Encounter Note(s) dated 7/28/25 indicated the resident was a fall risk and oxygen dependent but decided to return home against PT recommendations. It also indicated she would benefit from continued services to improve her strength and balance.The Transfer/Discharge Report dated 7/28/25 indicated the resident required a one-person assist with a gait belt for ambulation, was continent of bowel and bladder, and was able to feed herself. It also indicated she met her level of functioning but did not include a summary of her OT or PT services.The Progress Notes dated 7/29/25 at 11:30 AM indicated the resident discharged from the facility but did not include documentation of discharge instructions.The resident's Medical Record lacked a Discharge Summary and Plan of Care.On 10/14/25 at 9:31 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated the facility does not send a Discharge Summary or Plan of Care home with residents at the time of discharge. They stated the details of therapy and the residents' care are discussed with each resident and/or Power of Attorney (POA) throughout the resident's stay. They also stated rehabilitation notes are not included in the discharge paperwork given to the resident or resident representative.A document titled Discharge Summary revised 9/27/17 included the following:Responsibility: DON Social Worker Food Service Supervisor Activity Director Licensed Practicing Nurse (LPN) or Registered Nurse (RN) Purpose: To provide information regarding the care needed after discharge To document education completed upon discharge To summarize the course of the resident's stay at the facility When the facility anticipates discharge, a resident must have a discharge summery that includes: Equipment: A recapitulation of the resident's stay A final summary of the resident's status to include items in the following list, at the time of the discharge that is available for release to the consent of the resident or legal representative Medically defined condition and prior medical history Medical status measurement Functional status Sensory and physical impairments Nutritional status and requirements Special treatments Psychosocial status Discharge potential Dental condition Activities potential Rehabilitation potential Cognitive status Drug therapy A post-discharge plan of care that developed with the participation of the resident and his/her family, which will assist the resident to adjust to his/her new living environment GUIDELINE: A post discharge plan of care is not required for residents discharged to the hospital. It applies to a resident discharged to a private residence, to another nursing facility or skilled facility, or residential facility such as a board and care home or intermediate care facility for MR individuals. The post discharge plan describes the resident's and family's preferences for care, how they will access and pay for these services, and how care should be coordinated if continuing treatment involves multiple caregivers. It identifies specific resident needs after discharge such as personal care, sterile dressings, and physical therapy, and describes resident/caregiver education needs to prepare the resident for discharge.

Based on record review, staff interviews, and policy review, the facility failed to inform residents of an option to appeal a discharge from Medicare Part A Skilled Services for 1 of 4 residents (#1). The facility reported a census of 49 residents.Findings include:The Minimum Data Set (MDS) for Resident #1 dated 6/27/25 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of anemia, hypertension, renal failure, malnutrition, and metabolic encephalopathy (improper brain functions due to a metabolism disorder). It revealed the resident was admitted on [DATE] and received Occupational Therapy (OT) and Physical Therapy (PT) services.The Physical Therapy Treatment Encounter Note(s) dated 6/30/25 indicated the resident received skilled rehabilitation services from 6/20/25 to 6/30/25. It also indicated she was ready to discharge to her daughter's home the next day.The Progress Notes dated 7/01/25 at 10:45 AM indicated the resident discharged home with her daughter who received and understood the discharge instructions.The Notice of Medicare Non-Coverage (NOMNC) document dated 6/26/25 indicated Staff B, Human Resources and Financial Services (HR and Fin) contacted the resident's Power of Attorney (POA) at 10:07 AM. The document lacked a resident or POA signature which indicated receipt and understanding of the resident's right to appeal the discharge.On 10/13/25 at 3:08 PM, Staff B stated when she contacts the resident's representative or POA, she discusses the resident's end-of-skilled care date, the resident's discharge date if they're going home, and the last date the discharge can be appealed. On 10/14/25 at 1:36 PM, Staff B stated she was not aware Resident #1's NOMNC was not signed. On 10/14/25 at 1:48 PM, the Director of Nursing (DON) stated the facility did not know a signature was required if a call to the POA or representative was documented.A document titled SNF Notices of Non-Coverage - ABN/NOMNC revised 11/15/23 indicated the ABN (Advance Beneficiary Notice) must be reviewed with the beneficiary, or his/her representative and any questions raised during that review must be answered before it is signed. It also indicated ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative.

Based on clinical record review, staff interview, and instructions on CMS form 10123-NOMNC, the facility failed to provide appropriate notices of Medicare Non Coverage to 3 of 3 residents (Residents #13, #99 & #100) reviewed. The facility reported a census of 47 residents. Findings include: The census tab of the Electronic Health Record (EHR) for Resident #13 revealed the resident admitted under Medicare A payer source on 10/20/23 and Medicare continued to pay for his stay through 11/3/23. The Notice of Medicare Non Coverage (NOMNC) documented the resident was given this information on 11/3/23, failing to provide the required 2 day notice. The census tab of the EHR for Resident #99 revealed the resident admitted under Medicare A payer source on 7/18/23 and Medicare paid for her stay through 8/2/23. The facility failed to provide documentation the resident was ever provided a NOMNC. The census tab of the EHR for Resident #100 revealed the resident admitted under Medicare A payer source on 7/13/23 and Medicare paid for his stay through 7/20/23. The facility failed to provide documentation the resident was ever provided a NOMNC. The document titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 directs: A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility facility, and hospice services.The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. On 11/7/23 at 11:51 am, the Administrator stated the Social Worker is to be issuing the notices and has a checklist to follow. She stated the process had not been completed the correct way.

Based on clinical record review and staff interview, the facility failed to offer and provide the pneumococcal immunization for 1 of 5 residents (Resident #35) reviewed. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #35, dated 9/20/23 revealed an admitted to the facility on [DATE]. The MDS identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated cognition intact. The MDS documented Resident #35 had diagnoses to include post polio syndrome. The immunization tab of the Electronic Health Record (EHR) for Resident #35 documented the resident refused the pneumonia vaccination. The resident's chart lacked declination/refusal of the vaccine signed by the resident or a resident representative. The progress notes of the resident failed to reveal any documentation of the resident being offered or refusing vaccines at the time of admission to the facility. On 11/7/23 at 2:46 pm the Infection Control nurse stated the resident refused all vaccines at the time of his admission due to his diagnosis of post polio syndrome. She stated he was very against vaccines at the time. She said he is now more open to vaccines and received a flu shot and COVID vaccines in 2022 and had agreed to both flu and COVID vaccines this year as well. She stated he had not been offered the pneumonia vaccine since admission. She also stated she was not able to locate a signed refusal of vaccines in his chart. The Health Status Note dated 11/8/23 documented the resident had decided to get the pneumonia vaccine and the physician was notified. The facility policy/procedure titled Immunizations, revision date 3/1/21 directed the following required documentation: MD (Medical Doctor) order for the immunization Consent for the immunization including a record of presenting the resident educational materials, regarding risk and benefits of the immunization On the MAR (Medication Administration Record), document that the resident received or refused the immunization.

Based on food service observations, facility policy review and staff interview, the facility failed to serve food in a manner to prevent foodborne illness for one of two meals observed. The facility reported a census of 46 current residents. Findings include: Observation on 11/2/22 at 7:09 a.m. revealed Staff A, Kitchen Assistant, scratched his face, coughed into his fist and placed his index finger into his ear. Staff A failed to perform hand hygiene and then served residents breakfast drinks by grasping the top rims of cups. Staff A also touched residents, the handles of wheelchairs, and the handle of walkers without performing hand hygiene before he proceeded to pass breakfast plates from the kitchen window to residents. Staff A did not perform hand hygiene for the duration of the breakfast service observation. The facility's Hand Hygiene policy, reviewed 8/30/21, instructed that hand hygiene should be completed before touching a patient, clean or aseptic procedure, after touching a patient, after body fluid exposure and after touching patient surroundings. During interview on 11/3/22 at 10:05 AM, the Administrator stated she expected staff to perform hand hygiene throughout the meal service and after touching contaminated services. The Administrator also acknowledged that staff should avoid touching the drinking rims of cups.

Based on clinical record review, staff interview and facility policy review, the facility failed to refer one resident (#199) with a negative Level I result for the PASARR, who was later identified with newly evident or possible serious mental disorder, or other related condition, to the appropriate state-designated authority for Level II PASARR evaluation and determination for 1 out of 2 residents reviewed for PASARR requirements. The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #199 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired memory and cognition. Resident #199 admitted to the facility on [DATE]. The resident's diagnoses included Non-Alzheimer's dementia and anxiety. The MDS documented that Resident #199 felt down, depressed, hopeless, tired and with little energy during the assessment period. The resident did not experience delusions or hallucinations at the time. The MDS documented that Resident #199 displayed verbal behavioral symptoms during 7-day assessment. Another MDS assessment documented Resident #199 returned to the facility on [DATE] from an acute hospital visit. Resident #199's PASARR dated 1/20/22 recorded that no further Level I screening was required unless known to have or are suspected of having a serious mental illness or an intellectual or developmental disability and exhibit a significant change in treatment that is needed. The PASARR showed Resident #199 did not have a previous history of mental illness or related condition. The resident's clinical record contained no further PASARR evaluations. The Care Plan last revised 8/25/22 documented Resident #199 received outpatient mental health services with a psychiatric-mental health nurse practitioner. The Medication Review Report signed by the resident's provider on 10/21/22 showed diagnoses of hallucinations, generalized anxiety disorder and dementia with agitation. The Medical Diagnosis Report dated 11/3/22 for Resident #199 showed diagnoses of hallucinations on 1/27/22, generalized anxiety disorder on 4/8/22 and paranoid personality disorder on 11/2/22. The Medical Diagnosis Report also showed a new diagnosis of dementia with agitation on 10/17/22. The Clinical Physician Orders dated 11/3/22 for Resident #199 showed she received Seroquel (an antipsychotic medication) 25 mg (milligrams) daily beginning 11/2/22 for paranoid ideation. The facility's PASARR policy revised on 9/14/18 instructed that defined protocols will be utilized to determine if a change of condition PASARR is required for current residents. In an interview on 11/3/22 at 11:35 PM, the Administrator reported she did not believe Resident #199's new diagnoses of hallucinations, generalized anxiety disorder, paranoid personality disorder and new medication for paranoid ideation met the criteria to resubmit the PASARR for evaluation, subsequently the PASARR has not been resubmitted for evaluation of behavioral health needs for Resident #199.

Based on clinical record review, staff interview, and guidance from the Centers for Medicare and Medicaid (CMS), the facility failed to properly fill out the required Skilled Nursing Facility Advance Beneficiary Notice (ABN) of Non Coverage, CMS form #100555 for 3 of 3 sampled residents (Residents #26, #31 and #46). The facility reported a census of 46 residents. Findings include: 1.The document titled SNF ABN, CMS form #10055 with a date of 6/18/22 for Resident #26 revealed the form lacked the estimated cost of therapy nor provided an explanation that the estimated cost of therapy could not be obtained. 2. The document titled SNF ABN, CMS form #10055 with a date of 9/7/22 for Resident #31 revealed the form lacked the estimated cost of therapy nor provided an explanation that the estimated cost of therapy could not be obtained. 3. The document titled SNF ABN, CMS form #10055 with a date of 10/5/22 for Resident #46 revealed the form lacked the estimated cost of therapy nor provided an explanation that the estimated cost of therapy could not be obtained. The facility lacked a policy for Medicare and Medicaid Beneficiary Notices. The Centers for Medicare and Medicaid Beneficiary Notices website (https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN), last modified on 12/01/2021 at 8:00 PM, provided the link to the undated document titled Form Instructions Advance Beneficiary Notice of Non-coverage that provided instruction for ABN estimated cost of services. The form instructed that notifiers must complete the column under Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially non-covered services. Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under Blank (D). In general, we would expect that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. Multiple items or services that are routinely grouped can be bundled into a single cost estimate. For example, a single cost estimate can be given for a group of laboratory tests, such as a basic metabolic panel (BMP). An average daily cost estimate is also permissible for long term or complex projections. As noted above, providers may also pre-print a menu of items or services in the column under Blank (D) and include a cost estimate alongside each item or service. If a situation involves the possibility of additional tests or procedures (such as in laboratory reflex testing), and the costs associated with such tests cannot be reasonably estimated by the notifier at the time of ABN delivery, the notifier may enter the initial cost estimate and indicate the possibility of further testing. Finally, if for some reason the notifier is unable to provide a good faith estimate of projected costs at the time of ABN delivery, the notifier may indicate in the cost estimate area that no cost estimate is available. We would not expect either of these last two scenarios to be routine or frequent practices, but the beneficiary would have the option of signing the ABN and accepting liability in these situations. In an interview on 11/3/22 at 10:41 AM, the Administrator acknowledged the estimated cost of services would be vital for residents to make an informed decision to pay out of pocket for continued services. The Administrator stated, she had provided staff with ABN instructions, a binder and education. There is no reason for these forms not to be done right.

