Every finding on record at Good Samaritan - Waukon

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to follow the care planned transfer technique for 1 of 4 residents reviewed for transfers (Resident #1). The failure to follow the care plan resulted in a fractured humerus (upper arm) for Resident #1, complaints of pain, and bruising. The facility further failed to provide adequate supervision to a resident known to wander and exit seek for 1 of 5 residents reviewed for supervision (Resident #3). On 8/5/26, Resident #3 got out of the facility undetected, walked down the sidewalk before staff saw her, and crossed the street before staff could reach Resident #3.On July 1, 2026, the facility self reported the incident involving Resident #1 to the Department of Inspections, Appeals, & Licensing (DIAL). The facility did not self report the incident involving Resident #3. The facility fully corrected the deficient practice on August 6, 2026 by taking the following steps:Resident #1: -Resident #1 was seen by the Provider on 6/29/26 and had diagnostic testing completed on 6/30/26. -Education provided on 6/30/26 to Staff A, Certified Nursing Assistant (CNA) and Staff B, Licensed Practical Nurse (LPN) regarding following resident's plan of care and steps to access the Kardex (care guide). -Facility wide, the Interdisciplinary Team (IDT) team completed a review of care plans and Kardexes. -Individualized education on plan of care Kardex utilization and the SAFE Resident Handling Policy provided to all nursing staff on 6/30/26, or prior to the next scheduled shift. -One page job aide for Kardex present at nursing station. -Initiated on 6/30/26, transfer competencies audited five times per week for four weeks, monthly for three months, then taken to Quality Assurance Performance Improvement (QAPI) for further review. -Facility initiated Kardex return demonstration audits for five nursing personnel weekly for four weeks, monthly for three months, then taken to QAPI for further review. Resident #3: -Resident #3 was assisted to return to the facility on 8/5/26. Resident assessment completed with 1:1 staff supervision initiated. -Resident #3's Care Plan was updated. -On 8/6/26, Brightly colored signs placed at all exits reminding visitors not to allow unauthorized entry or exit. -Resident Safety Reminder added to admission packet. -Social Services and IDT educated on the addition of signage on the exit doors, and the Resident Safety Reminder added to admission packet. -Elopement drills increased to monthly frequency for three months, then review by QAPI committee.The facility reported a census of 52 residents.Findings include: 1. The Face sheet for Resident #1 recorded an admission date of 10/6/22. The Face Sheet listed diagnosis on admission including unspecified dementia, age related physical debility, and unspecified pain.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a functional limitation in range of motion on one side of his upper extremities and on both sides of his lower extremities. The MDS documented the resident was dependent (helper does all of the effort) on staff for transfers from chair to bed/bed to chair transfers and rolling from side to side in bed. The MDS revealed the resident received hospice care while a resident. Review of Resident #1's Care Plan focus area initiated on 10/7/22, revised on 7/6/26, revealed the resident an activities of daily living (ADL) self care performance deficit related to need assist with most ADLs. The Intervention dated 10/7/22 and revised on 7/6/26 revealed, Transfer Between Surfaces: 2 staff assist with total lift for all transfers. The Progress Note written on 3/21/26 at 5:53 AM documented the resident was transferring with a full body lift with 2 assist.The Care Conference note written on 3/31/26 at 3:05 PM documented the resident was a total lift (mechanical lift) for all transfers.The Progress Note written on 6/16/26 at 3:11 PM documented the resident transferred with 2 assist and a mechanical lift.The Progress Note written on 6/29/26 at 12:53 AM noted the resident had a noticeable tender spot/ lump on his right upper arm. He complained of pain with movement, was able to move his fingers freely and grab staff's hands. The resident told staff it hurts and denied falling or bumping the area.The Progress Note written on 6/29/26 at 12:08 PM noted the resident's Primary Care Provider (PCP) examined the resident's right upper arm swelling and tenderness. Ordered an antibiotic for possible cellulitis.The Progress Note written on 6/30/26 at 8:37 AM noted the resident's right arm was more swollen from below the elbow to the shoulder area, with bruising color at elbow and shoulder , with small noted blisters around the elbow. Noted small amount of bruising of right chest area. The resident was refusing to move his arm due to pain and lack of range of motion to arm. Resident smiling and enjoying the attention, but would say ouch when attempt to move arm. The PCP was notified and ordered an x-ray of his right arm, elbow, humerus, and shoulder.A Late Entry Progress Note effective 6/30/26 at 8:36 AM documented, Questioned resident during assessment with attendance of another staff member if another person had hurt him and he stated no. The Progress Note written on 6/30/26 at 4:57 PM documented the PCP reported the x-ray showed a comminuted/displaced humerus shaft fracture, and documented to use a sling for right arm daily for comfort. A Late Entry Progress Note effective 6/28/26 at 7:52 PM documented the resident was transferred into bed differently than care planned and obtained a fracture to his right humerus. He complained about pain about an hour after the transfer into bed. Swelling and fluid pockets noted a few hours later on the night shift. The Immediate Intervention and Education section of the Note documented, Education on safe resident handling and following care plan for all resident transfers provided to all nursing staff. A Late Entry Progress Note effective 6/28/26 at 9:00 PM documented the resident had reported pain in his arm. He was assessed with his right arm contracted consistent with baseline. Skin assessment of the right arm was completed with no abnormalities noted. He was able to move the arm slightly, squeeze the nurse's fingers, wiggle his fingers, and flex wrist.During an interview on 8/18/26 at 10:06 AM, Staff A, Certified Nursing Assistant (CNA) explained she was getting the resident ready for bed and had the sit to stand (mechanical stand) in the room but did not use it. She went and got the nurse to assist her with the transfer into bed. She further explained they pivot transferred the resident into bed. She acknowledged the resident was care planned for the mechanical lift but they did not use it.During an interview on 8/18/26 at 11:05 AM Staff B, Licensed Practical Nurse (LPN) explained she had just returned to work after being off for 6 months. She explained she was passing medications when the CNA asked for assistance to transfer the resident. She explained when she went off work, he was a 2-person pivot transfer and she had not been made aware his transfer status had declined or that his care plan had changed. She further explained the resident had complained about arm pain about an hour later. She assessed the resident, gave him some pain reliever, repositioned him and did not note any redness, swelling or bruising and he was able to grip her fingers. She thought his pain was related to his contracture.Review of Staff B's personnel file revealed she was terminated, in part, for not checking the resident's care plan. Review of Staff A's personnel file did not reveal a written discipline for not following the care plan. Review of the Safe Resident Handling Equipment Competency Validation Checklist signed by Staff A on 11/20/25 revealed the following per Transfers Surface to Surface with Total Lift: 1. Checks resident care plan or Kardex prior to transfer for type of equipment to be used, type and size of sling and amount of assistance required. Staff A met this part of the competency. During an interview on 8/19/26 at 2:50 PM, the Administrator explained that Staff A was terminated for attendance prior to getting the write up for not following the care plan.The facility policy titled Safe Resident Handling Program (SRHP) Resource Packet- R/S, LTC, AL last revised on 7/7/25 directed staff to follow the resident's plan of care for the mobility device, type and size of sling and the number of employees needed to safely transfer the resident.2. The Face Sheet for Resident #3 recorded an admission date of 8/8/22. The Face Sheet listed diagnoses including mild cognitive impairment, unspecified pain, abnormalities of gait (walking) and repeated falls. The MDS dated [DATE] documented the resident scored 8 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. Per this assessment, the resident had exhibited wandering behavior 1-3 days of the last 7 days, used a walker, and ambulated (walks) independently. Resident #3's Care Plan focus area initiated on 7/5/21, revised on 5/7/26, revealed Resident #3 had impaired thought processes related to impaired thought processes related to cognitive impairment, mental illness evidenced by poor decision making, confusion, history of transient ischemic attack (TIA) and cerebral infarction. Interventions included, in part: Monitor/document/report to health care provider any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status (initiated 7/5/21). The Intervention dated 7/5/21, revised on 2/2/23, revealed the following: Resident needs supervision with all decision making and is unable to manage medications or daily tasks of living without staff assistance. The Intervention dated 3/23/24 revealed, Provide resident with necessary cues-stop and return if agitated. The Care Plan focus area dated 5/19/21, last revised on 9/9/25, identified the resident had potential for elopement related to attempts to leave the facility. The Goal, initiated on 5/19/21, revised on 5/10/26 revealed, Resident will not leave facility unattended. Interventions included to check her wander guard (device worn on wrist or ankle that would sound an alarm when passed through a door) every shift to ensure it is in working order (initiated on 6/18/21, revised on 9/9/25) and ensure exit door alarms are in working order (initiated on 6/18/21, revised on 9/9/25). The Late Entry Progress Note effective 6/6/26 at 11:44 AM documented the resident wandered with the wandering being goal directed. The wandering behavior was identified as likely to affect the safety or wellbeing of herself or others.The Progress Note written on 6/6/26 at 3:33 PM documented the resident exited the building, ambulated across the street to the senior living facility, and sat on their outside patio furniture. Per the note, suspected resident knew code as the resident's wander guard did not alarm.The Progress Note written on 7/7/26 at 2:00 PM documented, Writer was in office when she noticed resident walking intently walking toward the main entrance. Writer went and spoke with resident, asking where she was going. [Resident #3] stated I'm going outside. Writer indicated that she needs staff to assist her outside and she commented that she didn't. Writer offered to take her to the courtyard and sit outside in a few minutes and [Resident #3] said that's too bac because I am going out now. A CNA (Certified Nursing Assistant) was able to redirect resident to another location in the facility and away from exit door. The Progress Note written on 7/7/26 at 2:39 PM documented family notification regarding a meeting to get the resident transferred to a place that could accommodate her exit seeking behavior safely.The Late Entry Note dated 7/9/26 at 3:50 PM for Elopement Evaluation revealed the resident was independently mobile, exhibited wandering behavior that was non-goal-directed or aimless, and wandering behavior was likely to affect the safety or well-being of self/others. The resident had a cognitive impairment or diagnosis with impaired judgement or wayfinding, and had a history of/attempted leaving the facility without informing staff. The resident had verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. The Mood/Behavior Note dated 7/22/26 at 7:52 PM revealed the resident walked by nurse at the nurses station and stated, Go to h*ll, are you in h*ll. Requesting to leave the facility to take a walk away from here. Wander guard band operational. The Progress Note written on 8/5/26 at 3:58 PM documented a CNA (Staff C, CNA) called the facility and asked Staff D, RN for assistance on the road. Resident #3 was outside with her walker, seeking to leave and refusing to return to the facility. The resident returned to the facility with the assistance of another CNA. The resident was insistent she was going to leave again.The Progress Note written on 8/6/26 at 1:30 PM documented family notification of needing transfer the resident immediately. The Note further revealed it was explained because the resident was found on the campus for a second time, needed to issue a 30 day notice and transfer immediately. Family does not understand how a nursing home that is supposed to be the last resting place for a resident needs to move them so this writer tried to explain to the family that due to resident exit seeking, cannot keep her safe in this environment and need to move her to a place that can better accommodate her needs. During an interview on 8/17/26 at 3:00 PM, Resident #3 explained she wanted to go outside. She continued, so many people want to go out, it takes a long time, so she went by herself. She acknowledged crossing the street explaining she wanted to go the the park. (There were no parks within a block of the facility in any direction.)During an interview on 8/18/26 at 9:50 AM, Staff D explained she answered the phone on 8/5/26 and it was Staff C reporting she had observed the resident on the property and she was refusing to return to the facility. Additional staff went out to assist and the resident was returned to the facility. Once back in the facility the resident was insistent, she was going to leave again. The resident had been seen less than 10 minutes prior in her room. Staff D further explained the resident went out the door when a visitor was opening the door to enter. The visitor was not familiar with the resident and let her out the door when Resident #3 expressed she was able to go outside.During an interview on 8/18/26 at 10:57 AM, the Administrator explained the wander guard would make a beeping sound at the nurse's station after a resident was standing by the door for a period of time to alert staff the resident was loitering. If someone keyed in the code in the door, the wander guard could pass through without additional alarms. The system was designed to work that way.During an interview on 8/19/26 at 2:28 PM, Staff C explained she was returning from her lunch break, and pulled into the employee parking area when she saw Resident #3 on the sidewalk. She got out of her car and as she was approaching the resident she called the facility to let staff know the resident was outside. She observed the resident cross the street before she could get to her. She reached the resident in the street side parking area. She was able to get the resident to sit on her walker and waited for assistance to help her back in the facility.Review of the Facility Policy titled Elopement- Rehab/Skilled & Adult Day Services last revised on 8/3/26 defined an elopement as a resident who needed supervision leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or necessary supervision to do so. The policy directed staff to have individualized care plan interventions to minimize the risk.

