Every finding on record at Good Samaritan - Saint Ansgar

Based on review of schedules and interview, the facility failed to provide 8 hours of consecutive Registered Nurse (RN) coverage daily. The facility reported a census of 37 residents. Findings include:A review of schedules revealed that consecutive Registered Nurse (RN) coverage was not provided on the following dates: 5/30/26, 5/31/26, 6/6/26, and 6/13/26. On 6/18/26 at 9:55 AM, the Administrator stated she did not realize the RN coverage had to be eight consecutive hours; therefore, the facility had an RN dividing up her day to provide eight hours of RN coverage a day. She stated the facility was doing it wrong, but now she knows. The Nursing Services Staff policy revised 10/14/25, included the following direction:The purpose of the policy was to provide appropriate staff for resident care in the nursing services department.The location will use the services of a RN for at least eight consecutive hours a day, seven days a week (except when waived by state regulations).

Based on observation, interview and record review, the facility failed to follow infection control practices to minimize the spread of infection for 1 resident reviewed (Resident #33). During an observation of a double urostomy (allows urine to exit through a stoma (opening) in your abdomen) change, the nurse touched several items with gloved hands, did not sanitize, and change gloves between right and left urostomy sites, and touched the tip of a stoma powder bottle to Resident #33's abdomen several times without wiping the tip of the bottle off before replacing the cap. The facility reported a census of 37. Findings include:Resident #33's Physician's Order, dated 3/12/24, directed licensed nurses to change the double urostomies twice a week on shower days and PRN (as needed) during the day shift every Tuesday and Friday. On 3/16/26 at 10:00 AM, observed Staff A, Licensed Practical Nurse (LPN), and Staff B, LPN, Clinical Learning and Development Specialist, in Resident #33's room. Staff B was present to observe. Staff A placed a barrier on a tray table, with supplies laid out on it in preparation to change the double urostomies. Staff A used hand sanitizer and donned gloves. Staff A removed the urostomy bag and stoma device from the right urostomy. Staff A cleansed around the tubing with soap and water, then dried the area. She then moved to the left urostomy site without removing her gloves or sanitizing her hands, and washed around the stoma and tubing at that site. While applying stoma powder, she touched the tip of the stoma powder bottle to Resident #33's skin on several different areas of the abdomen around both stomas. Additionally, Staff A touched bottles and other items on the tray table, including the stoma powder bottle, while still wearing gloves. Staff A did not clean the tip of the stoma powder bottle before screwing the cap back onto the bottle. Following the observation, Staff B acknowledged Staff A didn't sanitize her hands between the right and left stoma sites, Staff A touched the tip of the stoma powder bottle to Resident #33's skin, and she touched items in the tray with her gloved hands. The Administrator acknowledged the observations as concerns. The facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions, revised on 4/30/26, directed the following:Purpose: To prevent the spread of infection and communicable diseases to residents, employees, and visitors through infection prevention and control practices.Standard Precautions: A group of infection prevention practices that apply to all residents in any setting in which healthcare is delivered, regardless of suspected or confirmed infection status, to prevent the spread of infection.Standard Precautions: Based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents.Standard precautions include hand hygiene, the use of personal protective equipment (whenever there is an expectation of possible exposure to an infectious material), and cleaning and disinfection practices. These precautions should be used by all employees, contract workers, and volunteers.

Based on clinical record review, staff interviews, policy review, and the Resident Assessment Instrument (RAI) Manual, the facility failed to compete a Minimum Data Set (MDS) significant change assessment for a resident starting on hospice services for 1 of 2 residents reviewed (Resident #16). The facility reported a census of 38 residents. Findings include: The MDS dated [DATE] for Resident #16 documented a Brief Interview for Metal Status (BIMS) score of 9 indicating moderate cognitive impairment. Review of the Clinical Census revealed Resident #16 started on hospice care 11/15/23. Record review of Resident #16 Progress Notes dated 11/15/23 at 12:01 PM documented the resident was admitted to hospice services. An interview on 1/08/24 at 1:40 PM Staff A, Registered Nurse (RN) reported the facility should complete a new MDS when there is a significant change in the resident since last MDS completed and update the Care Plan. On 1/08/23 at 2:05 PM, the Director of Nursing (DON) reported an MDS is completed when there is a significant change, quarterly, annually, admission, death, or discharge. She expects staff to update the Care Plans daily. Review of the facility policy titled MDS 3.0 documents to see the RAI Manual on how to identify a significant change and the timeline for completing it. Review of the Long-Term Care Facility RAI 3.0 User's Manual dated 10/01/23 stated in Chapter 2, page 23, directed the following: A Significant Change in Status Assessment (SCSA) is required to be performed when a resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Based on clinical record review, staff interview, and policy review the facility failed to update the Care Plan to address risk factors and interventions related to high risk medication for 1 out of 12 residents reviewed for comprehensive Care Plans (Resident #16). The facility reported a census of 38 residents. Findings include: Resident #16's MDS assessment dated [DATE] documented a Brief Interview for Metal Status (BIMS) score of 9 indicating moderate cognitive impairment. Review of the December 2023 Medication Administration Record revealed the following orders: a. Lorazepam 0.5 mg PO (by mouth) every 2 hours as needed for anxiety/restlessness with a start date of 12/04/23 b. Morphine Sulfate 20 mg/ml give 0.25 ml PO every 2 hours as needed for pain/shortness of breath with a start date of 11/16/23. Review of the Care Plan lacked directions regarding the high risk medication to monitor for potential adverse consequences/complications. On 1/08/23 at 2:05 PM, the Director of Nursing (DON) reported she expects staff to update the Care Plans daily. Review of the facility policy titled Care Plan documented the plan of care should be modified to reflect the care currently required/provided for the resident. It lacked direction for timeline in which the care plan should be updated.