Based on clinical record review, staff interview and facility policy review, the facility failed to develop a care plan to address diuretic medication usage and anticoagulant medication and side effects to monitor for 1 out of 16 residents reviewed (Resident #31). The facility reported a census of 46 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #31 documented an admitted [DATE]. The resident's diagnoses included cancer, anemia, atrial fibrillation (an irregular heart rhythm), heart failure, high blood pressure and kidney disease. The MDS documented she received daily anticoagulant and diuretic medications. The Clinical Physician Orders dated 11/3/22 showed: a. Eliquis tablet 5 milligrams (mg) daily with a start date of 8/16/22 (Eliquis is an anticoagulant medication). b. Lasix tablet 20 mg daily with a start date of 8/16/22 (Lasix is a diuretic medication). The resident's care plan revised on 11/1/22 lacked any documentation pertaining to Resident #31's use, possible adverse reactions or effectiveness to monitor for during the resident's diuretic and anticoagulant use. The Medication Administration Reports for 10/22 and 11/22 documented that Resident #31 received Eliquis and Lasix daily as ordered. The facility's Care Plan policy, revised 9/27/17, directed staff to identify the needs and problems of residents based on nursing history and assessment, physician's orders, interfacility transfer forms (when available), past history and physical examination, and any other available information. Write approaches or actions in terms of staff behavior, i.e. what the staff will do to accomplish an objective. When asked if she expected anticoagulant medication, diuretic medication usage and adverse reactions be included in the care plan on 11/03/22 at 11:31 AM, the Director of Nursing stated the information is not there (on the care plan) but she knew staff monitored for those things.

Based on clinical record review, observations, resident and staff interviews and review of manufacturer's instructions, facility staff failed to provide safe transfer techniques for two of six residents reviewed. Staff failed to safely attached a Hoyer mechanical lift sling during observation of Resident #23's transfer and failed to use a gait belt when transferring Resident #27. The facility reported a census of 46 residents. Findings include: 1. According to the annual Minimum Data Set (MDS) assessment dated [DATE], Resident #23 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact memory and cognition. The resident required the assistance of two staff for transfers, did not walk during the 7-day assessment period and primarily used a wheelchair for locomotion. The MDS documented no falls since the previous assessment. The care plan updated on 10/19/22 showed that Resident #23 was a high risk for falls and required the use of the Hoyer mechanical lift for transfers. Staff were instructed to visually make sure the resident's recliner was in low position. The resident had limited physical mobility related to weakness, lack of motivation and a right shoulder fracture. During observation and interview on 11/2/22 at 9:50 AM, Resident #23 sat in her wheel chair with a supportive sling on her right arm. The resident said that she fell from her recliner when it was in high position and she was trying to reach for something on her bedside table. Resident #23 stated that since her fall, staff used a Hoyer lift for transfers rather than the EZ Stand. In an observation on 11/1/22 at 8:07 AM, Staff C, Licensed Practicing Nurse (LPN) assisted Staff D, Certified Nursing Assistant (CNA) to transfer Resident #23 from the bed to the wheel chair. Staff C mentioned that she hadn't used a Hoyer lift for a while and Staff D guided her through the process of attaching the sling to the machine. They attached the longest loop at the foot of the lift to the hooks with the left loop to the left side and the right loop to the right hook. Staff failed to cross the sling legs to help provide added support to the resident. Observation revealed staff used an EZ Way Classic total lift for the transfer. The EZ Way Classic (or Hoyer) Lift Operators Instructions, revised on 5/15/19 contained a section titled: Transferring Patient from bed to chair, wheelchair or toilet. Step 1 directed staff to make sure the sling centered beneath the patient. Attaching the sling directed the sling should be centered under the patient in bed. Figure 4 illustrated the sling centered under the patient before use. Sections 2 and 3 under Attaching the sling to the lift directed staff to cross over the right and left sling legs and attach these to the opposite sides of the lift. During an interview on 11/3/22 at 8:20 AM the Administrator stated they educate safe on mechanical lift transfers upon hire with orientation. They do not have annual competencies on use of the lifts but they had planned for someone to come in and go over education of use of lifts and safe transfers. 40905 2. The MDS assessment for Resident #27 dated 10/12/22 documented diagnoses that included Non-Alzheimer's dementia and depression. The MDS recorded the resident required the extensive assistance of one staff for transfers. The MDS documented the resident had a BIMS score of 1, indicating severe cognitive impairment. The assessment also documented he Resident #27 experienced unsteady balance and required assistance to stabilize while walking, turning around and during surface-to-surface transfers. Resident #27's care plan, initiated on 4/21/22, documented the resident needed the assistance of one for transfers. During an observation and interview on 11/1/22 at 1:50 PM, Staff E, CNA transferred Resident #29 from a wheelchair to the couch without use of a gait belt. Immediately following the transfer, Staff E acknowledged that Resident #27 needed the assist of one for transfers and that she should have used a gait belt. During an interview on 11/3/22 at 9:12 AM, the Director of Nursing stated the expectation that staff use a gait belt with resident transfers.

Based on interviews and record reviews, the facility failed to treat constipation in accordance with facility policy, physician's orders, and professional standards for 1 of 7 residents reviewed (Resident #5). The facility reported a census of 44 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 6/14/21, Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident demonstrated a short-term memory problem and moderately impaired decision-making skills. The MDS also documented Resident #5 required extensive assist with transfers and toilet use and was always incontinent of BM. The Care Plan dated 4/30/21 revealed Resident #1 demonstrated an activities of daily (ADL) self-care performance deficit related to behavior and dementia. The Care Plan directed staff to provide perineal (peri) care (cleansing the resident's private areas) with incontinence episodes and a pullup or a brief. The Progress Notes contained the following entries: a. On 6/13/21 at 1:55 PM, staff documented the resident again refused a suppository and stated he didn't feel like he needed one because he took himself to the bathroom that morning, although this was not witnessed by staff. The nurse educated the resident regarding the importance of making sure he had a BM, and the resident became upset and asked the nurse, Are you contradicting me? The nurse documented they allowed the resident to calm and they would monitor the resident's bowel status. b. On 6/14/21 at 5:32 AM, staff documented an Orders - Administration Note that showed they administered the resident a [MEDICATION(S)] Suppository 10 milligrams (MG) rectally as needed (PRN) for constipation. c. On 6/14/21 at 8:41 AM, staff documented an Orders - Administration Note that verified the [MEDICATION(S)] Suppository 10 MG suppository given rectally as needed (PRN) for constipation was effective. Additional review of the progress notes revealed a lack of documentation to indicate staff offered the resident Milk of Magnesia (MOM) and/or the resident refused MOM. The BM Record showed the resident demonstrated incontinence of bowel and had a BM on the following dates: a. On 6/8/21, the resident had a large, putty-like BM. b. On 6/10/21, the resident had a small loose/diarrhea BM c. On 6/14/21, no BM documented Review of the Medication Administration Record (MAR) dated 06/21 revealed the physician ordered Resident #5 the following medications and gave staff the following directives related to constipation management: a. Give a [MEDICATION(S)] Packet 17 grams (GM) by mouth in the morning for constipation in 8 ounces (oz) of fluid starting on 4/24/21 at 8:00 AM. Staff had documented they gave the medication daily until 06/13/21. b. Give Senna-Plus Tablet 8.6-50 MG by mouth two times daily for constipation beginning on 04/16/21 at 5:00 PM. Staff had documented they gave the medication two times daily until 06/13/21. c. Give [MEDICATION(S)] Suppository 10 MG rectally every 24 hours as needed for constipation if nothing by mouth (NPO) or MOM/[MEDICATION(S)] ineffective beginning 12/23/20 at 8:40 AM. Staff documented the resident refused the suppository on 06/13/21 and documented they administered the resident a suppository on 6/14/21. . d. Give Milk of Magnesia Suspension (MOM) 400 MG per (/) 5 milliliters (ml) by mouth every 24 hours as needed for constipation beginning 12/23/20 at 6:45 AM. The record did not contain documentation to staff offered the medication and/or the resident refused it. e. Give [MEDICATION(S)] Powder 17 GM (one scoop) by mouth every 24 hours as needed for constipation in 8 oz of fluid beginning 12/23/20 at 8:45 AM. The record contained no documentation related to its use or its refusal. On 11/15/21 at 10:14 AM, the Administrator said she knew the progress notes contained documentation that showed Resident #5 had a BM and that also showed the nurse offered him the suppository once before it was given. The Administrator commented she was sure the nurse did offer MOM because she is very obsessive about making sure residents have BMs, but verified the record contained no documentation of it. The undated Bowel Management Program directed the charge nurse to monitor the BM record at the beginning of each shift and implement the following unless otherwise outlined on the BM record: A. If no BM or only a small BM in 2 days, give MOM 30 ML (Physician's order needed). B. If no BM by the end of the next shift, give [MEDICATION(S)] or [MEDICATION(S)] suppository (Physician's order needed). C. If no results on that shift, do a rectal check, and if a BM is felt, administer a fleets enema (Physician's order needed). Document laxatives, suppositories, and enemas given on the MAR and on the BM record for the shift it was administered.

Based on observations, interviews, and record reviews, the facility failed to wear personal protective equipment (PPE) in accordance with CDC guidelines while screening people for COVID-19 as they entered the facility and delivering residents' meal trays. The facility reported a census of 44 residents. Findings include: Observation on 11/9/21 at 11:19 AM, revealed the Receptionist at the front desk screened the state surveyor for COVID-19 upon entrance to the facility without wearing a face mask. Closer observation revealed no face mask visible on the desk or near the employee. Observation on 11/9/21 at 11:48 AM, revealed Staff G, Dietary Aide, pulled down his mask and exposed his nose and mouth and spoke to Staff G, Dietary Aide. At 12:01 PM, Staff G delivered a plate to a resident with his mask down and nose and mouth exposed. At 12:03 PM, Staff G continued to deliver meals with his mask down and nose and mouth exposed. Observation on 11/10/21 at 8:15 AM, identified the Receptionist at the front desk screened the state surveyor for COVID-19 upon entrance to the facility and lacked a face mask with no face mask noted on the desk or near the employee. Observation on 11/15/21 at 9:10 AM, showed the Receptionist rose from behind the front desk, produced a thermometer, and took the surveyor's temperature without wearing a mask. She then she left the office, but prior to doing so she applied a face mask and went to the conference room. Additional observation revealed no residents present in the area. The POC Test Result Reporting form dated 11/15/21 showed the facility tested the Receptionist twice weekly since 9/14/21 on Mondays and Thursdays with the most recent test dated 11/15/21. The form documented each COVID-19 test result as negative. On 11/15/21 at 10:14 AM the Administrator explained she expected staff to wear a face mask while screening in staff, visitors, and residents. The Administrator commented she wondered if the Receptionist had an off day because she is usually very conscientious about wearing a mask. The Administrator added that she always saw her put on a mask to screen visitors. In a subsequent interview on 11/15/21 at 12:30 PM, the Administrator reported Staff G only recently began employment at the facility. She explained Staff G sometimes described the masks as too large and complained they didn't stay over his face. The Personal Protective Equipment (PPE) policy dated 9/10/21 directed see the Centers for Disease Control (CDC) for current Coronavirus Disease 2019 (COVID-19) Interim Infection Protection and Control Recommendations for Healthcare Personnel during the COVID-19 pandemic. According to the CDC website, the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 9/10/21 contained an Implement Source Control Measures section that documented source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have not been fully vaccinated. According to the website: https://covid.cdc.gov/covid-data-tracker/#county-view&list_select_map_data_parent=Risk&map-metrics-cv-comm-transmission=community_transmission_level&list_select_map_data_metro=all the county that contains the facilty ([NAME] County) had substantial to high community transmission rates at the time of the survey.