Based on observation, dishwasher instructional manual, document review, policy review, and staff interview, the facility failed to ensure staff were competent in procedures to test and document the hot water sanitation of the dishwasher. The facility identified a census of 57 residents.Findings include:A Vendor Service Ticket dated 10/1/25 documented the installation of a new high temperature dishwasher.Observation on 4/27/26 at 1:26 PM revealed a hot water sanitation dishwasher. The dishwasher placard located on the right upper side of the dishwasher documented a required wash temperature of 150 degrees Fahrenheit (F) and a final rinse temperature of 180 degrees (F). Staff D, Lead [NAME] obtained the quat bucket test strips and dipped the test strip in the water, then reported she didn't think that was right. Staff E, [NAME] voiced they use the digital thermometer to check the dishwasher to ensure it is sanitizing to temperature. After four cycles, the dishwasher displayed a wash temperature of 156 degrees Fahrenheit (F) and a final rinse temperature of 187 degrees F. Staff E placed the digital thermometer on a dishrack inside the dishwasher and ran the dishwasher through two additional cycles of which the digital thermometer registered a maximum final temperature of 170.6 degrees both times indicating the dishwasher was not at the required hot water sanitation temperature of 180 degrees (F). Staff E reported the vendor had just been at the facility and ran the digital thermometer through the machine with no problems. Staff E went to the Nutrition and Food Services Supervisor (NFSS) and returned with a different orange test strip and proceeded to run the test strip through the dishwasher. The test strip turned orange to indicate the final hot water temperature of 180 degrees (F). Staff E stated when they got the new dishwasher, they quit using the orange test strips in the machine. Interview on 4/27/26 at 1:38 PM Staff D reported she had never used the digital thermometer or the orange test strips to test the dishwasher temperature. She only recorded the temperatures off of the display monitor on the dishwasher. A review of the April 2026 Dish Machine Temperature Log, Thermal Sanitizer paper directed the staff to document the temperature of the wash and final rinse temperatures morning, noon and evening. The Log lacked further direction or documentation to guide or indicate a digital thermometer check or a sanitation test strip check had been completed.During an interview on 4/27/26 at 1:43 PM the NFSS reported she used the digital thermometer to check the dishwasher daily. She hadn't realized they needed to document the testing. She couldn't answer for what the other dietary staff were testing the dishwasher with. She didn't know what the facility policy required.Interview on 4/28/26 at 1:49 PM Staff D explained the orange test strips or the digital thermometer should be used to check the dishwasher sanitation. The last time she knew, the policy stated to check the dishwasher (sanitation) one time a day and record on the paper (Dish Machine Temperature Log Thermal Sanitizer). They used to write the check down on a separate piece of paper. But that went obsolete two years ago as there were too many back and forth issues with it. She had never done a test strip on the current dishwasher. On 4/27/26, they thought they were supposed to use the strips they used on the sanitizer buckets. The only training she received on the new dishwasher was if there were issues, they were to scan the QR code and if that didn't fix the problem, then they were to call the vendor for technical assistance. Interview on 4/28/26 at 1:53 PM Staff E voiced she had never been shown how to calibrate the digital dishwasher thermometer. Interview completed on 4/28/26 at 1:57 PM Staff D explained the dishwasher is a heat sanitation machine. She had never run the digital thermometer through the dishwasher. She reported they are to check the dishwasher at the start and end of the shift, then changed and stated it should be done three times a day. She had only been told to use the testing strips that turn orange. She never knew they had to document on the sheet if it was the strip test or the dishwasher thermometer that was used for the check. During an interview on 4/28/26 at 3:14 PM the NFSS reported the dishwasher vendor comes and uses the digital thermometer to check the dishwasher sanitation. They had younger staff in the evenings that kept getting the sanitizer strips wet so it wasn't cost effective. She had asked the consultant about using a digital thermometer to test the dishwasher temperature and was told it was okay. The staff were to be using the digital dishwasher thermometer daily to check on the dishwasher sanitation. She explained the staff would have received a general orientation on the dishwasher when it was replaced but she did not have any training records to show they had been trained on it or how to use the digital thermometer. She had talked with maintenance and he stated the machine just needed to be run more. She wasn't aware they needed to document the sanitizer checks on the dishwasher. Interview completed on 4/28/26 at 4:04 PM the NFSS reported the vendor had a form they could use for documenting the dishwasher sanitation checks. She planned to go back to using the orange testing strips and documenting on that form.During an interview on 4/30/26 at 8:14 AM the NFSS reported maintenance set the hot water booster for the dishwasher up higher. Observation of the dishwasher at this time revealed a wash temperature of 153 degrees and a final rinse temperature of 187 degrees with a strip test turning orange to indicate the dishwasher had sanitized at a minimum of 180 degrees. The NFSS further explained she removed the digital thermometer from the washroom so that staff did not get confused. She had not had time to check the calibration of the digital thermometer and there had been no specific frequency for ensuring the digital thermometer was correctly calibrated on a regular basis. She thought the new dishwasher had been installed around October 2025. The staff had not had updated training on the new dishwasher since it was installed. She did not have any records of updated training on checking the sanitation of the dishwasher. She reported she trains new staff upon hire on the dishwasher as part of the kitchen general orientation. Observation at this time revealed a plastic container of the orange test strips on the second shelf of a cart by the dishwasher and a clipboard by the sink with a plastic bag of orange test strips available. A 4/28/26 review of the 3/19/26 and 4/23/26 Vendor Service Call Reports documented the dishwasher with a wash temperature of 153 degrees, rinse temperature of 187 degrees with the detergent and rinse additives in range. The Call Reports lacked documentation if a digital thermometer had been utilized to check the dishwasher was adequate sanitizing at 180 degrees that matched the panel display. Interview on 4/30/26 at 8:53 AM the Vendor Service Representative reported he completes monthly visits. He only reads the rinse temperature off the dishwasher display. He does not use the thermometer when he checks the dishwasher. It is not a requirement for them as they are there to check if the chemicals are working correctly, not the machine. If the machine has been run continually and is not getting up to the 180 degree rinse temperature, then it could be an issue with incoming water coming into the machine too low and the heat booster can't keep up. The testing strips are not as accurate as the thermometer checks. If the thermometer did not show the machine reached the required rinse temperature, then that should have been identified, reported and looked into further. The new dishwasher machine was installed at the facility in October 2025. On 4/30/26 at 10:10 AM the Administrator voiced the Food Code documented the hot water sanitation had to be at 160 degrees. The specific dishwasher Instruction Manual, page 25, directed sanitation mode required a hot water rinse temperature of 180 degrees (F).The Warewashing-Mechanical and Manual Policy, revised 2/13/26 documented a Purpose to promote good practices during ware washing regarding the prevention of foodborne illness. The Warewashing definition specified cleaning and sanitizing of utensils and food-contact surfaces of equipment. The Policy directed food and nutrition employees would ensure that food preparation equipment, dishes and utensils were effectively cleaned, sanitized to destroy potential disease carrying organisms. The Procedure specified the Director of Food and Nutritional Services Supervisor would monitor completion of tasks and accuracy of records. Under Washing Operation the Policy directed staff to check compliance for wash and rinse cycles with each meal service: High temperature wash cycle 150-165 degree/rinse cycle 180 degrees (F) Per the food code, when hot water mechanical ware washing is in use, an irreversible registering temperature indicator shall be readily accessible for measuring the surface temperature to ensure that 160 degrees (F) is reached in the rinse cycle. Record the results of all completed tests in the Action Taken on the appropriate form.