Based on record review, staff interviews, and policy review the facility failed to provide quality and preventative care for 1 of 1 residents (Resident #30) when three (3) falls occurred after self transfers and/or ambulation in attempts to get to/from the bathroom and root cause analysis was not implemented into the residents plan of care. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #30 dated 2/26/23 revealed a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. It informed he needed extensive assist of one (1) person with bed mobility, transfers, walking in room, and toilet use. It also revealed he had a catheter in place and had a fall in the past month prior to his admission to the facility. Record review of an Incident Report dated 3/21/2023 for Resident #30 revealed he was found in his room on the floor when coming back from the bathroom and obtained an abrasion and a skin tear to his right elbow. Record review of an Incident Report dated 7/26/23 for Resident #30 revealed he was found in his room on the floor when attempting to go the the bathroom no injuries were obtained. Record review of an Incident Report dated 10/12/23 for Resident #30 revealed he was found in his room on the floor when coming back from the bathroom and obtained a skin tear to his right arm. The MDS Assessment for Resident #30 dated 10/30/23 documented a BIMS of 15. It informed he was dependent on staff for toilet use and needs substantial/maximal assistance (staff do more than half the effort) for chair to bed transfers, toilet transfers, and siting to standing. Record review of Resident #30's Care Plan on 1/8/2024 lacked revision to his plan of care and interventions implemented from falls while at the facility since his admission Care Plan on 2/22/2023. Record review of and e-mail correspondence on 1/9/24 at 2:13 PM with the Administrator revealed fall interventions are now put in place for Resident #30 Care Plan for falls that occurred on 3/21/2023, 7/26/2023, and 10/12/2023. She also informed two (2) interventions were resolved and have been unresolved now. She informed the facility is unsure why they were resolved. During an interview with the Director of Nursing (DON) on 1/10/2024 at 11:20 AM revealed she would expect all fall interventions to be implemented into the residents plan of care. Record review of the facilities policy Fall Prevention and Management dated 3/29/2023 instructed the facility to perform root cause analysis which is a method for identifying the cause of a problem so that the best solutions can be identified and put into place.

Based on record review, staff interviews, and policy review the facility failed to have the physician give rationale for continuation of antibiotic therapy for 1 of 1 residents (Resident #32) who entered the facility on a daily antibiotic. The facility reported a census of 38 residents. Findings include: Review of Resident #32's orders instructed for her to take an antibiotic (Minocycline 50 milligrams (mg)) everyday for prevention of Urinary Tract Infection (UTI) due to a personal history of UTI's. Review of Resident #32's Progress Notes revealed she had not been diagnosed for a UTI since admission to the facility. Review of a Progress Note dated 10/30/2023 at 11:36 AM by the facilities Consultant Pharmacist revealed a request was made to Resident #32's provider to review antibiotic (Minocycline) use. Review of a document titled, Note to Attending Physician/Prescriber dated 10/31/23 documented a note to Resident #32's provider informing him she is taking antibiotics (Minocycline 50 mg) everyday for prevention of UTI and extended use of antibiotics may increase the risk for bacterial resistance and to review continued need for use of the antibiotic to ensure the benefits exceed the risk. The physician signed and dated the document, however did not give supporting rationale to why she should continue to take the antibiotic. Review of Resident #32's current Care Plan on 1/10/2024 lacked documentation for when a review would be completed for extended use of her antibiotic treatment (Minocycline) everyday and side effects to look for. During an interview with the Director of Nursing on 1/10/24 at 11:08 AM revealed she would expect a rationale for continued antibiotic use. Review of the facilities policy titled, Medication: Drug Regimen Review dated 2/10/2023 revealed the following: Medication reconciliation is a comparison of admitting medication orders to medication taken at home and/or at the hospital to ensure order accuracy and resident safety. Medication reconciliation is an important process that must be completed for every resident upon admission.

Based on observations, interviews, and facility policy review, the facility failed to ensure containers of food were stored off the floor in the walk-in cooler and walk-in freezer to prevent potential contamination that could result in food borne illness. This had the potential to affect all residents who received meals from the kitchen. Findings included: Review of a facility policy titled, Food-Supply Storage - Food and Nutrition Services, dated 06/21/2002, revealed, All food/supply items are stored six inches off the floor. Stored items do not touch the walls, ceiling or sewer/waste disposal pipes. Observations during an initial tour of the kitchen on 09/06/2022 at 6:44 PM, revealed one box of pasteurized eggs and two boxes of pork loin stored directly on the floor of the walk-in cooler. The walk-in freezer was observed to have nine boxes of food on the floor, including boxes of eclairs, chicken breast fritters, pecan pies, carrots, and breaded chicken fried beef patties. During an interview on 09/06/2022 at 6:55 PM, Dietary Cook Staff A stated the food truck must have delivered that day, and the staff must not have had time to put the food away. Staff A further stated it was usually on the floor until someone from morning shift had time to put it away. During an interview on 09/06/2022 at 7:01 PM, Dietary Aide Staff B stated the food delivery truck came that morning and staff did not have time to put the boxes on the shelves. Usually, the food was left on the floor until the next day, when it was put away. During an interview on 09/07/2022 at 9:04 AM, the Dietary Director stated the boxes of frozen and refrigerated foods had not been put on the shelves because the holiday food had come in and was a larger order. The Dietary Director indicated the food should be put away and not left on the floor. The walk-in cooler and freezer were observed at this time, and no boxes were on the floor. The Dietary Director stated the boxes of food had been placed on the shelves that morning. During an interview on 09/09/2022 at 4:22 PM, the Administrator stated leaving food on the floor of the cooler, freezer, or stockroom was an issue and it was expected that staff put the food away when it was delivered.