Based on observations, document review, policy review, and staff interview, dietary staff failed to maintain clean and sanitary conditions in the kitchen, and failed to serve food under sanitary conditions in an attempt to prevent food borne illness during two of two meals observed, The facility identified a census 57 residents. Findings include: 1. Dining room observations revealed the following: a. On 09/09/19 12:15 PM Staff A Dietary Aide delivered a glass of milk by holding the rim of the glass b. On 09/09/19 12:16 PM Dietary Manager delivered a glass of tea by holding the rim of the glass c. On 09/09/19 12:24 PM Dietary Manager delivered a glass of milk holding the rim of the glass d. On 09/09/19 12:26 PM Staff A handled a coffee cup by rim of glass while making hot cocoa e. On 09/09/19 12:27 PM Dietary Manager delivered a glass of juice by holding the rim of the glass f. On 09/09/19 12:28 PM Social Service Director handled a drinking glass by the rim of the glass g. On 09/09/19 12:29 PM Staff C Dietary Aide delivered a glass by holding the rim of the glass h. On 09/10/19 08:20 AM Staff C D delivered drinks and held the rims of the glasses i. On 09/10/19 11:56 AM Staff B Dietary Aide held a coffee cup by the rim and filled it with hot water. j. On 09/10/19 12:02 PM Staff B delivered a glass by holding the rim of the glass k. On 09/10/19 12:08 PM Staff G CNA touched her hair 3 times then handled plates to be delivered l. On 09/10/19 12:10 PM Social Service Director touched her hair then handled plates to be delivered m. On 09/10/19 12:31 PM Social Service Director delivered a glass by holding the rim of the glass o. On 09/10/19 12:36 PM Staff A delivered a glass by holding the rim of the glass p. On 09/10/19 12:36 PM Staff C delivered a glass by touching the rim of the glass 2. During the initial kitchen tour on 9/9/19 at 9:30 AM, observations revealed the following: a. The red and green cutting boards were marred and no longer able to be sanitized effectively. b. The stove hood had a moderate amount of gray, dusty debris c. The Maxx-ice ice machine contained a brown residue on the plate above the ice bin d. The Manitowoc ice machine contained a reddish, wet, slimy substance on the upper edge by the door 3. Observation of the lunch meal service on 9/9/19 revealed the following: a. At 12:02 PM Staff I, Dietary Cook donned a pair of gloves and began preparation for the meal service. Staff I scratched her right arm with her gloved hand, removed a lid from the pan of lettuce, touched the ice in the pan under the pan of lettuce, then brushed her gloved hands on her scrub shirt. During meal service, Staff I touched multiple areas including her glasses, scratched the side of her face, touched menu slips, and picked up plates and plated food. b. At 12:15 PM, the social worker pushed her hair back with her bare hands, grabbed a bowl of cake and placed the cake on a tray to serve a resident. 4. On 9/10/19 at 11:37 AM, Staff J, dietary cook wore gloves as she plated food for residents. Staff J used her gloved hand and opened the walk-in cooler, obtained a bowl of cottage cheese, and placed the cottage cheese onto a tray. During meal service, Staff J picked up plates with her thumb touching the top edge of plate and plated food. Staff J used her gloved hand and placed bread onto plates, touched her glasses, touched menu slips, pan lids, and handled utensils, and plated food. During an interview, 9/10/19 at 1:40 PM, the facility's dietician reported she expected staff not wear gloves unless they handled ready to eat foods. The dietician reported when staff wore gloves, they had a tendency to touch other things. During an interview 9/11/19 at 1:00 PM, the Dietary Manager (DM) reported she expected staff only wear gloves when they handled raw food, and expected staff to wash their hands when they became soiled or when they touched other items. The DM reported she expected staff to hold a glass or bowl on the side rather than place their hand over the top of the glass or bowl. The DM reported the facility had developed a cleaning schedule, and staff marked off the task when completed. The DM also confirmed the stove hood and ice machines were dirty and needed to be cleaned. The DM confirmed the cutting boards (red / green) surfaces were marred, were difficult to sanitize in that condition and needed to be replaced. The DM reported she was not sure how often they replaced the cutting boards, but would replace them in the future when they were marred and unable to be sanitized. In a subsequent interview on 9/12/19 at 8:22 AM, the DM reported the facility had no policy regarding glove use in the kitchen. The weekly cleaning schedule dated 8/2019 revealed the stove hood and top had not been cleaned (no staff initials) and the ice machine were not listed at all.

