Every finding on record at Harmony Cedar Rapids

Based on observation, staff interviews and facility policy review, the facility failed to maintain infection control practices to help prevent the development and transmission of communicable diseases and infections during glucometer use for two residents reviewed for medication administration. (Resident #2, #3). The facility reported a census of 76 residents.Findings include:1.Resident #2's admission Record for admission date 3/12/26 identified the resident had diagnoses including Diabetes Mellitus type 2, congestive heart failure, and dementia. Resident #2's Physician Orders included an order for staff to check the resident's blood sugar by finger sticks four times a day, initiated 3/12/2026. On 4/9/2026, the resident's Care Plan directed staff to monitor his blood sugar as ordered. Observation on 4/21/2026 at 12:05 p.m. revealed Staff A, RN (Registered Nurse), retrieved the necessary items to check the resident's blood sugar. Staff A indicated it was the first time she worked at the facility. She collected the glucometer (device used to measure blood sugar) that sat on top of the medication cart without a barrier and entered the resident's room. Staff A donned gloves, placed the glucometer on the resident's blanket, and used an alcohol wipe to cleanse the resident's fingertip. She used a lancet to draw a drop of blood onto the test strip and noted the resident's blood sugar. Staff removed her gloves, exited the room and placed the glucometer on the medication cart without a barrier, and without sanitizing it. 2. Resident #3's MDS dated [DATE] revealed the resident had diagnoses including Polymyalgia Rheumatica, an autoimmune disorder and Diabetes Mellitus. The Physician Orders included an order for staff to check the resident's blood sugar by fingerstick four times a day, initiated on 3/15/2025.The resident's Care Plan directed staff to monitor the resident's blood sugars as ordered initiated 6/17/2025, and to monitor for signs and symptoms of infection related to the resident's autoimmune disorder initiated 11/19/2024.Observation on 4/21/2026 at 12:20 p.m. revealed Staff A retrieved the glucometer that sat on top of the medication cart since used to check Resident #2's blood sugar. Resident #3 sat at the dining room table. Staff A donned gloves and gathered the necessary items to check the resident's blood sugar. Staff A placed the glucometer on the dining room table without a barrier, used an alcohol wipe to cleanse the resident's fingertip, retrieved a drop of blood with the use of a lancet, and measured the blood sugar using a test strip and the glucometer. Staff A placed the glucometer on the medication cart without a barrier and without sanitizing it.On 4/21/2026 at 1:45 p.m. Staff B, DON (Director of Nursing) reported staff was supposed to sanitize glucometers using the [Brand Name wipes] in the container with the purple top in between uses. The facility Glucometer Cleaning policy revised 7/2023 included, Purpose: To ensure safe, convenient and proper cleaning and disinfection of Blood Glucose Meters in accordance to CDC (Centers for Disease Control and Prevention) guidelines and manufacturer's instructions to help prevent device exposure to blood borne pathogens.Procedures1. Wash hands thoroughly with soap and water or hand sanitizer before and after the procedure.2. Wear clean gloves.3. Place the equipment on a clean surface.4. Clean and disinfect glucose meter with EPA (Environmental Protection Agency)-approved disinfectant including [Names of Brand Name Wipes Redacted] before/after each resident use.5. Staff must follow manufacturers guidelines when cleaning the glucometer 6. Clean and disinfect the glucose meter before storing it with other clean equipment.The facility Infection Control policy revised 9/2023 included the following per the Patient Care Equipment section: -Handle contaminated equipment in a manner to prevent contamination of clothing, exposure to skin and mucous membranes or transfer of microorganisms to others or the environment; wear gloves if visibly contaminated; perform hand hygiene-Disinfect reusable equipment between patients (e.g., glucometers, lifts, scissors, blood pressure cuffs, etc.) with an EPA-registered disinfectant or hypochlorite solution-Discard single use items per manufacturer's guidelines-Clean and disinfect surfaces that are likely to be contaminated such as overbed tables and frequently touched surfaces in the patient care environment such as doorknobs, surfaces in and surrounding toilets.

Based on observation, interviews and facility policy review the facility failed to respond to call lights in a timely manner for 3 of 3 residents reviewed (Residents#12,#14,#27). The facility reported a census of 78 residents. 1.The Brief Interview for Mental Status (BIMS) assessment for R#12 dated 2/25/26 revealed the resident scored 15 out of 15, which indicated intact cognition. On 2/24/26 at 9:04 AM Resident #12 relayed the call light response had taken up to an hour, used either the phone or clock for timing the response. 2. The BIMS assessment for Resident #14 dated 2/3/26 revealed the resident scored 9 out of 15, which indicated moderately impaired cognition. On 2/24/26 at 9:03 AM Resident #14 relayed the call light response varied, quick at times or up to an hour, was not specific to a shift, varied. Resident #14 relayed timed the responses with the phone or clock. 3. The BIMS assessment for Resident #27 dated 2/16/26 revealed the resident scored 14 out of 15, which indicated intact cognition. On 2/23/26 at 3:45 PM Resident #27 relayed thought if staff were not in the hall to see the call light would have to wait, for example relayed last night on 2/23/26 roommate needed help and activated the call light, after ten minutes Resident #27 relayed went looking for staff propelled in wheel chair through halls could not find staff in the hall or in the break room and was about 35 more minutes before staff answered. On 2/26/26 at 12:40 PM, the room call lights were observed on for rooms [ROOM NUMBERS]. Continuous observation revealed the call light for room [ROOM NUMBER] was on for 20 minutes before being answered. Continuous observation revealed the call light for room [ROOM NUMBER] was on for 29 minutes before being answered. Several staff members were observed walking by the rooms without stopping to see if they could assist and numerous staff members were observed walking into and out of the staff break room during this time period. Two staff members were observed going into a resident's room at approximately 12:35 PM. During this observation, one of the staff members were observed coming out of the resident's room for more supplies and then returning. During this time, Staff K, Nurse Manager was observed at the nurse's station. When asked about call lights, Staff K advised the hall wasn't really short staffed but a lot of residents and staff are sick and it was a busy time of day so it is taking awhile for them to get call lights answered. She advised the expectation is call lights be answered as soon as possible and between 5 and 10 minutes. On 2/26/26 at 1:55 PM, Staff H Certified Nursing Assistant (CNA), was queried about call lights. She advised they try to answer the resident call lights within a couple minutes or at least go check on the resident and make sure the resident is okay and that the resident is aware that staff know they need something and they will return as soon as possible. Staff H advised she feels there is usually enough staff but there are always times depending on what time of day it is and what else is going on that it takes longer. Staff H advised there are times they are unable to answer call lights timely. When asked if there were staff members to assist in the hall Staff H advised she believed they were helping in the dining room. On 2/26/26 at 3:15 PM, the Director of Nursing (DON) advised it is her expectation that call lights be answered as soon as possible and they ask between 5 and 10 minutes. If the CNA's are unable to assist the resident at that time they should stop in and make sure they are okay and tell the resident they will be right back. It was the DON's expectation that staff were not walking past call lights without seeing if they could assist. The facility Call Light Policy dated 9/2023 was reviewed. The policy identified the purpose was to ensure that there was prompt response to the resident's call for assistance. The policy further revealed, The facility shall answer call lights in a timely manner.

