Every finding on record at Concord Care Center

Based on observation, clinical record review, resident and staff interviews, along with policy and procedure review, the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life during morning cares for 1 out of 5 residents reviewed. (Resident #3). The facility identified a census of 40 residents.Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 for which indicated intact cognitive decisions, was able to be understood and understand others, with no behaviors present. The MDS addressed the resident with limited range of motion in the upper and lower extremities on one side of the body and required substantial to maximal assistance of staff for toileting hygiene, upper and lower body dressing, and dependent on transfers and once in wheelchair is independent for mobility. The MDS included diagnosis of cerebrovascular accident (CVA), hemiplegia (severe or total paralysis of one side of the body, caused by brain damage, often from strokes) hemiparesis (one side muscle weakness, caused by central nervous system damage such as a stroke) and cataracts. The Care Plan Focus with no date, indicated Resident #3 will be assisted with activities of daily living (ADL) as required. Interventions include: one staff member to assist with dressing/grooming, always transfer toward left side, resident requires assist times two staff for transfers and EZ stand (a powered patient lift designed for transfer, and mobility), assist with toileting per residents' routine.An Abuse Allegation Investigation Report dated 4/10/26, documented Resident #3 reported Staff A, Certified Nursing Assistant (CNA), had entered Resident #3's room at approximately 6:45 AM on 4/2/26 or 4/3/26, and told Resident #3 it was time to get ready for the day and left the room. Resident #3 stated that Staff A, did not come back to her room for 20 minutes. When Staff A returned, Resident #3 asked for help and Staff A told Resident #3 that she was able to do it herself and left the room again. Resident #3 stated she needed assistance getting to the bathroom so Resident #3 got dressed herself and got herself to the bathroom. When Staff A, came back to the room again, Resident #3 was transferring off the toilet by herself and staff A asked what Resident #3 was doing. Resident #3 told Staff A that she needed to use the restroom and asked for help putting on a brief. Staff A, helped her put on the brief while Resident #3 held onto the bar in the bathroom. Resident #3 stated Then Staff A, wheeled me back, well no she didn't. Staff A helped me put on my foot pedal for my bad leg and left again, so Resident #3 went out and started my day. Resident #3 stated that she notified three staff regarding the incident. Resident #3 denies feeling unsafe around Staff A, and in the facility. Resident #3 does not feel that Staff A acted toward her in an abusive fashion. Resident #3 does not wish for Staff A to be prevented from working with Resident #3 in the future. I don't feel unsafe or not want Staff A around me. Staff A can work with me just fine, I just want Staff A to apologize. That is all. Resident #3 confirmed to the Administrator that she did not feel she was a victim of abuse, feels safe in the facility, and does not believe that Staff A intentionally upset Resident #3. The resident described the interaction as rude in nature and expressed a desire for an apology and further stated that no other concerns for receiving cares from Staff A in the future following a sincere apology. Staff A was immediately suspended at the time of the incident was reported on 4/10/26.The Trauma Screening Evaluation completed on 4/16/26 at 11:00 AM, documented per resident interview, is the resident a victim of abuse (physical, verbal, mental, in the past)? Response was yes with a response that the resident was a victim of verbal and physical abuse for 11 years by husband.The Plan of Care lacked any documentation of post trauma focus area and interventions for Resident #3.On 4/10/26 at 1:55 PM, observed Resident #3 was lying in bed on her back, call light attached to the left upper side rail and blanket over her.On 4/10/26 at 1:55 PM, Resident #3 stated that she was very upset, and explained on 4/3/26 about 6:40 AM, Staff A, came into my room and said hey, it is time to get up, and then left my room. Resident #3 stated she was puzzled that a staff member would come into my room and tell me that, so I threw my covers from across my legs and tried to move the bedside table away so that I could sit on the edge of the bed and try to reach my wheelchair for which had my clothes in it, I tried to get things moved and arranged so that I could get up and to the bathroom, then about 7:00 AM, Staff A came back into my room and said You are not up and dress, lets go. I asked Staff A if she can help me, Staff A said no I got other people to take care of, I thought to myself, like I am not people to. I was mad by this time and felt worthless, and that I was nothing and a nobody. I then got myself up and thankfully did not have an accident. I got into the bathroom and used the grab bar to stand up, sat down on the toilet. Staff A then came in again and said, what the hell are you doing. I was exhausted by this time from trying to get ready for breakfast. Staff A said let me help you put on your brief since you don't have it on right. I then went down for breakfast and ate. Resident #3 stated that while going down to the dining room, three staff were aware of the incident that happened.Interview on 4/10/26 at 2:20 PM, the facility Administrator stated was not aware of the incident that occurred on 4/3/26 and will start an investigation and visit with Resident #3.Interview on 4/15/26 at 12:15 PM, Staff B, Registered Nurse (RN) explained that Resident #3 came up to her, not sure of the date or time and stated that Resident #3 was upset that the brief was on sideways and if someone would come and assist with getting it changed. Staff B stated that there was no mention about an incident that happened between Resident #3 and Staff A. Staff B, explained that Resident #3 was more upset about the brief not being positioned correctly.Interview on 4/15/26 at 1:30 PM, Staff C, CNA, explained that on 4/4/26, around 12:00 PM, while giving Resident #3 eye drops, Resident #3 asked Staff C, to sit down on the edge of the bed, that Resident #3 wanted to tell Staff C something. Staff C stated that Resident #3 was upset that Staff A came into Resident #3 room, and Resident #3 clothes on the wheelchair and told Resident #3 that it was time to get up and then left the room, about 20 minutes later, Staff A came back into Resident #3 room and said 'what are you doing in the bathroom by yourself, and that Staff A assisted to get finish dressing. Staff C, stated that Resident #3 was visibly upset by crying and Resident #3 hit the top of the bed in frustration that this type of interaction occurred. Staff C stated that they told Staff B about the interaction between Staff A and Resident #3. Staff C, felt that it was more a respect and dignity issue rather that an abuse issue. Staff C, went onto say if it was considered an abuse issues, she would have separated Resident #3 and Staff A immediately. Staff C felt that it was a dignity and respect concern.On 4/15/26 at 1:45 PM, Staff A, CNA, stated that on 4/4/26 before breakfast, Staff A went into Resident #3 room and explained to Resident #3 that it was time to get up and placed Resident #3's leg brace, sock and clothes in Resident #3's wheelchair and that would be back after she answers a call light. Staff A came back into Resident #3 room, not sure of the time, and Resident #3 was already in the bathroom, standing up by using the grab bar and pulling up her brief, Staff A explained that she assisted with putting on the brief and pants and helped Resident #3 to sit in the wheelchair and then Resident #3 propelled herself out to the dining room for breakfast. Staff A explained that she did not mean to be rude and disrespectful to Resident #3.On 4/15/26 at 2:20 PM, the facility Administrator acknowledged that the expectation of all staff is to treat all resident's with dignity and respect, and follow the Resident Rights and Dignity policy and this is a good lesson learned by all.On 4/16/26 at 2:21 PM, Staff D, RN and Staff E, RN, both acknowledge that the expectation of all staff are to treat resident's with dignity and respect.The Resident Rights-Dignity and Respect policy dated 4/2024, documented that the purpose it to lay the foundation for treating all residents with dignity and respect and maintaining and enhancing his or her self-esteem and self-worth. Each resident has the right to considerate and respectful care and to be treated with honesty, dignity, respect and with reasonable accommodation of individual needs.

