Every finding on record at Great River Care Center

Based on observation, clinical record review, staff interview, family interview, police officer interview and facility policy review the facility failed to ensure the staff maintained all secured exit doors resulting in 1 of 3 reviewed residents (Resident #1), identified as exit seeking, exiting the facility while a staff member who entered allowed the resident to exit. The staff member failed to notify any nursing and/or management staff. The resident then walked 0.8 miles from the facility down an identified highway on an incline from a bluff and into town. The resident had left the facility for approximately 45 minutes before the nursing staff realized he was missing, when the resident's family called the facility and informed the staff. This deficient practice resulted in an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. The facility identified a census of 31 residents.The Iowa Department of Inspections, Appeals, and Licensing (DIAL) notified the facility of the IJ on 11/5/25 at 3:30 PM. The immediacy began on 11/2/25. The IJ was removed per past noncompliance on 11/3/25. The facility removed the IJ through the following actions: *Wander guard placement 11/3/5. *The nursing staff began holding missing resident drills on 11/3/25.*All staff received education on the following policies: missing resident/tenant policy, door alarm response times, prior to their next shift and via a mass text message to all staff.The facility implemented their plan of correction and removed the immediacy on 11/3/25. The scope was lowered from a J to a D. Findings Include:According to a Minimum Data Set (MDS) assessment form dated 10/24/25, Resident #1 had diagnosis that included a non-traumatic brain dysfunction, Hypertension (HTN), Alzheimer's Disease, anxiety, and disorientation. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which signified moderately impaired cognitive skills, Review of Resident #1's Care Plan revealed the following: a. The resident required 24 hour care related to (r/t) Alzheimer's Disease (Initiated 2/13/25). b. At risk for falls r/t pain, weakness and a history of falls. (Initiated 2/13/25). The intervention initiated 9/16/25 revealed, Independent with a front wheeled walker (FWW) for transfers and ambulation. c. Impaired cognition r/t Alzheimer's Disease. (Initiated 2/13/25). The intervention dated 2/13/25 directed staff to cue, reorient and supervise as needed. A Morse Fall Scale dated 10/22/25 at 8:18 a.m. indicated the resident as at high risk for falls. The resident scored 80 on the assessment. It was noted a score between 46 and 125 indicated high fall risk. Per the Fall Scale, Resident #1 exhibited weak fait, and overestimated or forgot limits related to abilities to ambulate safely. An Elopement Incident Form dated 11/2/25 at 7:20 a.m. included the following information: When housekeeper arrived to work at 7:20 a.m. she opened the front door. Resident was [NAME] at the front door and asked the housekeeper to hold the door open for him. The housekeeper held the door open and the resident went outside. Resident was dressed in jeans, sweater, baseball cap, sock and shoes. Resident does often stand at the front entrance and look out the window, however, never attempted to go outside prior. When staff noticed resident was not in his room, Nurse and all of the present staff searched the building for resident, which included every resident room, and then looked outside to see if he was there. Housekeeper then reported she let the resident out the front door upon her arrival to work. Nurse then called 911. Granddaughter then called right after getting off the phone with the police and reported the resident called her and stated he was downtown. Police arrived back to the facility with the resident. Full head to toe assessment done upon arrival back to facility, No injuries. Denies pain. Fingertips cold to the touch due the temperature outside. Resident had his walker with him and his glasses on. The Resident Description section of the Incident Report revealed, I just wanted to get away. Review of a Police Report dated 11/12/25 at 7:16 p.m, for incident date 11/2/25 at 8:06 a.m. included the following: On 11/2/25 at approximately 8:06 a.m., the police officer had been dispatched to the report of a person missing from the care center. The officer later identified the missing person as [Resident #1]. Upon speaking to the staff at the care center, they informed him that one of their staff members held the door open for the resident as he left the care center earlier that morning. The staff stated the resident was not supposed to leave the facility unless a family member picked him up. Then staff then notified the officer the resident's daughter had called the care center and told them the resident had been alone at his son's properly at [Address Redacted]. The officer arrived at [Address Redacted] at approximately 8:19 a.m. [Officer] located [Resident #1] standing on the sidewalk across the street from that address. The resident wore a grey sweatshirt and blue jeans. [Resident #1] stated that he walked to that location from the care center and stood on the sidewalk as he waited for his son, [Name Redacted], to pick him up. He (Resident #1) later stated he wished his son would come to pick him up because he felt cold. [Resident #1] stated he left the care center because he was tired of em there. He also stated, I can't take the sitting there in the, anymore. While talking to [Resident #1], he stated multiple times that he did not want to go back to the care center. [Resident #1 also stated that he was afraid if they got him there, they would not let him go .[Officer] asked [Resident #1] to walk back to my squad car so [Officer] could take him back to the care center. [Resident #1] agreed to do so. During an interview on 11/4/25 at 10:57 a.m., the State Climatologist identified the temperature in the area at the time of the elopement as 41 degrees Fahrenheit (F), 81% humidity, wind 3 miles per hour, wind chill 39 degrees F, mostly cloudy and no precipitation. During an interview 11/5/25 at 9:54 a.m., Staff A, Housekeeping confirmed Sunday morning 11/3/25 at approximately 7:30 a.m. she entered the front door of the building and there stood the resident with his walker. (It was noted 11/2/25 was a Sunday). He told her to hold it and out the door he went. The staff member confirmed she failed to observe him as he walked away from the facility. Later, someone said something about the resident and she told them he left the facility, then the staff began to look for the resident inside and outside the building, and then called the police. The staff member indicated in a matter of minutes the resident walked in the facility with the police. When questioned the meaning of a matter of minutes the staff member stated 1/2 hour to 1 hour. During an interview 11/5/25 at 10:15 a.m. the Regional Director of Operations indicated through their investigation, [Resident #1] had a mission. When they interviewed him he indicated he planned to go to his family members house across the street from his church in [City Name]. The resident actually made it it his friend's apartment and that