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to ensure ongoing coordination of dental services for 2 of 2 residents reviewed for dental services (Resident #10, # 76). The facility reported a census of 78 residents. Findings include: 1.Review of Resident #10's Minimum Data Set (MDS) annual assessment dated [DATE] listed diagnoses of Traumatic Spinal Cord Dysfunction, paraplegia, diabetes and renal disease. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The MDS did not code for dental, mouth or pain discomfort. The Care Plan focus for Resident #10 initiated 6/16/25 documented had complaints of pain related to obesity, gout, spinal cord injury, substance abuse history, kidney disease and diverticulitis, and had acute pain due to abdominal distention and recent diagnosis of stercoral colitis (inflamed bowel). The Care Plan did not address Resident #10 repeated complaints of teeth pain, which included abscesses. The Care Plan lacked interventions for teeth related pain or treatments for the infections. On 2/23/26 8:47 AM, Resident #10 relayed had tooth ache, had reported to nurse today on duty and received medications.On 2/24/26 at 11:00 AM, Advanced Registered Nurse Practitioner (ARNP), Staff D relayed Resident #10 is in agreement for dental services due to two abscesses. Staff D added major obstacle to locate dental services for those on Medicaid. On 2/26/26 at 11:06 AM the Staff K, Social Services relayed Resident #10 had just made an appointment set up for next week due to the emergency related dental needs, tooth abscess, and need for antibiotics. On 3/2/26 at 11:35 AM the facility contracted dental provider, Staff I, relayed the facility application for Resident #10 was received September 2025 and Resident #10 became eligible October 1, 2025. On 9/3/25 the facility Business Office Manager (BOM) relayed to hold the process because Resident #10 had no Client Participation (CP)(money to contribute). The NF also relayed would check with family and never heard back from the facility. Staff I relayed felt Resident #10 fell through the cracks because if a resident cannot contribute with a CP than this dental provider could bill Medicaid directly. Staff I explained would plan a follow up visit Resident #10 this week and relayed many procedures could be done at the facility for Resident #10.On 3/2/26 at 12:47 PM the BOM relayed the Nurse Manager determined Resident #10 would not qualify for dental services with the facility contracted provider since had no CP to contribute. The BOM relayed all that could be done is to call around to find a provider that would accept Medicaid. On 3/2/26 at 1:00 the Nurse Manager, Staff J relayed since Resident #10 does not qualify for services with the facility contracted dental provider, would have to try to get a local dentist that accepted Medicaid. Relayed didn't handle all the attempts to find a dental provider for Resident #10, and further explained thought there were transportation problems, the facility had a van, but Resident #10 was too long. The DON said Resident #10 would need therapy to work him and his wheel chair before Resident #10 could use the transportation. On 3/2/2026 at 2:46 PM R#10 relayed he had not refused going to dentist, did not go because was informed would not fit in the van. Relayed looked forward to going tomorrow, would not have refused, said that would be crazy, needed the teeth looked at. Relayed still having pain related to teeth. On 3/3/26 at 9:02 AM the Administrator relayed Resident #10 was coordinated for a trip out of town for a Medicaid approved dental appointment today, was able to go by local transit, felt he was good to go alone since he is alert and oriented. Relayed Resident could not have dental work done by their contracted provider since had no client participation. A Progress Note dated 8/28/25 documented dental concerns, Resident #10 said My mouth hurts history of cracked teeth. Resident #10 reported dental pain involving two teeth in the upper left quadrant, which began two days ago. Dental caries noted on the left upper teeth, initiated antibiotic therapy due to concern for potential gum infection. Advised patient to seek dental evaluation for further management, cracked tooth identified in the lower back region, recommended dental consultation for definitive treatment.A Progress Note dated 11/13/25 revealed Resident #10 relayed tooth pain came on all of a sudden and is worst in right lower as well as left lower, stated are 3 different teeth, aware the three teeth are cracked and are likely exposing the root which is causing pain, on examination there is no significant signs of infection, no redness or swelling noted but he does have significant decay and several teeth that are cracked. Resident #10 stated due to his insurance, noncompliance in the past he is unable to go to a dentist or have the facility dentist see him. Significant acute decay but no obvious sign of infection, However, given concern for possible infection or underlying infection in the gum, treated with antibiotics for ten days, ordered special mouthwash and pain medication. The Advanced Registered Nurse Practitioner (ARNP) relayed, discussed with the Director of Nurses, (DON) again regarding need for dental care.A Progress Note dated 11/17/25 revealed Resident #10 with persistent dental pain, had not improved with antibiotics. The pain is most bothersome in the lower jaw, specifically in in area with a cracked tooth. The patient has not been taking tramadol (pain medication) for pain relief, as they were unaware it was available PRN (as needed).The patient had a prior dental appointment scheduled but was unable to attend due to transportation issues, specifically sliding out of the chair on the bus. The patient stated would go to the dentist if transportation could be arranged, as the dental pain is significant. A Progress Note dated 11/18/25 revealed Resident #10 continued on antibiotics for mouth pain and teeth infection, palpated neck and sides of jaw, noted to have large lump, hardened area on right lower jaw area with neck lymph on right side more edematous than left, noted to be painful.A Progress Note dated 11/21/25 revealed Resident #10 encouraged to collaborate with therapy for transportation assistance, discussed this with therapy and they are in agreement to work with him again so that he can get his teeth fixed.A Progress Note dated 12/16/25 revealed Resident #10 presents for evaluation of dental pain. The patient reports pain in the left upper and right lower teeth. He has not been taking tramadol for pain relief, instead using Tylenol .several decayed and cracked teeth noted-no changes. A Progress Note dated 2/6/26 revealed Resident #10 presents with dental pain. The patient reports dental pain in the upper and lower teeth, described as zingers. He reports some relief with pain medication. He states he is willing to do whatever needs to be done to get in to see the dentist.A Progress Note dated 2/16/26 revealed Resident #10 presents with dental pain, requests pain medication, reported primarily for the lower teeth, noted a dental prosthesis or fragment that was previously causing discomfort is now gone, with only small fragments remaining. Resident #10 is inquiring about when he can get in to see someone to have his teeth pulled Previously noted split posterior lower tooth now absent with only small fragments remaining. A Progress Note dated 2/24/26 at 9:53 AM revealed Social Services, Staff K wrote, reached out to a dental provider about an upcoming appointment in March, reported back needed additional lab work. 2. Review of Resident #76's MDS dated [DATE] listed diagnoses of heart and lung disease, anxiety, and depression. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The Care Plan for Resident #76 initiated 10/22/24 documented chronic pain, did not address specifics related to teeth pain and abscess (infection). A Progress Note dated 2/23/26 documented, Resident #76 started on Cephalexin, antibiotic for dental abscess.The Medication Administration Record (MAR) for February 2026 revealed Resident #76 took Cephalexin, 500 milligram (mg) three times a day for infection for five days, started 2/21/2026.On 2/24/2026 at 8:16 AM Resident #76 relayed took antibiotics for tooth abscess, thought the Social Worker (SW) was looking at setting up a dental appointment. On 2/26/2026 at 11:22 AM, Staff K relayed looking for a provider to accept Resident #76, last referred would not accept, Relayed Resident #76 said could only pay ten dollars a month and the provider declined to service.The Facility Assessment, approved date 1/26/26 documented provision for dental services included (names redacted) of two dental providers.

Based on observation, staff interview and facility policy the facility failed to ensure a medication error rate of less than 5% when two errors were observed from thirty-one opportunities for 1 of 5 residents observed during medication observations (Resident #9). This resulted in a medication error rate of 6.45%. The facility reported a census of 78 residents.Findings include: Review of Resident #9's Minimum Data Set (MDS) dated [DATE] documented the resident took medications which included high risk medications, hypoglycemic for diabetes control and diuretics. The MDS further documented the resident had diagnoses which included heart disease and diabetes. Beginning observation on 2/25/26 at 9:27 AM Staff A, Certified Medication Aide (CMA) placed in a medication cup the following medications ordered for Resident #9.One of each of the following oral medications for Resident #91. methocarbamol , 500 milligrams (mg) 2. primidone, 50 mg3. furosemide, 40 mg4. atenolol, 50 mg5. jardiance, 10 mg6. potassium, 10 milliequivalent (MEQ)7. omeprazole, 20 mg8. senna, 8.6 mg9. metformin, 1000 mg10. ezetimibe, 10 mg11. iron, 325 mg12. fish oil, 1000 mg13. aspirin, 81 mg14. cetirizine, 10 mg15. pregabalin, 200 mgand two each of the 16th medication, acetaminophen 500 mg tabs to total 17 medications. On 2/25/26 at 9:52 AM CMA, Staff A relayed was ready to deliver the medications and counted the number of pills per request. Staff A relayed had 17 pills in the medication cup. Potassium capsule was a 10 Milliequivalent (MEQ) dose and the order was for 20 MEQ. The primidone tablet was a 50 milligram (mg) tab and the physician ordered 150 mg. Staff A confirmed had only one of each of those medications in the cup. On 2/25/2026 at 10:10 AM, met with the Director of Nursing and the Administrator for updates regarding medication observation, was relayed Staff was new CMA and agreed to send facility policy.A Document, undated, titled Medication Administration-Medication Pass documented the five rights of medication administration included the five rights: patient, medication, dose, route and time.