Based on clinical record review, facility investigation, resident and staff interview and review of policy and procedures, the facility failed to ensure all alleged violations of abuse involving mistreatment, verbal, and physical abuse, were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for 1 of 5 resident reviewed. (Resident #10). The facility reported a census of 40 residents.Findings include:Resident #10's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate impaired cognitive decisions. Resident #10 could understand others and others understood them. They had adequate vision with glasses and no behaviors or delirium and a schedule pain medication given daily. Resident #10 required partial to moderate assistance with all aspects of daily living (dressing, personal hygiene, transfers, oral hygiene and positioning) and one fall documented. The MDS included diagnoses of Non-Alzheimer's Dementia, hypertension, (a chronic condition where blood force against artery walls is consistently too high), heart failure, anxiety, depression and adult failure to thrive.The Care Plan Focus area with no date, indicated Resident #10 required assistance with activities of daily living, complaints of pain described as chronic due to lower back pain, and impaired cognitive function or impaired thought process such as short term/long term memory, easily confused, disoriented to place, time and situation, and needing assist with decisions. Interventions include: to keep routine and environment consistent, anticipate and meet all resident needs. Resident is impulsive and at times resistive to cares, if resistive with a staff member, switch out and have another staff attempt to assist resident. Substantial to maximal assistance of one staff for bed mobility, administer pain medications as ordered, evaluate pain level and monitor or alleviate activities that precipitate or aggravate pain.The Abuse Allegation Investigation Report dated 4/12/26, with an allegation date 3/10/26, notified on 4/12/26 by Staff F, CNA, that she received a phone call from Staff G, CNA, stating that she knew what current self-report investigation in the building entailed. Staff G, stated that she had witnessed Staff H, CNA, slap Resident #10's hand two times while completing cares. Administrator instructed Staff F, to immediately call Staff G and have her report this directly to the Administrator, per the education all staff had received regarding abuse reporting on 4/10/26. The facility does not have reason to believe the resident was abused by Staff H on 3/10/26. During the investigation, Staff G was not able to provide information as to why she did not immediately report this to a charge nurse or Abuse Coordinator, despite recently completing CNA training and facility education/expectations regarding alleged abuse. When questioned, Staff G, was not able to tell Administrator why she did not report this when she received a phone call for staff education on 4/10/26 regarding who the Abuse Coordinator is in the building and stated she just had not thought about it.The resident confirmed to the Administrator that she did not feel she was a victim of abuse, feels safe in the facility, and does not believe any staff harmed her. Resident was admitted to hospice services on 4/6/26 to assist with comfort and pain management. Staff do report this had been helpful in reducing resistance to cares, as she is more comfortable when they are working with her.On 4/17/26 at 9:55 AM, observed Staff F, CNA, and Staff I, CNA, transfer Resident #10 from the rock-n-go chair to the resident bed, during the transfer Resident #10 would say ow,ow,ow. Staff F explained to the resident that a transfer was being completed between the chair and bed. While Staff F and Staff I removed the hoyer lift sling from underneath Resident #10, while lying in bed, Resident #10 proceeded to keep saying ow,ow,ow.Interview on 4/17/26 at 11:00 AM, Resident #10 stated that no staff members have been mean to her during cares and that she feels safe at the facility.Interview on 4/16/26 at 3:25 PM, Staff G, CNA, stated that on 3/10/26 on the evening shift, Staff H and Staff G, were completing incontinent cares on Resident #10. Staff G felt that Staff H, was very fast and did not take her time with Resident #10. Staff G, felt that Staff H was rough when rolling Resident #10 from side to side, and Resident #10 was yelling, screaming and crying during the completion of incontinent cares. Staff G, verified that Resident #10 was hitting and swinging at Staff H while attempting to roll Resident #10 from side to side. Staff G, explained that Staff H, would take Resident #10's hands and slap them and explain to Resident #10 that cares needed to be completed. Staff G, stated that she did not know what to do with the situation that she observed and when an all staff education was completed on 4/10/26, Staff G, thought more and more about the incident and decided to call Staff F on 4/11/26. Staff F, informed Staff G, that it needed to be reported to the Administrator as soon as possible. Staff G, acknowledged that she had the Dependent Adult Abuse Reporting training and that from now on, Staff G, will report any allegation/accusation of abuse to the Abuse Coordinator right away. On 4/16/26 at 3:55 PM, Staff F, acknowledged that a phone call was received from Staff G on 4/11/26 and that Staff F, called the facility Administer to inform about an allegation of abuse that occurred on 3/10/26, and the Administrator explained to Staff F, that Staff G needed to call the Administrator right away. Staff F, explained that all allegations/accusations of abuse are to be reported right away to the charge nurse or administrator.On 4/16/26 at 4:22 PM, Staff H, explained that incontinent cares were completed on 3/10/26 about 8:45 PM, for Resident #10. Resident #10 was hitting/swinging while Staff H was rolling Resident #10 from side to side and that Staff H did pat Resident #10's hands to reassure that cares where going to be completed shortly. Staff H denied slapping Resident #10's hand during the incontinent cares that were provided.On 4/17/26 at 10:33 AM, Staff J, Licensed Practical Nurse (LPN), confirmed that on 3/10/26, Staff H and Staff G removed Resident #10 from the lobby area and took into Resident #10's room. Staff J stated that no yelling or screaming was heard coming out of Resident #10's room for which was right across from the nurses station and that Resident #10 will hit/scream/bite at staff members that are attempting to complete cares or do a transfer. Staff J, acknowledged that all staff had the Dependent Adult Abuse education on 4/10/26 and any allegation or accusation of abuse needs to be reported right away.On 4/17/26 at 12:02 PM, the facility Administrator acknowledged that all staff are expected to report any allegations of abuse or accusations to the Abuse Coordinator right away.Review of the Patient Protection Guidelines for Abuse Prevention, Reporting and Investigation dated 9/2025, residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, family members friends or other individuals. All allegations of Resident abuse should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. Report all allegations of Resident abuse to the Iowa Department of Inspection and Appeals and Licensing immediately and not later than two (2) hours.

Based on clinical record review, hospital encounter, and staff interview the facility failed to document on a resident with a change in condition for 1 of 6 residents reviewed. (Resident #2). The facility identified a census of 40 residents. Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive decisions. Resident #2 could understand others and others understood them, had adequate vision and hearing. Resident #2 was dependent with personal and toileting hygiene, dressing, transfers and was independent with oral cares and eating and no shortness of breath documented. The MDS included diagnoses of hypertension, (a chronic condition where blood force against artery walls is consistently too high), heart failure, renal failure, diabetes mellitus and adult failure to thrive.The Care Plan Focus area with a cancel date 3/30/26, indicated Resident #2 was at risk for ineffective breathing pattern related to congestive heart failure, resident becomes short of breath with exertion. Interventions include: to elevate head of bed, encourage participation in coughing, deep breathing and forced expiratory techniques as ordered, evaluate for shortness of breath, respiratory rate and effort and provide a calm and reassuring manner. Monitor and report to practitioner any signs or symptoms of cardiac complications.The Health Status Note documented on these dates and times:On 3/1/26 at 2:09 AM, resident requesting cough medicine at this time for unproductive dry cough.On 3/3/26 at 12:02 PM, upon administering AM medications resident complained of cough. Reports that it is a productive dough, and that her chest hurts from coughing all night long. She reports that she is having a hard time getting comfortable. Decreased appetite, and fatigue. Crackles noted to bilateral lobes. She has been utilizing an as needed albuterol nebulizer (a fast acting bronchodilator used to treat acute breathing issues, by opening up airways with a medication mist).On 3/3/26 at 5:41 PM, resident has not been feeling well this shift. She received new orders from provider and has been in bed resting thought out the shift as she has refused to get out of bed other than to go to the bathroom. Appetite has been poor today. She refused breakfast, but ate soup for lunch. Staff encouraging fluids with each interaction.ON 3/4/26 at 4:55 AM, resident requested to go to hospital. Primary care provider called and gave order to send by ambulance.The clinical record lacked documentation of any further assessment on the resident with a change in condition.The Patient Care Report dated 3/4/26 at 7:48 AM, the chief complaint as upper respiratory infection is declining. Dispatched at 6:50 AM for a patient with respiratory issues. Arrived on scene to find patient in lateral recovery position holding a garbage can off the side of the bed and having a tough time breathing, labored. I asked the nurse how long she had been like this and she said, most of the night. I used a pulse oximeter on finger monitor and received a reading of 83% oxygen saturation.The Encounter form dated 3/4/26 at 1:26 PM, chief complaint: shortness of breath, generalized weakness, patient transferred from care center for shortness of breath requiring more oxygen. It is understood patient has been coughing and requiring more oxygen. Patient have pain coughing up sputum. Patient is currently RSV positive and hypoxic on examination. Principle problems include: acute hypoxic respiratory failure requiring 2 liters of oxygen by high-flow nasal cannula. Suspected aspiration pneumonia, acute bronchitis with bronchospasm and generalized weakness.On 4/17/26 at 1:48 PM, Staff E, Registered Nurse (RN) acknowledged that the clinical record lacked documentation of lung sounds being completed and that it is an expectation of nurses to document abnormal lungs sounds per the standard of practice. The facility has a change of condition policy but no actual policy for assessment to be completed.