Based on clinical and hospital record reviews, staff, family and physician interviews, investigation revealed the facility nursing staff failed to administer medications as prescribed by the physician to avoid significant medications errors when the admitting nurse failed to transcribe physician orders [REDACTED]. The facility reported a census of 58 residents. Concerns noted for 1 of 10 residents sampled for review (Residents #3). Findings include: A Minimum Data Set (MDS) assessment tool dated [DATE] indicated Resident #3 admitted to the facility on [DATE]. The MDS indicated Resident #3 had short-term memory impairment and impaired cognitive skills in new situations only. The MDS also revealed Resident #3 was independent with bed mobility, transfers and walking in his/her bedroom. Resident #3 required supervision for dressing, eating and toilet use. Resident # required limited assistance with walking in the hallways, personal hygiene and bathing. Active [DIAGNOSES REDACTED]. The MDS indicated no antipsychotic medication use in the seven day assessment period. The Nurse Aid Care Plan dated [DATE] indicated Resident #3 required assistance with dressing, walking and transfers. The Plan of Care also included short-term memory impairment. A Physician Office/Clinic Notes, dated [DATE] completed by Physician #1 indicated Resident #3 came to the physician for evaluation of assistance at home. The present history included uncontrolled blood sugars and an inability to administer insulin ([MEDICATION NAME] and Humalog) for the prior five days due to action tremor. A Neurologist recommended adding [MEDICATION NAME] and decreasing [MEDICATION NAME] (an antipsychotic medication) on [DATE] due to action tremor. The neurologist recommended decreasing the [MEDICATION NAME] to 300 mg (milligrams) to BID (twice a day). Resident #3 had not decreased the dose as instructed. The resident lived alone and managed his/her own medications. The tremors affected his/her whole body at times. Resident #3 could no longer drive due to the tremors. The resident's family expressed concern regarding Resident #3's failure to take the prescriptions correctly. The physical examination included: systolic blood pressure 114 mmHg (millimeter of mercury), diastolic blood pressure 62 mmHg, blood glucose level Hi at 332 mg/dL(milligrams/deciliter), blood Calcium level Hi at 10.20 mg/dL and [MEDICATION NAME] Level Hi at 2.0 mmol/L (millimole.Liter). The physician's [DIAGNOSES REDACTED]. Course: Worsening. Plan: Action Tremor: decrease [MEDICATION NAME] to 300 mg BID, continue to monitor [MEDICATION NAME] levels, add [MEDICATION NAME] 25 mg every bedtime (hs), check [MEDICATION NAME]/[MEDICATION NAME] levels in one week. [MEDICAL CONDITION]: continue to decrease [MEDICATION NAME], recheck level in one week. The physician noted his/her concern about Resident#3 ' s ability to remember medication dosing. Pharmacy: [MEDICATION NAME] 50 mg oral tablet once a day, [MEDICATION NAME] 2.5 mg oral tablet daily, and [MEDICATION NAME] 300 mg oral, one capsule in the morning and one capsule in the evening. admission orders [REDACTED]. The admission orders [REDACTED]. The added medications included as needed Milk of Magnesia, Tylenol and Biscodly suppository. Review of the Medication Administration Record (MAR) for [DATE] revealed Resident #3 received [MEDICATION NAME] 300 mg one capsule in the morning and two capsules (600 mg) in the evening starting on [DATE] for a total of four days. The MAR listed the [MEDICATION NAME] medication was discontinued on [DATE] with a new order documented on the MAR to administer [MEDICATION NAME] 300 mg twice daily. One capsule in the morning and one capsule in the evening. According to the documentation on the MAR the facility administered one evening dose of 300 mg on [DATE] prior to the admission of Resident #3 to the hospital on [DATE]. When interviewed on [DATE] at 11:10 a.m. Staff A stated she worked as the facility's Compliance Officer. Staff A stated she admitted Resident #3 to the facility. Staff A stated she wrote the admission orders [REDACTED]. She stated the facility received the 7-page clinic note on [DATE]. Staff A stated she did not read the entire document. Staff A stated she wrote up the admission orders [REDACTED]. Staff A denied seeing the [MEDICATION NAME] Overdose [DIAGNOSES REDACTED]. Staff A stated Resident #3's family member left the facility before the nurse clarified the resident's medications. Staff A stated with all new admissions she rewrites the physician orders [REDACTED].#3 went to the clinic and would not reflect any new orders or changes made at that office visit. Staff A denied knowledge of what blood laboratory work was needed at the time of admission. Staff A stated she made a mistake and she did not catch the error. Staff A denied knowledge of how the error occurred. When interviewed on [DATE] at 11:50 a.m. the Director of Nursing stated she did not believe Staff A was in error. Nurse's Notes included: [DATE] at 11:30 a.m. [AGE] year-old Resident #3 admitted due to falls and tremors at home. Resident #3 not taking medications correctly at home. Was receiving home health services at home and was felt no longer able to stay safely at home. [DATE] at 9:00 p.m. Tremors noted. Assistance given with drinking water due to tremors. [DATE] at 9:00 p.m. Tremors continue. Assistance given with walking and cares, unsteady at times. [DATE] at 10:40 a.m. noted tremors at times makes thing difficult to handle, such as eating. [DATE] at 6:00 p.m. aid was assisting to walk to room when noticed was not walking well and sat Resident #3 down. Blood sugar was 29. [DATE] at 12:00 p.m., skin pale warm and dry, very dry. Assistance given with gait belt and walker with ambulation. Ambulation unsteady and shuffles, veers to side (both) in hallway. [DATE] at 4:20 a.m. staff found resident on the floor. Resident #3 confused times three (person, place and time). Heart rate: 64, assisted up with two staff at which time heart rate: 55. Needed much instruction and encouragement to follow commands. Helped to wheelchair. Heart rate: 47. Resident had frequent, random tremors noted/body especially extremities. Skin noted as pale and dry. [DATE] at 7:00 a.m. Notified Physician #2 by facsimile (fax) of fall. [DATE] at 12:20 p.m. called Resident #3 ' s family member to notify of fall. Family asked if Resident #3 was receiving the new medications prescribed by Physician #1. The nurse called the clinic to inquire about recent medication changes. Telephone order received from Physician #2. Blood sugar at noon was 56. Resident #3 continued to have tremors in both hands. Staff reported increase in weakness since arrival. [DATE] at 2:03 p.m. Resident #3 restless in room, attempting to get out of recliner. [DATE] at 8:00 p.m. Resident #3 required much encouragement and instructions with cares, medications, drinking and vital signs. Resident #3 required the assistance of two staff members with bedtime cares and transfer to bed. [DATE] at 8:30 a.m. at approximately 8:00 a.m. Resident #3 lying in bed, appeared flaccid, unable to follow commands, not opening eyes to verbal stimuli or touch. Hot to touch. Expiratory wheezes. Unable to verbalize any answers. Family notified and requested hospitalization . [DATE] at 11:45 a.m. Hospital staff reported Resident #3 admitted to hospital due to elevated [MEDICATION NAME] level and urinary tract infection [MEDICAL CONDITION]. [DATE] at 12:25 a.m. staff nurse received a phone call from one of Resident #3's family members who reported the facility nurses overdosed Resident #3 which resulted in kidney failure. The nurse informed the family member the facility did not overdose Resident #3 and instructed the family member to call the hospital. Review of Hospital Records included: ED (emergency department) Physician Notes dated [DATE] indicated Resident #3 presented to the emergency room with altered mental status. The physician assessment included neurological: lethargic and stuporous. Heart rate: 55, rhythm was sinus [MEDICAL CONDITION]. Laboratory testing on [DATE] at 9:30 a.m. included [MEDICATION NAME] level: 3.5 Critical. [DIAGNOSES REDACTED]. A History and Physical dated [DATE] indicated an initial work up in the ED noted [MEDICATION NAME] level of 3.5, level was 2 on [DATE] and the plan was to decrease the [MEDICATION NAME] dose however Resident #3 continued to receive the previous dose at the nursing home. AKI (acute kidney injury) with [MEDICATION NAME] level 1.7, baseline of 1 and elevated liver function. The UA (urine test) also looked dirty, [MEDICATION NAME] (antibiotic) initiated, heart rate in the 50's. [DIAGNOSES REDACTED]. The patient admitted to telemetry floor with confusion, AKI, myoclonic jerking can be explained by [MEDICATION NAME] toxicity. The physician requested nephrology consult for possible [MEDICAL TREATMENT] to dialyze [MEDICATION NAME]. Cardiology Consult Note dated [DATE] indicated [MEDICAL CONDITION] (slow heart rate) and sinus pauses likely related to [MEDICATION NAME] toxicity. Plan: Agree with [MEDICAL TREATMENT], Brady-arrhythmia should improve with decreasing [MEDICATION NAME] level. [DATE] Neurologist consult reported mental status alteration likely [MEDICAL CONDITION] due to urinary tract infection and [MEDICATION NAME] toxicity. A Pharmacy Antibiotic Kinetic Follow-up Progress Note dated [DATE] identified Resident #3 had [MEDICAL TREATMENT] on [DATE] to remove [MEDICATION NAME]. Acute Care Progress Note dated [DATE] noted the nursing home sent Resident #3 to the hospital due to altered mental status, fever and uncontrolled jerking. [MEDICATION NAME] level was 3.5 and was dialyzed. Still very confused with [MEDICAL CONDITION]. Breathing fast. NPO (nothing by mouth) due to swallowing was unsafe. Cardiology Critical Care Progress Note dated [DATE] noted sinus [MEDICAL CONDITION] and sinus pauses due to [MEDICATION NAME] toxicity, [MEDICATION NAME] toxicity, [MEDICAL CONDITION], altered mental status, UTI/sepsis, [MEDICAL CONDITION] with [MEDICATION NAME] Toxicity-levels decreasing 1.3, [DIAGNOSES REDACTED]s. Hospital Sign-Off Letter dated [DATE] indicated hospital course included Resident #3 admitted due to altered mental status. Cardiology consulted for [MEDICAL CONDITION]. Heart rate was ,[DATE] with pauses. It was felt [MEDICAL CONDITION] with pauses was secondary to [MEDICATION NAME] toxicity. Resident #3 was started on [MEDICAL TREATMENT] which helped improve heart rate. Nephrology Progress Notes dated [DATE] noted less twitch and [MEDICATION NAME] levels were better and kidney function was better, however mental status was worse. With fevers Resident #3 was worsening chest X-ray which could be aspiration, high liver function test and ammonia. Resident #3 failed the swallow study. Infectious Disease Progress Notes dated [DATE] noted [MEDICATION NAME] toxicity and [MEDICAL CONDITION]-TME due to [MEDICATION NAME] toxicity, liver disease. Resident #3 remained encephalopathic and largely nonresponsive. More hypoxic. The Chest x-ray dated [DATE] identified a left lower lobe infiltrate. Nephrology Progress Note dated [DATE] noted [MEDICAL CONDITION]: multifactorial. Contributing factors include hepatic [MEDICAL CONDITION] and [MEDICAL CONDITION]. [MEDICAL CONDITION]: may have nephrogenic DI (Diabetes Insipidis) due to [MEDICATION NAME]. Cardiology Progress Note dated [DATE] noted high level of care, Resident #3 unresponsive, metabolic [MEDICAL CONDITION], urine positive for K pneumonia ([DIAGNOSES REDACTED] pneumoniae), [MEDICAL CONDITIONS], dysphagia/impaired swallowing, systolic [MEDICAL CONDITION], sinus pauses, [MEDICAL CONDITIONS] present on admission and elevated transaminases. Will transfer to ICU (intensive care unit) for worsening respiratory status. Ruan Neuro Progress Note dated [DATE] noted toxic/metabolic [MEDICAL CONDITION]-patient less responsive today. Radiology Results dated [DATE] noted Lumbar Puncture performed due to unresponsive, comatose patient with fever. Noted Lumbar Puncture notation revealed a [DIAGNOSES REDACTED]. Pulmonary/Critical Care Brief Admit Progress Note dated [DATE] noted called to bedside for declining mental status and acute respiratory acidosis. Progressive decline in mental status. No gag reflex. Rapid, shallow, agonal respirations. Not responsive to painful stimuli. Obtunded Resident #3 likely secondary to hypercapnic [MEDICAL CONDITION] in addition to prior metabolic derangements. [MEDICATION NAME] toxicity. [MEDICAL CONDITION]-TME due to [MEDICATION NAME] toxicity, liver disease. Will intubate and start mechanical ventilation. Will provide lung protective ventilation. Intubation Progress Notes dated [DATE] indicated following intubation there were bilateral breath sounds and a positive color change in colorimetric capnography. Critical Care Progress Notes dated [DATE] noted Resident #3 was critically ill in [MEDICAL CONDITION]. No obvious explanation for the severe profound [MEDICAL CONDITION]. Feeding tube replaced. Infectious Disease Progress Note dated [DATE] noted Resident #3 had to be intubated due to worsening hypercarbia and [MEDICAL CONDITION] which improved since intubation. Renal function continued to deteriorate. EEG (electroencephalography) report revealed abnormal electroencephalogram. Moderate generalized slowing of the background activity seen with frontal dominant bilateral triphasic slow delta activity. The findings would be consistent with a moderate degree of cerebral dysfunction, likely due to underlying metabolic disorder. Critical Care Progress Notes dated [DATE] noted the patient was critically ill in [MEDICAL CONDITION]. Nephrology Progress Notes dated [DATE] noted AKI likely due to [MEDICAL CONDITIONS] due to [MEDICATION NAME] induced partial nephrogenic DI plus lack of access to free water, [MEDICATION NAME] toxicity resolved with [MEDICAL TREATMENT] and stopping [MEDICATION NAME]. Pulmonary/Critical Care Progress Note dated [DATE] noted Resident #3 ' s mental status was improving with correction of hypercapnic [MEDICAL CONDITION], correction of [MEDICATION NAME] toxicity, and electrolytes. Critical Care Progress Note dated [DATE] noted no obvious explanation for the severe profound [MEDICAL CONDITION]. Resident #3 withdrawing to pain, starting to follow commands. Syndrome of Irreversible [MEDICATION NAME]-Effected Neurotoxicity (SILENT)? Will have [MEDICATION NAME] level checked. Infectious Disease Progress Note dated [DATE] noted [MEDICAL CONDITION], not clear as to cause, possibly toxic/metabolic vs (verses) infectious given fevers. Could this be SILENT? [MEDICATION NAME] toxicity-possibly acute on chronic. [MEDICAL CONDITION] abnormalities appear improved now perhaps [MEDICATION NAME] induced. Nephrology Progress Note dated [DATE] noted Diabetes Insipidis from [MEDICATION NAME]. Discharge-Face Sheet dated [DATE] listed discharge Diagnoses: [REDACTED]. When interviewed on [DATE] at 9:12 a.m. Physician #1 stated he/she examined Resident #3 on [DATE] at which time Resident #3 ' s tremors were so high that Resident #3 not able to administer his/her own insulin. Physician #1 reviewed Resident #3's history regarding [MEDICAL CONDITION] and [MEDICATION NAME] use. Physician #1 planned to slowly decrease the [MEDICATION NAME] dose and then discontinue the [MEDICATION NAME] all together. On [DATE] Resident #3's [MEDICATION NAME] level tested high at 2.0. The physician ordered a decrease of the [MEDICATION NAME] from 300 mg every morning and 600 mg every evening to 300 mg twice daily. The physician also ordered a [MEDICATION NAME] level be tested in one week. When Resident #3 was admitted to the nursing home, Physician #1 expected the facility to read his/her 7-page clinic note where he/she clearly documented Resident #3 ' s [MEDICATION NAME] toxicity and ordered a decrease in the [MEDICATION NAME]. The physician also ordered [MEDICATION NAME] daily and would have expected the nursing home staff to alert him/her if Resident #3's blood pressure registered ,[DATE] or less. Physician #1 stated a nurse cannot discontinue or change a physician's orders [REDACTED]. The physician ordered and expected Resident #3 to receive [MEDICATION NAME] and [MEDICATION NAME] as ordered. Physician stated Resident #3's [MEDICATION NAME] level would have normalized the way he/she had ordered a decrease in dosage. The physician believed Resident #3 would not have required hospitalization and his/her [MEDICATION NAME] level would not have elevated had the nurse followed his/her orders. The physician believed the hospitalization and a [MEDICATION NAME] level of 3.5 could have been prevented and was avoidable. When interviewed on [DATE] at 11:13 a.m. Physician #2 stated he/she received a telephone call from Physician #1 who asked him/her to take over care of Resident #3 while the resident lived in the nursing home. Physician #2 stated he/she was not familiar with Resident #3 ' s medical history including [MEDICATION NAME] toxicity. When the nursing home faxed him/her Resident #3's admission orders [REDACTED]. He/she assumed the orders were as Physician #1 documented in his/her 7-page clinic note. Physician #2 stated he/she believed there was a strong possibility Resident #3's [MEDICATION NAME] level would have reduced and Resident #3 would not have required hospitalization had the nurse transcribed the orders correctly. Physician #2 stated he/she had patients in the past, come back from Des Moines after having hip or knee surgery and he/she would have no way of knowing of any medication changes. He/she relied on the facility nurses to transcribe the orders as written and not delete or change any physician order. When interviewed on [DATE] at 2:00 p.m. the Medical Director of the facility, Physician #3 stated he/she assumed and expected the facility nurses to transcribe physician orders [REDACTED].#3 stated he/she would not have immediate access to orders written by another physician. Physician #3 stated the nurse, Staff A was in error when she failed to transcribe the decreased dose of [MEDICATION NAME] as 300 mg twice daily. Physician #3 stated the nurse was in error when she failed to write the new medications as ordered by Physician #1. According to Physician #3 Staff A was in error adding as needed medications to Resident #3 ' s medication orders and clinical record. When interviewed on [DATE] at 4:15 p.m. Physician #4 stated Resident #3 had difficulty managing his/her medications while living alone at home. Resident #3 admitted to the nursing home due to tremors. The physician believed Resident #3 suffered from chronic [MEDICATION NAME] overdose for a couple of weeks and then it became toxic which required [MEDICAL TREATMENT]. Resident #3 also had [MEDICAL CONDITION] and the [MEDICAL CONDITION] may have added to the toxicity. Resident #3 had multiple medical issues during his/her hospitalization . The [MEDICAL CONDITION] could have been caused by the [MEDICATION NAME] toxicity and [MEDICAL CONDITION] may have contributed as well. Physician #4 stated the staff nurse should have followed the orders by Physician #1 and decreased the [MEDICATION NAME] dose as ordered. When interviewed on [DATE] at 2:07 p.m. one of Resident #3's family members stated on[DATE] Physician #1 informed him/her and the resident of the elevated [MEDICATION NAME] level and he/she was decreasing the [MEDICATION NAME] dose and was ordering [MEDICATION NAME]. Resident #3 wanted to stay at home and the physician assisted in obtaining home health services. The home health nurse stated Resident #3 required 24-hour services. When he/she brought Resident #3 to the nursing home on [DATE], he/she assumed the facility nursing staff would follow the physician's orders [REDACTED]. He/she visited Resident #3 on [DATE] and on [DATE] at which time Resident #3 appeared fine. When the nurse called him/her on [DATE] to report Resident #3's fall and stated Resident #3 was confused, he/she immediately asked the nurse about the [MEDICATION NAME] and [MEDICATION NAME] due to Resident #3 had increased confusion and falls at home with an elevated [MEDICATION NAME] level. The nurse denied knowing about the [MEDICATION NAME] or decreased [MEDICATION NAME]. When Resident #3 went to the hospital on [DATE] Resident #3's blood [MEDICATION NAME] level tested 3.5. Resident #3 went from the emergency room , to seventh floor, to intensive care. The physician asked him/her about the Resident #3's DNR (do not resuscitate) status. He/she was shocked, how could Resident #3 go from being okay on Tuesday to being on death's door on Saturday. Resident #3 was placed on a respirator, required [MEDICAL TREATMENT], had liver and heart damage. According to family Resident #3 almost died on two occasions and it took two and a half to three weeks before family knew Resident #3 was going to live. The family cannot figure out why the facility staff did not give the medications as ordered. According to Resident #3 ' s nurse ' s notes dated [DATE] at 1:00 p.m. family members for Resident #3 removed personal belongings from the facility and stated Resident #3 ' s family will be moving him/her closer to family. Note: At the time of the complaint investigation, the complaint was coded at a " J " level immediate and serious jeopardy. By [DATE] the facility had implemented measures to adequately address the jeopardy situation and the grid measurement was lowered to a " D " level. The facility updated the admission order policy to inlcude that the Director of Nursing and Assistant Director of Nursing would review all information received from the discharging facility. The physician would be notified of any discrepancies or need for clarification. admission orders [REDACTED]. The clinic physicians must complete the form titled Medication orders upon admission to Community Care Center for all residents coming from home to ensure accurate medication orders. The facility provided staff training for the updated admission order policy. As of the [DATE] exit conference the facility had failed to monitor nursing staff to assure compliance with admission order policy.