Based on the resident interview, staff interviews, and record review the facility failed to ensure a resident had a transfer sling before leaving for a dialysis appointment, which caused missed dialysis treatment for 1 of 3 residents reviewed for dialysis (Resident #4). The facility reported a census of 78 residents.Findings include: Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of end stage renal disease (ESRD) and dependence on renal dialysis.The Care Plan focus area for dialysis, dated 5/8/25, documented Resident #4 required dialysis related to ESRD, and the intervention dated 5/8/25 revealed resident received dialysis on Monday, Wednesday and Friday. On 2/23/26 at 11:13 AM, Resident #4 relayed was not able to get dialysis today because the staff did not put the transfer sling under the resident on the chair that is required by dialysis, and the dialysis clinic staff said the resident had to go back to the facility. Resident #4 relayed there would not be enough time going back and forth and it was frigid cold weather so had to wait until next appointment of Wednesday for dialysis (refers to filtering of the blood when the kidney cannot). Review of the Progress Note dated 2/23/26 at 5:08 PM revealed, Resident was transported to dialysis without the proper [Brand Name Lift] sling in place. Dialysis staff notified transportation and facility that required transfer equipment was not present. Resident was given the option to return to the facility to retrieve the sling and then return to dialysis; however, resident was informed that the dialysis session would be shortened due to time constraints. On 2/23/25 at 5:10 PM the Administrator relayed awareness that Resident #4 did not get dialysis today and reported education to staff had already begun. On 2/23/26 at 5:17 PM the Director of Nurses relayed it was a hectic morning with many residents not feeling well and felt staff just missed putting the required sling on the chair before resident transferred to it. A document titled nursing home dialysis transfer agreement signed 4/11/22 by facility representative revealed the facility contracted to assure the availability and timeliness of dialysis treatments for the residents with ESRD.

Based on observation, staff interviews, and clinical record review the facility failed to ensure safe transport of resident in a wheelchair for 1 of 5 residents reviewed for accidents (Resident #60). The facility reported a census of 78 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #60 scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Per this assessment the resident utilized a wheelchair for mobility and had the ability to wheel at least 150 feet in a corridor or similar independently.Review of the Care Plan intervention dated 2/27/24 revealed Resident #60 was an assist of two staff for transferring, and was non ambulatory. On 2/25/26 at 10:45 AM, Staff G, Activities Assistant pushed Resident #60 in their wheelchair while the wheelchair did not have foot pedals applied. Staff G approached the resident from behind, advised the resident they would push them to the activity area and swiftly pushed the resident down the hallway to the activity area, approximately 125 feet. The wheel chair did not have foot pedals, residents' feet scuffled rapidly on the floor in front of the wheelchair in response to being accustomed to locomoting themselves. During an interview on 2/25/26 at 10:50 AM, when queried about the assistance provided to Resident #60 in their wheelchair, Staff G explained they had not intended to push her all the way to the activity area but since they had already assisted, went ahead and pushed the resident the rest of the way. Staff G shared they came up behind the resident and started pushing her because the resident had blocked another resident from getting through the hall. Staff G advised they were aware foot pedals must be on a wheelchair when a resident was pushed. When queried, Staff G advised he was not aware of what was included in Resident #60's Care Plan. Staff G explained he did not think about how the resident shuffles her feet on the floor in front of her and this could have lead to an injury. During an interview on 2/25/26 at approximately 11:30 AM the Activities Director was interviewed and advised her staff are not Certified Nursing Assistants and for the most part do not transport residents. They will occasionally assist but they all know foot pedals have to be on the wheelchair or they can not push a resident in their wheelchair. It is her expectation a resident is only pushed in a wheelchair if the foot pedals are in place. During an interview with the Facility Administrator on 2/25/26 at approximately 12:30 PM, She advised it is her expectation if a resident is pushed or assisted in their wheelchair their foot pedals must be on. Footrests are a required safety component and must be in place prior moving a resident. On 2/26/26 at 1:55 PM Staff H, Certified Nursing Assistant (CNA) was queried in regards to wheelchair transports. Staff H advised if a resident is not able to propel themselves in their wheelchair they can only be assisted if they have their wheelchair pedals on and both feet are on the pedals. If the resident's feet are not securely on the pedals their feet could drag or get caught on something or bended back. On 2/26/26 at approximately 3:15 PM the Director of Nursing (DON) was interviewed. The DON advised the facility does not have a policy specifically for wheelchairs. The facility practices and follows the standards of care. The DON advised it is their expectation no resident should be pushed in a wheelchair without foot pedals. The DON advised staff are required to complete ongoing training including training regarding safety during wheelchair transportation and education is provided with facility compliance checks. The DON relayed the expectation is that staff are aware of the potential dangers and use foot pedals on wheelchairs when pushing a resident.