Based on observation, policy review, and staff interview the facility failed to prevent bare hands from contacting food during food preparation and keep cold foods below 41 degrees Fahrenheit (F) during meal service. The facility reported a census of 57 residents.Findings include:Observation on 4/28/26 at 10:26 AM Staff D, Lead [NAME] opened a plastic package of buns with her bare hands and proceeded to remove three buns from the bag and place the buns into a blender as she prepared a pureed taco burger for Resident #10. At 10:50 AM Staff D moved a dirty blender, measuring cup and spatula to the left side of the countertop, wiped her hands on along her uniform at both sides of her hips, then used a spatula to scrape three cookies off a baking sheet touching the cookies with her left hand as she scraped them from the baking sheet onto the spatula to place into a blender to puree. The pureed taco burger and cookie were served out to resident #10 during the lunch meal service. Observation on 4/28/26 at 11:25 AM the Nutrition and Food Service Supervisor (NFSS) washed her hands, applied gloves and placed cookies from a baking sheet into small plastic bags with her left gloved hand. She then removed the empty baking sheet with her left gloved hand and placed another baking sheet of cookies on top of the empty baking sheet. The NFSS proceeded to bag 13 additional plastic bags of cookies touching the cookies with her left gloved hand. The cookies were served out during the lunch meal service. At 11:31 AM Staff D filled three large metal pans with ice and placed the large pans of ice in the first three wells of the steam table. Staff D placed a large tray consisting of small plastic containers of salsa across the metal pan approximately 3-4 inches above the ice. Staff D then placed a large tray of small plastic containers of sour cream on top of the tray of salsa. At 11:42 AM Staff D completed pre meal temperatures with the salsa temperature at 40.4 degrees Fahrenheit (F) and the sour cream at 42.4 degrees (F). The meal service started at 12:00 PM and concluded at 1:15 PM. Post meal temperatures completed revealed the salsa at a temperature of 61.7 degrees and the sour cream at 63.1 degrees. During the provision of meal service which started at 12:00 PM as Staff D plated two taco salads. Her left thumb contacted the lettuce and the taco salads were served out to resident #30 and #35. Interview on 4/28/26 at 1:49 PM Staff E, [NAME] reported food cannot be touched with bare hands. They are to use gloves or tongs to handle food. Cold food has to be held below 41 degrees for serving. Interview completed on 4/28/26 at 1:57 PM Staff D explained they are not to touch food with bare hands. They should use a glove if they have to touch food. Cold food should be held below 41 degrees, then stated it could be 45 degrees. She voiced, it is okay for cold food to be held at 42 degrees so it must be okay if the cold food temperatures are below 45 degrees. During an interview on 4/28/26 at 3:14 PM the FNSS reported staff are not to touch food with bare hands. She expects the staff to use a glove or tongs to handle food. She expects the staff to hold cold foods below 42 degrees. At this time Staff D standing nearby responded she had touched the buns (during puree preparation earlier) and hadn't realized it. The Hand Washing and Glove Use Policy, revised 6/06/25, directed employees not to touch any food with bare hands. Proper utensils such as tissue, spatula, tongs and single-use gloves were to be used for food handling to reduce the risk of cross-contamination.The Food Temperature Monitoring Policy, revised 3/23/26, directed cold Time/Temperature for Safety (TCS) foods (food that requires time/temperature control to limit pathogenic microorganism growth or toxin formation), would be held at or lower than 41 degrees (F) and served promptly after being removed from the refrigerator. Temperatures would be taken periodically during or at the end of the meal service to ensure that holding temperatures were adequate.

Based on an electronic health record (EHR) review, policy review, and staff interview, the facility failed to submit a new Preadmission Screening and Resident Review (PASRR) assessment for 1 of 4 residents reviewed (Resident #7). The facility reported a census of 57 residents.Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS included diagnoses of anxiety disorder, depression and Post Traumatic Stress Disorder (PTSD- mental health condition triggered by experiencing or witnessing terrifying events). Resident #7 current PASRR Level 1 Screening Outcome dated 10/11/23 reflected a PASRR Level 1 outcome for no Level II required- no serious mental illness (MI)/intellectual disability (ID)/related condition (RC). The Level I included diagnosis of anxiety disorder and depression.Review of the EHR medical diagnoses listed active diagnoses of PTSD and major depressive disorder effective 9/11/24. The Care Plan Report identified a Focus area with a revision date of 8/7/25, for psychosocial well-being deficit related to childhood trauma with a diagnosis of PTSD. The Behavioral Health Progress Note dated 1/16/25 documented patient reports a history of physical and emotional abuse as well as neglect. The Behavioral Health Progress Note listed current psychotropic medications as follows:Sertraline 150 mg (milligram) daily for anxietyDuloxetine 60 mg in in the morning and bedtime for anxiety, mood and chronic painXanax 0.5 mg in the morning and bedtime for anxiety disorderThe Behavioral Health Progress Note listed active diagnoses of major depression and chronic PTSD. Follow up included: Will re-evaluate patient's status at the next appointment anticipated to be a 30-minute appointment that is anticipated to occur every 3 months for PASRR requirements. Resident #7's Order Summary Report included a listing of all active diagnoses, including the diagnoses of PTSD and major depressive disorder. The Primary Physician reviewed and signed the Order Summary Report in March 2026. Resident #7's Order Summary Report included a listing of all active diagnoses, including the diagnoses of PTSD and major depressive disorder. The mental health ARNP reviewed and signed the most recent Order Summary Report on 4/16/26. A Mood/Behavior Progress Noted dated 7/16/25 documented resident refused all medications and treatments. A Mood/Behavior Progress Noted dated 7/17/25 documented resident refused to take medication multiple times. A Mood/Behavior Progress Note dated 12/1/25 documented resident heard yelling out and demanded to know where everyone is. On 4/29/26 at 1:39 PM Staff A, Registered Nurse acknowledged Resident #7 had an active diagnosis of PTSD.On 4/29/26 at 3:00 PM, Social Services reported Resident #7 did have a diagnosis of PTSD. She reported she was the person responsible for submitting updates for PASRR when needed. The Social Services Director commented a diagnosis of PTSD doesn't always require an updated PASRR to be submitted. The Social Service Director acknowledged the most recent PASRR had been completed on 10/11/23. On 4/29/26 at 3:16 PM, the Administrator verbalized Social Services was responsible for submitting updates for PASRR.On 4/30/2026 9:13 AM, the Administrator verbalized unless there had been a significant change in behavior the PASRR may not need to be submitted for an update. It was a very gray area and still looking into it. A review of the Pre-admission Screening and Resident Review (PASRR) - Rehab/Skilled facility policy revised on 12/29/25 revealed the following: 1. If the resident is diagnosed with mental disorder while in the location, social services, or the designated individual, will contact the designated state agency for a Level II screening. 2. PASARR recommendations will be incorporated into the care plan (i.e., a PASARR recommendation for counseling to address a resident 's social withdrawal could be care planned under mood state).3. The location will notify the state-designated mental health or intellectual disability authority promptly when a resident with MD or ID experiences a significant change in mental or physical status. Examples of such changes include, but are not limited to:a. A resident who demonstrates increased behavioral, psychiatric, or mood related symptoms.b. A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment.c. A resident who experiences an improved medical condition, such that the resident's plan of care or placement recommendations may require modifications. d. A resident whose significant change is physical, but has behavioral, psychiatric, or mood-related symptoms, or cognitive abilities that may influence adjustment to an altered pattern of daily living.e. A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASARR Level II evaluation and determination.

Based on record review, staff interviews, and policy review, the facility failed to implement a Baseline Care Plan for 1 of 3 newly admitted residents (Resident #21). The facility reported a census of 57 residents.Findings include:Resident #21's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. Resident #21's diagnoses included dementia, anxiety, and depression. Resident #21 required staff assistance for all Activities of Daily Living (ADLs) and used a walker and wheelchair for mobility.In an interview on 4/30/26 at 10:17 AM, the MDS Coordinator confirmed that Resident #21 was admitted on [DATE] and the Baseline Care Plan should have been completed within 48 hours.In an interview on 4/29/26 at 11:35 AM, the Director of Nursing (DON) stated that the MDS Coordinator covered two facilities. The DON acknowledged that the facility experienced a breakdown in communication regarding who was responsible for completing the Baseline Care Plan.A review of Resident #21's records showed that as of 4/1/26, the facility only completed Care Plans for bed rails, skin impairment related to incontinence (without interventions), pain, and ADLs. This remained the only information present on the Baseline Care Plan for Resident #21 from 4/1/26 to 4/5/26.

Based on record review, staff interviews, and policy review, the facility failed to implement a Comprehensive Care Plan to include psychotropic medications for 1 of 3 newly admitted residents (Resident #21). The facility reported a census of 57 residents.Findings include: Resident #21's MDS assessment dated [DATE], triggered Care Area Assessments (CAAs) for cognitive loss/dementia, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcers, and psychotropic drugs. Resident #21 took antipsychotic, antianxiety, and antidepressant medications and was working with physical therapy.A review of Resident #21's Comprehensive Care Plan on 4/28/26 revealed that it did not include psychotropic medication monitoring or side effects.In an interview on 4/30/26 at 10:17 AM, the MDS Coordinator stated that a Comprehensive Care Plan should include medications, ADLs, diagnoses, skin integrity, treatments, falls, infections, and triggered items from the MDS. Regarding Resident #21, the MDS Coordinator stated she completed the antianxiety and antidepressant medication Care Plans on 4/29/26. She attributed the delay to human error and noted she usually double-checked these entries.

Based on record review, staff interviews, and policy review the facility failed to revise 1 of 1 residents Care Plan after the resident had Urinary Tract Infection (UTI) symptoms and was put on an antibiotic for a UTI (Resident #16). The facility reported a census of 57 residents:Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. Resident #16's diagnoses included dementia, personal history of urinary tract infections, and benign prostatic hyperplasia (enlarged prostate).Review of Resident #16's Communication/Visit with Physician progress note indicated that on 4/23/26 at 3:16 AM, the Physician responded to a fax regarding malodorous urine and increased weakness, and the Physician ordered a urinalysis with Culture and Sensitivity (C&S) for Resident #16.Resident #16's Health Status progress note showed that on 4/27/26, the Physician Assistant-Certified (PA-C) ordered Ciprofloxacin (Cipro) 500 milligrams (mg) twice a day (BID) for 7 days to treat the UTI for Resident #16.In an interview with the MDS Coordinator on 4/30/26 at 10:17 AM, revealed that a new antibiotic and a UTI required a revision to the Care Plan for Resident #16.Resident #16's Care Plan review on 4/29/26 showed the facility failed to include the UTI diagnosis or the antibiotic treatment for Resident #16.