Based on record review, staff, and resident interview, the facility failed to ensure adequate assessment and timely intervention of a resident's complaints, and adequate monitoring of a resident on Intravenous (IV) antibiotics for 1 resident reviewed (Resident #26). The facility reported a census of 35 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #26 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, peripheral vascular disease, benign prostatic hyperplasia, diabetes, stroke, pacemaker, and a below the knee right leg amputation. The resident had an indwelling urinary catheter, and Intravenous (IV) access. The Care Plan identified the resident required the use of an indwelling catheter related to urinary retention (resolved due to no longer having a catheter), with a goal the resident would remain free of complications related to the catheter. Interventions included monitoring for pain/discomfort due to catheter use, providing catheter care, and urology consult as needed. The resident's Progress Notes documented the following:On 8/14/25 at 12:25 p.m. the nurse was called to the resident's room for the resident requesting to speak with her. The resident stated he was pissing straight blood, and he needed to be seen today. He said he had an appointment with urology the next day, but he could not wait. The nurse explained she would get ahold of the provider for further guidance.On 8/14/25 at 1 p.m. placed a call to the provider's office and a voicemail left for the nurse to return this nurse's call in regards to bright red blood noted in the resident's catheter bag, and the resident complaints it hurt like hell. The resident did receive as needed (PRN) Morphine at 12:30 p.m.On 8/14/25 at 1:23 p.m. the resident transferred himself into his wheelchair and came to the nurses station with the same complaints. The nurse explained that she had a call out to his provider and waiting on call back. The resident became very angry and shouted, he had heard that so much, and the last time it took 5 days. He said he would just call 911 himself and sped off in the wheelchair back to his room. The Director of Nursing (DON), Social Worker (SW), and the Administrator went to the resident's room and attempted to speak with the resident.On 8/14/25 at 1:28 p.m. call placed (to provider) and asked for any available nurse to speak with in regards to the resident's complaint. The nurse sat on hold for 12 minutes before the receptionist got back on the line and stated that she would have a nurse call this nurse back when she got out of a patient room.On 8/14/25 2:13 p.n. the provider returned call with the new order to transfer to to the hospital for urinary pain and bleeding.On 8/14/25 at 3:25 p.m. called and spoke with first call and gave the nurse report in regards to the resident coming to the emergency room (ER). On 8/14/25 at 3:28 p.m. transportation left to transport the resident to the ER.On 8/15/25 at 1:30 a.m. the resident returned to the facility at 10:30 p.m. The resident was diagnosed with urinary retention. The catheter the resident had in place prior to the ER visit was replaced with a larger catheter, and had been draining freely according to the progress update written by the physician. The clinical record lacked documentation the facility did any assessment related to the resident's complaints of pain or bleeding. On 9/22/25 at 12:09 p.m. Resident #26 was very upset about one of the times he went to the hospital. He was having severe pain low in his abdomen and blood in his catheter. He wanted to go to the hospital and told by the Administrator that he could not go by ambulance because it wasn't a life threatening condition. He was very upset and waited several hours to get there, and he was in severe pain. He said when he got to the hospital his bladder was blocked. They had to do several procedures to get it open again. The resident said he had a bad heart and this kind of stress did not do good for it. This bothered him ever since it happened. The resident no longer had a catheter. On 9/22/25 at 1:11 p.m. the resident's family member stated all she knew was the resident called her and begged her to call the facility and tell them he needed to go to the hospital. She thought she talked with Administrator and was told he could not go by ambulance because it was not life threatening. She was told they had to wait for a physicians order, then had to wait for the transport van to return. They thought the resident had played with his catheter and his penis was sore. On 9/23/25 at 1:50 p.m. Staff A Licensed Practical Nurse (LPN) stated she worked 8/18/25 when the resident said he was bleeding in the catheter bag. She said she did not see blood, she just went by what the resident said. She called the provider's office and left a message. Before she had heard back from them, the resident came to the nurses station, very upset, and said he would call 911 himself. The DON (currently off), the SW, and the Administrator (on leave) went to talk to the resident to try and calm him down. She said there was something said about the resident not being transferred by ambulance because it was not life threatening. Staff A stated she did not take Vital Signs (VS) or check the resident's catheter bag, but she thought the DON had. She didn't know where she might have documented that. On 9/25/25 at 8:29 a.m. the Administrator (currently off) stated she became involved the day the resident wanted to go to the hospital because she was informed that he was very upset that he had to wait. She went and talked to the charge nurse, Staff A. She stated that she had tried to call the provider and left a message and was waiting for a call back. The Administrator went and talked to the resident and said that they didn't know if this would be the kind of thing that would require the ambulance and that the transport vehicle would be coming back soon and they would get him to the hospital. The Administrator remembered asking the charge nurse if they had assessed the resident and she said they had and that his vital signs were okay. The Administrator didn't know or remember if the catheter was draining or had blood in it. She herself did not see any part of it to know. She said they sent him and brought him back later. She had talked to his family after he went to the hospital, and she had voiced concern that they had to wait for the doctor to get back to them, and was not very happy about that. She doesn't recall telling the resident he couldn't go by ambulance because it wasn't life threatening. She didn't feel that it came out exactly that way. She said the resident had been transferring himself that day and that he may have pulled the catheter, causing discomfort and bleeding. On 9/25/25 at 10:30 a.m. the Nurse Consultant stated she had attempted to reach the DON, but she had just recently had surgery. 2) The Care Plan identified the resident on Enhanced Barrier Precautions (EBP) related to a Peripherally Inserted Central Catheter (PICC) Line, and diabetic ulcer wounds, with a goal to minimize the risk for transmission during high contact care activities with a target date of 11/17/25. The Medication Administration Record (MAR) for August 2025 documented the resident had an order for Vancomycin intravenous solution 1000 mg per 200 ml every 12 hours for infection with a start date of 8/6/25 and a stop date of 8/25/25. The Progress Notes documented the following:On 8/20/25 at 10:19 a.m. the resident left the facility for an appointment with infectious disease.On 8/20/25 at 1:13 p.m. transportation returned to the facility with the resident's wheelchair, and the following statement: Sent to the ER due to fever, dizziness, and abdominal pain. Questioned Urinary Tract Infection (UTI) and Sepsis, and signed by the Dr. On 8/20/25 at 6:15 p.m. received call from the ER notifying the resident would be admitted overnight due to a UTI. On 9/24/25 at 10:32 a.m. the Infection Preventionist (IP) stated when residents were on antibiotics they were on Hot Charting so they would be monitored and documented on at least daily. She said with a PICC line they would have VS daily and the documentation of VS would be on the MAR/TAR. She didn't know if there was a policy. The Treatment Administration Record (TAR) for August 2025 showed the resident had vital signs recorded on 8/7/25, and no other dates. The clinical record lacked documentation the facility monitored the resident related to the use of IV antibiotics via a PICC line. The facility policy, Alert Charting Guidelines revised 10/2023, documented the purpose to provide a guideline for monitoring documentation that may be needed following a change in resident condition or status. The Alert Charting Log is a tracking and communication system to alert licensed nurses to changes in a patient's condition that warrants continued observation. Examples of situations typically included on the Alert Charting Log included an acute or significant change of patient condition. Patients are entered on the Alert Charting Log when they are identified as requiring continued follow-up and documentation. Patients should remain on the log for a minimum period of 72 hours unless their condition has improved. Patients are removed from the Alert Charting Log when the resident's status had stabilized or the condition or symptom prompting the initial placement on the log had been resolved/stabilized.

Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance committee (QA) was attended by the required members to include 1) the Nursing Home Administer (NHA) or representative, 2) Director of Nursing (DON), 3) the Medical Director (MD) or representative and 4) 2 other members of the facility's staff present on a minimum of a quarterly basis. The facility reported a census of 77. Findings include: The Quality Assurance Committee Meeting Sign In sheets were provided by the facility since the facility's last recertification survey on 10/24/25. The first QA committee meeting was held on 2/28/25. The Medical Director or a designee for the Medical Director was not present. On 9/25/2025 at 2:24 PM Administrator acknowledged the concern that the Medical Director or his/her designee was not in attendance for the February QA meeting. A QAPI Quality Assurance Performance Improvement) Policy dated 10/2023, directed the following: Purpose: To describe the process steps for identification and resolution of actual or potential areas affecting qualityProcedure:1. The facility must maintain documentation and demonstrate evidence of its ongoing QAPI program.2. QAPI team must develop and implement appropriate plans of action to correct identified quality of care, quality of life or safety problems.3. QAPI team will monitor medical errors and adverse events and will systematically identify, report, track, investigate, analyze, and use data related to medical errors/adverse events within the facility to develop activities to prevent medical errors/adverse events.4. QAPI program must include the following five (5) elements:Design and scopeGovernance and leadershipFeedback, data systems and monitoringPerformance improvement plans (PIPs)Systematic analysis and systematic action5. Facilities QAPI must address all systems of care and management practices and include clinical care, quality of life, and resident choice. It should utilize the best available evidence to define and measure performance indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents. Facilities will use tools as defined in the Facility QAPI Plan to develop, monitor, and evaluate performance indicators.6. Input from direct care staff, other staff, residents, and resident representatives will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. The facility may use staff interviews, small group meetings, buddy program audit tools, and observations to aide in obtaining feedback. The feedback will be used to assist in Performance Improvement Plan (PIP) development.7. The QAPI team must regularly review and analyze data, including data collected under the QAPI program, including but not limited to the facility assessment and will act upon findings/data collected to improve performance. The members of the QAPI committee must meet at least quarterly and as needed to coordinate and evaluate effectiveness of activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program. The facility will have a facility specific QAPI Plan that is reviewed annually at a minimum.

Based on clinical record review and staff interviews the facility failed to complete a follow-up PASRR and resubmit to ASCEND for reevaluation according to the Preadmission Screening and Resident Review (PASRR) for 1 out of 1 resident reviewed, (Resident #11). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented diagnoses of anxiety disorder, depression, bipolar disorder and schizophrenia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Review of Resident #11's clinical record revealed that a Level 1 PASRR was completed on [DATE] with an approval period for 60 days that expired on [DATE]. Review of Resident #11's clinical record revealed that a Level 1 PASRR was completed on [DATE] with a Level 1 Outcome to refer for Level II onsite. Review of PASRR dated [DATE] revealed that the Level 1 screen was submitted on [DATE] over 4 months after the prior PASRR expired thus causing a compliance issue for the nursing facility. Review of Resident #11's clinical record revealed that a Level II PASRR was completed on [DATE] with a determination of short term approval ending [DATE]. Review of Resident #11's clinical record revealed that a Level 1 PASRR was completed on [DATE], after the ending date of [DATE]. Review of the Maximus PASRR and Level of Care Screening Procedures for Long Term Care Services revised on [DATE] revealed the purpose of the Level I screen is to identify individuals intended for evaluation through the PASRR Level II process, those individuals with known or suspected mental illness (MI) and intellectual disability (ID) or related condition (RC). The purpose of the Level I screen is to identify individuals intended for evaluation through the PASRR Level II process - those individuals with known or suspected MI and ID/RC. Effective [DATE], the Level I screen must be electronically submitted to Maximus; Before admission to a Medicaid-certified nursing facility (regardless of the applicant ' s method of payment) For residents of Medicaid certified nursing facility (NF) ' s experiencing changes in status that suggests the need for a first-time or updated PASRR LevelII evaluation as described in Section I.f of this document; Prior to the conclusion of an assigned time-limited stay for individuals with MI and/or ID/RC whose stay is expected to exceed a time-limited approval. Interview on [DATE] at 10:12 AM, with the Administrator revealed that the PASRR ' s were late when being resubmitted because she has been doing the Administrator position and Social Worker position since [DATE] until about 3 weeks ago.