is when he called his wife for assistance. During an interview 11/5/25 at 10:36 a.m., Resident #1 confirmed he left the building right out the front door because he said he was uptight related to (r/t) some of the things around the facility. The resident indicated he exited out the front door and walked down the highway into [City Name] to the vicinity of his son's house. He ended up across the street from his apartment by the church. The resident indicated his son had been working at the time so he had not been home. At that point the police intercepted him and brought him back to the facility. The resident indicated he walked the street or sidewalk whichever he could find on his way into town. The resident confirmed he felt cold when he left and he failed to wear a coat and gloves but he had not fallen. During an interview 11/5/25 at 11:26 a.m., Staff B confirmed she worked 11/2/25, arrived at 5:30 a.m., and entered the facility through the North dining room door at which time she observed the resident positioned at the dining room table. The staff member never observed him again until later that morning as she walked through the dining area. Later that morning staff had not observed him at the dining room table so Staff C, Certified Nursing Assistant (CNA) asked where he was as Staff B indicated she had not known. Staff then got on radio (walkie talkie) and asked if any staff knew the location of the resident. At that point everyone took off down the hallways, resident rooms, outside and through the entire building. The staff returned to the facility around 8 a.m. when the phone rang as the resident's family requested to speak to Staff D, Registered Nurse (RN). During an interview 11/5/25 at 11:41 a.m., Staff C confirmed she worked 11/2/25 from 5 a.m. to 1 p.m. and entered the facility through the North door in the dining room and observed the resident positioned at the dining room table where he sat per norm for the resident. Around 7 a.m. she had been in another resident's room when a call came over the walkie talkie and informed staff the resident had been exit seeking. As she left the resident's room Staff B told her the resident stood by the front door and was exit seeking so Staff C intervened. The resident told her he had been upset because he drank all of his coffee and he wanted more. Staff C redirected him and stated it had been cold outside at which time he responded by, yes you are right so he headed back towards his room. The next thing she knew around 7:50 a.m. to 8 a.m. while she assisted the resident's roommate in their room she noted the resident as not present so she informed Staff D the resident appeared missing. From what she knew, Staff D called the police and all staff looked down each hallway and rooms, one staff went to the assisted living and three staff outside and around the building. The staff member indicated maybe 10-15 minutes after that event began a police officer arrived without the resident and talked to Staff D then left the facility as a means to locate the resident. At a time unknown she observed the officer return with the resident, who appeared per normal self. During an interview 11/5/25 at 12:32 p.m., Staff D confirmed she worked 11/2/25 from 5 a.m. to 5 p.m. and entered the facility through the front door and felt the resident had been in his room at that time. Just before breakfast around 7:50 ish staff notified her the resident had not been in the dining room anymore. Staff already knew he had been wandering so they searched all the rooms in the facility, outside and the assisting living facility on grounds but no one found him. At approximately 8 a.m. she called 911 and as soon as she got off the phone the granddaughter called and said, you know the resident had not been in the facility rather he was at his son's apartment. The staff member validated they had been aware so she called 911 again and told them where he had been located per the family. The police went straight to the location and brought him back to the facility around 8:30ish with his walker and cell phone. When the staff member got to him he grabbed her hands and his hands were cold but his circulation was good. She then took him to his room and cranked up his heat as she performed a head to toe assessment with no negative outcome other than cold. During an interview 11/5/25 at 12:44 p.m., Staff E, CNA confirmed she worked Sunday morning and entered for her shift through the North side door in the facility however the resident had not been positioned at the dining room table upon her arrival. Staff E proceeded to get people up for the day and as she took residents to the dining area she indicated at approximately 6:30 a.m. the staff member observed the resident as he drank coffee at the dining room table. Later she heard someone paged the resident had been by the front doors looking outside so the staff were aware. Staff E proceeded to get people up and around 8 a.m. when she went up to the front of the building the girls asked if she had observed the resident. At that point, all the staff split up and went through the facility and looked outside. The staff member offered somewhere in her line of looking Staff A said around 7:20-7:30 a.m. she observed him by the front door and that she let him out to get some fresh air. Staff E then informed Staff D who made calls. Staff E confirmed she observed him from a distance when he returned with the police officer and denied having noticed anything abnormal at that time. During an interview 11/.5/25 at 1:55 p.m. Staff F, Dietary explained she worked on 11/2/25, arrived a little after 6:30 a.m., and observed the resident at the dining room table with a cup of coffee. At about 6:45 a.m. the staff member proceeded to set the tables for breakfast and observed him as he ambulated towards the front door. The staff member redirected him and asked him what he planned to do and he stated he wanted to leave. She basically tried to talk to him because he said someone planned to pick him up. She attempted to redirect him but he refused and went back to his room. The staff member had no more contact until he returned back with the police officer. During an interview 11/5/25 at 12:07 p.m., resident's family member offered at 6:45 a.m. the resident initially called her but she failed to answer the phone as she slept. The resident called again at 8:02 a.m. and 8:03 a.m. when she answered and he told her he was at his son's apartment on [Street Redacted] which had been a block and 1/2 down from the church and she thought approximately 0.8 miles away from the facility. This family member then called a granddaughter at 8:06 a.m. who lived approximately 20 minutes from the facility so the granddaughter called the nursing home and the local police department. The police officer picked up the resident and took him back to the facility. An observation 11/5/25 at 12:55 p.m. revealed the elopement pathway consisted of having walked down the highway into town, approximately 0.8 miles and on a busy road/highway. A Missing Resident/Tenant Policy dated 12/21/18 indicated the Purpose as an assurance of prompt and appropriate response by the staff and emergency personnel for maintenance of resident safety.