Based on record review and staff interviews, the facility failed to assure staff used gait belts during resident transfers to lessen or prevent injury and the Director of Nursing failed to supervise the implementation for the use of gait belt use as care planned for 1 of 13 current residents reviewed (Resident #2). The facility identified a census of 73 residents. Findings include: 1. Resident #2 had a quarterly Minimum Data Set (MDS) assessment with a reference date of 6/13/12 which identified [DIAGNOSES REDACTED]. The assessment documented the resident as unsteady, but able to stabilize without staff assistance when moving from a seated to a standing position and not stabilize him/herself when walking and turning around. The assessment documented Resident #2 fell on ce without injury since admission or the previous assessment. The Care Plan dated 10/16/2008 identified a problem with the potential for falls and injury due to vertigo (dizziness) and a history of falls. The Care Plan identified a problem with activities of daily living regarding vertigo and need for assistance with ADL ' s at times. The approach directed staff to ambulate to meals with the assistance of 1 staff person and a gait belt and a front wheel walker. The Incident Accident Report dated 7/7/12 at 9:40 AM documented the resident lowered to the floor when staff transferred the resident from the toilet and the resident's legs went out from under him/her. The report documented the resident had a fracture of the left ankle. The Nurse ' s Notes entry dated 7/7/12 at 2:25 P.M. documented the physician notified of the Portable X-ray report dated 7/7/12 which indicated the resident had a transverse non-displaced fracture through the medial malleolus (ankle). The physician ordered a CAM boot to be placed on the left leg and further ordered the resident to not bear weight on the left leg until the boot placed. The Fall Scene Investigation Report completed by the Director of Nursing on 7/9/12 documented staff educated to use a gait belt with all transfers. On 9/27/12 as 12:13 P.M. the resident ' s physician was interviewed and stated if the facility ' s policy required the use of a gait belt then staff should have utilized one for this resident. The physician further stated the resident to be weak from a hospitalization and had just returned to the facility on [DATE] from the hospital. On 9/26/12 at 3:30 P.M. Staff F, Certified Nursing Assistant (CNA) stated she transferred the resident without the use of a gait belt. She further stated she had just returned back to work from leave that day and had not been aware of the resident ' s change in functional abilities which occurred during her time off. Staff F stated that prior to her leave period the resident required stand-by assist and she did not use a gait belt and did not know the resident ' s care plan interventions directed to use one. Staff F stated she had been re-educated by the Director of Nursing (DON) to use a gait belt with all resident transfers and assisted ambulation. On 8/29/12 at 3:12 P.M. the DON stated that although the facility does not have a written policy regarding the use of gait belts, each nursing staff member is issued a gait belt during orientation and are educated to use it when a resident requires hands-on assistance with transfer and ambulation On 9/26/12 at 3:00 P.M. Staff I, CNA was interviewed and stated it is required to use a gait belt with all residents when assistance is required for transfer and ambulation. On 9/26/12 at 3:17 P.M. Staff H, CNA was interviewed and stated it is required to use a gait belt whenever a resident requires assistance with transfers or ambulation. On 9/26/12 at 3:25 PM Staff L, Licensed Practical Nurse (LPN) stated all staff members are required to use a gait belt whenever hands-on assistance is provided to a resident for transfer or ambulation.

Relates to complaint -C: Based on record review and staff interviews, the facility failed to adequately assess and provide timely physician intervention after a resident fell and had a change in physical condition for 1 of 13 current residents reviewed (Resident #1). The facility identified a census of 73 residents. Findings include: 1. Resident #1 had an annual Minimum Data Set (MDS) assessment with a reference date of 5/2/12, which identified pertinent [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance for transfers and bed mobility, did not walk, and had functional limitations of one leg with range of motion. The Care Plan with an effective date of 2/7/12 documented Resident #1 required assistance and the use of a mechanical lift (EZ stand) for transfers. The Nurse's Notes dated 7/9/12 at 9:30 AM documented the resident had been transferred from the toilet to a wheelchair with the use of a mechanical left and the resident's feet slipped off the foot rest and the resident had to be lowered to the floor by staff. The note documented the resident did not complain of pain above his/her usual level and no injury noted at this time. Staff notified the physician of the incident. The Nurse's Notes dated 7/9/12 at 8:00 P.M. documented staff reported the resident yelled out while being positioned in bed and rated the pain level in his /her ankles and eyes at 6-7 on a scale of 1-10. The note documented the resident had 1+ [MEDICAL CONDITION] in both feet as well as a 6 centimeter (cm) green petechia-like bruising on the left outer ankle and could move his/her toes with some slight discomfort. The entry did not contain documentation of physician notification of the change in the resident's condition. The next entry dated 7/10/12 at 2:00 A.M.) and written by Staff J, Licensed Practical Nurse (LPN), documented the resident's left outer ankle now had a green bruise present which measured 10 cm by 8 cm and felt hot to touch. The resident yelled out when touched in that area. The resident stated (the pain) not bad when not touched or moved. This entry also documented a fax sent to the physician's office at this time "to see about a portable x-ray". On 9/26/12 at 2:45 PM Staff J stated she faxed the resident ' s physician, rather than calling him, because she thought the physician would probably order an x-ray and she did not know if the portable x-ray company could come out at night. She did state, however, the resident could have been sent to the hospital emergency room . Staff J stated she discussed the resident ' s change in condition with another nurse and they decided to wait and have the day shift nurse contact the doctor. Staff J could not recall the name of the other nurse with whom she discussed the resident ' s change in condition with. The next entry dated 7/10/12 at 6:30 A.M. documented staff called the physician to notify him of pain, bruising and swelling in the left ankle. The physician ordered a portable x-ray. The Nurse's Notes entry at 9:00 A.M. documented the portable x-ray as completed. The entry at 12:30 PM documented the physician called the facility and ordered the resident to be transferred to the hospital. The portable x-ray report dated 7/10/12 documented an "obliquely oriented non-displaced fractures of the distal fibula and tibia (lower leg bones) The report also documented extensive soft tissue swelling of the area. On 8/29/12 at 2:25 PM the facility's Registered Nurse MDS Coordinator and wound nurse stated the facility expected physician notification of all changes in resident conditions. She further stated staff can contact a physician at any time of the day or night and should call the physician with condition changes if they occur after office hours. On 9/27/12 at 12:44 PM the resident ' s physician stated this resident had chronic pain, but if the nurse visualized changes in the resident ' s ankle after a fall then the nurse should have called the physician at that time for further direction.