Based on clinical record reviews, staff interviews and policy review, the facility failed to put effective interventions in place, and provide levels of assistance as directed by the Care Plan for Resident for 1 of 3 residents reviewed, (Resident #21). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 21 documented diagnoses of Alzheimer ' s Disease, depression, heart failure (inability for the heart to pump), and hypertension (high blood pressure). The MDS showed the Brief Interview for Mental Status (BIMS) score a 4 indicating severe cognitive impairment.The MDS listed Resident #21 as partial or moderate assistance for transfers, ambulation and toilet transfers. The Facility Incident Reports (IR) documented from November 2023 - October 2024 revealed Resident #21 fell on [DATE], 1/17/24, 1/30/24, 7/2/24, 8/2/24, and 10/15/24. The Care Plan with a target date of 11/11/24 revealed Resident #21 is at risk for falls related to gait, balance problems and dizziness. The interventions directed the following: Attach call sensitive call light to resident ' s blanket so that staff can be alerted when the resident attempts to self transfer. Do not leave me in the dining room unattended. Ensure that I am wearing appropriate footwear when I am ambulating, transferring, or mobilizing in a wheelchair. Frequent visual checks for her safety. I am on a diuretic in the AM which puts me at risk for falls. I am to wear slip-on shoes so I am not at risk tying lace shoes. I am unable to use my call light/pendant. Please anticipate and meet all my needs. I have an easy touch call light. Ensure my touch paddle call light is on top of my bed when I am in bed so if I choose to get up on my own, it will alert staff to come help me. I have been screened by occupational therapy (OT) and they have deemed it unsafe for me to have a lift chair. My lift chair in my room has been unplugged for my safety d/t my dementia, I cannot run my lift chair on my own. I often choose to self-transfer and not wait for staff to help me. I have a sign on my walker reminding me to take my walker with me wherever I go due to my memory. I forget to take my walker with me at times, this sign reminds me not to forget. Educate me on the need to use a walker for ambulation if I am not using it. I also have a sign on my wall and in my bathroom reminding me to keep my walker with me. I will sit at the nurse station when it is close to meal times. Review information on my past falls and attempt to determine the cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate me, my family, caregivers, and the interdisciplinary team as to potential causes. Staff are to assist me with making my bed when assisting me with AM cares. The Progress Notes dated 8/2/24 at 9:52 PM revealed Resident #21 had an unwitnessed fall in the dining room and received a superficial laceration to the left side of her head with a hematoma above it. Resident #21 also received a skin tear to the left elbow. The Progress Notes revealed they will discuss further interventions with the care team at a later date. The Progress Notes dated 10/15/24 revealed Resident #21 was found on the floor beside the wheelchair by staff walking into the dining room. Upon approaching Resident #21 revealed she was attempting to get up to go to the bathroom. The intervention for the fall was staff education provided on current fall interventions related to Resident #21 in the dining room. Review of the facility Care Plan History revealed the intervention of do not leave me in the dining room unattended was put into place as of 6/30/23. The facility policy named Fall Risk Assessment and Intervention with a revision date of 6/25/12 revealed residents will be assessed upon admission, re-admission, and change in condition for potential risk factors associated with falls. Initial interventions specific to the resident will be implemented at the time of the assessment. The assigned nurse will complete the tool on new admission, readmissions, and residents experiencing a significant change in condition. Determine the risk factors placing the resident at risk for falls by highlighting or circling those factors. Determine what interventions could be used, specific to the resident, and highlight or circle the appropriate interventions and or write additional interventions. The nurse completing the fall assessment will be responsible to communicate interventions to appropriate staff. Risk factors and interventions identified on the fall assessment tool should be carried over and used to facilitate development of the resident ' s plan of care. Elicit ideas to reduce the likelihood of falls from the resident family members, therapies, physician and interdisciplinary staff. Orthostatic blood pressure should be taken, if possible, following a fall to determine whether the fall could be related to dizziness associated with sudden drop in blood pressure with position changes. Should the resident experience a fall, an Incident Report and Quality Assurance Investigation form will be completed. Each fall will be assessed to try to determine the cause of the fall. The care plan must be reviewed with each occurrence and new or different approaches added relative to the assessed cause of the fall. Each addition to the care plan will be initialed by the person who added the new intervention followed by the date the new measure was initiated. Should a fall occur, the nurse will be responsible to assess the resident for injuries, notify the family and physician of the occurrence, and document results of findings in the Interdisciplinary notes of the residents medical record.