Based on record review, staff interviews, and policy review the facility failed to provide assessment and intervention for a resident who presented with Urinary Tract Infection (UTI) symptoms and obtain a Urinalysis (UA) timely after it was ordered by his Provider for 1 of 2 residents reviewed for UTI (Resident #16). The facility reported a census of 57 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. The MDS noted Resident #16 required substantial to maximal assistance with toileting and transfers and was always incontinent of urine (loss of bladder control). Resident #16's diagnoses included dementia, personal history of urinary tract infections, benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms, and weakness. On 4/20/26 at 4:12 PM, the Health Status progress note indicated a Certified Nursing Assistant (CNA) provided toileting care for Resident #16 and noted the urine had a foul smell. The CNA notified the Licensed Practical Nurse (LPN) who assessed the urine as dark in color and malodorous. Resident #16 demonstrated increased weakness during transfers and experienced bowel and urinary incontinence. On 4/23/26 at 3:16 AM, the Communication/Visit with Physician progress note stated the Physician responded to a fax regarding the malodorous urine and increased weakness. The Physician ordered a urinalysis with Culture and Sensitivity (C&S) due to the increased weakness and permitted a straight catheterization if necessary.On 4/25/26 at 6:50 AM, the Communication/Visit with Physician progress note recorded that a Nurse collected a urine sample via straight catheter. The Nurse transported the sample to the local hospital's laboratory for testing. On 4/25/26 at 10:57 AM, the Health Status progress note showed the Nurse documented that the laboratory results indicated multiple abnormal values. The Nurse faxed the results to the Physician and awaited a response.On 4/27/26 at 5:41 PM, the Health Status progress note reported that the nurse received lab test results showing greater than 100,000 colony-forming units of two different types of bacteria in the urine. The Physician Assistant-Certified (PA-C) prescribed the antibiotic Ciprofloxacin (Cipro) to be taken at a dose of 500 milligrams (mg) twice a day for 7 days to treat a Urinary Tract Infection (UTI). Review of Resident #16 Electronic Health Record (Progress Notes, Vital Signs and Assessments) lacked documentation of vital signs, other than for 4/22/26, and assessments completed from 4/20/26 to 4/26/26 to monitor his suspected UTI. In an interview on 4/30/2026 at 11:52 AM, Staff F, CNA, stated that Resident #16 had odorous urine and increased weakness a while back. Staff F noted, however, that Resident #16 had no complaints regarding urinary issues. In an interview on 4/30/2026 at 12:12 PM, Staff G, Registered Nurse (RN), stated that she noticed weakness in Resident #16 recently. Staff G explained that this change in condition should indicate the need to check vital signs and symptoms, and to begin charting every shift for 24 to 48 hours. She noted that Resident #16 required a straight catheterization to obtain the UA and confirmed has not seen any other symptoms typically related to a UTI for Resident #16 in the past two months.In an interview on 4/30/2026 at 12:15 PM, the Director of Nursing (DON) stated that if a resident exhibits weakness, odorous urine, or a suspected change in condition, staff should complete the Electronic Health Record (EHR) Assessment for Clinical Monitoring. The DON clarified that this assessment triggers a requirement for nurses to perform a clinical assessment every 12 hours. Additionally, the DON informed that the nurse who identifies the issue should also complete a Change of Condition Assessment. The DON acknowledged that this process was not followed for Resident #16 when he exhibited symptoms of a UTI.In an interview on 4/30/2026 at 12:40 PM, the Administrator stated for Resident #16, staff should have at least performed an assessment and obtained a urinalysis (UA) in a timely manner.The Nursing Documentation Guideline, Timelines policy dated December 2025 directed that the purpose of the policy was to systematically and continuously collect information about the health status of the resident and to ensure appropriate documentation was completed in a timely manner. The policy further revealed when a change in condition was identified in a resident, the nurse would use the Change in Condition evaluation to collect the data prior to communicating with the medical provider.

Based on record review and staff interviews the facility staff failed to provide 2 of 2 residents restorative programs as frequently as the program ordered (Resident #28 and Resident #4). The facility reported a census of 57 residents. Findings include: 1. Resident #28's Minimum Data Set (MDS) assessment dated [DATE] indicated he entered the facility in October 2011 and had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. He relied on staff for toileting, shower/bathing, and moving from a sitting to standing position. He did not complete a Restorative Program for at least 15 minutes during the past 7 days. He had diagnoses of a need for assistance with personal care, other abnormalities of gait (walking pattern) and mobility, and a traumatic brain injury. Resident #28's Care Plan, last revised on 12/8/25, included 3 Restorative Programs related to his traumatic brain injury: ambulation in the hallway, riding a pedaled bike for 15 minutes, and lifting a 4 pound weight with seated functional reaching.Resident #28's Documentation Survey Report V2 for February 2026 showed documentation did not apply for 6 days, 20 entries went missing with no charting completed, and he received one of his programs on 3 different days of the month.Resident #28's Documentation Survey Report V2 for April 2026 showed documentation did not apply for 19 days, 13 entries went missing with no charting completed, and he received one of his programs on 3 different days of the month.Resident #28's MDS dated [DATE] documented he completed an Active Range of Motion (moving joints through movement) for 15 minutes or greater 1 time in the past 7 days.2. Resident #4's MDS dated [DATE] indicated she entered the facility in November 2021 and had a BIMS score of 0 out of 15, indicating severe cognitive impairment. She needed substantial/maximal assistance from staff for transfers and moving from a sitting to standing position, and she did not walk. She had diagnoses of pain, atrial fibrillation (irregular heartbeat), depression, and hypertension (high blood pressure).Resident #4's Care Plan, last revised on 2/7/25, included 2 Restorative Programs to be completed 3 times a week.Resident #4's Documentation Survey Report V2 for April 2026 showed documentation did not apply for 7 days, she refused to complete programs on 7 days, 9 entries went missing with no charting completed, and she received a restorative program on 3 different days of the month.Resident #4's Documentation Survey Report V2 for February 2026 showed documentation did not apply for 7 days, she refused her programs on 2 days, 8 entries went missing with no charting completed, and she received one of her programs on 7 different days of the month.On 4/30/26 at 11:10 AM, Staff C (Certified Nursing Assistant/Restorative Aide) stated she worked 5 days a week at the facility and performed duties as a Certified Nursing Assistant (CNA) 1-3 times per week when pulled from restorative duties. Staff C noted that Resident #4 frequently refused services and Resident #28, who required daily restorative care, sometimes refused, though she approached him again later. Staff C observed that both Resident #4 and Resident #28 declined a bit since she returned from leave in February; the residents reported to her they did not receive restorative services for months during her absence. As a result, they didn't always want to participate with their programs and refused more often. In an interview on 4/30/2026 at 12:15 PM, the Director of Nursing (DON) confirmed that Resident #4 and Resident #28 should receive their Restorative Programs as ordered.

Based on observation, document review, and staff interview, the facility's administrative staff failed to ensure the staff secured all locked exit doors, resulting in 1 of 3 reviewed residents (Resident #1) at risk for elopement exiting the facility without the nursing staff's knowledge. Due to the facility staff's failures, Resident #1 eloped from the building through the maintenance office door without the nursing staff's knowledge and was missing for approximately 45 minutes before the nursing staff realized Resident #1 was missing by locating Resident #1 laying outside on the ground. The facility's administrative staff identified a census of 51 residents at the time of the on-site investigation.The Iowa State Survey Agency (SA) notified the facility's administrative staff that the situation presented an Immediate Jeopardy situation on [DATE] at 6:00 PM. The immediacy began on [DATE]. The facility's administrative staff removed the immediacy on [DATE] when they took the following actions:- The nursing staff monitored Resident #1's location every 15 minutes, starting [DATE]. - All the keypad locks were immediately disabled and locked at all times on [DATE]. The facility changed the maintenance office door keypad lock on [DATE] to a manual lock key system that remained locked at all times. All remaining doors that utilized keypad locks did not have access to an outside door. The remaining doors were assessed for resident safety if they were able to breach the door. Any doors with keypad locks that were identified as needing to be changed from the keypad to a manual lock were changed on [DATE]. - The nursing staff began holding missing resident drills on [DATE].- All staff received education on elopements prior to their next shift, starting on [DATE].- The staff redirected all security cameras to ensure visibility of the exterior doors on [DATE].- The staff held a QA meeting on [DATE] and continued to monitor elopements through the QA process.As a result of the facility staff's actions, the scope and severity lowered from J to D. The SA surveyor verified the implementation of the removal plan occurred prior to the start date of the on-site investigation. The facility identified a census of 51 residents. Findings Include:A care plan identified the following Focus areas:a. Impaired cognitive function/Dementia or impaired thought process. (revised [DATE])b. Impaired visual function related to (r/t) Macular Degeneration evidenced by (e/b) blindness. (revised [DATE])c. An Activities of Daily Living (ADL) self-care performance deficit r/t Macular Degeneration (e/b) a visual deficit. (revised 7.2.25) The Resident ambulated with the assistance of one (1) staff member and a front wheeled walker in his room and hallway.d. A potential for elopement r/t statements of his desire to have returned home and attempted to go outside. (initiated [DATE])e. At risk for falls r/t vision and a history of falls prior to admission (initiated and revised [DATE])f. An actual fall occurred with a minor injury r/t his gait imbalance and poor vision. (revised [DATE])Review of the facility staff's timeline of events on [DATE] included the following: 1 :45 a.m. - Requested to go to bed so a Certified Nursing Assistant (CNA) took the resident to his room. 1 :47 a.m. - The CNA exited the room after assistance to bed. 1 :50 a.m. - The resident exited his room and turned right outside of his room door. 1 :51 a.m. - Ambulated in the hallway past the Director of Nursing Services (DON) office. 1 :52-1:53 a.m. - Ambulated past the Health Information Management (HIM) and education offices. 1 :55-1:58 a.m. - Ambulated through the dining room and exited through the activity room door. 1 :59-2:06 a.m. - Attempted to open each door. 2:06 a.m. - Entered the maintenance office. 2:12 a.m. - Ambulated on the sidewalk outside the maintenance office to the parking lot/dumpster area where the resident remained. 3:03 a.m. - Located by staff in the parking lot by the dumpster. 3:33 a.m. - Director of Nursing Services notified of the resident's unplanned exit 4:45 a.m. - Administrator notified of an unplanned exit. 4:56 a.m. - Maintenance notified of unplanned exit. 5:30 a.m. - Maintenance assessed lock functionality. A Resident Event form indicated, on [DATE] at 3 a.m., that Staff A, Certified Nursing Aide (CNA), found Resident #1 outside the building but still on the facility's grounds. Resident #1 was fully clothed, wearing a t-shirt, zip up sweatshirt, sweatpants, sock, and black tennis shoes. The form also indicated Resident #1 was previously exit seeking.Review of Resident #1's medical record revealed that Staff D, LPN, documented on [DATE] at 3:52 AM, that the prior night around supper time, Resident #1 wheeled himself to the facility's exit doors and was attempting to exit the building, while making statements that Resident #1 wanted to leave the facility.A Witness Statement form signed by Staff A, CNA on [DATE] at 3:49 a.m., included that at 3:03 a.m., she punched out for a break. When outside she heard someone say help. The staff member looked over to the dumpsters and observed the resident as he laid on the ground. The staff member went over and asked him if he was OK and positioned his head on her foot and called the facility for assistance. During an interview [DATE] at 11:19 a.m., Staff A indicated she worked the front of the building until 2:10 a.m., at which time she moved to the back of the building where the resident resided. When she arrived at the back of the building she received report but had not visualized the resident due to all of the call lights she answered. After she answered the lights, she went outside through the break room door for her break. After she opened the second door to the outside, she heard someone say hey. The staff member looked over and observed the resident as he laid on the ground, positioned his back with his legs straight out in front of him almost up against the dumpster. However, his head had been closer to the dumpster than his feet because of the angle of his position. The resident's entire body had been positioned on the cement sidewalk. The staff member positioned her foot under his head to rest his head then called the facility. The resident attempted to position his own arm behind his head as he moved all over the place. The resident told the staff member he had not known what he had been doing, as he laughed and then stated he wanted to go to his truck over there so they could go somewhere. The staff member confirmed the resident attempted to exit seek all of the time. During an interview on [DATE] at 2:13 p.m. Staff B, Licensed Practical Nurse (LPN) indicated she was to work the North and South hallway and received a telephone call from Staff A who found the resident and asked for assistance. This staff member had not responded because the other nurse on duty went outside to assist with the situation. When Resident #1 returned to the facility, they placed him in the shower room and completed a head to toe assessment where bruising had been noted on his right flank.During an interview [DATE] at 12:56 p.m. the DON and Administrator indicated that Resident #1 was able to leave the building because the electronic door lock's batteries had died, resulting in the door not locking, which allowed Resident #1 to leave the building through the maintenance office without the staff's knowledge.During an interview [DATE] at 12:04 p.m., the State Climatologist indicated the temperature at 69 degrees Fahrenheit (F), 93% humidity, North / North East (NNE) winds at 6 mph and cloudy. The facilities Elopement policy revised [DATE] included the following: Definition: When a resident/client who needed supervision left the premises or safe area without authorization.