Based on record review, interviews, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the medication regimen for 1 (Resident #24) of 5 residents whose medication regimen was reviewed for unnecessary medications. Specifically, Resident #24's MDS inaccurately indicated the resident was receiving insulin when he/she was not. Findings included: Review of a facility policy titled, MDS 3.0 (Minimum Data Set) RAI (Resident Assessment Instrument) - Rehab / Skilled & [and] Therapy and Rehab, dated as reviewed/revised 06/06/2022, revealed, Each discipline will be responsible for completing its section(s) of the MDS in [facility's electronic health record software program]. The policy also indicated nursing was responsible for completion of MDS Section N-Medications. Review of an Admission Record revealed Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS, dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section N of the MDS indicated the resident received insulin injections on seven days during the seven-day assessment period. Review of an Order Summary Report for active orders as of 08/08/2022 (the date of the MDS assessment) revealed Resident #24 had no physician's order for insulin injections. Review of the August 2022 Medication Record revealed no insulin injections were scheduled or administered to Resident #24. Review of discontinued physician orders in the electronic health record revealed Resident #24 had a physician's order for [MEDICATION(S)] insulin that was discontinued on 06/03/2022. Review of a care plan, dated 12/07/2021, indicated Resident #24 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/09/2022 at 8:35 AM, Registered Nurse (RN) Staff C stated Resident #24 had not been receiving insulin injections in the last few months. During an interview on 09/02/2022 at 9:43 AM, Resident #24 stated he/she had accomplished his/her goal of getting off insulin and had not been receiving insulin for a while. During an interview on 09/09/2022 at 3:57 PM, MDS Coordinator Staff D stated the information for the MDS assessment was gathered from the resident's electronic health record (EHR). She stated she looked on the EHR medication record to see what medications the resident took during the seven-day look-back period. She stated she must have overlooked the insulin for Resident #24 and was going to submit a correction for the MDS. During an interview on 09/09/2022 at 4:03 PM, the Administrator stated she expected the MDS assessments to accurately reflect the resident's condition at the time of the assessment.

Based on record review, interviews, and facility policy review, the facility failed to update the care plan for 1 (Resident #24) of 5 residents whose medication regimen was reviewed for unnecessary medications. Specifically, the facility failed to revise Resident #24's care plan when a diabetes medication was discontinued. Findings included: Review of a facility policy titled, Care Plan, dated as revised 05/03/2022, revealed, The plan of care will be modified to reflect the care currently required/provided for the resident. The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated, and updated when there is a significant change in the resident's condition. Review of an Admission Record revealed Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a care plan, dated as initiated 12/07/2021 and last revised 08/26/2022, indicated the resident required diabetic therapy. A planned intervention was to monitor the resident's condition based on clinical guidelines or clinical standards of practice related to the use of [MEDICATION(S)] (a diabetes medication). Review of a Progress Note, dated 08/26/2022, revealed a, Communication with Physician, which indicated a verbal order was obtained for [MEDICATION(S)] 10 mg daily, to start that day; however, review of an additional Progress Note, dated 08/26/2022, revealed the resident was supposed to start [MEDICATION(S)] due to elevated blood sugars, but the pharmacy relayed that the medication would be costly for the resident. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's August 2022 Medication Record revealed the 08/26/2022 order for [MEDICATION(S)] was added to the record but was not signed off as being administered and was discontinued. During an interview on 09/09/2022 at 8:35 AM, Registered Nurse (RN) Staff C stated Resident #24 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was not sure if this information was on the resident's care plan. She stated any staff could update the care plan, but it was usually done by the Director of Nursing (DON). The DON was out of the facility and unavailable for interview. During an interview on 09/09/2022 at 3:57 PM, MDS Coordinator Staff D stated the facility needed to improve on updating the care plans, and this was something they knew they needed to work on. She stated the care plans were reviewed quarterly, and if the care plan needed to be updated with an activities of daily living (ADL) function, she would update it. She stated if there was a medication change, the DON would update the care plan, and if an alarm was initiated or removed, the nurse taking the order should update the care plan. During an interview on 09/09/2022 at 4:03 PM, the Administrator stated her expectation was that the care plan accurately reflected the care the resident required.

Based on employee file review, background check review, policy review, and staff and corporation interviews. The facility failed to access the Single Contact Repository (SING) to perform the required back background check the State of Iowa directs for health care facilities in the Iowa Code. The facility hired and employed staff to work with residents without running the required SING background check from staff hire dates and throughout the time it brought to their attention by the survey team of the noncompliance for 4 of 5 employee files reviewed (Staff F,G, I, H). The facility reported a census of 32 Residents. Findings include: Record review of four employee files found the following documentation to be lacking: - Staff F, Certified Nurse Aide (CNA) with a Hire date of 08/04/2020 did not contain a SING check. - Staff G, CNA with a Hire date of 09/10/2020 did not contain a SING check. - Staff I, Registered Nurse (RN) with a Hire date of 09/10/2020 did not contain a SING check. - Staff H, Food Service Worker with a Hire date of 01/04/2021 did not contain a SING check. During an interview on 04/07/21 at 9:22 a.m. with the facility's corporate, Supervisor of Talent Acquisition Operations, Human Resources, revealed the facility stopped completing SINGS in June 2020 and switched over to another company that completed all the required background checks. Informed it was at the direction of a state entity, but unable to produce any proof or documents the entity directed them to do this. She revealed her corporations legal team reviewed prior to the implementation and changes. During a follow up email on 04/07/21 at 12:51 p.m. with the corporate office, Supervisor of Talent Acquisition, Operations and Human Resources, revealed she would be in contact with the facility Administrator for the four staff names to have a SING completed. -