Based on clinical record review, resident interview, family interview, staff interviews, facility records and facility policy review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility for 3 of 3 residents reviewed ( Resident #24, #22 and #3). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #24 dated 9/20/24 assessment identified a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. The Clinical Census revealed Resident #24 resided in room [ROOM NUMBER]-1. On 10/21/24 at 11:38 AM, Resident #24 reported she has waited for her call light to be answered for up to 45 minutes. She stated it has happened on several occasions but could not remember what time of day. She reported she used her phone to time the call light response. She stated she almost had a bowel and bladder accident from waiting for the call light to be answered. She stated she has gotten good at holding her bladder/bowel. A facility call light report for 9/23/24 to 10/23/24 revealed Resident #23 had the following call lights over 15 minutes: 9/24/24 at 7:03 PM= 27 minutes 9/25/24 at 6:58 PM= 19 minutes 9/26/24 at 4:34 PM= 21 minutes 9/26/24 at 7:08 PM= 18 minutes 9/27/24 at 6:33 AM = 19 minutes 9/28/25 at 7:32 AM= 18 minutes 9/28/24 at 9:04 PM= 21 minutes 9/29/24 at 4:52 AM= 21 minutes 9/29/24 at 1:02 PM = 25 minutes 10/1/24 at 4:49 PM= 17 minutes 10/2/24 at 8:34 AM= 20 minutes 10/2/24 at 12:56 PM =18 minutes 10/2/24 at 4:34 PM =33 minutes 10/2/24 at 8:32 PM= 17 minutes 10/3/24 at 12:08 AM= 17 minutes 10/3/24 at 4:43 AM= 17 minutes 10/3/24 at 6:51 AM= 18 minutes 10/3/24 at 2:00 PM= 19 minutes 10/3/24 at 7:22 PM= 34 minutes 10/5/24 at 6:52 AM= 32 minutes 10/7/24 at 8:52 AM= 18 minutes 10/9/24 at 10:40 AM= 20 minutes 10/11/24 at 6:34 AM= 19 minutes 10/12/24 at 6:56 PM= 29 minutes 10/13/24 at 7:10 AM= 45 minutes 10/13/24 at 3:26 PM= 21 minutes 10/14/24 at 3:05 AM= 26 minutes 10/14/24 at 6:52 AM= 20 minutes 10/14/24 at 10:14 AM= 20 minutes 10/15/24 at 6:25 PM= 22 minutes 10/16/24 at 7:29 PM=21 minutes 10/17/24 at 6:37 PM= 20 minutes 10/18/24 at 6:41 AM= 23 minutes 10/19/24 at 12:48 PM=21 minutes 10/19/24 at 6:32 PM= 20 minutes 10/21/24 at 9:42 PM= 17 minutes 10/22/24 at 10:21 AM= 23 minutes 10/23/24 at 7:12 AM= 42 minutes 2. The MDS for Resident #22 dated 9/18/24 assessment identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The Clinical Census revealed Resident #22 resided in room [ROOM NUMBER]-2 Triple. On 10/21/24 at 3:01 PM, Resident #22 ' s Niece/POA reported she had a concern at the facility related to staffing and call light response times. She stated Resident #22 complained of long call lights (20 minutes) on the weekend. She stated the facility had provided call light reports to her in the past. She stated Resident #22 can get anxious and upset quickly regarding her call light. She reported Resident #22 ' s anxiety feeds on itself. Resident #22 ' s niece/POA requested that the surveyor look at a recent call light report while at the facility. A facility call light report for 9/23/24 to 10/23/24 for room [ROOM NUMBER] bed #2, #3 and #4 revealed Resident #22 had the following call lights over 15 minutes: 9/23/24 at 7:23 AM= 22 minutes 9/23/24 at 12:53 PM= 19 minutes 9/23/24 at 7:28 PM= 20 minutes 9/24/24 at 10:44 AM= 20 minutes 9/24/24 at 6:29 PM= 21 minutes 9/25/24 at 6:59 PM= 21 minutes 9/26/24 at 8:25 AM= 19 minutes 9/26/24 at 4:17 PM= 24 minutes 9/26/24 at 5:33 PM= 19 minutes 9/27/24 at 8:09 AM= 33 minutes 9/27/24 at 6:56 PM =21 minutes 9/28/24 at 8:15 AM= 21 minutes 9/28/24 at 9:25 AM= 19 minutes 9/28/24 at 7:07 PM= 24 minutes 9/29/24 at 8:26 AM= 19 minutes 9/29/24 at 8:59 AM= 18 minutes 9/29/24 at 7:52 AM= 28 minutes 9/30/24 at 9:12 AM= 34 minutes 9/20/24 at 4:26 PM= 20 minutes 10/1/24 at 4:51 PM= 41 minutes 10/1/24 at 7:44 AM= 48 minutes 10/1/24 at 12:00 PM= 20 minutes 10/1/24 at 2:27 PM= 21 minutes 10/2/24 at 8:42 AM= 23 minutes 10/3/24 at 7:03 AM=19 minutes 10/3/24 at 11:28 AM= 20 minutes 10/3/24 at 6:44 PM= 29 minutes 10/4/24 at 6:34 AM= 20 minutes 10/4/24 at 7:31 AM= 19 minutes 10/4/24 at 12:48 PM= 34 minutes 10/4/24 at 6:13 PM= 20 minutes 10/5/24 at 7:35 AM= 25 minutes 10/5/24 at 7:43 PM= 22 minutes 10/6/24 at 7:40 AM= 27 minutes 10/7/24 at 9:12 PM= 22 minutes 10/8/24 at 6:14 AM= 31 minutes 10/9/24 at 5:26 AM= 22 minutes 10/10/24 at 6:12 AM= 23 minutes 10/10/24 at 8:09 AM= 22 minutes 10/10/24 at 6:57 PM= 21 minutes 10/10/24 at 7:23 PM= 22 minutes 10/12/24 at 8:08 PM= 19 minutes 10/13/24 at 8:35 AM= 33 minutes 10/14/24 at 8:27 AM= 23 minutes 10/15/24 at 11:26 AM= 19 minutes 10/15/24 at 6:35 PM= 20 minutes 10/16/24 at 6:41 AM= 49 minutes 10/17/24 at 12:37 PM= 23 minutes On 10/23/24 at 3:01 PM, the Administrator reported the facility had started a PIP (Process Improvement Plan) team in September related to an increase in call light times for various reasons. On 10/23/24 at 3:43 PM, the Administrator reported her expectation was for all call lights to be answered within 15 minutes or less. She stated that the goal of the PIP team was for call lights to be answered in under 15 minutes. On 10/24/24 at 8:30 AM, the Administrator acknowledged Resident #22 long call light times. She reported Resident #22 had anxiety and used her call light frequently. She reported Resident #22 was admitted to Hospice level of care this week. She reported the call light PIP team was working on getting back to consistent staff assignments and establishing resident routines to help decrease call light response time. The Administrator also reported there had been some malfunctions with the call light application and she had been working with IT to get the concerns addressed. On 10/24/24 at 9:15 AM, Staff A, LPN (Licensed Practical Nurse) reported call light response time can vary depending on the residents and staffing. She stated call lights can go over 15 minutes at times but usually it was because the staff member forgot to turn the light off. On 10/24/24 at 10:23 AM, Staff B, CNA (Certified Nursing Assistant) reported for the most part, she felt the facility was staffed appropriately. She stated there were times when the call lights would go over 15 minutes. She stated she felt the facility was trying to work on staffing and call light response times. On 10/24/24 at 10:26 AM, Staff C, CNA reported staffing and the ability to answer call lights depends on the day and what you walk in to. She reported there was a meeting recently and long call lights (over 15 minutes) were discussed. She stated the Administration told the staff they could ask for help with the call lights when needed. She reported she really has not gotten the help when she has asked for it. She verified call lights go over 15 minutes at times. The facility policy titled Call Light Policy revised 7/26/24 documented it was the policy of the facility to ensure that there was prompt response to the resident's call for assistance. The facility to ensure the call light system was in proper working order. The policy documented the facility shall answer call lights in a timely manner. 49056 3. Resident #3 ' s MDS assessment dated [DATE] identified a BIMS score of 13, indicating intact cognition. Resident #3 required partial/moderate assistance for transfers, personal hygiene. Resident #3 required substantial/maximal assistance for toilet use. The MDS included diagnoses of hypertension (high blood pressure), cancer, heart failure and renal insufficiency. During interview on 10/21/24 at 12:37 PM Resident #3 reported call light times are terrible. Resident #3 reported that sometimes the call light works well and sometimes the staff are not aware it is on. Resident #3 reported they forgot about her for 1/2 hour. Resident #3 reported that she watched the clock and had a terrible time. Resident #3 reported that she has been incontinent of bowel at times. Review of facility call light reports dated from 9/23/24 to 10/20/24 for Resident #3 revealed: a duration of 26 minutes on 9/23/24 at 5:05 PM a duration of 22 minutes on 9/24/24 at 11:31 AM a duration of 36 minutes on 9/25/24 at 9:09 AM a duration of 24 minutes on 9/25/24 at 11:12 AM a duration of 22 minutes on 9/27/24 at 12:36 PM a duration of 26 minutes on 9/27/24 at 9:41 PM a duration of 33 minutes on 9/28/24 at 1:13 PM a duration of 21 minutes on 9/29/24 at 10:59 AM a duration of 25 minutes on 9/30/24 at 7:54 AM a duration of 23 minutes on 9/30/24 at 8:57 PM a duration of 24 minutes on 10/1/24 at 7:37 AM a duration of 23 minutes on 10/1/24 at 6:41 PM a duration of 26 minutes on 10/3/24 at 1:35 PM a duration of 27 minutes on 10/7/24 at 4:54 PM a duration of 26 minutes on 10/9/24 at 11:13 AM a duration of 28 minutes on 10/10/24 at 11:39 AM a duration of 24 minutes on 10/11/24 at 9:16 PM a duration of 29 minutes on 10/14/24 at 1:15 PM a duration of 25 minutes on 10/15/24 at 12:19 PM a duration of 25 minutes on 10/17/24 at 11:14 PM a duration of 26 minutes on 10/18/24 at 2:10 PM a duration of 21 minutes on 10/19/24 at 6:56 AM a duration of 22 minutes on 10/19/24 at 11:00 AM.