Based on record review, staff interview, and policy review the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the Director of Nursing (DON), the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and the Infection Preventionist (IP) were all in attendance for the first quarter of 2025 Quality Assurance (QA) meeting. The facility reported a census of 51 residents. Findings include: Record review of the facilities Quality Assurance and Performance Improvement Plan (QAPI) committee meeting Sign-in Sheet's for the first quarter of 2025 revealed the following: 1/24/25 - Medical Director and IP not in attendance 2/21/25 - Medical Director and IP not in attendance 3/28/25 - DON and IP not in attendance During an interview on 4/16/25 at 11:08 AM the Administrator revealed she would like the Medical Director to attend monthly meetings but scheduling has been hard and would expect all required staff to be in attendance. Record review of the facilities 2025 Quality Assurance and Performance Improvement Plan dated 1/24/25 instructed the following: The administrator is the leader of the QAPI Committee, with assistance from the QAPI Coordinator, and is responsible for its effective operation. The location QAPI Committee ensures an effective QAPl program is in place and the program is adequately resourced with time, personnel, training (including contract staff), equipment, and financial resources.

Based on electronic health record (EHR) review, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual review, and staff interviews the facility failed to submit six completed Minimum Data Set (MDS) assessments for 1 of 1 residents reviewed (Resident #201). The facility reported a census of 51 residents. Findings include: A review of the EHR, MDS detail listing for Resident #201 revealed the following: 3/13/2025 - Annual - None PPS / M D S 3.0 - Completed 12/19/2024 - Quarterly - None PPS / M D S 3.0 - Completed 10/3/2024 - Quarterly - None PPS / M D S 3.0 - Completed 7/18/2024 - Quarterly - None PPS / M D S 3.0 - Completed 6/11/2024 - End of PPS Part A Stay / M D S 3.0 - Completed 4/20/2024 - Admission /Medicare - 5 Day / M D S 3.0 - Completed 4/17/2024 - Entry / M D S 3.0 - Accepted A review of all completed but not accepted MDS's for Resident #201 documented the unit was neither Medicare nor Medicaid certified and MDS data is not required by the state. The submission information for all completed but not accepted MDS's for Resident #201 documented do not submit to the Centers for Medicare and Medicaid Services (CMS). During an interview on 4/14/25 at 12:35 PM, Staff D, Business Office Manager revealed the facility is dually certified for all beds with CMS. During an interview on 4/14/25 at 12:45 PM, Staff E, MDS Coordinator/Infection Preventionist reported she and/or another staff member are responsible for completion of the MDS. Staff E revealed when the MDS's have been completed they are submitted to CMS. Staff E acknowledged she completed section A of the MDS, identifying the unit is neither Medicare nor Medicaid certified and MDS data is not required by the state. Staff E acknowledged the facility is certified to participate in the Medicare and Medicaid programs. Staff E revealed she reviews the export ready file to review the MDS's to be submitted and verifies the files have been accepted. During an interview on 4/14/25 at 1:00 PM, the Director of Nursing (DON) revealed the facility follows the RAI manual for completing and submission of the MDS assessments. The DON verified 6 of the 7 MDS assessments for Resident #201 had not been submitted. A review of the Long-Term Care Facility RAI 3.0 user's manual Version 1.19.1, October 2024 revealed nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. Skilled nursing facilities (SNFs) and non-critical access hospitals (non-CAH) with a swing bed agreement (swing beds) are required to transmit additional MDS assessments for all Medicare beneficiaries in a Part A stay reimbursable under the SNF Perspective Payment System (PPS). All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). Required MDS records are those assessments and tracking records that are mandated under OBRA and SNF (PPS). Assessments that are completed for purposes other than OBRA or SNF PPS reasons are not to be submitted to iQIES, examples include, but are not limited to, private insurance and Medicare Advantage Plans (i.e., Medicare Part C). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications available on the CMS MDS 3.0 website at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html. The provider indicates the certification or licensure of the unit on which the resident resides in item A0410, Unit Certification or Licensure Designation. In addition to reflecting certification or licensure of the unit, this item indicates the submission authority for a record. o Value = 1 Unit is neither Medicare nor Medicaid certified and MDS data is not required by CMS or the State. o Value = 2 Unit is neither Medicare nor Medicaid certified but MDS data is required by the State. o Value = 3 Unit is Medicare and/or Medicaid certified.