Based on observation, staff interview, resident interview and policy review the facility failed to follow professional standards when returned medications refused back to the medication cart to administer at a later time for 1 of 5 residents observed during medication administration (Resident #13), and failed to provide medications by the proper route for 1 of 1 reviewed for tube feeding (Resident #1). The facility reported a census of 78 residents. Findings include: 1.Review of Resident #13's Minimum Data Set (MDS) dated [DATE] documented took medications which included antipsychotic, antidepressant and anticonvulsants. The MDS further documented the resident had diagnosis included high blood pressure, anxiety, depression and seizure disorder. The February 2026 Medication Administration Record (MAR) documented Resident #13 medications for the AM included: a. amlodipine (antihypertensive)b. aripiprazole (for depression) c. atenolol (antihypertensive)d. bisacodyl (for constipation)e. clopidogrel (related to stroke)f. losartan (antihypertensive)g sertraline (for anxiety disorder)h. levetiracetam (for seizures)i. Tylenol (for arthritic pain) On 2/25/26 at 8:47 AM Certified Medication Aide (CMA) Staff A reported she had the morning medications for Resident #13. Staff A counted and relayed had 12 pills in a medication cup. Staff A proceeded to Resident #13's room. Resident #13 was lying in bed relayed did not want the medications. Staff A went back to the medication cart and placed a piece of tape over the med cup and wrote the residents first name and room number on the tape and relayed the process with resident refusals is the nurse would try to give them if the CMA was not able to. On 2/25/26 at 10:01 AM CMA, Staff A alerted the Licensed Practical Nurse (LPN) Staff B that Resident #13 refused morning medications. Staff LPN, Staff B took the medication cup of pills from the CMA, walked away with the medication cup. Queried Staff B, agreed had planned to offer the medications to Resident #13 and acknowledged she did not dispense the medications into the cup. Staff B agreed at this time not to give for resident safety. On 2/25/2026 at 10:10 AM met with the Director of Nursing (DON) and the Administrator for updates regarding medication observation, discussion of setting up medications and another staff giving the medications. The DON relayed not sure that this was a problem, perhaps the CMA would watch the nurse. Queried about giving medications that were not dispensed by the person administering, the DON and the Administrator relayed would have to look into the process's. The Facility Policy titled, Medication Administration-Medication Pass revised 5/2023 directed for refusals to dispose of the medication appropriately, document refusal and provide notification. 2. Resident #1's MDS assessment dated [DATE] documented a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The MDS documented Resident #1 had a feeding tube. The MDS documented Resident #1 received antipsychotic, antidepressant, antibiotic, opioid, antiplatelet and anticonvulsant medications. The MDS listed diagnoses of pneumonia, dysphagia (difficulty swallowing), dyskinesia of the esophagus (a condition where the muscles of the esophagus contract abnormally or fail to coordinate, preventing food from moving smoothly to the stomach), and schizophrenia. The Care Plan Report initiated on 9/8/25 identified Resident #1 with altered nutritional status and a history of G-Tube (gastrostomy tube) feedings. Tube feedings discontinued in February 2026 for comfort measures, oral diet resumed at her request for comfort. The Care Plan Report identified Resident #1 took psychotropic, opioid pain, and anticonvulsant medications directing staff to administer medications as ordered. A Physician Order dated 2/3/26 listed a regular diet of pureed texture with thin liquids. The Physician Orders listed the following medication with route of administration:a. Acetaminophen oral tablet - give1000 mg via G-Tube three times a dayb. Acetaminophen oral tablet 325 MG - give 650 mg via G-Tube every 6 hours c. Amitriptyline HCl oral tablet 25 MG - give 25 mg via G-Tube at bedtimed. Calcium 600+D oral tablet 600-10 MG-MCG (microgram) - give 1 tablet via G-Tube one time a [NAME]. Calcium Carbonate oral tablet chewable 500 MG - give 1000 mg via G-Tube every 4 hours as neededf. Guaifenesin oral liquid 100 MG/5ML -give 20 ml via G-Tube every 6 hours as neededg. Lamotrigine oral tablet 100 MG – give 100 mg via G-Tube two times a dayh. Lansoprazole oral capsule delayed release 30 MG - give 30 mg via G-Tube one time adayi. Magnesium hydroxide oral suspension 400 MG/5ML- give 30 ml via G-Tubej. Melatonin oral tablet 3 MG - give 3 mg via -G-Tube every 24 hours as neededk. Midodrine HCl oral tablet 10 MG - give 10 mg via G-Tube three times a day l. Polyethylene Glycol 3350 powder -give 17 gram via G-Tube every 24 hoursm. Prednisone oral tablet 20 MG - give 20 mg via G-Tube one time a dayn. Multivitamin oral tablet -give 1 tablet via G-Tube one time a dayo. Zyprexa Zydis oral tablet disintegrating 15 MG - give 15 mg via G-Tube at bedtimeThe Order Review Summary Report was reviewed and electronically signed by Resident #1's physician on 2/24/26. On 2/25/26 at 10:04 AM, Staff E, Licensed Practical Nurse (LPN) verbalized Resident #1 had a feeding tube in place. Staff E reported she administered Resident #1's morning medications (crushed) orally (by mouth). Staff E acknowledged the Physician Orders directed medications to be administered via G-tube. On 2/25/26 at 10:21 AM, Resident #1 stated she takes her medication orally with pudding. Resident #1 verbalized she has a pureed diet and received medications orally for about a month. On 2/25/26 at 10:42 AM, Staff D, Advanced Registered Nurse Practitioner (ARNP) reported Resident #1 was comfort focus and when someone was comfort focus medications could be provided orally. Staff D verbalized Resident #1 had a history of aspiration (accidental inhalation of foreign material such as food or liquid) but opted for comfort focus. Staff D reported G-Tube feedings stopped about a month ago. Staff D didn't know when the order to administer medications changed from G-Tube to orally. On 2/25/26 at 10:53 AM, Director of Nursing (DON) verbalized the facility didn't have an order to provide medications orally for Resident #1 prior to 2/25/26. On 2/25/26 at 11:05 AM, a Progress Note documented Staff D, ARNP gave an order for medications to be administered by orally. On2/25/26 at 11:35 AM, the Administrator verbalized the expectation is medications are administered as ordered. On 2/25/26 at 12:42 PM, Staff F, LPN acknowledged Resident #1's medications are administered crushed orally in pudding. Staff F reported Resident #1 likes to have her medications in chocolate pudding. Staff F reiterated medications hadn't been administered via her G-Tube. On 3/02/26 at 4:04 PM, Staff E recalled Resident 1's diet order changed around 2/4/26. Staff E verbalized she had conversations with Staff D about the medications. Staff E acknowledged she hadn't transcribed the order to change the route of administration. Staff E verbalized it was a mistake on her part. Review of the Medication Administration Record for February 2026, revealed Staff E administered medications on 2/9/26, 2/15/26, 2/23/26 and 2/25/26. Staff F administered medications on 2/6/26, 2/7/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/18/26, 2/20/26, and 2/21/26. Review of the undated Medication Administration – Medication Pass facility policy listed the 5 rights of medication administration as:1. Right patient2. Right medication3. Right dose4. Right route5. Right time Review of the Physician Orders/Transcription of Orders facility policy revised on July 2023 revealed, in part, Orders must contain name, strength, route, dose, quantity, diagnosis/indication for use, and specific duration of therapy indicated.

Based on the resident interview, staff interviews, clinical record review, and dialysis contract/agreements the facility failed to direct staff of transfer requirement for dialysis appointments on the resident's care plan (Resident #4), and failed to address a resident's teeth pain and the related infections on the care plan (Resident #10) for two of twenty-one residents reviewed for care plans. The facility reported a census of 78 residents.Findings included:1.Resident #4, Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of end stage renal disease (ESRD) and dependence on renal dialysis. The Care Plan initiated 4/17/25 documented Resident #4 required dialysis on Monday, Wednesday and Friday. The Care Plan did not direct staff to ensure the sling is required to be sent to enable transfer to dialysis chair. On 2/23/2026 at 11:13 AM Resident #4 relayed was not able to get dialysis today because the staff did not put the transfer sling under me on the chair that is required by dialysis. Resident #4 relayed not all staff know about the requirement and felt she was at fault for not telling the staff.On 2/26/25 at 2:30 PM the Administrator and Director of Nurses(DON) acknowledged the Care Plan should direct residents care and needs.A document titled, Nursing Home Dialysis Transfer Agreement, signed 4/11/22 documented the facility desired to assure the availability and timeliness of dialysis treatments for the residents with End Stage Renal Disease (ESRD). A document titled, Dialysis-off site, revision date 12/24 documented , there must be coordination of care and services provided between the facility and the dialysis center and this is documented in the patient care plan.2. Review of Resident #10's MDS dated [DATE] documented diagnoses included traumatic spinal cord dysfunction, paraplegia, diabetes and renal disease. The BIMS assessment scored 15 out of 15, which indicated intact cognition.A Progress Note dated 11/18/25 documented, Resident #10 continued on antibiotics for mouth pain and teeth infection. A Progress Note dated 12/16/25 documented, Resident #10 reports pain in the left upper and right lower teeth, several decayed and cracked teeth noted. A Progress Note dated 2/6/26 documented, Resident #10 presents with dental pain dental pain in the upper and lower teeth, described as zingers. A Progress Notes dated 2/16/26 documented, Resident #10 presents with dental pain requested pain medication, reported primarily for the lower teeth.The Care Plan focus for Resident #10 initiated 6/16/25 documented had complaints of pain related to obesity, gout, spinal cord injury, substance abuse history, kidney disease and diverticulitis, and had acute pain due to abdominal distention and recent diagnosis of stercoral colitis (inflamed bowel). The Care Plan did not address Resident #10 repeated complaints of teeth pain including abscesses. The Care Plan lacked interventions for teeth related pain or treatments for the infections. The Facility Policy titled Care Plan Policy, revised March 2025, directed to put in place person-centered plans outlining care for the resident, to be reviewed and revised after completion of MDS assessments when applicable and with changes that warrant a care plan revision.

Based on clinical record review and staff interview, the facility failed to code dental concerns appropriately on the quarterly and annual Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed (Resident #10). The facility reported a census of 78 residents. Findings include:Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed diagnoses of Traumatic Spinal Cord Dysfunction, paraplegia, diabetes and renal disease. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The MDS lacked any coding in the dental section for mouth, facial pain or discomfort. Review of Resident #10's Annual Minimum Data Set (MDS) assessment dated [DATE] again lacked any coding in the dental section for mouth, facial pain or discomfort. A Progress Note dated 8/28/25 revealed Resident #10 said My mouth hurts, had history of cracked teeth, presented with dental pain, caries noted on the left upper teeth, and initiated antibiotic therapy due to concern or potential gum infection. A Progress Note dated 11/13/25 documented, Resident #10 relayed tooth pain, 3 different teeth, cracked, likely exposing the root, significant decay and several teeth that are cracked. A Progress Note dated 11/17/25 documented, Resident #10 with persistent dental pain despite completing antibiotics, had not improved with antibiotics.A Progress Note dated 11/18/25 documented, Resident #10 continued on antibiotics for mouth pain and teeth infection.A Progress Note dated 12/16/25 documented, Resident #10 reports pain in the left upper and right lower teeth, several decayed and cracked teeth noted.A Progress Note dated 2/6/26 documented, Resident #10 presents with dental pain dental pain in the upper and lower teeth, described as zingers.A Progress Notes dated 2/16/26 documented, Resident #10 presents with dental pain requested pain medication, reported primarily for the lower teeth.On 3/3/26 at 9:03 AM the Administrator email documented the facility followed the Resident Assessment Instrument (RAI) user manual for MDS assessment completion.