Based on observations, record review, policy review, staff interviews, and the facility's oxygen supplier interviews, the facility failed to change oxygen tubing for residents that require supplemental oxygen. The facility did not follow professional standards with routine oxygen tubing changes and lacked documentation of when oxygen tubing was changed. The facility also does not follow the facilities oxygen supplier recommendations for tubing changes recommendations for 4 of 5 Residents reviewed (Resident #2, #13, #26, #178). The facility reported a census of 32. Findings include: Interview on 04/01/21 at 11:42 a.m., with Staff D, Registered Nurse (RN) reported five residents required oxygen at the facility. She stated the Residents have it ordered for either Hospice care or [CONDITION(S)] (COPD), and that the night shift changes oxygen tubing every Saturday. Observations on 04/01/21 at 11:47 a.m., with Staff D, RN, revealed the following: - Resident #13 - oxygen tubing dated 03/13 - Resident #26 - oxygen tubing not dated - Resident #179 - oxygen tubing not dated - Resident #80 - oxygen tubing dated 03/30 - Resident #2 - oxygen tubing dated 03/12 Staff D, RN, on 04/01/21 at 12:10 p.m., reviewed the six residents Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/01/21 at 12:11 p.m., interview with the Director of Nursing (DON), RN. - Reported that oxygen-tubing changes should be documented on the TAR. - Denies using any paper documentation of oxygen tubing changes. - The DON reviewed the medical record for six of six residents and was unable to find documentation of the oxygen tubing changes in the electronic health record. - The DON acknowledged oxygen-tubing changes were not documented; she stated she would expect her staff to change oxygen tubing weekly either on Wednesday or over the weekend on the overnight shift. Interview with Staff D, RN, on 04/01/21 at 12:12 p.m., revealed five of the five residents had their oxygen tubing changed immediately after her observations on 04/01/21 at 11:47 a.m. On 04/01/21 at 1:30 p.m., the DON provided the surveyor with a policy for oxygen tubing and stated it was the only policy she had, and did not have anything that directed them on how often the oxygen tubing was supposed to be changed. On 4/5/2021 at 12:17 p.m., an interview with the facilities oxygen supply company revealed the nasal cannula (part that goes into the nose) tubing should be changed weekly and the tubing that connects the nasal cannula to the machine should be changed monthly. In addition, provided information if it was only worn at night it could be longer. Review of the facilities policy titled, Oxygen Concentrator - Rehab/Skilled dated 09/21/2020 lacked guidelines for the oxygen tubing Review of the facilities policy titled, Oxygen Use Safety- Rehab/Skilled dated 09/21/2020 lacked guidelines for the oxygen tubing. Review of an untitled document, dated 12/20/2020 directed the following: - Oxygen tubing is to be changed on all residents that have oxygen every Saturday night - Saturday night nurses are expected to observe each room for those residents who have oxygen and nebulizers and change accordingly. - Initial and date on tubing. -

Based on observations and staff interviews the facility failed to ensure proper use of gloves, tongs, and scoops during meal preparation and service to prevent contamination. One staff was observed touching non-food items with gloved hands and utensils and then handling and serving food with the same gloved hands and utensils. The facility reported a census of 32. Findings include: On 03/29/21 at 12:00 p.m., Staff F, Cook, took temperatures of the food placed in the steam table then served up the food on dinnerware to residents. During temperature taking and service, Staff F placed the thermometer and the scoops on the countertops, then back into the food, and then served the food. Staff F grabbed stainless steel container containing ground chicken with tongs, moved the container over then grabbed chicken breast with the same tongs and served the chicken breast. After serving all of the residents, Staff F made a sandwich for a resident who requested it instead of the chicken. Staff F put on gloves, opened cupboard doors, grabbed a plate, butter knife and butter container and bread packaging. She grabbed the bread out of the packaging and then buttered the bread with the butter knife while holding the bread. Staff F then grabbed a pair of scissors and cut open a package of turkey lunchmeat, grabbed the turkey out of the package and placed it on the sandwich. Staff F did not change her gloves. Staff F served the sandwich. Staff F then temped the rest of the food at 12:30 pm. In an interview directly following the temping of the food on 3/29/21 at 12:30 p.m., Staff F was asked about sitting the scoops and thermometer on the countertops and then back into the food, Staff F stated she should not have done that. She stated she should have placed the utensils on plates and not the countertops. When asked about grabbing the container of ground chicken with the tongs, moving it over and then grabbing the chicken breast with the same tongs, Staff F stated that they were both chicken. When told she touched the container with the tongs and then the chicken, she stated she guessed that was wrong, then said she should not have grabbed the chicken breasts with the tongs that she used to grab the container. When asked about the sandwich and touching the cabinet handles, butter container, butter knife, bread bag, scissors, turkey container, bread slices and turkey all with the same gloves, Staff F said she should not have done that. Staff F stated she should have not put the gloves on until she was ready to touch the food only and should wash her hands between glove usages. In an interview on 03/29/21 at 2:00 p.m., the Dietary Manager stated, after told of observations, that Staff F should not have placed the utensils on the countertops and then place them back into the food. Staff F should not have used the tongs to move the ground chicken container and then used the same tongs to grab out chicken breasts. The Dietary Manager stated that Staff F should not have touched bread or turkey with the same gloves that had touched cabinet handles, butter container, butter knife, bread packaging, and turkey packaging. In an interview on 03/31/21 at 4:30 p.m., the NHA stated her expectation of Staff F would have been not to touch food with gloved hands that had touched other surfaces. The cook should not have placed utensils down on surfaces and then place them back into the food nor should Staff F have used the tongs to move a container and then grab chicken breasts with the same tongs. A Food Handling-Food Nutrition policy dated 05/19/20, documented that food was to be handled in a manner that would minimize the risk of contamination. The policy documented that proper utensils and single use-gloves are used for handling food. Hands were to be properly washed and gloves were only to be worn when appropriate. A Hand Washing and Glove Use-Food Nutrition policy dated 05/17/20, documented that employees were to limit the potential for cross-contamination by using gloves correctly and only when appropriate. Employees were to use utensils and single service deli papers whenever possible instead of gloves when touching any food; ready to eat or otherwise. Gloves were to be worn when handling ready to eat food and completing a single task. Gloves were to be changed before handling ready to eat food. -