Based on record review, staff interview, and policy review the facility failed to recheck oxygen saturation levels for 1 of 1 residents with a respiratory illness to ensure it remained within set parameters to keep above 90% SpO2 (peripheral oxygen saturation) set by the Doctor and ensure oxygen was care planed and interventions implemented (Resident #26). The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #26 documented a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. The MDS documented she received oxygen and was dependent on staff for dressing, toileting, and transferring and does not walk. The MDS also documented diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, aphasia, non-traumatic brain dysfunction, cancer, diabetes mellitus, and hip fracture. Record review of Resident #26 current orders in her Electronic Health Record (EHR) on 4/16/25 documented a current order with a start date of 1/29/25 to apply Oxygen 2 Liters Per Minute (LPM) per nasal cannula to keep oxygen saturation above 90% for COPD. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 4/15/2025 10:05 AM 88.0% Oxygen via Nasal Cannula 4/15/2025 9:33 AM 88.0% Oxygen via Nasal Cannula Record review of Resident #26 Progress Notes documented the following significant documentation follow up to the oxygen saturation level on 4/15/2025 at 11:18 AM lung sounds diminished, shortness of breath eased with oxygen on and neb treatments. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 4/13/2025 2:15 AM 91.0% Oxygen via Nasal Cannula 4/12/2025 11:20 PM 88.0% Oxygen via Nasal Cannula 4/12/2025 6:15 PM 88.0% Oxygen via Nasal Cannula 4/12/2025 10:46 AM 89.0% Room Air 4/12/2025 10:15 AM 89.0% Room Air 4/12/2025 2:15 AM 88.0% Room Air 4/11/2025 6:15 PM 87.0% Room Air 4/11/2025 9:59 AM 86.0% Oxygen via Nasal Cannula 4/11/2025 9:30 AM 91.0% Room Air 4/11/2025 2:15 AM 89.0% Room Air 4/10/2025 6:15 PM 88.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation follow up to the oxygen saturation level: On 4/13/2025 at 5:35 PM continues on supplemental oxygen and often removes nasal cannula and has to be redirected to keep it on or put it back on. Oxygen saturation levels do still drop with removal of oxygen. On 4/12/2025 at 1:45 PM lung sounds diminished, oxygen saturation over 90% with oxygen on. On 4/11/2025 at 10:13 PM she removes nasal cannula. On 4/11/2025 at 11:31 AM oxygen levels vary, was 86% with oxygen on, other times it was 91% and 93%. On 4/10/25 at 10:41 PM is alert but disoriented, seems restless, moving around in her bed. On 4/10/25 at 3:40 PM lung sounds diminished, oxygen saturation over 90% with oxygen per nasal cannula. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 4/5/2025 9:36 AM 93.0% Oxygen via Nasal Cannula 4/5/2025 9:21 AM 89.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation follow up to the oxygen saturation level on 4/5/25 at 9:37 AM lung sounds with slight wheezing, nebulizer treatments assist with ability to take deep breathes oxygen saturation 93% on oxygen. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 4/4/2025 9:42 AM 92.0% Oxygen via Nasal Cannula 4/3/2025 9:49 PM 89.0% Room Air 4/3/2025 10:24 AM 91.0% Room Air 4/2/2025 10:29 PM 88.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation follow up to the oxygen saturation level: On 4/4/25 at 1:09 AM has been alert but still very confused, unable to finish sentences. On 4/4/25 at 12:03 AM does not keep oxygen nasal cannula in nose. On 4/3/2025 at 10:55 AM oxygen saturation 92% on room air, lung sounds shallow with minimal wheezing. Record review of Resident #26 oxygen saturations in her Electronic Health Record (EHR) documented the following outside of parameters and the follow up oxygen saturation: 3/30/2025 10:08 PM 90.0% Room Air 3/30/2025 4:25 PM 88.0% Room Air 3/30/2025 10:35 AM 91.0% Room Air 3/29/2025 10:14 PM 89.0% Room Air 3/29/2025 7:29 PM 89.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation follow up to the oxygen saturation level: On 3/29/25 at 10:46 PM disoriented, unable to verbalize appropriately, though she is sometimes able to communicate with gestures and pointing. On 3/28/25 at 12:13 AM had removed oxygen, it was put back on. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 3/18/2025 11:03 PM 92.0% Oxygen via Nasal Cannula 3/18/2025 10:47 AM 80.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation prior to the oxygen saturation level on 3/18/25 at 1:10 AM she is alert and disoriented and confused, she thinks she knows what she is talking about but makes absolutely no sense she has been restless this shift, but appears comfortable and denies need for pain medication. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 3/16/2025 9:14 AM 91.0% Oxygen via Nasal Cannula 3/16/2025 3:45 AM 88.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation related to the oxygen saturation level on 3/16/25 at 3:04 PM she is very anxious and says she is in pain. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 3/15/2025 10:01 AM 92.0% Room Air 3/14/2025 7:45 PM 89.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation related to the oxygen saturation level on 3/14/25 at 11:41 PM she is unable to communicate verbally with any clarity and at 11:09 PM is alert but disoriented, she refuses her oxygen sometimes by taking it off and it is put back on. Sometimes she just screams help rather than using her call light, at this time she is settled down and quiet. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 3/3/2025 7:32 PM 93.0% Oxygen via Nasal Cannula 3/3/2025 7:48 AM 82.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation related to the oxygen saturation level on 3/3/25 at 7:52 AM and 7:48 AM she was informed of benefits of wearing oxygen and risks of declining at 4:43 PM she initially refused oxygen but after reattempts she consented. Record review of Resident #26 oxygen saturations in her EHR documented the following outside of parameters and the follow up oxygen saturation: 3/2/2025 8:50 AM 94.0% Oxygen via Nasal Cannula 3/1/2025 7:23 PM 79.0% Room Air Record review of Resident #26 Progress Notes documented the following significant documentation related to the oxygen saturation level on 3/2/25 at 12:21 AM she is alert but disorient and has refused oxygen so her oxygen saturation has been low, measure at 79%. She is very confused, cannot speak sensibly, and gets irritated when people don't understand her. Record review of Resident #26 Progress Notes documented the following significant documentation related to the oxygen saturation level on 3/1/25 at 7:25 PM she refuses oxygen, will continue to offer. Record review of Resident #26 current Care Plan and Baseline Care Plan on 4/15/25 revealed they lacked goals and interventions regarding her need for oxygen. On 4/15/25 at 3:19 PM a request was made to provide a policy or procedure related to any of the following: change in condition, respiratory and/or oxygen assessments. The facility provided a Change In Condition Evaluation policy dated 4/6/25 and Respirations policy dated 10/29/24, however the policies provided did not include direction regarding oxygen saturation levels and what to do. Review of the facility policy Care Plan dated 12/2/24 instructed the following: The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services. During an interview on 4/16/25 at 10:30 AM with the MDS Coordinator revealed a residents Baseline Care Plan, Comprehensive Care Plan should have oxygen on it if the resident uses oxygen and relevant interventions if a resident would routinely attempt to take oxygen off.

Based on clinical record review, policy review, and staff interview the facility failed to care plan high risk medications to include side effects to be monitored for 2 of 5 residents (Residents #20 and #29) reviewed for high risk medications. The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) for Resident #20 dated 3/20/25 documented the resident received an antipsychotic on a routine basis. The MDS documented the resident was also taking an antidepressant, diuretic (fluid pill), and an opioid (narcotic) pain medication. 1. The Care Plan for Resident #20 lacked side effects to be monitored for the antipsychotic medication. 2. The Care Plan for Resident #20 lacked side effects to be monitored for the antidepressant medication. 3. The Care Plan for Resident #20 lacked side effects to be monitored for the diuretic medication. 4. The Care Plan for Resident #20 lacked side effects to be monitored for the opioid pain medication. During an interview on 4/16/25 at 10:30 AM, the MDS coordinator acknowledged the Care Plan should include side effects to be monitored for the antipsychotic, antidepressant, diuretic and opioid medications. The MDS coordinator explained she didn't know she needed to include the side effects on the Care Plan. The facility policy titled Psychotropic Medications - Rehab/Skilled last reviewed on 12/30/24 directed staff to monitor for side effects of psychotropic medications. The facility policy titled Care Plan- R/S, LTC, Therapy and Rehab last revised on 12/2/24 directed staff to have an individualized, person centered, comprehensive plan of care. The policy further directed staff to modify the plan of care to reflect the care currently required by/provided to the resident. 50874 5. The MDS with a reference date 2/27/25, documented Resident #29 had diagnoses of heart failure, hypertension, renal insufficiency, diabetes mellitus, and non-Alzheimer's dementia. Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognitive status. Resident #29 had been dependent on staff for assistance with toileting hygiene, lower body dressing, and putting on/taking off footwear. A review of the electronic health record (EHR), Orders tab revealed Resident #29 received the following diuretics: * Metolazone oral tablet 2.5 MG every morning on Monday and Thursday * Torsemide oral tablet 5 mg every day in the afternoon * Torsemide oral tablet 10 mg every day in the afternoon * Torsemide oral tablet 20 mg every day in the morning A review of Resident #29's Care Plan had a focus area initiated on 5/18/22 that stated the resident is on diuretic therapy related to edema. Interventions directed staff to monitor resident condition based on clinical practice guidelines or clinical standards of practice related to the use of a loop diuretic (Torsemide). The Care Plan failed to list Metolazone. The Care Plan failed to list interventions to direct staff to monitor for the adverse effect for the use of diuretics. The adverse effects for Torsemide include: * Chest pain * Decreased urination * Increased thirst * Irregular heartbeat * Mood changes * Muscle pain or cramps * Nausea or vomiting * Numbness or tingling in the hands, feet or lips The adverse effects for Metolazone include: * Dizziness * Weakness * Restlessness * Headache * Muscle cramps * Joint pain or swelling * Constipation * Diarrhea During an interview on 4/16/25 at 11:24 AM, Staff E, MDS Coordinator/Infection Preventionist acknowledged the Care Plan lacked the adverse effects of diuretic use and failed to include Metolazone.

Based on staff interview, record review, and policy review the facility failed to treat two out of three residents reviewed with dignity. The facility reported a census of 52 residents. Findings include: Review of Resident #1 face sheet reveals she was in room [ROOM NUMBER]-B. Review of Resident #2 face sheet reveals she was in room [ROOM NUMBER]-A. On 1/29/25 at 12:32 PM Staff A, Certified Nursing Assistant (CNA) stated on 1/23/25 in the evening an incident in room [ROOM NUMBER] occurred. I was in the room for a transfer with my coworker Staff C, CNA and there was a conversation about another staff member. The conversation was related to frustration because someone had left a dirty depend in the trash can and I was frustrated because the same staff member had taken a lift and had two people in a room for a transfer that only needed one person. I was not aware the daughter of Resident #1 was in the room. On 1/29/25 at 1:37 PM Staff B, Licensed Practical Nurse (LPN) stated she was not working but stopped in to talk to another nurse on the evening of 1/23/25. She said she stopped in the hall and started a conversation with Staff C, CNA who took Resident #2 into room [ROOM NUMBER] to provide cares. They then had a conversation in the room about other residents. I was not working and went in a residents room discussing other residents with Staff C and it was completely wrong. I did not realize the daughter was in the room. Staff C was in hallway and she was assisting Resident #2. During an interview with Staff C, CNA on 1/29/25 at 1:48 PM she stated she was working the evening of 1/23/25 and she did evening cares with Resident #2 in her room. She did upper body cares with an off duty nurse present in the room and she did have a conversation with her about non-work related things. She completed the residents cares and then went and got another CNA to assist with Resident #2 transfer into bed. They did converse about the situation and other staff and frustration with things not being done. I did not see the daughter sitting in the room and she was sitting behind the privacy curtain on Resident #1 side of the room and it was pulled from the wall over. We should not be talking about residents or other staff while providing cares and in residents rooms. During an interview on 1/29/25 at 3:34 PM with the Administrator she stated the conversation that took place in the residents room between staff members was not appropriate. They should not have talked about other staff members or residents. I was disappointed to hear they were speaking about other staff members. I would not expect them to be talking about other residents and family members. The facility provided a policy titled Resident Dignity - Rehab/Skilled dated 12/11/24 which directed the facility will promote care for residents in a manner and in an environment that maintains or enhances each residents dignity and respect in full recognition of his or her individuality. The policy directed staff to treat residents with respect (for example, addressing residents name of their choice; avoid using labels for residents, such as feeders;not excluding residents from conversations or discussing residents in community settings in which others can overhear private information).