Based on observations, resident, family, and staff interviews, and facility assessment review, the facility failed to ensure residents had a safe, homelike environment for three of four residents reviewed (#10, #27, #38).The facility reported a census of 78 residents.Findings include: 1. Resident #38's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS documented Resident #38 required partial to moderate assistance with toileting and frequently incontinent of urine. On 2/23/26 at 11:50 AM, Resident #38's room was observed. The resident was asleep in their wheelchair. Soiled linens and bedding were observed on the resident's bed. The sheets had a dried brown substance on them. There was a distinct foul smell throughout the room. On 2/23/26 at 1:32 PM, the soiled linens remained on Resident #38's bed. The bed pad and soiled sheets were observed in the same state as earlier in the day. The soiled linens had not been changed and the resident's bed had not been sanitized. Bed padding and sheets were soiled with what appeared to be a dark dried substance. On 2/23/26 at 4:16 PM, during a representative interview concern was expressed that Resident #38 was frequently incontinent of urine and often observed in wet and soiled clothes. On 2/24/26 at 10:30 AM, Resident #38 was observed in her room, sitting in her wheelchair, watching TV. There were no sheets on the resident's bed. When queried, Resident #38 indicated staff had taken the dirty sheets off the bed his morning and hadn't put any back on. Staff had not cleaned or sanitized the resident's mattress. When asked, the resident shared staff usually don't make her bed until she yells at them to make it. An offensive odor was coming from the vicinity of the bed and flooring. On 2/24/26 at 1:42 PM, Resident's room was observed and the bed was still not made and there were no linens on either bed in the room. When asked, the resident shared they don't always make it right away. On 2/24/26 at 2:06 PM, Resident #38 was in her room sitting in her wheelchair and reading a book. Resident's bed was still not made. On 2/25/26 at 7:55 AM Resident #38 was observed sitting in her room in her wheelchair. Her bed had been made from the previous afternoon but was again observed soiled sheets with dried feces that had not been cleaned up. When asked, the resident shared she had been up for awhile. On 2/25/26 at 12:30 PM, the resident's room had been cleaned and there was clean bedding. On 2/26/26 8:50 AM, Resident #38's linen was observed soiled. The resident advised she had been up for awhile. Resident was asked if staff removed the soiled linens, sanitized her bedding and put new clean linen on. the resident shared, staff usually make the bed when they get around to making it, sometimes in the evening. On 2/26/26 at 1:55 PM, Staff H, Certified Nursing Assistant (CNA) advised if a resident's bed was soiled the CNA's would remove the soiled linens right away and clean and sanitize the bed and flooring if necessary. Staff H also advised she has seen Resident #38 bed still soiled much later in the day that if should have been. On 2/26/26 at 3:15 PM, the Director of Nursing (DON) was queried about soiled linens and bedding. She advised it is her expectation that all staff are meeting standard housekeeping and sanitary expectations. It is her expectation that soiled linens be taken care of as soon as possible. On 3/3/26 the Facility Resident Room-Daily Cleaning list dated 10/2023 was provided. The purpose of the duty list stated it is to provide a clean and sanitary room for each resident. The Facility Assessment with an Administration review date of 1/21/26 was reviewed and indicated the resident is provided with a clean and sanitary environment which included linen, sheets, towels, bath blankets, blankets, pillows and bedspreads. 2.Resident #27's MDS dated [DATE] revealed a BIMS assessment score of 15 out of 15, which indicated intact cognition. On 2/23/26 on 3:49 PM relayed could not recall when the bedding was done, thought was several weeks or more and was supposed to be done when had a shower. Resident #27 relayed requested a new pillow cover yesterday and that part of the bedding was changed. 3. Resident #10's MDS dated [DATE] revealed the BIMS assessment scored 15 out of 15, which indicated intact cognition. On 2/26/26 at 9:00 AM during a confidential interview was relayed, had observed Resident #10 sheets and bed pad soaked and stained with wet and dry urine due to the nursing facility staff not changing the sheets.

Based on clinical record review, staff and resident interviews, manufacturer's recommendation and facility policy review the facility failed to transfer one of four residents reviewed in a safe manner (Resident #1). On 11/13/25, Resident #1 fell backwards from the stand lift, reported pain 9 out of 10 to the left hip, was sent to the hospital, and had a femur fracture which required surgical repair. The facility reported a census of 83 residents.The facility corrected the deficient practice per past noncompliance on 11/28/25 through the following actions:*Nursing staff re-educated on the proper use of mechanical lifts*Facility wide audit of mechanical lift equipement.*Nursing staff completed a skills check-off for standing lift and full body mechanical lift.*Audits of resident transfers using mechanical lifts.*Nursing staff interview related to refusal of safety straps and use for Resident #1.*Resident interviews regarding use of stand lift.Findings include:The Minimum Data Set (MDS) assessment for Resident #1 dated 10/15/2025 listed diagnoses of multiple sclerosis (MS), multidrug-resistant organism (MDRO), and anxiety. The MDS reflected the Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS revealed Resident #1 was dependent on staff for transfers in and out of the bed, dependent for sitting to standing, and for toilet transfer. The MDS revealed Resident #1 lacked a history of falls. The Care Plan for Resident #1 dated 12/26/24 identified the resident required assistance with activities of daily living (ADL) due to progressive MS. The Care Plan goal dated 2/28/24 with target date 10/22/25 reflected [Resident #1] will maintain current transfer status. An intervention dated 12/27/24 directed transferring: stand lift with assistance of 2 staff. Nonambulatory. The Change of Condition Progress Note dated 11/13/2025 at 11:46 PM reflected a CNA (Certified Nurse Aide) notified the nurse that during the transfer of Resident #1 with the stand lift Resident #1 let go of stand lift handlebars suddenly while telling CNA that she felt dizzy mid transfer. The CNAs reported that resident fell backwards onto floor hitting head on floor and lying supine .Resident stated that she had all of a sudden felt dizzy while transferring and that was the last thing she remembered about the transfer. Assessed resident and she had no visible injuries from fall on back of head but did have 9/10 pain on left hip and requested to wait until emergency medical services (EMS) arrived to be moved. The facility Fall Investigation Report for date of incident 11/13/25 reflected Resident #1 had not fallen at the facility prior to the fall on 11/13/25. The Incident Summary reflected on 11/13/2025 at approximately 9:21 p.m., Resident #1 requested to go to bed from her wheelchair (w/c). Staff B, CNA and Staff A CNA attempted to transfer Resident #1 from the w/c to the bed using the stand lift. The summary reflected during the transfer, Resident #1 reported she felt dizzy, released her hands from the lift, and slipped through the sling, resulting in a backward fall to the floor. The resident stated she that she struck her head and landed in a supine position. A post-fall assessment revealed Resident #1 reported 9/10 pain localized to the left hip.The Fall Investigation Report included the following staff statements:a. Staff B's statement revealed, in part, while Staff A was positioning Resident #1 in the stand lift, Staff B informed Staff A that she would need to move Resident #1 back slightly so that Staff B could reposition the wheelchair. After Staff A adjusted Resident #1, Staff B proceeded to move the wheelchair. As Staff B was turning down the bed, Staff B heard a crash. Initially Staff B believed the tray table had been bumped; however, Staff B then observed Resident #1 on the floor, lying on her back. Resident #1 was not secured with the belt, as she typically declines its use. b. Staff A's statement reported Resident #1 refuses to use the safety belt during transfers, and also declines the use of the leg straps, stating they are too tight. Staff A's statement revealed Staff A was unsure how the fall occurred, as she was positioned in front of Resident #1 and Staff B was positioned behind her. Staff B moved to reposition the wheelchiair, and at that moment Resident #1 stopped talking, released her grip from the handles, and fell. Resident #1's statement reflected she knew who attempted to transfer her, and staff were in process of transferring her when she suddenly found herself on the floor. Resident #1 revealed she never refused to use the safety straps. The History and Physical (H&P) dated 11/14/25, with date of service 11/13/25, reflected Resident #1 presented to the ER for evaluation of left hip pain after a fall. The note revealed during the transfer Resident #1 fell out of the sling of the stand lift, and had an acute intertrochanteric fracture of the left femur. The hospital Consult note dated 11/14/25 identified Resident #1's emergency room (ER) x-rays revealed a subtrochanteric displaced fracture (a break in the upper part of the thigh bone) with severe osteopenia (significantly low bone density but not yet osteoporosis). The General Progress Note dated 11/15/2025 at 9:59 PM staff called hospital for report on Resident #1, the hospital reported a femur fracture that resulted in surgery performed on 11/14/2025.The Progress Notes dated 9/15/25 through 11/14/25 lacked any refusals from Resident #1 to use the safety belt with transfers. The Employee file for Staff A held an Employee Warning Notice dated 11/17/25, and reflected on 11/13/25, Staff A failed to use all the safety features on the facility sit to stand when transferring a resident. The failure resulted in a resident fall causing a major injury. The Skills and Techniques Evaluation dated 3/31/25 for Staff A reflected validation/verbal understanding for transfers. The Employee file for Staff B held Employee Warning Notice dated 11/17/25, and identified on 11/13/25, Staff B failed to use all safety features on the facility sit to stand when transferring a resident. This failure resulted in a resident fall causing major injury. Staff B completed training and signed off acknowledging the Company lift program on 3/26/2025 and 8/19/2024.The Skills and Techniques for Staff B dated 12/31/24 reflected validation/verbal understanding for transfers. On 12/22/25 at 1 PM Resident #1 reported Staff A and Staff B were the CNAs with her and then she was on the floor on 11/13/25. She reported she thought she fainted. She said she's never refused to use the belt/strap during a transfer. On 12/22/25 at 3:31 PM Staff B reported Staff A hooked Resident #1 up to the stand lift while she got the bed ready. Staff B stated she thought Staff A hit the table and looked over to see Resident #1 on the floor. She confirmed the facility terminated her employment due to the incident. On 12/22/25 at 5:38 PM Staff A said she got Resident #1 ready for bed, hooked up the stand lift, moved Resident #1 3 or 4 inches and she fell to the floor. Staff A reported she failed to work with Resident #1 before 11/13/25. Staff A revealed Staff B told her not to use the safety belt/strap. Staff A reported she put the belt around her back and under Resident #1's arms and hooked the strap to the stand lift and failed to hook the buckle around Resident #1's waist and failed to hook the strap around her legs.On 12/23/25 at 8:59 AM Staff C, CNA reported Resident #1 told her in the past the straps are tight but never refused to use the safety belt/strap. Staff C reported if a resident refused to use the safety item, she would notify the nurse. On 12/23/25 at 2:14 the Director of Nursing (DON) reported both Staff A and Staff B agreed they needed to use the straps on the stand lift. The DON reported the facility terminated the employment of Staff A and Staff B as a result of their failure to use the stand lift as the facility expected.The DON reported the fall and fracture for Resident #1 was preventable. The DON stated if a resident refused to use safety items, she expected the staff to let the nurse know. On 12/23/25 at 2:20 the Administrator reported she expected the CNAs to transfer Resident #1 with the stand lift with the belt/straps in place. The Administrator revealed the fall and fracture for Resident #1 was 100% preventable. The Administrator reported both the Staff A and B were terminated. The facility provided a Lifts Program Skills Check-Off Sheet for Stand Assist Mechanical Lifts dated 7/2018, directed fasten the safety belt around the resident's waist. The facility provided a lift Instruction, undated, included the following: Standing Clip Sling is intended to be used together with a lifting device to provide body support during raising to a standing position and short transfers of adult patients/residents. Applying the Sling directed place the sling around the patient's lower back .Make sure that: patient's arms are outside the sling, support belt is positioned loosely around the patient's body and support belt is not twisted or trapped behind the patient's back .Make sure you place the leg flaps around the legs and these are not twisted. Fasten the support belt securely by pressing the buckles or hook and loop attachments together. The support belt should be tight but comfortable for the patient.