Based on observations, staff interview and facility policy review, the facility failed to ensure staff followed isolation infection control protocols when they did not disinfect items, including a meal tray, goggles and a laptop, that came out of an isolation room as well as placing the garbage can for doffing Personal Protective Equipment (PPE) in the hallway for 1 of 1 residents (Resident #80) that was in isolation. The facility identified a census of 32. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #80's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS), showed a score of 14 out of 15 indicating this resident's cognitive functioning was intact. The resident required extensive assist of 2 for transfers and toilet use as well as extensive assist of 1 for dressing and personal hygiene. The MDS documented that this resident was in isolation or quarantine for active infectious disease. The MDS documented that Resident #80 was admitted on [DATE] from the community. An observation on 03/29/21 at 1:10 p.m. revealed that Staff E, Physical Therapy Aide (PTA), came out of Resident #80's room carrying her laptop. Staff E sat her laptop on the isolation cart, doffed her gown and gloves, and placed in the trashcan that was sitting out in the hallway, and then picked up her laptop and walked on down the hall where other residents resided. Staff E did not remove her mask and did not disinfect her goggles or laptop. Staff A, Certified Nurse Assistant (CNA), removed her goggles and placed on a face shield. Staff A wore her mask in and donned a gown and gloves. Resident #80 was in isolation. Resident asked if his door could remain open. Staff A told him that she could not. Staff A grabbed the lunch tray from inside this resident's room and carried it out. Staff A was unable to doff her PPE while holding the tray. Staff A requested Staff B's, CNA, assistance with the tray. Staff B took the tray from Staff A and carried it to the kitchen through the main dining room without wearing gloves. Staff A doffed her PPE and placed it in the garbage outside of the room. Staff B knocked on the kitchen door and then opened the door touching the doorknob with her bare hand. Staff B then handed the tray to the Staff C, CNA, and left. Staff C was working as a dietary aide that day. Staff B did not tell Staff C that the tray was from the isolation room. Staff C stated she did not know the tray came from the isolation room. Staff C stated, if she had known it was an isolation tray, she would have put the tray on a cart, covered it with a towel and left it for 2 hours prior to washing it. Staff C confirmed that she had already broke down the tray and placed the dishes on the racks to go through the dishwasher. Staff C said she was also a CNA and Staff B should have told her it was the isolation room tray. In another observation, which was seen directly after exiting the isolation room with Staff A, Staff E was noted to be walking back down the hallway. When asked about removal of PPE and sanitizing of equipment, Staff E stated she should have changed her mask and should have sanitized her goggles and laptop when she exited Resident #80's room earlier. An interview on 03/31/21 at 8:00 a.m., the Director of Nursing (DON), stated this resident is in the low risk gray zone. The DON stated the resident had been screened daily and did not have any symptoms (of Covid 19). The DON stated resident was at high risk for falls so they would update his care plan to include that the door can be open to his isolation room for safety reasons. When asked about Staff E not doffing her mask and applying a new one, and not sanitizing her laptop or goggles, the DON stated she agreed with Staff E in that she should have doffed her mask and donned a new mask. DON stated she should have sanitized her laptop. However, the DON stated Staff E should not have gone in to the isolation room with her goggles on. Staff E should have taken off her goggles placed them on the cart and put on a disposable face shield. When asked about the isolation lunch tray observation, the DON said that all of that was wrong, which included Staff B carrying the tray with her bare hands, opening up the kitchen door and touching the door knob in the process, handing the tray to the dietary staff (Staff C) and not telling Staff C that the tray came from an isolation room. The DON stated the tray should have been placed in a bag. She said the tray should have set for 2 hours prior to running it through the dishwasher. The DON stated Resident #80 is in isolation as he was a new admit. DON stated that Resident #80 had his 2nd vaccination the day before. In an interview on 03/31/21 at 3:02 p.m., the DON stated the garbage can that was sitting in the hallway should be inside of the room. The DON stated she would move it inside of the room right away. In an interview on 03/31/21 at 3:34 p.m., Staff A stated if the cart (dietary cart in the hallway with trays on it) would have still been out in the hallway she would have sprayed the tray down and let it sit for a while and then taken it back to the kitchen and let them know it had been sanitized. She would have sprayed it down with the stuff on the isolation cart labeled hand