Based on observation, clinical record review, policy review and staff interview, the facility failed to provide a water flush per the physician order, measure the formula amount during feeding set up and raise the head of the bed to 45 degrees in the provision of feeding tube care for 1 of 1 resident sampled (Resident #4). The facility identified a census of 29 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 with unclear speech (slurred or mumbled words), rarely/never able to make self-understood, and rarely/never able to understand others. Resident #4 had a long/short-term memory impairment, unable to recall the current season, location of room, staff names and faces, that he was in a nursing home and severely impaired decision-making ability (never/rarely made decisions). Resident #4 exhibited fluctuating inattention (difficulty focusing attention). The MDS listed diagnoses of anoxic brain damage (lack of oxygen to the brain which can cause lasting cognitive effects), dysphagia (difficulty or inability to swallow), gastrostomy status (a feeding tube inserted through the gastric system to provide nutrients and fluids into the body), and profound intellectual disabilities. Resident #4 received 51% or more of total calories and 501 cc (cubic centimeter)/day or more through a feeding tube in the last 7 days while a resident. A Physician Visit Note, encounter date 5/09/25, documented Resident #4 with a profound intellectual disability, chronic anoxic encephalopathy, presence of a percutaneous endoscopic gastrostomy (PEG) tube (feeding tube), oropharyngeal dysphagia (difficulty swallowing) and history of a gastric ulcer. A Progress Note dated 6/21/25 at 1:21 AM documented Resident #4's feeding tube was obstructed and unable to flush to continue the feeding.A Progress Note dated 6/21/25 at 9:48 AM detailed notification to the on-call provider with orders to send Resident #4 to the emergency department (ED) for evaluation of clogged a clogged feeding tube. Staff A, Licensed Practical Nurse (LPN) obtained a Verbal Physician Order to send Resident #4 to the ED on 6/21/25 at 9:59 AM. A 6/25/25 Appointment Note detailed a new feeding tube was placed. The Facility Appointment Physician Response Resident #4 feeding tube had been exchanged, flushed and was working. A New Verbal Physician Order dated 6/25/25 at 2:19 PM ordered Jevity 1.5 Cal/Fiber Oral Liquid Nutritional Supplement, give 1100 ML (milliliter) via feeding tube in the afternoon via pump at 110 ML/hour with auto flush at 15 ML/hour. Elevate the head of the bed (HOB) 45 degrees or higher during feed for two hours after the feeding.An Order Summary Report signed by the Provider on 6/30/25 listed the following physician orders:a. Flush: 150 Milliliters of tap water into feeding tube before the start of feeding. Start date 8/08/25. b. Jevity 1.5 Calories/fiber Oral Liquid Supplement, give 1100 ML via feeding tube in the afternoon via pump at 110 ML/hour x 10 hours with auto flush at 15 ML/hour x 10 hours. Elevate the head of the bed 45 degrees or higher during the feeding for two hours after feeding. Start date 4/15/25. The Nutritional status Care Plan revised 7/11/25 noted Resident #4 received nothing by mouth and needed an alternate feeding method due to aspiration (the inhalation of a substance like food, liquids into the lungs) and a diagnosis of difficulty swallowing. The Care Plan directed to elevate the head of the bed as ordered; provide water flushes as ordered, and to provide tube feeding as ordered.Observation on 8/18/2025 at 12:57 PM and 1:46 PM revealed Resident #4 sat in a recliner in the front lounge muttering non-sensical speech to himself and as staff walked by. During an observation on 8/18/25 at 3:44 PM Resident #4 lay in bed on his back with the head of his bed up approximately 30 degrees. Resident #4 continued to mutter non-sensical speech. Staff B, Registered Nurse (RN) hung a 1000 ML feeding bag on a pole, then poured four 8 ounce (oz) (237 ML) containers of Jevity 1.5 Formula into the feeding bag for a total of of 948 ML. Staff A then poured an unspecified amount out of a fifth Jevity container into the feeding bag topping just over 1000 ML. Staff B voiced Resident #4's orders were to receive 1100 ML, so she just poured a little extra in the bag above the 1000 ML line and that should be about right. Staff B poured 500 ML of tap water into a separate feeding bag. Staff B primed the feeding pump line set and set the pump to 110 ML per hour with a 15 ML water flush every hour. Staff B hooked Resident #4 feeding tube up, then raised the head of his bed up a little more, but not to 45 degrees. When asked if the feeding pump provided a water flush prior to and after the feeding, Staff B responded she wasn't sure and would have to check the physician orders on the water flush. During an interview on 8/18/25 at 4:10 PM Staff B checked Resident #4 flush orders. Staff B scrolled Resident #4's physician orders in the computer and stated she had not completed the 150 ML water flush per the physician order prior to starting the Jevity feeding. An 8/19/25 review of Resident #4 Electronic Medication Administration Record (EMAR) showed Staff B documented off the following physician orders as completed:a. Flush 150 ML of tap water into the feeding tube before the start of feeding every day shift. State date 8/08/25. b. Jevity Cal/Fiber Oral Liquid Nutritional Supplement, give 1100 ML via feeding tube in the afternoon via pump at 110 ML/hour for 10 hours with auto flush at 15 ML/hour x 10 hour. Elevate HOB 45 degrees or higher during feed for two hours after feeding. During an interview on 8/20/25 at 1:39 PM Staff C, Certified Nursing Assistant (CNA) reported Resident #4 could not express any feeling or verbalize directly. He just had gibberish and random sounds that he made.Interview completed on 8/21/25 at 9:18 AM revealed Staff D, CNA verbalized Resident #4 couldn't carry a regular conversation. Observation on 8/21/25 at 9:47 AM revealed Resident #4 sat in the front lounge recliner vocalizing random sounds. During an interview on 8/21/25 at 11:05 AM the Director of Nursing (DON) explained all the physician orders were on the EMAR. She expected the nurses to verify the physician orders for the tube feeding, gather all supplies, double check the physician orders, take the laptop into the resident's room with them, verify the feeding rate and amount prior to starting the tube feeding, and ensure