Based on observation, record review, interviews with staff, family and physician, the facility failed to plan nursing services to effectively monitor anticoagulant medication according to physician's orders [REDACTED]. Resident #1's physician directed staff to recheck his/her blood clothing test (INR) in a week. Resident #1 continued to receive [MEDICATION NAME] medication without monitoring the impact of anticoagulant (blood thinning) medication and was subsequently hospitalized for [REDACTED].The finding constitutes an immediate jeopardy to residents health and safety. In addition, the facility failed to plan for and direct staff to consistently communicate laboratory test to Resident #11 ' s physician. The facility identified a census of 62 current residents. Findings include: 1.A Minimum Data Set (MDS) assessment with a reference date of 11/7/11, assessed Resident #1 with a brief interview for mental status score of 9 (moderate impairment). The MDS identified the resident as independent with bed mobility, transfers and ambulation in room. The resident required extensive assistance of one staff with dressing and bathing. The MDS identified [DIAGNOSES REDACTED]. An 11/11/11 pain assessment tool documented the resident denied pain. A review of the resident's admission orders [REDACTED].) daily. On 12/8/11 at 12:55 p.m., the Director of Nursing stated she checked with the resident's pharmacy and the resident had been taking [MEDICATION NAME] since 2005. A laboratory report dated 11/1/11 identified the resident with an INR (blood clotting test) of 3.3 (high). The lab INR reference range for females is 0.9-1.1 ratio and therapeutic INR range for patients on [MEDICATION NAME] is between 2.0 and 3.0. The facility sent a facsimile (FAX) to the physician dated 11/1/11 with the prior lab results and medications ordered. The physician responded to the FAX with an order for [REDACTED]. Review of Medication Administration Records identified the resident continued to receive [MEDICATION NAME] 5 milligrams daily from 11/1/11 to 11/19/11. The MAR indicated [REDACTED]. Nurses notes identified the following information: On 10/30/11 at 3 p.m., Resident #1 admitted to facility with history [MEDICAL CONDITION](stroke) with right sided weakness and contracture of right hand. Resident admitted for stay at facility while spouse (who is primary caregiver) has hip surgery and rehab following surgery. Resident alert and oriented times three and has slurred speech secondary to [MEDICAL CONDITION]. Usually able to make needs known. On 10/31/11 at 12 p.m., the resident transferred with standby assistance and one staff. He/She self propelled wheelchair to the dining room. On 11/1/11 at 3:40 p.m. documented " doctor noted labs with recheck PT/INR in one week " . On 11/11/11 at 10 p.m., the resident continued to complain of groin pain. Staff notified the physician and received an order for [REDACTED]. On 11/12/11 at 12 a.m., the resident continued to complain of left groin pain. The resident wanted to go to the hospital. Staff reassured the resident and gave PRN (as needed) Tylenol ([MEDICATION NAME]) and the resident agreed to try it for pain. At 4:30 a.m. of the same date, the resident continued to complain of pain and staff administered PRN pain medication. At 4:50 a.m. the resident identified the pain as a little better but wants to go to the hospital. The facility notified the physician and the resident transferred to the hospital at 5:15 a.m. The resident returned to the facility at 9 a.m. Review of hospital records dated 11/12/11 identified the resident with hemoglobin of 12.1 (normal) Normal hemoglobin range is 11.5 to 16.5. A physician orders [REDACTED]. The physician directed staff to use heat to the groin and administer [MEDICATION NAME] more often up to four times a day. The physician also ordered [MEDICATION NAME] 10 milligrams (mg.) three times per day as needed for muscle spasms. The emergency room (ER) forms identifying blood work performed and did not identify that a check of the INR level was done in the ER. A review of the Laboratory Reports dated 11/12/11 showed no lab test completed for coagulation [MEDICATION NAME] time ([MEDICATION NAME]/INR). Following return from the ER, nurses notes identified on 11/12/11 at 2:30 p.m., the resident slid in front of the bed while getting out of the bed. The resident forgot to put shoes on. No injuries identified. Nurse ' s notes identified the following: On 11/13/11 at 8 a.m., the resident complained of moderate groin pain. Blood pressure 100/68, Pulse 84 Respirations 20 Temperature 97.9 degrees. Oxygen saturation 98% on room air. On 11/14/11 at 3:30 p.m., the resident with 3.5 centimeters (cm.) by 3 cm. dark purple raised area to right forearm with hard lump in center. The notes identified Resident #1 is on [MEDICATION NAME] and [MEDICATION NAME] and staff will monitor the area. Ice applied to area. Staff notified the physician of the bruising with no new orders received. On 11/15/11 at 1 p.m. Staff documented the resident up per usual. Blood pressure 103/61, pulse 92, respirations 20 Temperature 97.9 degrees Oxygen saturation 96% on room air. The resident did not want to get out of bed for breakfast but did get up for lunch. The resident continued to identify pain in the groin. The facility notified the physician of the pain. The physician ordered [MEDICATION NAME]/ APAP (narcotic) 5/325 one every 6 hours as needed for breakthrough pain. On 6:10 p.m., the resident identified the pain is better is with the new medication. On 11/16/11 at 7:50 p.m., the resident's groin pain continues. Family at bedside and informed of new medication offered. Discussed spouse wanting something more for pain. Informed family, resident and spouse that facility would be more aggressive with PRN medications and see if the resident could obtain relief or if more needed to be done. A facsimile dated 11/16/11 at 2:30 p.m. identified physical therapy (PT) unable to work with the resident because resident showed reservations to move. The facility requested an order for [REDACTED]. three times per day as needed for 10 days. On 11/17/11 at 1:45 p.m. Blood pressure 107/56 pulse 82 temperature 97.9 degrees Oxygen saturation 95% on room air. PRN pain medication and relaxant given. Resident not as tearful or grimacing as yesterday Multiple bruising observed left lateral trunk, left lateral leg and right upper arm of various sizes and colors. The facility notified the physician of the bruising with no new orders received. Documentation on plain white paper dated 11/17/11, regarding the bruising identified two bruises on the left anterior arm measuring 4 cm. by 2 cm. and 1.5 cm. by 1.5 cm., the right upper arm 1.5 cm. by 1.5 cm. purple bruise and 4 cm. by 2 cm. bruise. a 9 cm. by 15 cm. bruise to the left lateral side, 4 cm. by 2 cm. light purple bruise and another 4 cm. by 2 cm. bruise, the left lower leg contained (4) 1 cm. by 1 cm. bruises, one 1.5 cm. by 1.5 cm. bruise, one 1.5 cm. by 1 cm. bruise, one 1.5 cm. by 2 cm. bruise one 1 cm. by 0.5 cm. bruise, one 0.5 cm. by 0.5 cm. bruise and left foot 2.5 cm. by 2 cm. purple bruise. An interdisciplinary care plan, dated 11/17/11, identified the resident with special needs due to "uses [MEDICATION NAME] (blood thinner), monitor for increased bruising. The care plan did not identify possible risks associated with the use of the drugs, such as hemorrhage or prolonged bleeding time. The care plan indicated the resident planned to return home after the resident's spouse discharged from skilled care. Nursing 2011 Drug Handbook, facility drug reference, identified adverse reactions of [MEDICATION NAME] which included: hemorrhage, mouth ulcerations and sore mouth and melena (blood in stool). Overdose signs and symptoms included: blood in stools or urine, excessive bruising, persistent oozing from superficial injuries, melena and petechiae. Nursing considerations included: [MEDICATION NAME] can cause major or fatal bleeding. Regularly monitor INR in all patients. Consider more frequent monitoring in those at high risk for bleeding. Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds. On 11/18/11 at 4 a.m., the resident slept fair in between getting up to the bathroom. The resident utilized [MEDICATION NAME] with positive results. The resident's color was good with skin warm and dry. The resident continued to point to left groin when asked where pain is. (No vitals documented ) A 24 hour report record (not a part of the resident's permanent record) identified day shift checked the resident's blood pressure as 104/63, pulse 98 and temperature 97.1 degrees. On 11/18/11 at 10 p.m. documented the resident as tearful and restless not knowing what he/she wants. Staff administered pain medication, muscle relaxant and anti-anxiety drugs. The resident ' s lips appeared dry and cracked with ointment applied. (No vitals or body assessment documented) A treatment administration record (TAR) identified a weekly skin assessment completed on 11/18/11 however there was no documentation from this date regarding the findings of the weekly skin assessment. On 11/19/11 at 6 a.m., the resident wanted pain medication. Staff administered PRN [MEDICATION NAME]. The resident refused to come out for breakfast due to pain with movement to left lower leg. The resident stated the pain medication was helpful. The resident appeared tired and pale and complained of no sleep due to pain the previous night. (No vitals signs or body assessment documented.) On 11/19/11 at 7 p.m. the resident had pain medication, anti-anxiety medication and muscle relaxer with no complaints. (No vital signs or body assessment documented.) On 11/20/11 at 6:10 a.m., the resident's spouse approached the nurse ' s station asking if Resident #1 could have more for pain. The spouse requested the nurse examine Resident #1. Resident #1 was in bed and complained of groin pain. The resident appeared tearful and denied concerns other than the pain. Blood pressure 95/52, pulse 90, respirations 20, temperature 98.6 degrees. Oxygen saturation 96%. Staff administered [MEDICATION NAME] (muscle relaxant) and [MEDICATION NAME] (for pain) at 6:15 a.m. At 8 a.m., the resident's spouse reported Resident #1 was not any better and wanted Resident #1 sent to the hospital. Staff informed spouse if PRNs did not relieve pain, they would call physician. At 9:30 a.m., staff spoke with the physician who ordered the following: "Give 2 [MEDICATION NAME] 50 mg. one time now. If no relief by 10 a.m. today, give 2 [MEDICATION NAME] (narcotic) 5/325. If no relief by 11 a.m. ship to hospital." At 11:15 a.m. the resident rated the pain at 7 out of 10 scale with 10 being the worst pain. Staff documented multiple bruises in various stages of healing on arms and legs. Spouse stated the resident "bruises easily". The resident transported to the ER for evaluation. At 1:45 p.m. of the same date, the hospital phoned and stated the resident admitted with low hemoglobin and abnormal PT/INR. Hospital records dated 11/20/11 identified the resident with a low critical hemoglobin reading of 6.8 (normal is 11.5 to 16.5), a low hematocrit 20.2 (normal 36-48). A hospital history and physical (H&P) dated 11/20/11 documented the resident presented to the ER with complaints of abdominal pain, widespread bruising and bleeding from tongue and lips. The H&P identified the [MEDICATION NAME] INR is elevated off the scale of the machine (not able to measure). The assessment was: [MEDICAL CONDITION], [MEDICATION NAME] Overdose and Prolonged [MEDICATION NAME] time. The resident admitted to the hospital for intravenous fluids and pain control, transfusion of packed red cells, administration of Vitamin K (to clot blot) and follow up coagulation studies. On 11/21/11 at 8:16 a.m. the hemoglobin measured 10.3 (low) and hematocrit 29.3 (low). [MEDICATION NAME] (to measure blood clotting) 89.2 (normal 9.0 to 12.6) and INR 11.20 (high). On 11/22/11 at 9:10 a.m. an occult blood test was positive. On 11/22/11 at 6:45 a.m., [MEDICATION NAME] measured 48.4 (high) and INR 4.90 (high). On 11/22/11 at 12 p.m., hemoglobin 9.9 (low) and hematocrit 28.7 (low). A review of the clinical record revealed no "recheck" INR performed as order by the physician on 11/1/11 until the resident was hosptalized on [DATE]. The finding constitutes an immediate jeopardy to the resident's health and safety. On 12/6/11 at 2:35 p.m., Staff Director of Nursing stated the physician order [REDACTED]. Staff did not place it on the calendar. She stated when the order was discovered as not followed, staff did not go through other residents that received [MEDICATION NAME] to ensure their orders were not missed. On 12/7/11 at 10:26 a.m., the DON stated she thinks staff placed the INR order on the calendar for Resident #1's spouse instead of Resident #1. Both the spouse and Resident #1 received [MEDICATION NAME]. On 12/7/11 at 1:58 p.m., the pharmacist confirmed the resident received 19 doses of [MEDICATION NAME] 5 milligrams during the month of November 2011, which accounted for the correct number of doses the resident should have received. Nurses notes identified the resident returned to the facility on [DATE] at 2:30 p.m. Upon return to the facility physician orders, dated 11/22/11 identified the [MEDICATION NAME] as discontinued and the physician directed staff to perform INR testing on 11/23/11. A laboratory report dated 11/23/11 identified the [MEDICATION NAME] as 77.5 (high) and INR as 7.2 (high). The facility notified the physician who directed staff to recheck the INR on Friday (11/25/11). A laboratory report identified the 11/25/11 INR as 11.6 (high). On 11/25/11 the physician directed staff to administer Vitamin K (for clotting) and recheck INR on Monday 11/28/11. The INR on 11/28/11 was 3.1. A facsimile indicated the physician directed the facility to continue to hold the [MEDICATION NAME] and recheck the INR on 11/30/11. The INR reading on 11/30/11 was 2.6 (therapeutic range) On 12/7/11 at 9:51 a.m., the surveyor spoke with the resident's physician. When asked if the lack of checking the INR on 11/8/11 as ordered made a difference in how ill the resident became, the physician stated if the facility checked the INR as ordered, it probably would have caught that the INR was on its way up. The physician stated the resident's condition when he/she arrived at theER on [DATE] was potentially life threatening. The resident received Vitamin K to promote blood clotting, received blood and was assessed with [REDACTED]. When asked how the INR rose to 11.6 following return from the hospital when the [MEDICATION NAME] as no longer ordered, the physician stated the resident received Vitamin K intramuscularly and absorption of Vitamin K can be off. Another potential is it was not collected at the appropriate time-if it ' s collected in the morning or evening can make a difference or blood could clot in the tube. The physician stated he verified with the facility that they no longer administered [MEDICATION NAME] to the resident and also questioned if the resident could be getting the spouse's [MEDICATION NAME] by accident. The facility assured the physician the [MEDICATION NAME] as discontinued and the resident did not receive any doses since return. Observation showed, on 11/28/11 at 12:50 p.m., the resident in bed. At that time, the resident's spouse stated the resident bruised all over due to thin blood. The resident required Vitamin K. At that time, the spouse stated the resident needed a pain pill and had not received one yet. The resident waited 5 minutes already. At 1:25 p.m. of the same date, the surveyor spoke with Staff J charge nurse and asked if she gave the resident a pain pill yet. Staff J then went to room and administered pain medication. When asked where the pain was, the resident grimaced and identified pain in the "whole body". At 3:50 p.m., the resident remained in bed and shook head yes when asked if the pain medication helped. The Director of Nursing provided the surveyor with information that stated the facility identified the concern of the missed PT/INR check on 11/21/11. On 11/21/11, the facility abated the IJ when they implemented a new checklist that staff will use with all new orders to ensure staff complete all steps in the order notation process. The facility appointed one staff on 11/21/11 to double check labs orders as of 11/21/11 and that individual will send all labs to the physicians and noting any new lab orders on the calendar on the lab day. A staff person would be assuming these responsibilities in the absence of the designated staff. The facility also identified residents on anticoagulants will be checked weekly by the designated staff to ensure all PT/INRs have been obtained as ordered. As of 12/5/11, the facility completed training of the prior to all nursing staff. This lowered the severity of the deficiency to a G level as the facility had not had time to monitor the new process designated to staff to ensure PT/INR lab test were being completed as ordered. 2. The MDS dated [DATE] documented the pertinent [DIAGNOSES REDACTED]. The same MDS documented a Brief Interview of Mental Status score of 12 which indicated mild cognitive impairment. The Resident Care Plan problem dated 3/31/08 identified the resident on [MEDICATION NAME] and directed staff to monitor the resident for signs and symptoms of bleeding and bruising. The admission orders [REDACTED]. The admission orders [REDACTED]. The Nurse's Notes dated 12/6/11 at 9:10 AM documented the ordered labs drawn. The Nurse's Notes dated 12/7/11 at 1515 (3:15 PM) documented the facility received the lab results and faxed them to the resident's physician. The lab reports documented the resident's potassium level as 5.9, ( the normal indicated as 3.5-5.3) the PT result of 43.0 (the normal indicated as 9.0-11.5) and the INR 4.5 (the normal indicated as 2.0-3.0 for moderate intensity [MEDICATION NAME] therapy and 3.0-4.0 for higher-intensity [MEDICATION NAME] therapy). The Nurse's Notes dated 12/9/11 at 1700 (5:00 PM) documented the physician notified of the elevated INR and the facility received new orders. The telephone order dated 12/9/11 at 5:00 PM directed staff hold the resident's [MEDICATION NAME] and recheck the PT/INR on 12/12/11. The MAR for 12/11 for Resident #11 documented staff continued to administer potassium chloride 20 mEq on 12/7/11, 12/8/11,12/9/11,12/10/11and 12/11/11 at 8:00 AM and administered [MEDICATION NAME] 5 mg 12/7/11, 12/8/11, and 12/9/11 at 5:00 PM. During interview on 12/21/11 at 2:49 PM the physician for Resident #11 stated he expects the facility to call all abnormal lab results to him. He stated that he had not been made aware of the abnormal potassium level until he visited the facility on 12/12/11 and reviewed the lab reports. The physician stated that administration of potassium chloride and [MEDICATION NAME] to the resident with abnormally high lab levels had the potential to harm the resident. The Doctor's Orders and Progress Notes dated 12/12/11 completed by the physician documented he reviewed the lab values from 12/6/11 and documented he had not been notified of the resident's elevated potassium level but did receive a call about the elevated INR(which had been documented in the Nurse's Notes as done on 12/9/11). The physician ordered a recheck of the resident's potassium level and to discontinue the potassium chloride until the lab result received. The telephone order dated 12/12/11 at 1830 (6:30 PM) directed staff to resume administration of the resident's potassium chloride at 20 mEq daily. During interview on 12/21/11 at 1:15 PM the facility's DON stated the family of Resident #11 requested the use of an alternative lab due to the high cost of a lab transportation fee charged by the facility's contracted lab. The DON stated the alternative lab is slow in getting results to the facility and did not send the results of the 12/6/11 labs until 12/7/11. She further stated the nurse who received the lab report on 12/7/11 should have noted the high potassium level and the high PT/INR and called the physician, rather than faxing the abnormal results to the physician. The DON said that she had re-educated all nurses regarding an updated facility policy on handling lab results and will provide a copy of the education.