Based on observation, clinical record review, policy review, and staff interview the facility failed to provide appropriate catheter care to prevent potential cross contamination that could lead to a urinary tract infection (UTI) for 1 of 1 residents sampled (Resident #38). The facility identified a census of 52 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status Score of 7 indicating severe cognitive impairment with a diagnosis of Non-Alzheimer's Dementia. The MDS documented Resident #38 as dependent upon staff for managing his urinary catheter for diagnoses of benign prostatic hyperplasia and neurogenic bladder. A review of the April and May 2024 Medication Administration Records (MARs) documented Resident #38 received Levaquin (antibiotic) tablet 500 milligrams (MG), one tablet by mouth one time day for UTI for three days from 4/29/24 - 5/01/24. A review of the June 2024 MAR showed Resident #38 received physician ordered Levofloxacin (antibiotic) oral tablet 250 MG, two tablets by mouth one time only for UTI on 6/23/24 and Levofloxacin 500 MG one tablet by mouth in the evening from 6/24/24 - 6/29/24 to equal seven days of antibiotic therapy. The Care Plan revised 6/18/24 documented Resident #38 used an indwelling catheter related to incomplete bladder emptying and noted the Resident at a risk of infection. The Care Plan directed the following interventions: a. Certified Nursing Assistants (CNAs) to provide catheter care morning and evening. b. Report unusual observations/conditions to the nurse. c. Monitor/document pain/discomfort due to the catheter. d. May wear a leg bag during the day and straight catheter drainage bag at night. e. Monitor/record/report to the health care provider for signs and symptoms of UTI: pain, burning/blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, a change in behavior, and a change in eating patterns. A review of the Physician Orders on 7/09/24 showed the following: a. Catheter 20 French 30 cubic centimeter (CC) with balloon to straight drainage. Change the catheter as needed if dislodged or plugged and unable to clear with irrigation. b. Catheter bag: change drainage bag monthly and as needed if plugged and unable to clean with irrigation. c. Flush Foley catheter twice a day. d. Flush Foley catheter with 50 milliliters (ML) normal saline every 6 hours as needed. e. May convert to drainage system to leg bag while up as needed. f. Urojet (numbing agent used to control pain during catheter insertion) with Foley catheter changes from emergency room visit as needed related to neuromuscular dysfunction of the bladder, unspecified. Start date 6/21/23. g. Cranberry concentrate oral capsule 500 MG, give one capsule by mouth in the morning related to personal history of UTI. Start dated 7/11/23. Resident #38 Kardex, under Bladder/Bowel/Toileting, directed the Resident used a 20 French catheter, utilized incontinence products, could wear a leg bag during the day and a straight catheter (urinary) drainage bag a night and to report unusual observations/conditions to the nurse. During an observation on 7/08/24 at 11:15 AM Resident #38 urinary drainage bag tipped forward out of the dignity bag underneath his wheelchair with three inches of the catheter tubing in direct contact with the floor. The urinary drainage bag tubing contained yellow, cloudy urine with mucous present. On 7/09/24 at 7:52 AM Resident #38 lay in a low bed. The urinary drainage bag lay with half the bag laying on the fall mat outside the bed and the other half laying on the floor. The Resident rested with his eyes closed and his left foot out of the bed on the floor next to the urinary drainage bag. During an observation on 7/10/24 at 7:09 AM Resident #38 lay in a low bed. The urinary drainage bag lay directly on the floor draining yellow urine. Observation on 7/10/24 at 8:26 AM revealed Resident #38 lay in a low bed. The urinary drainage bag lay directly on the floor with the drain tube out of the holder directly in contact with the gray fall mat on the floor off the left side of the bed. The urinary drainage bag was almost half full of yellow urine. On 7/10/24 at 10:35 AM Staff A, CNA reported urinary drainage bags are not to touch the floor. Staff A reported there had not been a privacy bag on the resident's bed this morning. She should have gone to laundry to get a privacy bag for the bed. She confirmed Resident #38 did not have a dignity bag over his drainage bag while in bed this morning. The dignity bags are kept in the laundry room and she did not go get a dignity bag for his bed. On 7/10/24 at 12:24 PM Staff B, CNA explained urinary catheter bags and tubing should not make contact with the floor. She verbalized they hang the urinary drainage bag off the side of the bed when the resident is in bed. If the resident is in a low bed, a plastic bag should be put over the drainage bag to keep the bag from contacting the floor or a dignity bag should be used over the drainage bag. During an observation of Resident #38 room on 7/10/24 at 12:32 PM, the gray fall mat noted to be folded in half with the outside of the mat touching the right side of the recliner and the other side of the mat touching the left side of the trash can. The sides touching the surfaces could potentially lead to cross contamination if the mat came into contact with the urinary drainage bag. On 7/10/24 at 2:42 PM Staff C, Registered Nurse (RN) reported if a resident is in bed, they hang the urinary drainage bag off the side of the bed. When asked what is the practice when a resident is in a low bed, she responded a barrier should be used under the bag. When asked further about the barrier, Staff C reported she wasn't sure what the facility practice was and didn't want to answer wrong. She would have to check on that. During an interview on 7/10/24 at 2:55 PM the DNS reported Staff C had just asked her about barriers for the catheter bags for the low beds and she was going to look up the policy. She expects the urinary drainage bags will not come into contact with the floor, but reported she needed to look up the policy to see what they were supposed to do. The DNS verbalized the fall mats should be folded inward so that the surface that could come into contact with the urinary drainage bag would not cause a problem. During an interview on 7/11/24 at 8:05 AM the DNS reported she expected the staff to utilized a dignity bag over the urinary drainage bags when the resident is in a low bed. The dignity bag straps could be adjusted so the bag is up off the floor even when used on a low bed. The Catheter: Care, Insertion, Removal, Drainage Bags, and Irrigation Specimen Policy revised 2/10/23 directed catheter tubing should never be allowed to touch the floor. Catheter (urinary drainage) bags should be covered when up in a chair and out in public or visible from the door/hall. The Policy lacked direction to the staff to keep the urinary drainage bags from coming into contact with the floor.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required time frame for 2 of 2 residents sampled for hospice care (Resident #40 and #10). The facility reported a census of 52 residents. Findings include: 1. Resident #40 Electronic Census Record documented she admitted into hospice care on 6/17/24. Resident #40 SCSA MDS with an assessment reference date of 6/27/24 showed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive loss. The MDS listed diagnoses of Non-Alzheimer's Dementia, heart failure, diabetes mellitus, and end stage renal failure. The MDS documented Resident #40 received hospice care services. A 7/10/24 review of the MDS Summary Page showed the SCSA MDS completion date as 7/05/24, greater than 14 days after the significant change determination date. On 7/10/24 at 11:43 AM the MDS Coordinator reported she attended a meeting in June (2024) and they talked about the MDS SCSA needing to be completed within 14 days. She looked at the RAI manual and found out the SCSA MDS's had been completed too late, but she hadn't really reported the error to the facility. She reported she is aware of the requirement now. She reported she follows the facility MDS policy and the RAI for completing the MDS. During an interview on 7/10/24 at 12:41 PM the Director of Nursing Services (DNS) reported she didn't know what the requirements were for the completion of a SCSA MDS. She would have to defer to the MDS Coordinator and the facility policy. She would expect the MDS Coordinator to follow the facility policy. The MDS 3.0 RAI Policy, revised 7/01/24, provided by the facility, under Procedure: Significant Change MDS outlined the following process: a. When a significant change is identified, the professional employee identifying the change will notify the social worker, RN Coordinator or designated employee so that a timeline may be established and communicated to the team members. b. The team member who identified the change will document in the progress notes that a significant change has occurred and will identify whether the change is an improvement or a decline and in what areas. The Procedure further directed to follow steps #3-#18 of the policy. c. Step #4 directed the MDS Coordinator or designee to open the MDS within the 14 day look back in Point Click Care (PCC). d. Step #13 directed for a comprehensive MDS (SCSA is a comprehensive MDS assessment) the RN MDS Coordinator/RN Designee would electronically sign V0200B1 and date V0200B2 signifying the completion of the RAI process. The Policy included to see also the Resident Assessment Instrument User's Manual. The LTC RAI 3.0 User's Manual Version 1.18.1 October 2023 page 1-4 documents the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. The LTC RAI 3.0 User's Manual Version 1.18.11 October 2023 Page 2-17 directs the MDS completion date is no later than the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Page 2-25 directs An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. 42134 2. Resident #10's Progress Note written on 6/10/24 at 4:24 PM documented the resident had received an order for hospice. Progress Note written on 6/10/24 at 4:25 PM documented the family was notified of the hospice order and services provided. Progress Note written on 6/10/24 at 4:28 PM documented the family decided on a hospice provider but wanted to discuss the decision with additional family members. Progress Note written on 6/11/24 at 3:48 PM documented the family had made a definitive choice of hospice provider. Hospice was in the building and initiated the process. Progress Note written 6/12/24 at 6:51 PM documented Resident #10 was admitted to hospice services. The SCSA was signed off as complete on 7/1/24 (19 days after admission to hospice).