resident is in the appropriate position and comfortable with no irregularities with the feeding tube placement or site. If questions, she expected the nurses to come ask prior to the feeding tube administration. She then expected the nurses to check on the tube feeding hourly to ensure the resident tolerating and was going well. She voiced she would like the nurses to check the physician orders three times to ensure it is accurate and they were following the physician orders for the tube feeding. The Enteral Feeding Tube Policy, effective 6/20/22, documented the facility would provide and implement a plan of care for the delivery of nutrients per feeding tube when nutrients could not be obtained through the oral route. The Policy under Continuous Infusion directed the following:a. The HOB must be elevated 30-45 degrees at all times if tube feeding is continuous, unless the physician specifies another position. b. For Jejunostomy tube feedings, measure the amount of tubing between the end of the tube and the point where the tube enters the body. Do not initiate feedings if the tube length has changed from baseline measurements. Check for residual in stomach per the physician order.c. Initiate feeding, fill formula bag with prescribed formula. Connect to infusion pumps, spike containers and prime the tubing. d. Connect formula bag to pump to the end of the feeding tube. Set the pump to the physician orders. e. Flush tubing with 30-60 ML of water, per the physician's orders.

Based on record review, staff interviews, and policy review the facility failed to revise the Care Plan to include hospice care for 1 of 1 residents reviewed (Resident #24). The facility reported a census of 25 residents. Findings include: The Minimum Data Set (MDS) report dated 8/01/24 for Resident #24 indicated a Brief Interview for Mental Status (BIMS) score of 0/15, indicating severe cognitive impairment. The MDS further indicated diagnoses including: Alzheimer's disease, non-Alzheimer's dementia, and seizure disorder. The Progress Note dated 8/08/24 documented Resident #24 admitted to hospice on this date. A review of Resident #24 Care Plan, revised 9/30/24 revealed the plan lacked a focus area for hospice care. In an interview on 10/02/24 at 8:59 AM the Assistant Director of Nursing explained Staff A, Nurse Consultant was in charge of updating the Care Plans both upon admission and as things change. In an interview on 10/02/24 at 9:01 AM Staff B, Nurse Consultant explained she expected the Care Plan to be updated by the next business day. She confirmed Staff A does the quarterly, annual, admission, and weekly updates to the Care Plan. She noted she helped with the updates as well. In an interview on 10/02/24 at 11:02 AM Staff A explained they usually have a specialized hospice focus section on the Care Plan. She noted she was not sure why it did not get on there for Resident #24. She reported they want to update the Care Plan as soon as they can. The facility policy titled Comprehensive Care Plan, revised 7/18/22 instructed the Care Plan to describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required. It further instructed the planning for care, treatment, and services to include the following: - Develop a plan for care, treatment, and services that includes resident care goals that are reasonable and measurable - The frequency of care, services, and treatment - Team members responsible for care, services, and treatment - Regularly reviewing and revising the plan for care, treatment, and services After initiation of the plan of care by nursing, those disciplines consulting in the care shall contribute to the plan as appropriate to the resident's assessed needs. All staff using the computerized plan of care shall be responsible for interdisciplinary collaboration to establish goals and appropriate interventions, as well as ongoing evaluations and revisions.

Based on observation, clinical record review, policy review, manufacturer's full prescribing information, and staff interview, the facility failed to administer medicated eye drops per the physician order and per the manufacturer's prescribing information for 1 of 1 residents sampled (Resident #15). The facility identified a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive loss. The MDS listed diagnoses of Alzheimer's Dementia and primary open-angle glaucoma, left eye, mild stage. A Order Summary Report signed by the Provider on 10/24/23 detailed the following physician orders: 1. Latanoprost Solution 0.005 % (percent) instill 1 drop in both eyes one time a day related to primary open angle glaucoma, left eye, mild stage. Start date 5/11/21. 2. Dorzolamide Hydrochloride Solution 2 % instill 1 drop in right eye two times a day related to primary open angle glaucoma, left eye, mild stage. Start date 5/10/21. During an observation on 10/25/23 at 7:12 AM Staff B, Registered Nurse (RN) administered Dorzolamide 2%, placing one drop to each eye. At 7:14 AM Staff B reported she was administering the Latanoprost and placed one drop of Latanoprost 0.005% into each eye for Resident #15. Staff B failed to administer the medications according to the written physician order and failed to administer according to the manufacturer's Full Prescribing Information. On 10/25/23 at 8:56 AM the Administrator reported the facility follows the eye drop manufacturer's recommendations. A Review of the October 2023 Medication Administration Record (MAR) showed Staff B signed the following medications as being administered according to the physician orders for 10/25/23 at 7:00 AM: 1. Latanoprost Solution 0.005 % instill 1 drop in both eyes one time a day related to primary open angle glaucoma, left eye, mild stage. Start date 5/11/21. 