sanitizer. Staff A then said she would have used the bleach they used in the shower room and she would have let it sit out in the hallway covered with a towel. Staff A stated she would have thought Staff B would have taken it and sanitized it and then sat it on the cart outside the kitchen and let the kitchen staff know that it needed to sit for a while. Staff A did not give a timeframe on how long the tray would need to sit. On 03/31/21 at 3:43 p.m., the DON brought a care plan for Resident #80. She updated the care plan to include the door could be left open. On 03/31/21 at 4:00 p.m., the Nursing Home Administrator (NHA) stated they did not know what sanitizer was in the spray bottle labeled hand sanitizer. The NHA checked with the office manager and reported the office manager stated the hand sanitizer in the spray bottle on the isolation cart is Poet. The NHA stated they were going to get rid of all spray bottles and just use the Poet bottle that the sanitizer comes in. On 03/31/21 at 4:30 p.m., the NHA was asked what her expectations were regarding Staff E not sanitizing her laptop or goggles and not removing her mask, and the tray coming out of Resident #80's room and not being sanitized. The NHA stated that the laptop and goggles should have been sanitized and the mask should have been removed and replaced with a new one. The tray should have been sanitized and placed in a bag. In an interview on 04/01/21 at 9:42 a.m., Staff B stated she should have sanitized the tray or at least bagged it. Staff B stated when they had Covid 19 they used all paper products for meals. Staff B said she was not going to lie, they have been just taking Resident #80's tray right to the kitchen since he admitted . Staff B stated the facility had Covid back in November/December. Since December, there has been staff that has gotten Covid but no other residents. Staff B said for new admits they have just used trays and have not used disposable products from what she could remember. There was another resident in room [ROOM NUMBER] that was in isolation and they did not use disposable dining products with him. They just brought the tray back to the dining room. On 04/01/21 at 11:10 a.m., the Infection Preventionist (IP), Licensed Practical Nurse (LPN), when asked about the lunch tray, PPE and sanitizing equipment stated the resident only had one vaccination when he was admitted so was placed in isolation. She stated the PPE required to go into Resident #80's room (isolation) was gown, gloves, mask and face shield. Her expectations would be that clean PPE be worn into the room and sanitize when coming out. She stated the tray should have been sanitized and the laptop and goggles should have been sanitized as well as the mask should have been doffed. She stated that in a red zone, they would have used disposable dinnerware but because he was not in a red zone they do not use disposable dinnerware related to dignity, The DON agreed with her and said the resident was in a gray zone and the tray coming out of this resident's room should have been sanitized. A Zone Color Description and Precautions chart dated 11/30/20 and provided by the DON, documented healthcare workers should wear full COVID-19 level PPE (Gloves, Gown, N-95 Mask and face shield). It documented that when a resident is in his/her room and if safety can be maintained, the room door should be closed. The Gray Zone was to be established upon admission. Residents are kept in this zone for 14 days. If the resident is asymptomatic at the end of 14 days without antipyretics, the resident will be moved to the Green Zone. Healthcare workers should wear PPE as follows: surgical mask or N97 respirator if supply allows eye protection, gown, and gloves as needed when taking care of these patients. A Putting On/Taking Off Personal Protective Equipment PPE (Donning/Removing) Policy dated 11/17/20, documented to remove all PPE before exiting the patient room except a respirator. PPE included was gloves, goggles or face shield, gown, mask or respirator. A Standard Isolation Precautions-Policy dated 04/30/20, documented that nursing services notifies the food and nutrition department when a resident is confined in his or her room for meals due to an infection. Nursing delivers, the tray when resident is isolated in his or her room. The policy documented that nursing was to bag the tray and return the tray to the food and nutrition department for standard dishwashing procedures. Food and nutrition employees were to use gloves when handling isolation trays in dish room and wash their hands thoroughly when done. Food and nutrition employees were to rinse dishware under running water instead of using the sprayer. A CDC Modifies Quarantine and Visitation Guidance published on 03/10/21, recommended to long term care facilities that fully vaccinated new admissions no longer need to quarantine upon admission to the facility. It furthermore stated that new admissions who also do not have a known exposure to COVID-19 in the prior 14 days no longer need to be kept in isolation. An Iowa Immunization Registry Information System printout for Resident #80, documented that the COVID 19 vaccine was administered on 03/04/21 and 03/30/21.