Based on record review, resident interviews, staff interviews, and facility reported payroll data the facility failed to provide adequate staffing to meet resident needs. The facility reported a census of 77 residents. Findings include: A document titled PBJ (Payroll Based Journal) Staffing Data Report representing 7/1/24 through 9/30/24 indicated data submitted by the facility triggered for excessively low weekend staffing. The undated Facility Assessment in effect at the time of the PBJ report documented 272 FT Licensed nursing hours per week and 952 nursing assistant hours per week based on an average daily census of 67.3. Page 1 of the assessment noted it was reviewed annually, updated if indicated and whenever there was a significant change in the assessment of the facility including but not limited to changes in facility capacity or services provided. An interview with Resident #64 (Brief Interview for Mental Status score of 15/15 indicative of intact cognition) on 01/12/25 at 11:04 AM revealed she sat on a bedpan for 'a long time.' A further interview on 01/15/24 at 11:45 AM determined she was left on the bedpan recently for 45 minutes. The resident could not remember the day but thought it might have been the past weekend during the day. When asked what she felt the cause was, Resident #64 stated it was a staffing issue. She reported the staff who were in the facility were great but had to 'run their asses off' because sometimes there were not enough of them to help everyone who needed it. During an interview on 01/13/25 at 02:03 PM the DON stated she thought the facility had enough staff during the weekends. She reported the facility did use more agency staff on the weekend. On 1/14/25 at 12:49 PM the Administrator provided a recap of the daily census for 7/1/24 through 9/30/24 that documented an average daily census of 76.8. He stated the Facility Assessment was not updated during that time, but was updated in November 2024. During an interview on 1/15/25 at 11:07 AM Staff C, Medical Records/Scheduler stated the facility used a matrix on a spreadsheet to determine staffing needed. She reported weekend staffing was the same as weekdays, determined by the number of residents entered. When asked if resident acuity was considered as part of the matrix, she said there was nothing in the spreadsheet for acuity. At 11:20 AM on 1/15/25 Staff D, Certified Medication Aide, stated the most important resident needs were met. When asked if there were enough staff to address all of the resident's care planned needs she said probably not all of them. She stated some residents took longer, had more to take care of, and used lifts that take time and two people. She indicated need depended on census and felt quality of care was important. Staff D also noted the ability to participate in team meetings, care planning meetings, training, and taking time with residents depended on staffing and census. On 1/15/25 at 11:50 AM the Administrator reported the facility had reviewed the data submitted for the PBJ and came up with the same result that indicated low weekend staffing.

Based on Iowa Physician Orders for Scope of Treatment (IPOST) form review, Electronic medical record review, and staff interview the facility failed to ensure consistent documentation of code status for 1 of 24 resident reviewed for advanced directives (Resident #64). The facility reported a census of 77 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 medical diagnoses included Heart disease, anemia, acquired absence of parts of digestive tract, and discitis referring to inflammation of the spinal column. The Brief Interview for Mental Status (BIMS) exam scored 15 out of 15 which indicated intact cognition. The electronic medical record, profile sheet for Resident #64 directed, Do not resuscitate, DNR. The Care Plan revealed a focus initiated [DATE] for Resident #64 advance directive status and included intervention, documented, the electronic medical record, chart to identify code status, DNR. An IPOST form signed by Resident #64 on [DATE] was located at the nurse's station in the code status binder for staff access in the event of an emergency, directed Cardiopulmonary Resuscitation (CPR). The form was signed by the provider on [DATE]. During an interview on [DATE] at 2:05 PM the Director of Nurses (DON) relayed the nursing staff can go to the electronic medical record to access resident code status or can view the code status from the IPOST document in the code status book. The DON relayed the code status would be the same in either location. The DON acknowledged the electronic medical record and IPOST did not match for Resident #64 and a correction was needed immediately to ensure resident wishes were followed in the event of a cardiac arrest. The DON reported there is not a policy to direct the advance directive process. The staff would follow the standard procedure if a resident requested DNR, the physician order is signed or the IPOST form is used.

Based on record review, staff interviews, and policy review the facility failed to submit a discharge Minimum Data Set (MDS) within the required time frame for 1 of 3 residents reviewed for MDS (Resident #53). The facility reported a census of 77 residents. Findings include: The MDS for Resident #53 dated 8/27/24 documented a planned discharge from the facility, return not anticipated. Staff B, MDS Coordinator, signed the completed document on 9/4/24. The MDS was not marked as submitted. Progress Notes for Resident #53, dated 8/27/24 at 2:58 PM, documented the resident was discharged to another facility. On 1/14/25 at 3:00 PM the Administrator stated they did not have a specific policy for MDS assessments and the facility followed regulations. An interview with Staff B on 1/15/25 at 9:12 AM revealed the document was somehow changed to do not submit in the electronic health record. She stated it was probably something she did and acknowledged the MDS should have been submitted. At 9:30 AM an additional interview with Staff B determined she followed the Resident Assessment Instrument (RAI) Manual for processing MDS data.