Based on observation, record review, interviews with family, physician and staff, the facility failed to provide nursing provisions with timely assessment and interventions for one of eleven residents with an adverse change in physical condition. The facility failed to assess Resident #6's dehydration risk factors and intervene in response to the resident's symptoms and condition changes. The facility also continued to administer a laxative daily, when bowel records identified the resident with loose stools. Resident #6 entered the hospital with severe dehydration and acute [MEDICAL CONDITION]. The facility census was sixty-two (62) residents. Findings include: According to the MDS assessment with a reference date of [DATE], Resident #6 demonstrated impaired long and short term memory and moderately impaired cognitive skills for daily decision making. Resident #6 had difficulty communicating some words or finishing thoughts but was able if given enough time. The MDS documented Resident #6 required extensive assistance with activities of daily living including bed mobility, transfers dressing, toileting, personal hygiene and bathing. The resident required limited assistance of one staff with eating. The resident could not ambulate and used a wheelchair for mobility. The MDS documented the resident was always incontinent of urine and bowels. The assessment identified Resident #6 with [DIAGNOSES REDACTED]. The assessment revealed the resident had occasional pain and received scheduled pain medication. The assessment revealed the resident had a fall without injury since the previous assessment. A CAA Review Report documented the resident with a fall on [DATE] while outside with his/her family member. The family member forgot to lock the resident's wheelchair brakes and the resident rolled off the side of the walkway, tipping the wheelchair and landing on buttocks. No apparent injury and the physician examined the resident and ordered x-rays of the knees due to complaints of pain with no fracture identified. Social service progress notes dated [DATE] stated the resident's family member wanted a large commode for the resident. The resident occasionally has diarrhea and takes [MEDICATION NAME] (a laxative) every day. Nursing will see if physician could or would cut back on the [MEDICATION NAME]. Social service notes also stated the resident had frequent urinary tract infections. The record lacked evidence the facility checked with the physician regarding the use of the [MEDICATION NAME]. A data base for nutritional assessment/reassessment dated [DATE] identified the resident's fluid needs as 2768 cc. The resident received a diuretic [MEDICATION NAME] 40 milligrams twice a day. Regarding nausea/diarrhea the entry stated: "None noted". A food intake record showed Resident #6's fluid intakes well below what the resident required to maintain adequate hydration: On [DATE], 1520 cc's. On [DATE], 840 cc's. On [DATE], 960 cc's. On [DATE], 720 cc's. On [DATE], 1040 cc's. On [DATE], 840 cc's. On [DATE], 840 cc's. On [DATE], 720 cc's. On [DATE], 720 cc's. On [DATE], 840 cc's. (120 cc of total was supplement) On [DATE], 980 cc's (120 cc of total was supplement) On [DATE], 340 cc's. On [DATE] at 9:15 a.m., the Director of Nursing stated the facility began monitoring intakes on [DATE] due to the resident's weight loss. The facility only monitors intakes if there are nutritional issues. The resident weighed 203 pounds on [DATE]. The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]". The medication was never "held" as the MAR indicated [REDACTED]. A doctor order and progress form dated [DATE] identified the resident with decreased level of consciousness, low grade fever, sacral skin breakdown. The physician suspected a urinary tract infection and discontinued the [MEDICATION NAME] due to loose stools. Nurses notes did contain any type of assessment or notation of a condition change regarding the resident's status. On [DATE] the resident admitted to the hospital on [DATE]. The history and physical form stated staff at the facility found the resident less responsive. For the past week the resident ate and drank less becoming more weak . The resident had a distant history of urinary tract infection. The resident also has significant diarrhea where it " poured out of" the resident for one day according to their family member. The physician saw the resident in the emergency room and found the resident severely dehydrated. The physician admitted the resident to the hospital for acute [MEDICAL CONDITION], dehydration, elevated INR (test for blood clotting) and urinary tract infection. An X-rays showed a non-displaced right fibular fracture. The initial baseline metabolic profile showed Sodium 150 (high), potassium 3.6 (normal), hemoglobin 10.6 (low) hematocrit 35 (low) CO2 of 27(normal), BUN (blood urea nitrogen 124 (high), creatinine 2.7 (high) glucose 166 (high) and calcium 8.9 (normal). On [DATE] at 9:50 a.m., one of the physicians that provided care to the resident in the hospital stated the diarrhea contributed to the resident's dehydration diagnosis. The fact the facility continued to administer the [MEDICATION NAME] when the resident had loose stools was a significant medication error. The physician stated he found nothing infectious caused the diarrhea when staff performed testing at the hospital. Review of the resident's care plan failed to identify a potential problem with dehydration and therefore, did not contain interventions to assist with the prevention of dehydration. On [DATE] at 10 a.m., the resident's family member stated when she informed the Director of Nursing (DON) that her parent had diarrhea the DON stated the resident did not have diarrhea. At that time, the family member questioned whether her parent should continue to receive [MEDICATION NAME] but the facility continued to administer it. On [DATE] at 12 p.m. the Director of Nursing stated the family member never visited with her about the resident having diarrhea. Staff Interviews revealed the following information: On [DATE] at 1:40 p.m. Staff E (certified nurse aide) reported Resident #6 had "constant loose stools". Staff would chart it on the bowel record with a star by it and the nurse would check the bowel record. On [DATE] at 1:25 p.m., Staff F (certified nurse aide) stated Resident #6 had loose stools. Every time staff raised the resident in the Hoyer it would have loose stools. On [DATE] at 12:05 p.m., the Director of Nursing stated Staff F rarely worked with the resident because Staff F usually worked on the other side of the building. On [DATE] at 1:10 p.m. Staff G (certified nurse aide) stated the resident had loose stools but it wasn't large amounts. Staff G stated she did not report it and did not know if other staff did. Staff G stated she didn't work with the resident often. On [DATE] at 1:03 p.m. Staff H (certified nurse aide) stated the resident had loose stools and staff reported it to the nurse. On [DATE] at 12:40 p.m., Staff I (certified nurse aide) stated every time staff got the resident up he/she had loose stools and staff reported it to the nurse. On [DATE] at 11:50 a.m. Staff J (licensed practical nurse) stated the resident had normal aches and pains-nothing out of the ordinary. The resident had loose stools off and on. Staff would hold or taper the [MEDICATION NAME]. On [DATE] at 11:40 a.m., Staff K (certified nurse aide) stated the resident had loose stools and staff reported it to the nurse. On [DATE] at 11:22 a.m., Staff L (registered nurse) stated she did not work with the resident much but did not recall the resident with pain or reports of loose stools. On [DATE] at 10:49 a.m., Staff M (registered nurse) stated the resident's family member had concerns with the resident's bowels. Staff did not report loose stools. Staff M stated the resident hasn't really had formed stools since admission. The resident was on [MEDICATION NAME]. The physician reviewed the [MEDICATION NAME] and spoke with the resident's family member. On [DATE] at 3:50 p.m., the resident's physician stated he did not remember about the resident's loose stools. He stated he just took over two to three months ago and can't recall. On [DATE] at 11:42 a.m., the Director of Nursing stated since surveyor identification of [MEDICATION NAME] continued despite loose stools recorded on the bowel record, the facility nurse aides will document bowel movements every shift on a roster form and give the paper to the nurse at the end of the shift. On [DATE] the resident discharged from the hospital to inpatient Hospice care and expired [DATE].