2. Dorzolamide Hydrochloride Solution 2 % instill 1 drop in right eye two times a day related to primary open angle glaucoma, left eye, mild stage. Start date 5/10/21. On 10/25/23 at 2:10 PM Staff B reviewed the eye drop medication orders for Resident #15. She reported she had been very nervous and had not realized she gave two drops of the Dorzolamide. She verbalized she saw the right eye and then saw the left eye in the diagnosis part on the MAR and that had confused her. She reported she usually follows the physician orders. She further explained she did not know what the manufacturer's wait time was between medicated eye drops. She verbalized she thought the wait time was between 2-3 minutes. She had not received any medication training by the facility when she started at the end of August 2023. She explained when you are an agency nurse, facilities expect you to know what you are doing when you start. During an interview on 10/25/23 at 2:35 PM the Director of Nursing reported she expects the nurses to follow physician orders and follow the manufacturer's recommendations for use. She reported the nurses would have to look up the manufacturer's recommendations prior to administering medicated eye drops. The Medication Administration Policy revised 4/01/23 provided by the facility under Procedure directed the nurse to verify the resident, drug, strength, dose, route, and hours of administration with the Medication Administration Record. The Dorzolamide Hydrochloride Solution/Drops, Bausch & Lomb Incorporated Full Prescribing Information under Dosage and Administration directed the following: the dose is one drop of Dorzolamide Hydrochloride Ophthalmic Solution in the affected eye(s) three times daily. Dorzolamide Hydrochloride Ophthalmic Solution may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart. The Latanoprost Solution/Drops, Aurobindo Pharma Limited Full Prescribing Information under Dosage and Administration directed the following: the recommended dosage is one drop in the affected eye(s) once daily in the evening. Latanoprost Ophthalmic Solution may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least five (5) minutes apart.

Based on observation, clinical record review, policy review, and staff interview the facility failed to uphold resident dignity for 1 of 6 residents sampled (Resident #22). The facility identified a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The Resident required extensive assistance of one staff member for transferring and toilet use and noted Resident #22 as being always incontinent of urine. The MDS listed active diagnoses of diabetes mellitus, morbid obesity, and overactive bladder. The Care Plan revised 2/17/23 documented the Resident's ability to complete activities of daily living had deteriorated related to osteoarthritis and the resident was at a risk of falling due to a deranged knee, morbid obesity, and osteoarthritis. The Care Plan directed the staff to walk the resident with one assist, gait belt, and front wheeled walker and to provide toileting assistance before and after meals, at hour of sleep, and as needed. During an observation on 10/24/23 at 9:24 AM Staff A, Certified Nursing Assistant (CNA) placed a gait belt around Resident #22 waist, assisted to stand from her wheelchair and walked approximately 10 feet from her wheelchair into the bathroom. At 9:25 AM Resident #22 while looking forward at the toilet verbalized the toilet is still dirty. It hasn't been cleaned yet. Staff A continued to have the resident turn to sit on the toilet and did not acknowledge the resident had verbalized the toilet was dirty. Staff A left the bathroom door open with the window curtains to the outside room window open which faced out to a wooded bluff with a house visible on the upper bluff, and the facility liquefied petroleum (LP) gas tanks visible from the window. At 9:29 AM Staff A closed the room curtains to the outside window. At 9:35 AM Staff A assisted Resident #22 off the toilet and ambulated the Resident from the bathroom to her recliner. Staff A closed the bathroom door, washed her hands, and left the Resident's room without cleaning the toileting. Observation of the Resident's toilet on 10/24/23 at 9:36 AM revealed an approximate 3 inch by 4 inch area of stuck down dried brownish tan substance, with the appearance of smeared bowel movement (BM), extending out from the top of the toilet seat rim and around the back toilet inner seat rim. Observation of Resident #22 bathroom toilet seat on 10/24/23 at 12:30 PM revealed a 2 inch by 4 inch faded yellow discoloration, with the appearance of being stained, along the back rim of the toilet seat. Observation of Resident #22 bathroom toilet seat on 10/25/23 at 1:20 PM revealed a 1 inch by 4 inch faded yellow discoloration on the back of the inner rim of the toilet seat. On 10/25/23 at 1:30 PM Staff C, Housekeeping, reported they clean all resident rooms daily. She reported she had noted the yellow staining on the back toilet seat rim for Resident #22 toilet. She reported the Resident's roommate does have periodic episodes of getting bowel movement on the toilet. She reported she cleans the resident's bathroom toilet every day. She uses Clorox Hydrogen Peroxide Cleaner to clean the toilet seat, but she could try to use Clorox bleach to try to remove the stain. On 10/25/23 at 1:38 PM Staff D, CNA, reported she would not sit a resident down on a toilet that had BM on the toilet seat. She would wipe the toilet seat off with a rag and then get the disinfection wipes to clean the toilet seat before assisting the resident with toileting. On 10/25/23 2:29 PM the Assistant Director of Nursing reported it is not dignified to sit a resident down on a dirty toilet seat. She reported she would get the pink disinfectant spray and follow the manufacturer's recommendation for cleaning the toilet seat. During an interview on 10/25/23 at 2:31 PM the Director of Nursing reported she expected staff would disinfect the toilet seat before assisting the resident with toileting cares. It would not be dignified to sit a resident down on a toilet that had BM on the seat. The facility Resident [NAME] of Rights established the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of residents. Under Respect and Dignity the [NAME] of Rights further directed the resident has a right to be treated with respect and dignity, including the right of residents to receive services in the facility with reasonable accommodation of a resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The Basic Cleaning Concepts undated provided by the facility identified general sanitizing to make surface or area clean by removing dirt, germs, and unwanted substances. The Basic Cleaning Concepts specified High Touch Areas/surfaces are those that have frequent contact with hands. High touch surfaces in care areas require increased frequent cleaning and disinfection than minimal contact surfaces. Cleaning is usually done at least daily and more frequently if the risk of environmental contamination is higher. The Basic Cleaning Concepts identified toilet seats as a high touch area in the resident restroom.