Based on staff interview, clinical record review, and Preadmission Screening and Resident Review (PASRR) form evaluation the facility failed to ensure a re-screen for 1 of 2 residents reviewed in the PASRR sample. Resident #45 exceeded the sixty (60) day convalescent care approval without the required re-screening. The facility reported a census of 77 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #45 diagnoses included quadriplegia, seizure disorder, malnutrition, pressure ulcers, and unspecified intellectual disabilities. The Brief Interview for Mental Status (BIMS) was not scored, documented resident was unable to complete the interview. The Care Plan focus dated 10/11/24 for Resident #45 documented PASRR baseline, new admission, intervention to follow PASRR recommendations as applicable. The Care Plan focus initiated 10/18/24 documented the resident had impaired cognitive function and impaired thought process related to developmental and intellectual disability. The PASRR form dated 10/8/24 documented resident #45 evaluation determined a PASRR condition, noted suspected or confirmed PASRR condition that included intellectual disability. Approved for convalescence categorical approval for period of 60 days, expected to discharge within 60 days and If stay goes beyond the nursing facility must submit a status change, required prior to the 60th day. On 1/13/25 at 1:40 PM the Director of Nurses relayed the Social Services, Staff A, was responsible for the initial PASRR and follow up. During an interview on 1/13/25 at 1:45 PM the Social Service, Staff A, revealed they are new to working with PASRR's, acknowledged resident #45 was granted the 60-day approval and should have been reevaluated. On 1/14/25 at 3:00 the Administrator relayed the facility does not have a policy on PASRR completion and follows the regulation.

Based on record review, staff interview, Preadmission Screening and Resident Review form (PASRR) the facility failed to code diagnosis of intellectual deficits (ID) and inaccurately coded for hospice on the Minimum Data Set (MDS) assessments for 2 of 3 residents MDS assessments reviewed (Resident #35, #45). The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #45 diagnoses included quadriplegia, seizure disorder, malnutrition, pressure ulcers, and unspecified intellectual disabilities. The Brief Interview for Mental Status (BIMS) was not scored, documented the resident was unable to complete the interview. The MDS section labeled PASRR did not code to reveal resident's intellectual disability. The PASRR form, notice date 10/9/24 relayed Resident #45 approved for 60-day convalescence, had suspected or confirmed PASRR condition that included intellectual disability. The form documented, the PASRR condition must be documented in the MDS. The PASRR form specifically directed to code on the MDS resident's diagnosis of intellectual disability. Review of the MDS indicated lack of completion of both sections directed to be completed. The Care Plan focus dated 10/11/24 for Resident #45 documented PASRR baseline, new admission, intervention to follow PASRR recommendations as applicable. The Care Plan focus initiated 10/18/24 documented the resident had impaired cognitive function and impaired thought process related to developmental and intellectual disability. On 1/15/24 at 9:30 AM the MDS Coordinator, Registered Nurse, Staff B relayed they are responsible for completing MDS documents and follow the Resident Assessment Instrument (RAI) Manual for MDS coding. Staff B relayed Resident #45 should have been coded for intellectual deficit. On 1/14/25 at 3:00 the Administrator voiced they do not have a specific policy on MDS completion, relayed they follow the federal mandated process. 49698 2. Review of Resident #35's facility census indicated on 10/10/24 the resident was changed from Hospice private pay to private pay. Review of Resident #35's Significant Change MDS dated [DATE] indicated Resident #35 received Hospice services. Review of Resident #35's Physician Order Summary indicated admission to Hospice related to Lewy Body Dementia on 4/16/24 with a discontinue date of 10/9/24. Review of Resident #35's Care Plan indicated on 4/17/24 Hospice Care was required due to a diagnosis of Lewy Body Dementia and resolved on 10/11/24. Review of Hospice Discharge Summary dated 10/7/24 indicated Resident #35 started Hospice care on 4/16/24 and effective discharge date of [DATE] as Resident #35 was determined to no longer meet criteria for hospice care. During an interview on 1/15/25 at 10:10 AM, Staff B, MDS Coordinator, stated the Significant Change MDS completed on 10/29/24 was due to Resident #35 being discharged from Hospice Care. While reviewing the Significant Change MDS, Staff B acknowledged the MDS indicated Resident #35 was receiving Hospice care and stated this was not accurate and needed to be corrected.

Based on observation, policy review, and staff interview the facility failed to treat residents with dignity, respect, and honor residents' rights for 2 of 5 residents reviewed (Residents #12 and #14). The facility reported a census of 71 residents. Findings include: During an observation on 11/5/25 at 11:37 AM, Resident #12 was in the doorway to her restroom, facing out of the restroom utilizing the mechanical stand. Staff A, Certified Nursing Assistant (CNA) was in the Resident's room, in front of the resident. Staff B, CNA was in the restroom, directly behind the resident. The resident was receiving incontinence cares from Staff A and Staff B. She was unclothed and exposed from her waist to her knees. The resident was in full direct view of her roommate. The privacy curtain was not pulled. While Staff B was providing cares to Resident #12, Staff C, Guest Services Aide, entered the room, without knocking, and walked through the room to the closet. While Staff C was entering the room, Resident #12 was visible to anyone in the hallway. While Staff A and Staff B were continuing to provide cares, Staff D, Licensed Practical Nurse (LPN) entered the room after knocking but not waiting for a response, again exposing the resident to anyone in the hall. Staff D walked over to the roommate and then pulled the privacy curtain. During an observation on 11/5/24 at 1:02 PM Staff E, CNA assisted Resident #14 to the restroom. Resident #14 had a strong odor of urine. When standing from her wheelchair, her pants were observed to be wet with urine. Staff E assisted Resident #14 to use the toilet, applied a clean brief and pulled up the resident's wet pants. The resident was assisted to return to her wheelchair in the wet pants. Facility Policy titled Incontinent and Perineal Care last revised on 7/31/24 directed staff to provide privacy and avoid unnecessary exposure of resident. The policy also directed staff to make the resident comfortable, groom and change clothing. Facility Policy titled Mechanical Lift Transfer last revised on 2/2024 directed staff to provide privacy. Facility Policy titled Resident Rights - Dignity and Respect last revised 4/2024 directed staff to treat each resident with dignity, respect and reasonable accommodation of individual needs. During an interview on 11/6/24 at 11:18 AM, the Director of Nursing (DON) explained she would expect staff to knock on a resident room door and wait for a response prior to entering. She further explained she would expect residents to be provided privacy during cares and to have wet pants changed at the time of toileting.

Based on observation, clinical record review, and staff interview the facility failed to follow safe transfer techniques for 1 of 2 residents observed during a transfer (Resident #14). The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) for Resident #14, dated 9/26/24, documented the resident was frequently incontinent of urine. The Care Plan interventions for the resident included transfers with assist of 2, assist with toileting per the resident's routine, and the resident wears incontinence briefs. During an observation on 11/5/24 at 11:37 AM, Staff A, Certified Nursing Assistant (CNA) entered Resident #14's room with the mechanical stand lift. Staff A stated she did not know where her partner went and proceeded to attach the sling around the resident, fasten waist straps, connect the sling to the stand, and placed the resident's feet on the foot plate. Staff A turned to the surveyor, removed her mask and explained the resident was supposed to be an assist of 2 for transfers and there were supposed to be 2 people to run the stand lift but she didn't know where her partner was. She repeated she was supposed to have another person with her but didn't know where she was. Staff A then proceeded to use the stand lift to raise the resident from her wheelchair and move her from the wheelchair across the room towards the bathroom. As she approached the bathroom door, Staff B, CNA entered the room and assisted with completing the transfer to the toilet. The policy titled Mechanical Lift Transfer, last revised 2/2024, directed staff that it was advisable to have 2 staff members present (for use of the lift) and each person's plan of care should be followed. During an interview on 11/6/24 at 11:18 AM, the Director of Nursing (DON) explained she would expect the mechanical stand/lift to he used with 2 staff members.