Based on record review, interview, and facility policy the facility failed to have the minimum number of required members for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 36. Findings include: On 10/24/24 at 11:24 AM, review of the facility documents titled QAPI meeting revealed: Document dated 5/7/24 lacked the signature of the Infection Preventionist (IP). Document dated 6/2024 lacked the signature of the IP. Document dated 7/2024 lacked the signature of the IP. Document dated 9/10/24 lacked the signature of the IP. Document dated 10/8/24 lacked the signature of the IP. Review of the facility provided document titled Quality Assurance Performance Improvement (QAPI) Plan with an effective date of March 1, 2024 revealed the QA meetings are held at minimum on a quarterly basis; more frequently, if necessary with Medical Director, Director of Nursing, Administrator, Infection Preventionist and additional members including social services, therapy, housekeeping, laundry, maintenance, dietary manager and pharmacy consultant. During interview on 10/24/24 at 12:10 PM, the Administrator acknowledged and verified the IP was not at the QAPI meetings. The Administrator stated that the IP was probably working the floor during the QAPI meetings. The Administrator revealed that they went over the IP ' s information during the meetings.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for pressure ulcers, (Resident #33). The facility reported a census of 36 residents. Findings include: Resident #33's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 05, indicating severely impaired cognition. The MDS identified Resident #33 required partial/moderate assistance with transfers including to the toilet. The MDS documented Resident #33 was occasionally incontinent of urine. Resident #33 ' s MDS included diagnoses of hypertension (high blood pressure), legally blind, and anxiety disorder. The MDS documented Resident #33 had one stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed). The Care Plan with target date of 9/11/24 revealed Resident #33 had a pressure ulcer on the coccyx related to immobility. The care plan documented Resident #33 required staff assistance for her toileting needs. On 10/21/24 and 10/22/24, observation revealed a enhanced barrier precaution sign was not on Resident #33's door. On 10/22/24 at 3:28 PM, observed Staff D, CNA (certified nursing assistant) and Staff E, CNA transfer Resident #33 to the commode using a gait belt and a pivot disk. Staff E reported Resident #33 ' s incontinent brief was a little wet. Staff E removed the dirty brief and threw it in the garbage. Staff E removed his gloves and sanitized his hands. Staff D applied a new brief, removed his gloves and washed his hands. The DON (Director of Nursing) offered to pull back the wound dressing on the buttocks so the surveyor could see the pressure ulcer when Resident #33 stood up. Staff E reapplied the gait belt. Staff D applied gloves. Staff E stood Resident #33 up using the gait belt and a pivot disk. Staff D cleansed the front perineal area. While Resident #33 was standing, the DON partially removed the wound dressing on the buttocks enough to visualize the wound and then replaced the dressing. Staff D then completed peri care in the back. Staff D removed his gloves. Staff D did not complete hand hygiene after completing peri care and removing the gloves. Staff D then pulled up Resident #33 brief, pants and assisted Staff E with transferring Resident #33 to the recliner. Staff D moved the table next to the recliner and assisted Staff E with scooting Resident #33 back in the recliner. Staff D then put on a pair of gloves without completing hand hygiene and handed a blanket to Staff E to place on Resident #33. Staff E gathered up the trash with his gloved hands and took it to the bathroom. Staff E then removed his gloves and washed his hands. During observations both the CNA's and the DON did not wear a gown during high contact resident care activities. On 10/22/24 at 3:45 PM, the DON acknowledged and verified enhanced barrier precautions were not in place related to Resident #33 ' s chronic pressure ulcer. She reported that the staff should have worn gowns.The DON also acknowledged hand hygiene should have been completed after peri care was completed and the gloves removed. A facility policy titled Infection Prevention and Control Program Guidelines reviewed 1/5/24 documented hand hygiene should be performed before and after assisting a resident with toileting (hand washing with soap and water) and after removing gloves. The policy reported Enhanced Barrier Precautions was an approach of targeted gown and glove use during his contact resident care activities, designed to reduce transmission of staphylococcus aureus and multi drug resistant organisms. The policy documented enhanced barrier precautions may be applied to residents with chronic wounds. The policy further documented high contact resident care activities that required a gown and gloves for enhanced barrier precautions included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff maintained a safe and secure environment for 1 of 3 residents reviewed, (Resident #1). The facility identified a census of 38 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 9/22/23 indicated Resident #1 had diagnosis that included cancer, anemia, coronary artery disease (CAD), diabetes mellitus (DM), non-alzheimer's dementia and parkinson's disease. The assessment indicated the resident as rarely/never understood others, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (severely impaired cognitive skills), transferred and required locomotion assistance of staff on and off the unit with extensive assistance of two (2) staff and non-ambulatory. A Fall Risk Assessment form dated 6/15/23 at 5:35 a.m. identified the resident as at a moderate risk for falls. According to the facilities internal investigation form (not dated) the resident transferred with a standing lift device and 2 staff assistance and self propelled his wheel chair. On 9/25/23 at 12:30 p.m. the resident had been found as he laid in the entry way of his room on the floor with his feet towards the door and his head towards the foot of his bed, on his right side with his right arm pinned underneath him where his hands/fingers were visible by his right buttock area. Staff A, Certified Nursing Assistant (CNA) stated the resident had been close to his doorway to his room as he attempted to propel himself off the carpet to the hardwood floor without success. The CNA assisted the resident over the area as the resident leaned forward too far and caught his feet under the wheel chair, which caused him to fall forward onto the floor, face first. Immediately Staff B, Registered Nurse (RN) assessed the resident with limited range of motion (ROM) performed due to the position on the floor and the staff inablity to have repositioned him up off the floor. The resident remained alert and talked most of the time. The resident sustained a laceration on his right eye that measured 2.0 centimeters (cm) by (x) 0.5 cm, a scraped right knee that measured 5.0 cm x 5.0 cm and a right knee laceration that measured 2.0 cm x 5.0 cm. The staff transferred the resident to a local emergency room (ER/ED) who then transferred the resident to another hospital where then neurologist determined there had been no evidence of a brain hemorrhage or spinal fractures. Upon discharge the resident returned to the facility at his prior level of function. During an interview on 12/7/23 at 1:33 p.m. Staff A, Certified Medication Aide (CMA) and (CNA) indicated the resident had been positioned in the hallway about 10 feet away from the doorway of his room as he propelled himself in his wheel chair. As the staff member came down the hallway with another resident the 2 could not get around the resident so the staff member directed resident #1 to have picked up his feet which enabled her assistance through his doorway to the room. As the staff member attempted to propel the resident into his room he placed his feet on the floor. The staff member then felt resistance and the resident fell forward straight onto his face while she tried to grab him. The staff member described the resident as without capability to have placed his hands out in front of him as a means to have broken the fall. The staff member immediately called for assistance. Staff B, RN responded right away. The staff member completed an assessment which included ROM and vital signs. Following the assessment the staff members placed a sling device and transferred him from the floor to his bed with five (5) staff members present and eventually transferred him to the local hospital. The staff member confirmed she failed to have placed the resident's foot rests on his wheel chair prior having propelled the resident into his room. During an interview on 12/7/23 12:31 p.m. Staff C, CNA confirmed when staff propelled residents in a wheel chair, at any time, even over a door stoop, foot rests had been required on the wheel chair. During an interview on 12/7/23 at 12:54 p.m. Staff D, licensed practical nurse (LPN) confirmed if staff propel residents in their wheel chairs foot pedals had been required, even through a doorway.

Based on personnel record review, and staff interview, the facility failed to assure the required pre-employment checks were completed for 1 of 5 staff reviewed (Staff B). The facility reported a census of 49 residents. Findings include: A facility New Hire List for 2016-2017 included Staff B Registered Nurse (RN) on 2/1/17. A Hireright corporate criminal screening, documented the completion date 2/17/17 of a national sex offender registry, and wide screen plus national criminal search of Staff B (over 2 weeks after the hire date). The personnel record lacked an abuse registries background check. During an interview on 9/27/17 at 4 p.m. the Administrator stated Staff B contracted through an agency and had never been in the United States before. The contracting agency was responsible for all required checks on Staff B. The Administrator stated the criminal check was not completed until 2/17/17 because she had to be assigned a social security number when she first started. Staff B contracted for 3 years and started 2/1/17, before the (Hireright) criminal check completed. An International Staffing Agreement dated 12/5/16 documented the staffing agency would conduct background investigations as required by visa regulations and laws of the state of Iowa. The facility Abuse Prevention, Training, and Investigations policy revised 8/24/17 defined an employee as any individual who is paid either by the healthcare facility or any other entity (temporary agency, private duty, medicare/medicaid, or independent contractors) to provide direct or indirect treatment or services to residents of the facility. A Single Contact Repository (SING) background record check would be completed through the Iowa Department of Administrative Services website prior to the offering of a position of employment and no more than 30 calendar days before starting employment. The background check would include criminal history, dependent adult and child abuse registries, and the sex offender registry. Verification of the checks were retained on file in the facility (Exception: Independent contractors may provide assurance that the required verification is retained within their primary place of business,

Based on record review and staff interview, the facility failed to assure a resident with a pressure ulcer received necessary services to promote healing for 1 of 2 residents (Resident #3). The facility reported a census of 49 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #3 independently transferred and ambulated, and required limited assistance with dressing. Resident #3's [DIAGNOSES REDACTED].#3 had no pressure ulcers. A Weekly Pressure Ulcer Progress Report, dated 8/21/17, identified Resident #3 with a Stage II pressure ulcer on top of the right foot bunion area measuring 0.9 by 0.6 cm, pink/red in color. A Wound Care, Skin Integrity Evaluation by the wound care nurse dated 8/29/17 documented Resident #3 had a Stage III pressure ulcer of the hallux of the right foot. The Progress Notes dated 9/8/17 at 2:19 p.m. documented the dietician followed Resident #3 for a Stage III pressure ulcer on the right foot (2-1/2 weeks after the pressure ulcer identified. Resident #3 had good intakes at meals with a stable weight. Resident #3 may benefit with [MEDICATION NAME] (dietary supplement to aid in healing) 2 times a day. A Progress Note dated 9/15/17 (a week later) at 4:57 p.m. documented Resident #3 reviewed by the dietician due to monitoring for pressure ulcer to the right bunion, and recommending the resident take [MEDICATION NAME] 1 packet 2 times a day. Staff A Registered Nurse (RN) prepared a fax and sent to the physician to review. The physician responded 9/18/17 the okay to the dietician's recommendation (4 weeks after the pressure ulcer identified). During an interview on 9/26/17 at 1:05 p.m. Staff A stated they needed to get faxes out by 4:30 p.m. on Friday. She could not explain why the fax regarding the [MEDICATION NAME] did not go to the physician until a week after the recommendation. The facility document titled Pressure Ulcer Development Protocol (not dated) listed standard interventions to implement once a pressure ulcer is identified. The interventions included to email the dietician to review the resident's labs, weight trends, and comorbidities for recommendations of additional interventions such as pro-stat, extra protein or house supplement. The clinical record lacked documentation of when the facility notified the dietician of Resident #3's pressure ulcer.