Based on observation, clinical record review, policy review, resident and staff interview the facility failed to notice, assess or provide any treatment for 1 of 1 resident (Resident #5) reviewed for skin concerns. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) for Resident #5 dated 4/28/22 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note dated 7/12/22 documented the resident's International Normalized Ratio (INR, a blood test to determine how long it takes blood to clot) was 2.5 and continue the [MEDICATION(S)] dose of 2.5 mg on Sunday, 5 mg on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. The Progress Note dated 7/17/22 at 12:29 AM documented the resident was getting up from supper and lost his balance and fell backward into the wall. The Progress Note dated 7/17/22 at 6:30 PM documented no injury. The Progress Note dated 7/18/22 at 7:46 PM documented no injuries. During an observation on 7/18/22 at 10:40 AM, a large bruise was present on resident's left thumb, down his hand and on his anterior wrist. The bruise was dark purple. During an interview at the same time, the resident stated he didn't know how it happened, that he probably bumped it. The Progress Note dated 7/19/22 at 9:21 PM documented no injuries. The facility policy titled Skin Checks, dated 7/12/18 documented a procedure including any abnormalities noted during the resident bath would be documented by the bath aide on the skin check form. During an interview on 7/20/22 at 9:33 AM, Staff A, RN, stated she had initiated a new skin sheet and assessment on the bruise at this time. Review of the form titled Skin Condition Record documented the bruise was first observed on 7/20/22. The form documented the size of the bruise 10 cm x 9 cm. During an interview on 7/20/22 at 10:09 AM, the DON stated the resident had a bath on Monday (7/18/22) and the CNA's did not notice a bruise at that time. She stated she did not know what time he received his bath. She stated she would expect the bath aide to document any bruise on the bath sheet and report it to the charge nurse.

Based on observation, clinical record review and staff interview, the facility failed to utilize a bolster cushion as planned for proper positioning for one resident reviewed. (Resident #12) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #12 had a long and short term memory impairment and required extensive assistance with bed mobility, transfer, dressing, personal hygiene and limited assistance for dining needs. The Admission Record documented the resident had [DIAGNOSES REDACTED]. The care plan documented an activities of daily living deficit related to the resident's need for assistance and weakness. A care plan intervention dated 9/22/17, directed staff to utilize a bolster to the left side of the resident's dining room chair. The Adaptive Device List dated 10/9/19, failed to list the residents bolster cushion. During observation on 10/14/19 at 1:04 p.m., on 10/15/19 at 8:42 a.m. and at 1:00 p.m. and on 10/16/19 at 8:59 a.m., the resident sat in the dining room chair without a bolster cushion to the left arm of the dining room chair as planned. Observation revealed the resident had a slight lean to the left side and on 10/16/19 the residents left arm dangled at a forty-five degree angle. During interview on 10/16/19 at 1:47 p.m., Staff E, Certified Nurse aide, CNA reported if a resident had special adaptive equipment it would be communicated on the Adaptive Device List in the staff communication book. Staff [NAME] reported the Adaptive Device List was updated weekly by the restorative nurse. During interview on 10/16/19 at 1:37 p.m., Staff B, Registered Nurse, RN reported there was a therapy section in the staff communication book and resident adaptive equipment was kept updated weekly. During interview on 10/16/19 at 1:48 p.m., Staff C, RN reported she updates the Adaptive Device List weekly which was usually based on therapy recommendations. Staff C reported she would update the Adaptive Device List to include a dining room chair bolster if the equipment was required by the resident. Staff C stated staff should follow the Adaptive Device List. During interview on 10/16/19 at 1:57 p.m., the Director of Nursing (DON) reported she would expect staff to follow the resident's care plan for use of a bolster cushion.