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to perform restorative nursing programs per the restorative assessment and care plan to attain/maintain or prevent decline for 2 of 3 residents sampled for range of motion (Residents #11 and #23). The facility identified a census of 50 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #11 with a long/short term memory impairment and severely impaired decision-making ability. The Resident required total assistance with bed mobility, toilet use and personal hygiene. The Resident required extensive assistance with transfers and dressing. The MDS listed diagnoses of non-traumatic brain dysfunction, Alzheimer's Disease with late onset, and Non-Alzheimer's Dementia. The current Care Plan updated 4/04/23 directed the staff to provide active assisted range of motion (AAROM) to the resident's bilateral shoulders, elbows, and wrist for 10 repetitions for 1 set, bilateral knee flexion/extension or hip flexion/extension 10 repetitions for 1 set, and bilateral hamstring and heel cord stretches for 30 seconds for 3 sets. Further review showed the Care Plan identified Resident #11 at risk of falls related to decreased mobility. An interview on 5/10/23 at 1:15 p.m. with Staff A, Registered Nurse (RN)/Clinical Care Leader, reported the blank spots on the Restorative Record Report were not signed off because the program had not been completed. She verbalized she was one person for fifty residents and she most likely didn't have time to complete it. She is the only one to do restorative for the building. If a resident refused or she couldn't complete the program it would have been documented on the report. Further review of Resident #11's medical record revealed the resident had been treated by Physical Therapy on 4/7/20. The Physical Therapy discharge date d 4/7/20 documented to continue the restorative nursing program. The Occupational Therapy Summary dated 4/20/20 detailed Resident #11 had been discharged with a restorative nursing program in place. On 5/10/23 at 1:45 p.m. a review of the Restorative Record Report from 3/1/23 - 5/10/23 revealed the following days were blank in Resident #11's restorative documentation: a. March 3rd, 15th, 24th, 27th, 31st for AROM of lower the extremities. b. March 2nd, 4th, 9th, 11th, 15th, 18th, 20th, 25th, 30th for AROM of the upper extremities. c. April 3rd, 5th, 10th, 14th for AROM of the lower extremities. d. April 4th, 6th, 15th, 18th, 20th, 22nd, 25th, 27th, 29th for AROM of the upper extremities. e. May 3rd for AROM of the lower extremities. f. May 4th and 6th for AROM of the upper extremities. On 5/11/23 at 9:26 p.m. the Director of Nursing Services (DNS) reported the restorative nurse currently has the primary responsibility for completing the restorative programs. She stated there is a current gap in the restorative program and they are aware of it and working on it. She voiced she expects the restorative programs to be completed as written. The Rehabilitation/Skilled and Long-Term Care Therapy and Rehabilitation Policy revised 11/28/22 documented a purpose to (1) provide appropriate restorative nursing care to each resident; (2) assist in the implementation of a restorative nursing program in the location; (3) identify the residents appropriate for a restorative nursing program; (4) provide appropriate treatment for the resident's activities of daily living and to provide a safe environment through training and supervision. The Policy directed each resident would receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as defined in the nursing assessments. The restorative care will be outlined in the resident's nursing care plan. Care includes safe measures to prevent complications and contractures, maintain strength and self-care abilities including eating, dressing, promoting mobility, and a feeling of well-being. Based on the resident's comprehensive assessment, the location ensures the residents ability in activities of daily living does not decline except when unavoidable for reasons of disease progression, deterioration of physical condition associated with disability, or refusal of care/treatment by the resident or legal representative. Evidence of any of these reasons will be reflected in the medical record. The goal of restorative nursing care is to attain or maintain the maximum possible independence and/or prevent rapid declines through their interventions for each resident. The Policy directed the restorative nurse has the overall responsibility and accountability for the restorative program. In the event the location does not have a designated restorative nurse, the responsibility and accountability remain with the director of nursing services (DNS) of his/her designee. The Rehabilitation/Skilled Long-Term Therapy and Rehabilitation Policy under Assessment Guidelines directed the following: 1. If a nursing assessment indicates an ADL or ROM deficit, assess the need for a therapy screen. If the therapist determines a need for evaluation, obtain the resident/responsible party's permission before obtaining a physician's order to evaluate and treat. a. The therapist may recommend a restorative nursing program. Because this is a nursing program, the restorative nurse and the resident should be involved in developing and care planning the interventions. b. Therapists communicate all recommended programs through the restorative nurse. The restorative nurse is responsible to develop the care plan approaches and teach and train the nursing employees on the appropriate programming. c. If an evaluation is not indicated, an appropriate restorative program may be implemented by the restorative nurse. An order from the attending physician is not required. d. Individual resident clinical records of restorative programs are maintained and include: (1) Specific care/treatment modalities (2) Frequency and duration (3) Tolerance (4) Precautions or contraindications (5) Response to care/treatment (6) Progress or lack of progress 2. Changes in condition or lack of progress are reported to the restorative nurse in a timely manner. 3. The residents plan of care is reviewed at least quarterly and as needed by the restorative nurse for potential changes/problems. If indicated, the program will be reviewed in consultation with the appropriate therapist and attending physician. a. The restorative nurse or MDS nurse will participate in the care plan conferences for all resident with an established restorative program. Examples of condition for implementation of a restorative nursing program include: 1. Medical conditions that affect joint motion 2. Surgically replaced joints 3. Pressure ulcers 4. Limited range of motion; disease process and prognosis, spasticity, contractures, or decreased sensation. 5. Activity tolerance decreased and immobility decreased. 42133 2. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #32 had a long and short term memory impairment with severely impaired decision making. The resident required total assist with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS further documented a functional limitation in range of motion to bilateral extremities of the upper and lower body. The MDS listed a diagnosis of Alzheimer's Disease with late onset and documented Resident #32 received two days of restorative nursing during the assessment look back period. The Restorative Nursing Documentation-V2 report dated 4/13/23 completed by Staff A, Clinical Care Leader and Registered Nurse (RN), documented Resident #32's overall evaluation showed signs of decline. Staff A documented to continue the current therapy order for the Resident's end stage dementia. The restorative documentation further documented Resident #32 required the restorative program in attaining or improving function or to help the resident maintain current function and/or prevent/slow decline. Staff A documented the Resident's restorative program did not need to be reviewed and the resident continued to exhibit upper and lower extremity impairment on both sides of the body. The Restorative Nursing Documentation under Care Planning interventions documented the resident would remain free of complication related to immobility including contractures, thrombus (a blood clot formed within the vascular system of the body and impeding blood flow) formation, skin breakdown, and fall related injury through the next review date. The Care Plan intervention documented to complete nursing rehab #1: passive range of motion three times a week. Active range of motion with the bilateral upper extremities, all motions x 15 repetitions and Nursing rehabilitation #1: passive range of motion bilateral lower extremities 15 repetitions three day a week. The current Care Plan revised 4/17/23 documented Resident #32 had a need for a restorative intervention due to an activities of daily living self-care performance deficit/limited physical mobility/communication problem related to dementia. The Care Plan directed the staff to provide nursing rehab #1: active range of motion three times a week to the upper extremities, all motions x 15 repetitions, revision on 1/06/2023. A Review of the facility 2023 Restorative Records revealed the following dates were blank on the documentation records: 1. March 2nd, 4th, 9th, 11th, 16th, 18th, 21st, 23rd, 25th, 30th. The Record documented Resident #32 received the restorative program 7 times for the entire month. 2. April 4th, 6th, 13th, 15th, 18th, 20th, 22nd, 25th and 27th. The Record documented Resident #32 received the restorative program 8 times for the entire month. 3. May 2nd, 4th, and 6th. The Record documented Resident #32 received the restorative program twice from 5/1/23 - 5/10/23. Further review of the facility 2023 Restorative Records lacked documentation of any lower body exercise program to address the lower body bilateral functional limitation documented on the MDS for Resident #32. On 5/08/23 at 10:00 a.m. Resident #32 sat in an upright position with her hips and knees flexed for a seated position in the broda chair. The Resident's left hand observed to be clasped closed and the right hand 3rd, 4th, 5th digits closed into the palm. During an observation on 5/09/23 at 7:50 a.m. Resident #32 sat in a broda chair in an upright seated position with her knees flexed at a 90 degree angle in good alignment. The Resident's left hand observed to be clasped closed and the right hand 3rd, 4th, 5th digits closed into the palm. During an observation on 5/09/23 at 2:08 p.m. Staff A performed passive range of motion (PROM) to the left fingers, wrist, elbow, and shoulder for 15 repetitions, then repeated the passive range of motion on the right fingers, wrist, elbow, and shoulder for 15 repetitions. Staff A reported she does upper body range of motion on one day and lower body range of motion on another day. She alternates days from upper to lower body range of motion (ROM) programs. A review of the Resident #32's medical record on 5/10/23 revealed the resident had received physical therapy from 11/14/22 - 12/01/22 for chair positioning. The resident range of motion programs were not reviewed. A review of the Care Conference Notes on 5/10/23 revealed the conference note documentation on 1/24/23 and 5/31/23 lacked documentation pertaining to the resident's restorative needs, risks, or decline. During an interview on 5/10/23 at 1:46 p.m. Staff A reported the blanks in the restorative record meant she didn't attempt or complete the restorative program that day. She voiced she hated to even document on the record if she didn't even attempt the restorative program. She is the only staff member that performs the restorative programs. She reported Resident #32 did not receive her restorative program on the days the restorative record had blanks. On 5/11/23 at 9:26 a.m. the Director of Nursing Services (DNS) reported Resident #32 did not have a lower body restorative program. She stated they had looked way back in the Resident's medical record and there had been some documentation about her lower leg edema and not tolerating much with her lower body due to edema but not specifically with range of motion. She stated the restorative nurse currently has the primary responsibility for completing the restorative programs. The DNS reported there is a current gap in the restorative program and they are aware of it and working on it. She voiced she expects the restorative programs to be completed as written.

Based on observation, document review, and staff interview the facility failed to post the required daily staff posting in an area that was highly visible/accessible to the public. The facility reported a census of 50 residents. Findings Include: During an observation completed upon entrance to the facility on [DATE] at approximately 9:30 a.m. revealed a 5/05/23 staff posting on the front open office door. The staff posting on the office door did not appear to be highly visible to the public coming in or exiting out the front facility doors. During an observation on 5/9/23 at 1:34 PM there was no staff posting on the office door where it had been previously or anywhere else in the facility. During an observation on 5/10/23 at 10:00 AM there was no staff posting on the office door where it was on Monday or anywhere in the facility. During an interview on 5/10/23 at 10:45 AM the Facility Administrator stated the staff posting is supposed to be on a clip board hanging on the office door. He acknowledged it was not present at this time. The clipboard was found on a table in the office tucked behind some other items. The clipboard and staff posting was not visible to staff, residents, or the public.

Based on clinical record review, observation, review of manufacturer's recommendations and staff interview, the facility failed to follow accepted standards of practice for one of 22 total residents reviewed (Resident # 36). The facility identified a census of 44 residents. Findings include: 1. According to Minimum Data Set assessment of 12/10/21, Resident #36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation of medication administration on 1/4/22 at 8 AM, Staff A, LPN (Licensed Practical Nurse) administered a scheduled inhaled medication, [MEDICATION(S)] (to treat lung disease), to Resident #36 as ordered. When Resident #36 completed use of the inhaled medication, Staff A did not offer or encourage Resident #36 to rinse their mouth after use and did not have a receptacle for the resident to rinse their mouth and spit into. Staff A then proceeded to administer oral medications to Resident #36 that were taken with water and swallowed without rinsing. During an interview 1/5/22 at 2:03 PM, the facility's DON (Director of Nursing) was informed of the inhaled medication administration observation on 1/4/22. The DON stated that at times, Resident #36 can be set in their ways and refuse to follow directions. When informed that Staff A did not instruct or provide Resident #36 with items needed to rinse their mouth with water and spit it out before taking the oral medications and swallowing the water, the DON acknowledged that because the inhaled medication contained a steroid the resident should have been directed to rinse their mouth and provided with items needed to do this. Review of Instruction for Use of the [MEDICATION(S)] medication, provided by the facility DON who had their pharmacy fax the information with directions for use from the manufacturer of the medication, revealed Step 6 directed users to Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water.