Based on record review, staff interviews, and policy review the facility failed to complete an advance directive form signed by the resident or resident representative for 19 days after a resident verbally informed the facility of his wishes as a Do Not Resuscitate (DNR), for 1 of 1 residents reviewed (Resident #179). The facility reported a census of 32 residents. Findings include: Interview of Resident Community Relations Director on 04/06/21 at 3:54 p.m. revealed Resident #179 verbally decided on a code status of DNR on date of admission. Review of Resident #179 Admission Record, dated 03/26/21, documented an admitted [DATE]. Review of Resident #179 Transfer Orders/Instructions dated 03/11/2021, documented a transfer code status of Do Not Attempt Resuscitation (DNAR). It also documented the DNAR was NOT executed by the Resident. Review of Resident #179, Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/06/21 at 3:54 p.m., with the Resident Community Relations Director revealed the discharge orders from the hospital are verbally asked by the nurse to the resident on admission and then put into the Electronic Health Record (EHR). She stated that she was informed Resident #179's wife was unsure if they had an IPOST on the date of admission and that wife wanted to go check at home and ultimately reported that she did not find one. The resident knew he wanted to be a DNR on date of admission (03/11/21). The IPOST was not done until 03/30/21. -

Based on policy review and staff interviews the facility failed to provide education and training for their staff on policy updates on when to perform Cardiopulmonary Resuscitation (CPR). The facility policy reviewed/revised on [DATE] instructed staff to NOT provided Cardiopulmonary Resuscitation (CPR) for a resident who has NO advance directives on file. The facility reviewed/revised a separate policy on [DATE] to provide CPR to residents that have NO advance directives on file. Findings include: The facilities policy titled [NAME] Policy ENTERPRISE Rehab/Skilled Nursing Therapy & Rehab Cardiopulmonary Resuscitation (CPR) - Rehab/Skilled, Outpatient Therapy. With a review/revised date of [DATE] and Approved by Senior Director, Therapy and Rehabilitation, Vice President, Nursing and Clinical Services, Good Samaritan Society. Formulated by Nursing practice specialist and instructed staff of the following. CPR must be initiated unless: - The resident has a do not resuscitate (DNR) order - The resident has NO advance directive on file - The resident does not have a valid DNR on file that includes a medical order issued by a physician or other authorized non-physician practitioner the resident has obvious signs of clinical death - The initiation of CPR could cause injury or peril to the rescuer Interview on [DATE] at 2:57 p.m. with Staff J, Registered Nurse (RN), when asked about the policy revealed that it did not make any sense, we would perform CPR. Nurse questioned surveyor, wouldn't we? Staff J stated she has never been educated on this policy and does not know where to find this policy. Interview with Resident Community Relations Director, on [DATE] at 3:54 p.m. revealed that the CPR policy does not make sense. On [DATE] at 4:22 PM, Resident Community Relations Director, brought a different policy to surveyor and stated that was the one they were currently using. Policy titled Advance Care Planning and Advance Directive. She stated the one originally given to the surveyor on [DATE] was outdated. Review of the policy provided by the Resident Community Relations director on [DATE] at 4:22 p.m. titled, [NAME] Policy ENTERPRISE Rehab/Skilled Nursing, Advance Care Planning, and Advance Directive. With a reviewed/revised date of [DATE]. Formulated by Social Services Consultant and approved by the Director Professional Nursing and Care Management. The bottom of page 5 of 6 revealed the following. If [CONDITION(S)] occurs, CPR would be initiated unless: - A valid DNR order is in place - Obvious clinical signs of irreversible death - Initiating CPR could cause injury or peril to the rescuer Interview with the Director of Nursing (DON), RN, on [DATE] at 4:25 p.m. revealed she has not been educated on any policy changes. She revealed the facility was updating their CPR policy and taking verbiage out and reviewing it after it was brought to their attention. Staff had not been updated on any of the policies. -

Based on interviews and clinical record reviews, the facility failed to limit as needed [CONDITION(S)] drugs to 14 days without physician rationale in 1 of 5 residents reviewed (Resident #27). The facility reported at census of 32. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE], documented Resident #27's diagnoses included Alzheimer's disease, anxiety disorder, and depression. A Brief Interview for Mental Status (BIMS) recorded a score of 07 out of 15, revealing a severe cognitive deficit. This resident required supervision with setup help only for transfers and supervision of 1 for toilet use and personal hygiene. Resident #27's admitted was 03/03/21. An untitled recommendation sheet provided by the consultant pharmacist, documented that on 03/29/21 a medication regimen review (MRR) was completed. The recommendation was for a 14-day continuation for a current order. An interview on 04/01/21 at 10:35 a.m., the Pharmacist Consultant identified the 14 day [CONDITION(S)] medication from the MRR for this resident was [MEDICATION(S)] ([MEDICATION(S)]). The Pharmacist stated that PRN [CONDITION(S)] should not be ordered for more than 14 days without physician approval. An interview on 04/01/21 at 11:45 a.m., the Director of Nursing (DON) stated the facility struggles because residents doctor's do not always want to follow guidelines with medications, The DON stated she was aware that PRN [CONDITION(S)] should be discontinued after 14 days if there is not an order and rationale stating otherwise. An interview on 04/01/21 at 1:31 p.m., the Pharmacist Consultant stated he comes to the facility on ce a month. He saw that an as needed (PRN) [MEDICATION(S)] was ordered without a discontinuation date. He said he always, when he sees a prn [CONDITION(S)] as a new order, notifies the physician. The resident was admitted on [DATE] so he had done one MRR on 03/29/21. On 04/01/21 at 2:00 p.m., the Nursing Home Administrator (NHA) stated that a PRN [CONDITION(S)] needed to be discontinued after 14 days unless the primary care provider orders it for longer with rationale. A Medication Record dated 03/01/21-03/31/21, documented [MEDICATION(S)] (an anti-anxiety medication) was ordered to be given every 4 hours PRN. The start date was documented as 03/03/21. The discontinued date was documented as 03/30/21 exceeding 14 days. A Medication Record dated 04/01/21-04/30/21, documented [MEDICATION(S)] was ordered to be given every 4 hours as needed for 14 days. The start date was 03/30/21 with X's placed in the signature boxes starting on 04/14/21. A [CONDITION(S)] Medication Policy dated 11/19/20, documented PRN orders for [CONDITION(S)] drugs are limited to 14 days. Furthermore, it documented that if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she will document rationale and indicates the duration for the PRN order. -

Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance committee (QA) attended at least quarterly by the required members to include 1) the Nursing Home Administer (NHA) or representative, 2) Director of Nursing (DON), 3)the Medical Director or representative and 4) 2 other members of the facility's staff. The facility reported a census of 32. Findings include: The Quality Assurance Meeting Records provided by the DON revealed the Medical Director attended the QA committee meetings on a quarterly basis on 03/19/20, 06/18/20, 09/17/20, 12/17/20, and 03/18/21 but not on the monthly meetings in between. These records showed the NHA also attended the same meetings the Medical Director did. These records also showed at least 2 more staff were in attendance. The Quality Assurance Meeting Records revealed that the DON attended on 03/19/20, 12/17/20 and 03/18/21. On these 3 days, all 4 required members of the QA committee attended. On 06/18/20 and 09/17/20, the facility failed to ensure the required members were present at least quarterly for the facility's QA meetings, as the DON did not attend these two meetings. In an interview on 04/01/21 at 11:33 a.m., the DON reviewed the Quality Assurance Meeting Records and acknowledged that she was not present at the 06/18/20 and 09/17/20 QA meetings. On 04/01/21 at 2:00 p.m., the NHA stated that she is familiar with the QA committee meeting quarterly and the need for members to be present. She stated she would be sure that the DON was present or phoned in for these meetings in order to be in compliance with the regulation. The NHA stated that at another facility she actually had Covid and was sick but phoned in to a QA meeting even though she felt awful in order to have the required members in attendance. -

Based on clinical record review and staff interviews, the facility failed to revise the plan of care for three of nine residents reviewed. (Resident #36, #29 & #12) The facility census was 42 residents. Findings include: 1 The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #36 received Hospice care while a resident at the facility. Review of current care plan revealed no planning for coordination of care and services between Hospice and the facility. 2 The MDS assessment dated [DATE], documented Resident #29 received an antibiotic, diuretic and insulin every day during the look back period (5/7-13/19). The (MONTH) Medication Administration Record [REDACTED]. The (MONTH) MAR indicated [REDACTED]. The plan of care lacked care planning of the antibiotic, diuretic or insulin medication. 3 The MDS assessment dated [DATE], documented Resident #12 received a diuretic every day in the lookback period (4/1-8/19). The (MONTH) MAR indicated [REDACTED]. The plan of care lacked care planning of diuretic medication. During interview on 6/11/19 at 8:35 a.m., the Director of Nursing (DON) stated she would expect Hospice services, diuretics, antibiotics and insulin to be care planned.

Based on clinical record review and staff interview, the facility failed to renew a 60 day short term nursing facility approval for PASRR (Preadmission Screening and Resident Review) for one of 12 residents reviewed. (Resident #29) The facility census was 38 residents. Findings include: 1. Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A PASRR assessment completed [DATE], documented a Level 1 pre-admission screening has been submitted. This level 1 submission shows [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medication has been prescribed. This screening shows that there have been no signs or symptoms related to mental illness. No intellectual disability or related conditions have been reflected on this review. Based on the information received, level 2 criteria for a 60 day convalescence approval has been met. A level 2 evaluation will not currently be required. Should more than the approved days be needed the nursing facility should submit a status change to Ascend 7 days prior to the end of this authorization and a level 2 will be initiated. If any symptoms of psychiatric instability develop the nursing facility should submit a status change to Ascend immediately for further evaluation. The facility was informed of the 60 day short term nursing approval on [DATE]. The resident remained at the facility after the 60 conditional approval expired and the facility did not submit another PASRR assessment. During interview on [DATE] at 2:30 p.m., the social worker stated the family was unsure if they wanted to keep the resident at the facility and another PASRR did not get submitted until [DATE]. The Level 1 form dated [DATE], documented a resident review was submitted for a resident with a 60 day approval on [DATE] which has expired. Due to the status change it was not submitted in a timely manner.

Based on observation, clinical record review and staff interview, the facility failed to complete a prompt assessment for skin issues for one of 12 residents reviewed. (Resident #139) The facility census was 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #139 required extensive assistance with bed mobility, dressing, transfers and locomotion and had [DIAGNOSES REDACTED]. The Care Plan dated 2/23/18, identified the resident with the potential for pressure ulcer development related to limited mobility incontinent, poor nutrition, weight loss. Interventions included to notify nurse immediately of any new areas of skin break down, redness, blisters, bruises, discoloration, etc. noted during bath or daily care. Observation on 3/5/18 at 9:21 a.m., revealed the resident had purple areas on their right forearm, elbow and upper forearm. Observation on 3/5/18 at 12:10 p.m., revealed the resident wearing a short sleeve shirt and was sitting at the dining room table. Observation revealed purple areas to the residents right forearm and lower upper forearm. Observation 3/6/18 at 8:42 a.m., revealed the resident wearing a short sleeved shirt while at the dining room table eating breakfast. Observation revealed purple areas noted on the residents right upper and lower forearm. Observation on 3/7/18 at 8:21 a.m., revealed the resident had purple areas on their right upper forearm and lower inner and outer forearm. During interview on 3/7/18 at 8:40 a.m., the director of nursing (DON) stated the clinical record lacked documentation of the purple areas on the resident right forearm and the DON expected staff to notify the charge nurse or the director of nursing of any bruising that might occur. A skin observation form dated 3/7/18 at 9:00 a.m., documented the following skin issues: a. left elbow, red/purple bruises-measure 1.8. centimeters (cm) by 2 cm, 1.2 cm by 0.4 cm. b. bruise to left forearm-measures 0.5 cm by 0.6 cm. c. bruise to left upper forearm-measures 0.8 cm by 1 cm. d. right elbow, red/purple bruise-measures 1 cm by 1 cm, 0.3 cm by 0.2 cm and 2 cm by 1.8 cm. e. upper right forearm-bruise-measures 1.2 cm by 0.4 cm. f. upper right forearm-bruise measures 2 cm by 1.8 cm, bruise measuring 0.2 cm by 0.1 cm. The Progress notes dated 3/7/18 at 10:20 a.m., documented the resident had several small, red bruise like areas to the residents right forearm in several different spots and one on the left elbow area.