Based on record review, physician and staff interview, the facility failed to provide nursing provisions with timely assessment and interventions for one of seven residents with an adverse change in physical condition. Resident #8 complained of lower extremity pain for two days and during that time required additional staff assistance for transfers as he/she could not bear weight. The facility staff failed to document or assess the resident's condition which showed a fractured foot. The facility identified a census of 75 current residents. Findings include: 1. A Minimum Data Set (MDS) assessment with an observation end date of [DATE], assessed Resident #8 with impaired long and short term memory and modified independence with decision making. The resident required extensive staff assistance with bed mobility, transfers, wheelchair mobility, dressing, toileting, personal hygiene and bathing. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with pain in the previous 5 days. The resident received PRN (as needed) pain medications. The MDS also identified shortness of breath with exertion, sitting at rest and while lying flat. The MDS identified the resident with a condition or chronic disease that resulted in life expectancy of less than 6 months. Resident #8's care plan with the goal date of [DATE] directed staff to provide assistance of one (1) staff with ADL (activities of daily living) and to monitor skin and report reddened or any usual marks during cares; and to monitor and report signs and symptoms of decline in ADL ' s to nurse. Review of the resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A nursing home note dated [DATE] at 4:08 p.m. identified the physician visiting the resident for a 60 day routine visit. At that time, the physician documented the resident complained of the right leg falling asleep. The resident sat outside for awhile and feels that caused it. Physical examination of extremities stated, "Free of [MEDICAL CONDITION]". The physician indicated he did not examine the resident's feet at that time, because the resident complained of the right hip and attributed it to sitting outside too long. On [DATE] the resident had the right hip x-rayed with no fracture identified. Nurses notes did not contain documentation regarding the resident's complaints until [DATE] at 11:50 p.m. written by Staff R, RN (registered nurse). The entry identified complaints of bilateral foot discomfort. Staff administered medication for pain and a follow up entry dated 3 a.m. on [DATE] indicated the resident slept well. The entry did not contain an assessment of the lower extremities or feet. Interview with staff working [DATE] on the 2 p.m. to 10 p.m. shift revealed: On [DATE] at 2:50 p.m., Staff A, RN (registered nurse) stated the resident complained of his/her leg asleep on the afternoon of [DATE]. Staff A stated he was not aware the resident went outside because the resident "was never out of bed much". Staff A stated he looked at the leg and suggested the resident get up to get circulation going and the resident refused. At suppertime the resident requested that Staff A rub the leg. Staff A stated he did not have time due to passing medications. A certified nursing assistant/CNA (Staff E) told him the resident said his/her foot hurt. Staff A stated he checked the foot and did not see any abnormality. The surveyor and Staff A then reviewed the resident's medication record. It did not show Staff A administered any type of pain medication on the 2 p.m. to 10 p.m. shift. Staff A confirmed he did not see he administered Tylenol ([MEDICATION NAME]) as he previously thought. The only medication initialed as given to the resident was 9 p.m. [MEDICATION NAME] (antianxiety). Staff A stated the resident went from one complaint to the next so he gave the [MEDICATION NAME] because he was not doing the resident any good. Staff A stated if he didn't document in the nurses notes, he should have. During assessment, Staff A did not observe swelling, redness or bruising. There was not even much tenderness. The resident could perform circular range of motion at the ankle. Staff A later found out the resident had a foot fracture. Staff A could not imagine how the resident fractured his/her foot because the resident did not do enough to cause a traumatic injury. On [DATE] at 2:27 p.m. Staff E, CNA stated she worked [DATE] and at 2:20 p.m., the resident wanted to go outside. The resident sat outside until approximately 3 p.m. when (s)he came back inside. Staff E thought Staff I, CNA brought the resident back inside. Staff E stated after 30 minutes outside, she checked to see if the resident wanted to come back inside, but the resident wanted to stay out a little longer. When staff saw the resident, his/her feet were behind him/her in the dining room. The resident did not use foot pedals. Staff E placed the resident's feet up on a chair because (s)he complained of them tingling and feeling asleep. The feet weren't on the chair long and the resident began hollering saying he/she felt uncomfortable so they took the resident back to the room and laid the resident down. The resident would not stand or turn. It took 2 staff to transfer the resident instead of the usual one. Staff E then summoned Staff A. The resident didn't want to get up for supper and after supper the resident wanted a pain pill. Staff E informed Staff A. At 9 p.m. the resident complained of his/her foot hurting. Staff E thought it was the right foot. Staff E informed Staff A. On [DATE] at 11:46 a.m. a Hospice Social Worker stated she saw the resident the afternoon (unable to recall time) of [DATE] and the resident acted different than usual. The resident complained of their legs hurting. The Hospice Social Worker spoke with Staff A about it. She also called the on call Hospice nurse. She stated the resident did not mention what occurred to cause of the pain. Documentation on [DATE] during 2 p.m. to 10 p.m. shift revealed the medication administration records showed the resident did not receive pain medications until 11:30 p.m. on [DATE]. Review of nurses notes for that date and time did not identify documentation or assessment of the resident's complaints or lower extremities. Interview with staff working on [DATE] during the 10 p.m. to 6 a.m. revealed: On [DATE] at 4:12 p.m., Staff R, RN stated the resident complained of his/her legs hurting. The resident said (s)he sat outside and it was hot out and next time the resident would limit it to 30 minutes outside. The resident stated both legs hurt but Staff R did not think it as anything unusual. She attributed it to weather changes and the resident does complain at times. Staff R stated she did not do a visual inspection of the legs or feet. Staff R stated she gave the resident PRN medications and the resident then slept all night. She stated the nurse aides did not report anything unusual regarding the resident. Interview with staff working on [DATE] during the 6 a.m. to 2 p.m. shift revealed: On [DATE] at 11:10 a.m., Staff O, CNA stated the resident seemed short of breath and had pain in his/her legs on [DATE]. The resident seemed more anxious than usual. Staff O stated the resident did not use foot pedals due to resident wheeled self. When staff pushed the resident, he/she usually just held feet up. On [DATE] at 1:08 p.m. Staff B, LPN (licensed practical nurse) stated she and the resident's daughter assessed the resident's lower extremities. The feet contained discoloration that the daughter thought was mottling. The top of the left foot had a pea size area and an area under the left great toe. There was a bruise on the top of the right foot. On [DATE] at 10:47 a.m. Staff X, RN stated the resident hollered with pain "it hurts" on both [DATE] and [DATE]. Staff X stated that was a behavior change for the resident because the resident did not usually holler out with pain. Documentation [DATE] 6 a.m. to 2 p.m. shift revealed: review of medication records [REDACTED].) 2 tablets on [DATE] at 7 a.m. with little relief of pain. Staff B then administered more Tylenol 500 mg. 2 tablets at 10:45 a.m. with no relief at 11:30 a.m. Staff then administered [MEDICATION NAME] (narcotic) at 11:30 a.m. for pain with relief at 12:15 p.m. Therefore, the resident had pain from at least 7 a.m. to 12:15 p.m. Nurses notes dated [DATE] did not contain an entry until 12:30 p.m. when staff identified a decline in ambulation and the resident unable to move the right leg. The resident complained of numbness. Staff used the EZ stand for transfers. The resident's daughter arrived and requested medication changes and the physician informed of the condition change. At 1:05 p.m. the physician ordered x-rays for the right hip. The first assessment documented identified bruising to the top of the left foot and under the great toenail and bruising to the top of the right foot. Review of [DATE] telephone orders identified a new order for [MEDICATION NAME] (for arthritis pain) 15 mg. daily and [MEDICATION NAME] (for pain) 50 mg. every 4 to 6 hours as needed and x-ray of the right hip. On [DATE] at 2:10 p.m., Staff Q (Director of Nursing) stated staff did not complete an incident report or bruise investigation sheet for the bruises assessed. Staff Q stated staff should have completed a "bruise sheet." Interview with staff working on [DATE] during the 2 p.m. to 10 p.m. shift revealed: On [DATE] at 2:40 p.m., Staff C, LPN stated the resident complained of right hip pain and portable x-ray arrived and x-rayed the right hip, which was negative for fracture. Staff C gave the resident [MEDICATION NAME] for the pain. The resident ate cookies and a sandwich in his/her room for supper. Staff C provided scheduled nebulizer treatments at 5 p.m. and 9 p.m.. Staff C listened to lung sounds and the resident's oxygen saturation was 94%. Staff C did not note an increased problem with the resident's respiratory status. Staff C stated she did not note bruising on the resident's feet and the resident did not seem different that evening. Staff C stated staff is to use foot pedals if they push the resident. Documentation [DATE] 2 p.m. to 10 p.m. shift: Medication records identified Staff C administered [MEDICATION NAME] at 2:30 p.m., 3:40 p.m., and 6:15 p.m. with relief of pain. Interview with staff working on [DATE] during the 10 p.m. to 6 a.m. shift revealed: On [DATE] at 6:11 p.m., Staff M, RN stated he assisted a nurse aide with a transfer of the resident. The resident complained of his/her leg hurting and it was thought the resident may have a sprain. Staff M stated the resident stood but favored the injured foot. Staff M stated he observed both feet and did not see bruises. He stated the resident did not have increased respiratory difficulty that night. Staff M stated the resident is usually asleep at night when Staff M works so Staff M was not that familiar with the resident. On [DATE] at 11:15 a.m., Staff P, CNA stated the resident pulled the call light, on [DATE] 10 p.m. to 6 a.m. shift and said he/she thought they needed the bathroom. The resident was normally assisted with one staff. Staff P attempted to transfer the resident and the resident would not stand. The resident complained of his/her leg bothering She got Staff M to assist with the transfer. They got the resident to the toilet and told the resident to pull the call light when done. The resident sat on the toilet 10 to 15 minutes and stated they could not use the toilet. The resident did not bear weight when going back to bed even with use of the EZ stand and staff had to hold up the resident's bottom so he/she would not go down. Staff P stated the resident complained he/she could not stand. Staff P stated there was nothing unusual with the resident's breathing. Staff P stated she did not see bruising on the resident's feet but stated she was "shocked" the resident seemed so different that night. Staff P stated the resident did not use pedals. He would usually just pick feet up when staff pushed the chair. Documentation on [DATE] during the 10 p.m. to 6 a.m. shift revealed: Medication records identified Staff M administered [MEDICATION NAME] at 8:46 p.m. with pain results "slightly better" at midnight and [MEDICATION NAME] at 9:15 p.m. with pain relief only "slightly better" at midnight. Staff did not administer any further pain medication. Nurses notes did not contain an entry regarding the resident's condition. The record lacked evidence the facility notified the resident's daughter of the resident's continued pain and transfer problems. Documentation on [DATE] during the 6 a.m. to 2 p.m. shift revealed: On [DATE] at 8:30 p.m., Staff B, LPN documented that the resident continued to decline and could not bear weight or hold on for transfer with EZ stand. The resident's oxygen level measured 85% with oxygen at 2 liters. The resident could not sit in a wheelchair due to constant movement in the chair. The resident complained of severe pain in hips and back. Staff B administered the resident's routine medication including [MEDICATION NAME] 15 mg. After breakfast staff observed the resident with increased respirations and pursed lip breathing. Staff transferred the resident to bed and the resident responded with "better" when asked about pain. Staff B notified the resident's daughter and requested transfer to hospital for further evaluation. At 8:45 a.m., Staff B administered [MEDICATION NAME]. At 10 p.m. the resident transported to the hospital. Medication records identified the resident did not have relief of pain at 9:20 a.m. following the [MEDICATION NAME] administered. On [DATE] at 10:50 a.m., Staff B stated the resident did not use foot pedals when the resident propelled self. When staff pushed the resident, they used foot pedals because they don't know when the resident might drop his/her feet. On [DATE] at 2:46 p.m., Staff K, CNA stated the resident did not use foot pedals because he/she propelled self in wheelchair. On [DATE] at 11:26 a.m., Staff Q (Director of Nursing) stated the resident propelled his/her own chair and when staff pushed the resident would hold up feet. The resident did have pedals that staff could use. Staff Q stated the facility did not have a policy regarding use of foot pedals. On [DATE] at 11:39 a.m., Staff Q (Director of Nursing) stated after the surveyor left the faciity on [DATE] she attempted to find out who brought the resident in from the outdoors on [DATE]. She could not find who had brought the resident in. All staff working denied bringing the resident in. She thought the resident may have gotten him/herself inside. The door was heavy so it would have been hard for the resident to do but Staff Q thought s/he might have. She stated while interviewing, she spoke with the maintenance man who informed her on [DATE] he was doing maintenance work in the room adjacent to Resident #8's room. He disconnected electricity to Resident #8's room to install an outlet in the next room. Resident #8 became angry, kicking and hitting the wall. On [DATE] at 12:40 p.m. Staff U, maintenance man stated on [DATE] in the morning he worked in Resident #7's room and needed to shut the electricity off. Resident #8's room was next to Resident #7's, so the electricity shut off affected Resident #8's room too. He stated Resident #8 kicked the wall continuously and also pounded the wall upset because his/her TV did not work. After dinner the resident remained upset and still kicked the wall. He stated the resident kicked hard and it sounded like it would "come through the wall". Resident #7 informed Staff U that the resident does this "all the time". On [DATE] at 10:45 a.m. Staff U stated he did not know if any staff intervened to calm the resident or check on the resident's needs. Staff U stated he went in and apologized to the resident and informed the resident he worked as fast as possible to complete the job. On [DATE] at 10:26 a.m., Resident # 7 whose room was next to Resident #8's stated one day Resident #8 pounded the wall all day and night and would pound periodically on other days. Resident #7 stated it's like the resident didn't know what to do with him/herself. Interviews of staff working on [DATE] during the 6 a.m. to 2 p.m. shift revealed: On [DATE] at 11:02 a.m. Staff V, CNA stated she never saw the resident hit or kick the wall. On [DATE] at 10:52 a.m., Staff W, CNA stated the resident that lived next door to Resident #8 complained Resident #8 would pound the wall with his/her fist and yell "Help". Staff W thought the resident pounded with his/her fist not the feet. On [DATE] at 10:47 a.m., Staff X, RN stated once when she first began employment the resident pounded the wall with his/her fist. Staff X didn't think the resident could kick that hard with feet. Staff X stated she heard that Staff E brought the resident in from the outdoors on [DATE] and the resident caught his/her feet On [DATE] at 2:33 p.m. Staff E, CNA denied bringing the resident in from the outdoors the afternoon of [DATE]. On [DATE] at 10:35 a.m. Staff K, CNA denied knowledge of the resident kicking or pounding the wall. On [DATE] at 10:38 a.m., Staff Y, CNA denied knowledge of the resident kicking or pounding the wall. On [DATE] at 12:20 p.m., Staff T, LPN and charge nurse for Resident #8 on [DATE] stated she did not know of the resident ever pounding or kicking the wall and did not recall the resident doing so on [DATE] or that the resident's TV did not work that day. Review of the resident's [DATE] care plan did not identify this behavior. An emergency physician record dated [DATE] identified the resident as "acting different" and unable to bear weight for 2 days and left foot bruising and right hip and leg pain. The report stated the resident had recent trauma of getting left foot caught under the wheelchair. A history and physical emergency room note dated [DATE] assessed the resident with "intractable pain uncontrolled with outpatient oral therapy". The History and Physical (H & P) report from the hospital dated [DATE] revealed the resident was active until Friday and "it appears that the patients feet were caught underneath the wheelchair sometime on Friday and since then has not been ambulating well." The resident developed bruising of the left foot. It is hard for the resident to localize pain due to dementia. An x-ray performed of the hip was normal. Examination of the foot revealed some bruising on the lateral left foot. The right great toe has a fungus underneath with some redness. Assessment is Left lower lobe pneumonia with [MEDICAL CONDITION] and inability to bear weight secondary to left fourth and fifth metatarsal fracture, pain in the right hip possibly from bursitis. The physician suspected aspiration pneumonia. A [MEDICATION NAME] Patch (narcotic) was initiated to assist with pain control and [MEDICATION NAME] for breakthrough pain. The H & P identified that the resident's [MEDICATION NAME] and [MEDICATION NAME] did not help. A Discharge Summary dated [DATE] identified the resident presented to the emergency room with pneumonia and intractable leg pain. The resident ultimately expired on [DATE]. On [DATE] at 1 p.m., the resident's physician stated the foot fractures were not pathological. The record lacked evidence the facility notified the resident's family member of the resident's continued pain and transfer difficulties from [DATE] at 4:25 p.m. until [DATE] at 8:30 a.m. During interview on [DATE] at 7:47 p.m., the resident's family member stated s/he would have wanted the facility to notify him/her of the resident's change in condition and continued pain. Although the exact origin of the resident's foot injury could not be determined, the facility staff failed to assess and provide adequate treatment to address Resident #8's pain.