Based on observation, clinical record review and staff interview,the facility failed to provide supervision during toileting as planned for one resident observed during personal cares. (Resident #12) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #12 had a long and short term memory impairment and required extensive assistance with bed mobility, transfer, dressing, personal hygiene and limited assistance for dining needs. The Admission Record documented the resident had [DIAGNOSES REDACTED]. A progress note dated 7/22/19, documented the resident on the bathroom floor with the walker on top of them. The progress note documented staff was encouraged to stay with the resident while on the toilet. A progress note dated 6/26/19, documented the resident sitting on the bathroom floor with the walker sideways on the floor. A care sheet dated 8/26/19, in the resident's room documented a T for toileting that was highlighted in red, that directed staff not to leave the resident alone in the bathroom. The care plan showed the resident at a risk of falls due to a history of falls, visual difficulties, weakness and [MEDICAL CONDITION]. An intervention dated 7/22/19, directed staff not to leave the resident alone in the bathroom. During observation on 10/14/19 at 11:18 a.m., Staff D, Certified Nurse Aide, CNA assisted the resident onto the toilet in the resident's bathroom. Staff D walked out of the resident's bathroom around the backside of the bathroom door to access the resident's sink to wash her hands. Staff D walked to the resident's closet approximately ten feet from the bathroom door to obtain an adult brief. The resident's bathroom door remained opened approximately twelve inches. Staff D failed to keep the resident in visual sight and within arms reach. During observation on 10/15/19 at 1:05 p.m., Staff E, CNA stood outside the resident's closed bathroom door without direct supervision of resident. Staff [NAME] reported she was waiting for the resident to be done in the bathroom so she could assist the resident off the toilet. Staff [NAME] opened the resident's bathroom door at 1:10 p.m., to ask the resident if they wanted to get off the toilet. The resident responded they wanted to sit on the toilet longer. Staff [NAME] shut the bathroom door and continued to wait outside the closed bathroom door without visualization or within arms length of the resident. Staff F, CNA entered the resident's room at 1:20 p.m., and began to set up the resident's care supplies. Staff F opened the resident's bathroom door at 1:25 p.m., to check on the resident. Staff F closed the resident's bathroom door while the resident remained seated on the toilet. Staff [NAME] opened the resident's bathroom door at 1:34 p.m., and asked the resident if they were ready to get off the toilet. During interview on 10/16/19 at 1:33 p.m., Staff A, CNA reported there was a care sheet in each resident's room above the bed. There was a T for toileting on the care sheet, if highlighted, the resident was not to be left alone in the bathroom. Staff A reported staff need to stay in the bathroom with the resident or be within arms reach of the resident. During interview on 10/16/19 at 1:36 p.m., Staff B, Registered Nurse, RN reported there was a care sheet in each resident's room that communicates if a resident was not to be left unattended in the bathroom. Staff B stated staff need to stay in the bathroom with the resident or would need to keep the bathroom door cracked and have eyes on the resident. During interview on 10/16/19 at 1:47 p.m., Staff C, RN reported if a resident needs supervision in the bathroom staff should stay in the bathroom with the resident. During interview on 10/16/19 at 1:55 p.m., the Director of Nursing (DON) reported she would expect staff to stay within arms reach of the resident or have direct visualization when the resident was on the toilet if the resident's care plan stated not to leave the resident unattended in the bathroom.

Based on observation and staff interview, the facility failed to remove expired medications from the medication room and the medication cart. The facility census was 35 residents. Findings include: 1. During medication room observation on 10/16/19 at 10:05 a.m., the following medications was expired in the medication room: -One box, 100 count Geri Care [MEDICATION NAME] Suppositories, expired 5/2019. The box contained 40 Suppositories. -Three bottles of Ocular Vitamins, expired 8/2018 -One opened bottle of Ocular Vitamins with 18 tablets out of 60 tablets remaining, expired 8/2018 -One bottle of [MEDICATION NAME] Coated Aspirin, expired 1/2019 -Vitamin B6 100 tablet bottle, expired 5/2019 -One bottle Fish oil concentrate, 60 soft gels, expired 3/2019 -One bottle Vitamin B6 250 mg, 100 tab bottle, expired 1/2019 -One bottle Vitamin B12 500 mcg, 100 mcg 130 tablet bottle, expired 8/19 -One bottle Sunmark D3 2000IU, 100 softgel tab bottle expired 2/2019 During a medication inspection of the 200 and 300 wing medication cart the following expired medications was found: One bottle half full of regular liquid antacid, expired 5/2019 One opened bottle half full of Aspirin 325 mg, expired 8/2019 One opened bottle of fish oil 500 mg softgels, expired 5/2019 The Medication Room and Medication Cart Inspection Reports dated 11/30/18, 2/18/19, 5/10/19 & 9/27/19 documented an inspection was completed by the consulting pharmacist quarterly. During interview on 10/16/19 at 11:59 a.m., the Director of Nursing (DON) reported the pharmacy consultant does a medication room inspection on a quarterly basis. The nurse consultants review the medication room on a weekly basis and the night nurses should be checking the medication expiration dates during the weekly cleaning of the medication carts.

Based on record review and staff interview, the facility failed to follow the manufacturer's instructions regarding disinfectant use for sinks and toilets. The facility identified a census of 30 residents. Findings include: 1. During an interview on 1/15/13 at 12:02 p.m., Staff A, Housekeeper, reported he/she cleaned sinks and toilets with a disinfectant labeled Ful-Trole 64. Staff A stated the staff did not have to leave the product on the cleaning surface for any particular length of time. Staff A stated he/she left the disinfectant spray on for 1 to 2 minutes, then continued to scrub, rinse and dry as needed. In addition to Ful-Trole 64, Staff A reported he/she used another toilet bowl cleanser (950 Bowl Cleaner) 3 times a week, mainly for hard water spots. Staff A stated the staff do not need to leave the product on the cleaning surface for any particular length of time. Staff A said he/she applied the disinfectant, scrubbed and rinsed or wiped dry. The instructions for the use of Ful-Trole 64 and 950 Bowl Cleaner directed the consumer to allow the product to maintain contact with the affected surface for 10 minutes.

Based on staff interview the facility failed to ensure the Medical Director attended QA committee meetings at least on a quarterly basis. The facility census was 30 residents. Findings include: During an interview 1/17/13 at 8:10 a.m. the facility Administrator stated that the Medical Director does not usually attend their monthly Quality Assurance (QA) meetings but does review the minutes of the meeting, sign off on them, and give any input they have. The Administrator stated the Medical Director did physically attend one meeting but would check for attendance sheets. During an interview 1/17/13 at 8:45 a.m. the facility Administrator stated they could not find any attendance sheets to verify the Medical Director physically attended any QA meetings but they would make sure the Medical Director will attend in the future.