Based on observation, resident and staff interview, the facility failed to ensure staff offered six residents interviewed a snacks before bedtime each night. The facility census was 48 residents. Findings include: 1. During group interview on 9/26/16 at 1:00 p.m., six of six residents present confirmed not being offered bedtime snacks every night. 2. Observation on 9/27/16 at 7:15 p.m., revealed a basket on a table near the facility front nurses station with bags of chips (Doritos and Funyans) and pretzels. During interview on 9/27/16 at 8:25 p.m., Staff C, Certified Nurse Aide, CNA stated she passed snacks 1 or 2 hours after the supper meal. Staff C stated staff did not go to each resident's room with a snack basket (and identified the snack basket as the basket that held the chips and pretzels), but stated staff went to each resident's room and asked the resident if they wanted chips, cookies or something. Observation on 9/27/16 at 7:15 p.m., Staff B, CNA entered room 2S with 2 residents present in the room and asked the residents if they were good on drinks and failed to offer either resident a snack. At 7:10 p.m., Staff C entered room 3S with 2 residents present and asked the residents if they wanted water or anything. Staff C failed to offer a snack such as chips or cookies. At 7:50 p.m., Staff C entered room 4S occupied by one resident, carrying a small bottle of water and left the room. At 7:55 p.m., the resident stated Staff C did not offer the resident a bedtime snack. At 8:10 p.m., Staff B entered the residents room and asked the resident how things were going, voiced being glad someone supplied the resident with a little bit of water but failed to offer the resident a snack. During interview on 9/28/16 at 9:45 a.m., the Director of Nursing stated staff was aware of the residents who did not routinely want a bedtime snack and offered residents who did want a bedtime snack, a snack every night. According to the Minimum Data Set with assessment reference date of 8/23/16 Resident #7 had a BIMS score of 15, cognitively intact skills for daily decision making. The resident required extensive assist with eating. During interview on 9/28/16 at 12:00 p.m. Resident #7 stated no when asked if staff offers him/her a snack after supper. According to the Minimum Data Set with assessment reference date of 9/2/16 Resident #8 had a BIMS score of 15, cognitively intact skills for daily decision making. The resident required extensive assist with eating. During interview on 9/28/16 at 2:40 p.m. Resident #8 was asked if he/she had been offered something to eat after supper before he/she goes to bed. Resident #8 stated he/she is not asked if wants a snack before bed. According to the Minimum Data Set with assessment reference date of 9/11/16 Resident #9 had a BIMS score of 15, cognitively intact skills for daily decision making. During interview on 9/28/16 at 2:25 p.m. Resident #9 was asked if he/she had been offered something to eat after supper before he/she goes to bed. Resident #9 stated he/she is not asked if wants a snack before bed. The resident stated if he/she asks for one staff does get it for him/her.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff checked the expiration date of insulin prior to administering for one resident on [MEDICATION NAME] insulin. (Resident #13) The facility census was 48 residents. Findings include: 1. The Minimum Data Set assessment dated [DATE], documented Resident #13 had a [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The order directed staff to administer 10 units every morning and 8 units at lunch, subcutaneous. During observation on [DATE] at 12:15 p.m., Staff A, registered nurse, RN drew up 8 units of [MEDICATION NAME]for the resident. The [MEDICATION NAME]had a sticker on the bottle that showed the vial was opened on [DATE]. The pharmacy label on the bottle noted the insulin expired 28 days after opened. Staff A checked to see if the resident had another vial of [MEDICATION NAME]. During interview on [DATE] at 12:25 p.m., Staff A stated the resident did not have another vial of [MEDICATION NAME], so she pulled a vial from the emergency kit to administer the [DATE] lunch dose. Staff A stated the bottle opened on [DATE] expired on [DATE]. Staff A stated she had used the outdated vial of [MEDICATION NAME] to administer the morning dose on [DATE]. Staff A confirmed the resident had received five doses of the outdated [MEDICATION NAME] since it had expired on [DATE].

Based on observation, dietary menu review and staff interview, the facility failed to ensure resident food items were served at the appropriate temperature in order to reduce the chance of foodborne illness for one meal observation for one resident on a mechanical soft diet. (Resident #14) The facility census was 48 residents. Findings include: 1. During interview on 9/27/16 at 11:34 a.m., Staff E, Dietary Cook, identified Resident #14 as the only resident on a mechanical soft/ground meat diet. A facility menu for a noon meal service on 9/27/16, included a mechanical diet of ground chicken and an alternate choice for ground pork. Observation on 9/27/16 at 11:17 a.m., revealed Staff D, Dietary Aide, took the temperature of all food on the steam table prior to the noon meal service. Ongoing observation revealed Staff D took the temperature of a single serving of ground pork that registered 129 degrees Fahrenheit (F) and registered a single serving of ground chicken at 132.4 degrees F. Ongoing observation revealed Staff D pushed the steam cart across a hallway to the dining room. At 11:20 a.m., Staff E, Cook took both of the ground meat containers off of the steam table and carried the containers back to the kitchen. Staff E stated the ground meats needed to be re-heated. Observation on 9/27/16 at 11:32 a.m., revealed a pan of ground pork and a pan of ground chicken on top of the stove top burner in the kitchen. Staff E took the temperature of the ground pork and it registered at 158 degrees F and the ground chicken registered at 147.4 degrees F. Staff E left the pans of ground chicken and ground pork on the stove top burner for approximately one additional minute, covered the meats up with tin foil and without checking the temperature of the meats again, carried the pans of meat back to the steam table in the dining room. At 11:34 a.m., Staff D stated Resident #14 chose to eat the ground chicken and served one serving of the ground chicken to the resident for consumption. During interview on 9/28/16 at 8:30 a.m., the Food Service Manager stated the facility lacked a policy for safe food temperatures, but instead followed the Food and Drug Administration Food Code manual. During interview on 9/28/16 at 9:45 a.m., the Food Service Manager stated dietary staff needed to maintain a serving temperature for ground pork at 145 degrees F and ground chicken at 165 degrees F. If the temperature dropped below a safe serving temperature of 165 degrees F, both the pork and chicken needed to be re-heated again to a temperature of 165 degrees F.

br>Based on observation and staff interview the facility failed to maintain a clean and sanitary food preparation area. The facility census was 49 residents. Findings include: 1. Observation at the time of the initial kitchen tour on 10/26/15 at 9:10 a.m., revealed the following: a. 4 sprinklers heads and conduit pipes above the stove with brown, grayish debris hanging down above food. 2. Observation during the meal service on 10/27/15 at 11:15 a.m., revealed multiple sprinklers and conduit pipes above the stove with dust and debris hanging down over the food area. Interview on 10/27/15 at 11:15 a.m., Dietary Supervisor) confirmed and verified that the sprinklers and pipes above the food areas needed to be cleaned on a more regular basis. Interview on 10/27/15 at 11:55 a.m., the dietary supervisor confirmed and verified that the sprinkler heads and conduit needed to be cleaned as soon as possible and needed to be cleaned on a more regular basis. The Concord Care Center work schedule dated 10/19 with an X in the box documented tasks for October: Fire sprinkler system: Check the sprinkler heads to be sure they are free of corrosion, paint or other foreign material that there is nothing within 18 inches of them (every 3 months) Interview on 10/28/15 at 2:45 p.m., the dietary supervisor confirmed and verified to the facility administrator while in the kitchen that the sprinklers and conduit pipes needed to be cleaned as the surveyor pointed them out and that the dietary department cleaned the areas as soon as possible.

br>Based on record review and staff interview the facility failed report an allegation of abuse and the facilities investigative findings to the State of Iowa survey and certification agency as required for 2 of 12 active residents reviewed, (Resident #6 and #9). The facility reported a census of 49 residents. Findings included: According to the Minimum Data Set with assessment reference date of 6/15/15 Resident #6 had a BIMS score of 15, cognitively intact skills for daily decision making. An Incident Report dated 7/16/15 noted at 6:00 p.m. Resident #6 stated that another resident, Resident #9, was wanting to get back in the facility and bumped Resident #6. Resident #6 tried to get out of the way and bumped Resident #9 back and then Resident #9 swung at him/her and hit Resident #6 in the left upper arm. An assessment was completed of the residents upper body and no injuries were noted. Intervention for preventive measures included the residents stay away from each other. Resident #6's responsible party and physician were notified of the incident. According to the Minimum Data Set with assessment reference date of 10/4/15 Resident #9 had a BIMS score of 15, cognitively intact skills for daily decision making. An Incident Report dated 7/16/15 noted at 6:05 p.m. Resident #9 reported that he/she could not get inside from the far north side of the smoking area because another resident was in the way and would not let him/her pass. Resident #9 stated Resident #6 rammed into his/her legs with their wheelchair. Resident #9 stated he/she then punched Resident #6 in the arm. Resident #6 then moved out of the way so Resident #9 could get inside to eat supper. Intervention for preventive measures included: Resident #9 decided he/she is going to stay under the shaded part of the paved area to stay out of the way of the smokers. Resident #9's responsible party was notified of the incident. Resident #9's care plan was updated on 7/17/15 to please encourage me to use the dining room door when I go out/come in during smoke times to avoid altercations with other residents. I can get easily frustrated when I want to go out/come in and there are smokers blocking my way. During interview on 10/26/15 at 3:15 p.m. the Administrator stated she did not think the incident on 7/16/15 with Residents #6 and #9 needed to be reported to the Department of Inspection and Appeals.