Based on observation, clinical record review and staff interview, the facility failed to follow physician orders [REDACTED]. The facility census was 40 residents. (Resident #5) Findings include: 1. The Admission Record [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented Resident #5 with a brief interview for mental status (BMI) scored seven out of sixteen. The MDS identified the resident required extensive assistance with activities of daily living and had functional limitation in range of motion to lower extremity. The nurse's notes dated 09/15/11, documented the resident's left heel had two open areas on it, one measures 3.3 centimeter (cm) by 1.2 cm and the other measures 0.9 cm by 1.0 cm. A physician order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A facsimile dated 10/28/11 at 00:30 a.m., documented the resident had a red area on the achilles tendon area on the right leg that measured 3.5 cm diameter and a 1.3 cm by 1.9 cm open area in the center of red area with scant serosanguineous drainage. Observation on 12/14/11 at 1:22 p.m., revealed resident lying in bed on his/her back with shoes on and heels not off the bed. At 2:11 p.m., revealed resident continued to lie in bed on his/her back with shoes on and heels not off the bed. At 2:36 p.m., revealed resident lying in bed on his/her back with shoes on and heels not off the bed. At 3:04 p.m., revealed resident lying in bed with heels flat on the mattress, and black shoes on his/her feet. At 3:38 p.m., revealed resident lying in bed with black shoes on his/her feet and heels not off the bed. During an interview on 12/14/11 at 3:55 p.m., Staff A (Director of Nursing) acknowledged the resident's heels not off the bed and the shoes need to be off, and the resident's heels need to be floated while in bed. Observation on 12/15/11 at 9:41 a.m., revealed resident lying in bed on the right side with his/her heels not off the bed. At 10:15 a.m., revealed the resident continued to lie in bed with his/her heels not off the bed.

Based on observation, clinical record review and staff interview, the facility failed to provide complete perineal care for one of eleven residents reviewed, and failed to provide oral cares for four of eleven resident reviewed during personal cares. The facility census was 46 residents. (Resident #4, #3, #1, #7) Findings include: 1. The admission record [DIAGNOSES REDACTED]. The Minimum data set (MDS) assessment dated [DATE], documented the resident had long and short term memory problems with moderately impaired decision making abilities. The MDS identified the resident required extensive assistance with transfers, toilet use, and personal hygiene (included brushing teeth). The resident care plan with a team conference dated 07/21/10, documented a problem with risk for impaired skin integrity and urinary incontinent related to diagnosis. Interventions included: a. Toilet before meals, after meals, at hour of sleep and as needed, resident wears briefs. c. Provide incontinent care after each incontinent episode, apply barrier. Review of the plan of care, documented a problem with activities of daily living (ADL) related to weakness, recent hospitalization and impaired cognition. An intervention included that the resident required staff assist with dressing and personal cares. During observation on 10/20/10 at 7:14 a.m., Staff A, Certified Nursing Assistant (CNA) and Staff B, Registered Nurse (RN) provided incontinency cares. Staff A cleansed the resident's perineal area with wash clothes and good technique. Staff rolled the resident onto the left side and Staff A cleansed and dry the resident's right hip, thigh, buttock and coccyx area with good technique. Staff A placed a clean brief underneath the resident and removed the soiled one. Staff A failed to cleanse the resident's left buttock, hip, and thigh area of urine residual. Staff A and Staff B assisted the resident to finish getting dressed for the day. They ambulated he/she to the bathroom and washed the resident's face, combed the hair, cued and assisted the resident to wash their hands. Staff transferred the resident into a wheelchair and propelled he/she to the dining room for breakfast. Staff did not cue or set the resident up for oral cares. During an interview on 10/20/10 at 7:51 a.m., Staff A, RN revealed the pad saturated with urine all over the back, hips, and buttocks. Staff A acknowledged they forgot to cleanse the resident's left hip, thigh and buttocks. 2. The Admission record [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], documented the resident had long and short term memory impairments with moderately impaired decision making abilities. The MDS documented the resident required extensive assistance with transfers and personal hygiene (included brushing teeth). The Resident Care plan with a team conference dated 10/04/10, documented instructions for one staff to assist the resident with personal cares and dressing. During observation on 10/20/10 at 6:46 a.m., Staff A, CNA and Staff B, RN assisted the resident with morning cares. Afterwards, staff transferred the resident to the wheelchair and propelled the resident down to the dining room for breakfast. Staff did not cue or set the resident up for oral cares. During observation on 10/20/10 at 9:40 a.m., revealed after breakfast Staff A assisted the resident to the toilet and to bed without providing oral cares. 3. The Admission Record [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], documented the resident had short and long term memory impairments with severely impaired decision making abilities. The MDS documented the resident required extensive assistance with transfers and total dependence of staff for personal hygiene (included brushing teeth). Observation on 10/20/10 at 7:46 a.m., revealed the resident at the dining room table after receiving a shower. During observation on 10/20/10 at 9:15 a.m., revealed after breakfast Staff A, CNA assisted the resident to the toilet and to bed without providing oral cares. During an interview on 10/20/10 at 7:46 a.m., Staff C, CNA stated staff on the floor usually do oral cares after breakfast and he/she did not do oral cares during the shower process. During an interview on 10/22/10 at 7:22 a.m., Staff E, CNA stated dependent resident's personal cares are completed prior to breakfast and that included oral cares. During an interview on 10/22/10 at 8:15 a.m., Staff D, Licensed Practical Nurse (LPN) stated personal cares are completed prior to the resident going out for breakfast and that included oral cares. 4. Review of the MDS assessment dated [DATE], documented Resident #7 required extensive assistance of one staff person to complete personal hygiene & toilet use. During observation of personal cares on 10/20/10 at 7:50 a.m., revealed Staff C, CNA assisted the resident with all ADL's except oral care/brushing teeth. After cares, Staff assisted the resident into the main dining room for breakfast. After continuous observation through breakfast until 9:15 a.m., Staff F, LPN assisted the resident from the main dining room and assisted the resident into bed without completing oral care/brushing teeth.