Based on observation, clinical record review, resident and staff interview, the facility failed to maintain personal privacy for one of eleven residents observed receiving cares. The facility census was 44 residents. (Resident #3) Findings include: 1. The Resident Care Plan, with a team signature sheet dated 06/27/11, documented Resident #3 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 06/06/11, documented Resident #3 had a brief interview for mental status (BIMS) score of 15. The MDS documented resident required extensive to total dependence for bed mobility, transfers, dressing, and toilet use. Observation on 06/29/11 at 8:24 a.m., Staff D (certified nursing assistant) and Staff F (certified nursing assistant) preformed morning cares for the resident. Staff D proceeded to place resident clothing above he/she waist. Staff D provided cares, Staff ran out of gloves, Staff F proceeded to leave the bedside and retrieve gloves for Staff D. Staff D and Staff F proceeded to position resident on to he/she right side and provide cares. Staff D ran out of gloves, Staff F proceeded to leave the bedside and retrieve more gloves for Staff D. Staff D failed to cover the resident up while waiting for Staff F to retrieve more gloves, and exposed the resident to the observers in the room. Observation on 06/30/11 at 8:29 a.m., Staff D and Staff E (certified nursing assistant)provided morning cares for the resident. Staff D proceeded to place resident clothing above he/she waist. Staff D provided cares to the resident and during the entire cares, resident left exposed to the observers in the room. Interview on 06/30/11 at 9:08 a.m., resident stated that he/she felt uncomfortable and wished staff would of covered their private area up when not performing cares.

Based on observation, clinical record review, and staff interview, the facility failed to perform complete perineal cares for one of seven residents reviewed with perineal cares. The facility census was 44 residents. (Resident #4) Findings include: 1. The History and Physical, dated 05/11/11, documented Resident #4 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment reference, dated 05/20/11, documented Resident #4 with a Brief Interview for Mental Status (BIMS) of 12. The MDS documented resident required extensive assistance for toileting and total dependence with transfers, and incontinent of bladder. The Urinary Continence Evaluation, dated 05/13/11, documented resident unable to tell if needs to void or when has already voided. Staff anticipate needs. Offers bed pan if not incontinent or provide incontinence care if needed. The resident care plan, with a team conference dated 06/03/11, documented a problem of at risk for falling because of my Parkinson disease progression. Interventions include: a. I now use the bed pan when I need to go to the bathroom. I can't tell when I need to go, please check me often. I wear briefs, staff change these as needed. Certified nursing assistants also complete all my personal hygiene and put barrier cream on as needed. Observation on 06/28/11 at 3:50 p.m., Staff A (certified nursing assistant) and Staff B (certified nursing assistant) performed incontinent cares for the resident. Staff B proceeded to remove the wet brief from underneath the resident. Staff A and Staff B positioned resident on he/she left side and Staff B provided incontinent cares. Staff B proceeded to cleanse the residents vaginal area cleansing from front to back using wet wipes while resident on he/she left side. Staff B then proceeded to put on a clean brief underneath the resident. Staff B failed to cleanse the resident left and right groin, hips, thighs, and buttocks, for which these areas were touching the residents wet brief. Interview on 06/28/11 at 4:27 p.m., Staff B stated that the brief had been very wet and soiled when removed from underneath the resident. Interview on 06/28/11 at 4:44 p.m., Staff C (licensed practical nurse) stated that the staff failed to cleanse the areas on the resident that were in contact with the soiled brief.

Based on record review, staff, family and physician interviews, the facility failed to ensure residents are free from significant medication errors for one of 7 residents reviewed. Resident #1 did not receive a heart medication for approximately 2 weeks. In the emergency room , it was discovered Resident #1 had [MEDICAL CONDITION] with rapid ventricular rate. The facility identified a census of sixty-six (66) residents. Findings Include: 1. A Minimum Data Set (MDS), with an assessment reference date of 9/1/10 assessed Resident #1 with no memory impairments. The MDS identified the resident's admitted as 8/25/10. The resident required extensive staff assistance with bed mobility, transfers and ambulation. The resident's [DIAGNOSES REDACTED]. The Daily skilled nurses notes, dated 9/9/10 at 7 a.m., stated staff entered the resident's room. The resident appeared red, clammy, sweaty and unresponsive with frequent strong full body jerking episodes noted. At that time, the resident's blood glucose level was 23. Staff attempted to administer [MEDICATION NAME] gel but the gel ran out of the resident's mouth. Staff then administered [MEDICATION NAME] IM (intramuscularly). The resident's vital signs measured his/her blood pressure at 108/62, pulse at 126, and respirations at 26 with his/her temperature at 98.2 degrees. At 7:20 a.m. staff notified the physician of the resident's condition. The physician directed staff to transport the resident to the emergency room . At 8 a.m., the resident transported to the emergency room . A hospitalist final report dated 9/10/10 stated the resident transported to the local emergency room for low blood sugar. While there, they discovered the resident's heart in [MEDICAL CONDITION] with rapid ventricular rate. The resident transported to a larger hospital for further evaluation and treatment. The principal discharge [DIAGNOSES REDACTED]. A medication discrepancy report identified the facility aware the resident did not receive the medications on 9/9/10 at 4:30 p.m. The resident's family member called from the hospital, at that time, to update the facility on the resident's condition. At that time, the family member asked if the resident received the medication [MEDICATION NAME] (for irregular heart rate) during the resident's stay at the facility because the medication list sent to the hospital did not include it. Staff confirmed the medication as absent from the medication administration record. The report identified staff failed to note the order for the medication, therefore staff did not transcribe it to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] According to the Administrator's written summary (undated) of the incident, the facility staff attempted several times to obtain a fax of the resident ' s pre-admission assessment (that included physician's order [REDACTED]. The summary identified after the resident had been sent to the ER and then the hospital, the family called the facility on 9/9/10 and asked why Resident #1 was not on the [MEDICATION NAME] medication. The facility staff informed the family there was no physician's order [REDACTED]. On 9/30/10 at 3:03 p.m., Staff B stated she admitted the resident to the facility on [DATE]. The fax machine did not operate properly so the hospital stated they would send the medication orders with the resident when (s)he arrived at the facility for admission. After the resident arrived, Staff B noted the orders and filled out the medication administration records. On 9/9/10 the resident went to the hospital with a low blood sugar. That day, the resident's family member called and spoke with Staff E. Staff E discovered 3 medications not noted on 8/25/10 and therefore not administered to the resident. The medications were in the hospital packet and contained the page of medications that did not come through on the fax. The orders were in the director of nursing's office since 8/25/10. Following the error, the facility developed an action plan so this type of thing will not happen again. The ED (Emergency Department) list of medications for home dated 8/25/10 included: [MEDICATION NAME] 120 milligrams (mg.) one-half tablet twice per day (for fast, irregular heart rate), [MEDICATION NAME] 25 mg. daily (diuretic) and [MEDICATION NAME] 40 mg. daily (to lower cholesterol). Review of the resident's August 2010 and September 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/5/10 at 10:55 a.m., the resident's family member stated his/her parent admitted to the nursing home on 8/25/10 due to weakness for a short term stay until his/her parent developed enough strength to return home. The family member stated his/her parent was at the nursing home for 2 weeks when (s)he developed a low blood sugar and transported to the hospital. The family member stated at the hospital, she/he discovered his/her parent's [MEDICATION NAME] medication and other medications were not on the medications list. The family member stated his/her parent's heart was irregular at the hospital. The family member stated upon admission to the nursing home on 8/25/10, Resident #1's physician's order [REDACTED]. The family member stated the nursing home staff did not check the envelope for two weeks. On 10/6/10 at 10:38 a.m. the surveyor spoke with the resident's regular physician and asked if failure to receive the medications ([MEDICATION NAME] and [MEDICATION NAME]) contributed to the [MEDICAL CONDITION] with rapid ventricular rate found when the resident went to the emergency room (ER) on 9/9/10. He stated the resident had a history of [REDACTED]. Anytime you stop the medication you can go back to [MEDICAL CONDITION]. He stated the resident's low blood sugar could also have caused the [MEDICAL CONDITION]. Not receiving the medications could have caused the [MEDICAL CONDITION] but it may not have. He stated when he found out about the medication errors he was not happy. The physician identified the resident at home now and doing well. Regarding the medication [MEDICATION NAME], www.medicinenet.com states, "Do not stop taking this medication without consulting with your doctor. Some conditions may suddenly become worse when you suddenly stop this drug. Some people who have suddenly stopped taking similar drugs have had chest pain, [MEDICAL CONDITION] and irregular heart beat. If your doctor decides you should no longer use, he or she may direct you to gradually decrease your dose over one to two weeks. " On 10/23/10 at 6:55 p.m., the hospitalist that cared for the resident during the 9/9/-10/10 hospitalization stated the lack of [MEDICATION NAME] since nursing home admission to 9/9/10 could have had an effect on [MEDICAL CONDITION] control. The lack of [MEDICATION NAME] was either the primary contributor to [MEDICAL CONDITION] or it was secondary to the [DIAGNOSES REDACTED]. The hospitalist stated he did not recall the major injury form he signed. On 10/12/10 at 4:24 p.m., the resident's cardiologist stated failure to receive the [MEDICATION NAME] for 2 weeks prior to 9/9/10 ER trip "was part of it". He stated there were other issues such as low blood sugar that contributed to the resurgence of the resident's [MEDICAL CONDITION]. He stated if the resident did not receive the [MEDICATION NAME] it certainly could result in the resident reverting to [MEDICAL CONDITION].