Based on record review, policy review, and interviews the facility failed to ensure services provided to residents met professional standards of quality by failing to follow physician's orders for 1 of 5 residents reviewed (Resident #3). The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) for Resident #3 dated 9/23/24 documented diagnoses of benign prostatic hyperplasia (enlarged prostate), hemiplegia (loss of strength or paralysis) affecting the right dominant side, and non-Alzheimer's dementia. MDS Section C documented a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicative of moderate cognitive impairment. The Care Plan dated 3/9/24 documented the resident required assistance with activities of daily living and had occasional urinary incontinence. A Progress Note labeled General Progress Note dated 10/20/24 at 6:56 PM indicated the resident was brought back to the facility from the emergency room at 6:56 PM. The note documented the cause of the resident's testicular pain was not clear. There was no evidence of a bladder infection. The ultrasound showed epididymal and testicular cysts. It included documentation that the resident was to have an appointment with a urologist on or around 10/27/24. An additional note at 7:22 PM documented a copy of the hospital note was faxed to the advanced registered nurse practitioner and a copy was placed in the Assistant Director of Nursing box to schedule the urology follow up the next day. A Progress Note completed 8 days later, dated 10/28/24 at 2:50 PM, revealed the call was made to urology and nursing was awaiting a return call. During an interview on 11/4/24 at 10:23 AM the resident indicated the cysts have caused some pain. He shrugged when asked when his appointment to have the cysts checked was. On 11/6/24 at 3:18 PM the Director of Nursing (DON) reviewed the resident's health record and stated her nurse should have made the appointment the next day (10/21/24). When she realized it had not been made, she called herself on 10/28/24. They said they would get back to her. On 11/7/24 at 8:36 AM the DON confirmed the information from the prior interview and stated the provider never called the facility back to say they were not going to see him. He was already established with another provider and was referred back to them. She stated she followed up today and the resident now had an appointment scheduled for Friday (11/8/24). A policy titled Physician's Orders, reviewed and revised 8/16/24, documented it was the policy of the facility to ensure all resident medications, treatments, and plan of care must be in accordance with the licensed physician's orders. The facility would follow physician orders as written and orders would be carried out in reasonable time.

Based on observation, policy review, and staff interview the facility failed to provide proper and complete incontinence and catheter care for 3 of 3 residents observed (Residents #12, #13, and #14). The facility failed to ensure staff wore masks in resident areas during the current COVID outbreak. The facility reported a census of 71 residents. Findings include: During an observation on 11/5/24 at 11:08 AM, Staff F, CNA and Staff G, CNA entered Resident #13's room to provide incontinence and catheter cares. Staff F and Staff G donned Enhanced Barrier Precautions (EBP) Personal Protective Equipment (PPE). Staff F removed the catheter drainage bag from the side of the bed. Staff F and Staff G worked collaboratively to remove the resident's pants and brief. Staff G cleansed the front perineal area and the catheter. The resident was assisted to turn on his right side. Staff F removed the resident's brief that had a small amount of BM observed. Staff F used personal cleansing wipes and wiped up the middle, between the buttocks. She did not clean the buttocks, hip or leg areas. The resident was assisted to roll onto his left side. Staff G cleansed the residents right buttock and placed a clean brief under the resident. The resident was assisted to roll onto his back. Staff F and Staff G worked collaboratively to fasten the brief. Staff G removed her gloves, did not perform hand hygiene, and put pants back on the resident up to his thighs. Staff F placed a plastic barrier on the floor, placed a graduate on the floor and proceeded to empty the catheter drainage bag. She dumped the urine in the toilet, rinsed the graduate using the faucet in the sink and placed cleaned graduate in storage area. Staff F and Staff G worked collaboratively, rolling the resident to his sides to finish pulling up the resident's pants. Staff F picked the resident's shoes up off the floor and put them on the resident. Both CNAs removed their gloves and washed their hands (this was the first time during the observation that Staff F removed her gloves or performed hand hygiene). During an observation on 11/5/24 at 11:37 AM Staff A, CNA entered Resident #14's room. Staff A removed her mask while standing within 6 feet of a resident, with both residents in the room, during a COVID outbreak to explain to the surveyor she did not know where her partner was and was going to proceed to provide care despite the resident being care planned for 2 staff members to assist. After repeating this a second time, she put her mask back on. After applying gloves, she pushed the mechanical stand up to the resident, put the sling around the resident, attached sling to the stand, ensured the resident's feet were on the foot plate. She used the lift to stand the resident and move towards the restroom. Staff B, CNA entered the room and applied gloves and guided the resident to the toilet, pulled the resident's pants and brief down. The resident was lowered to the toilet. Staff B removed gloves and left the room. Staff A remained in the room. A short time later Staff B reentered the room and washed her hands. Staff A removed her gloves and washed her hands. When she finished washing her hands, before drying or reaching for a paper towel, she shut off the water. Both CNAs applied gloves. The resident was assisted to stand using the mechanical stand lift run by Staff A while guided by Staff B. The resident was moved to the doorway allowing Staff B to stand directly behind the resident. Staff B cleansed the resident by reaching between the resident's legs from behind and wiping her perineal area. The reach from behind cleansing was only cleansing the middle. The resident's thighs, buttocks and hips were not cleansed. Staff A and Staff B worked collaboratively to pull up the resident's brief and pants. Staff B then removed her gloves. Staff A moved the resident to her wheelchair using the mechanical stand and lowered her to her wheelchair. Staff A removed her gloves and took the lift out of the room. She returned to the room, removed the concentrator tubing from the resident, placed the portable oxygen tubing in the resident's nose, turned on the portable oxygen and adjusted the resident's hearing aid before washing her hands. During an observation on 11/5/24 at 1:02 PM Staff E, CNA took Resident #12 to her room. Resident #12 had a strong urine odor when she was taken to her room. Staff E washed her hands and applied gloves. She then swung the foot pedals back on the wheelchair, angled the wheelchair towards the restroom and locked the brakes. She removed the resident's shawl, applied the gait belt, assisted the resident to stand and ambulate to the restroom. She then pulled down the resident's pants and brief. The brief was saturated with urine and discarded. She then removed the gait belt from the resident before removing her gloves and performing hand hygiene. When the resident was finished on the toilet, Staff E applied gloves, put a clean brief on the resident, pulled her brief and pants up to her knees, put the gait belt on the resident and assisted her to stand. She used personal cleansing wipes to clean the resident. She cleansed the perineal area, and inner thigh. She used the same wipe surface for multiple wipes. She failed to clean the hips and buttocks. Facility Policy titled Catheter Care: Indwelling Catheter, last revised 12/2023, directed staff to apply clean gloves before emptying a catheter drainage bag. Facility Policy titled Handwashing, last revised 5/20 directed staff to dry hands thoroughly with a paper towel and discard and then use a dry paper towel to turn off the water. Facility Policy titled Incontinent and Perineal Care directed staff to use clean gloves when putting on clean briefs. During an interview on 11/6/24 at 11:18 AM, the Director of Nursing (DON) explained she would expect staff to follow policy and procedure and EBP when emptying at catheter. She would expect clean gloves when going from dirty to clean, and would expect clean gloves between incontinent care and catheter emptying. She explained she would expect hand hygiene to be performed after glove removal.

Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to implement their infection control policy to ensure MRSA (a contagious staph bacteria infection) was contained. Staff interviews revealed Resident #1 had a suprapubic catheter leaking urine onto clothes and sheets; staff were unaware Resident #1 was positive for MRSA due to a Nurse not reporting Lab Results and the facility did not provide personal protective equipment for staff use for 4 days. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 21, 2023 on July 26, 2023 at 4:30 p.m. The facility staff removed the Immediate Jeopardy on July 27, 2023 by implementing the following actions: a. Resident #1, who resides in the facility, was assessed and placed in isolation to include remaining in room for meals while on isolation. b. A facility wide audit was completed on 7/27/23 to identify residents currently on antibiotics for treatment of UTI's (Urinary Tract Infections) to validate and identifed organism/isolation status. c. An audit completed on 7/26/23 of patients on isolation to validate appropriate PPE (personal protective equipment) is outside of the room and staff are aware of the isolation precautions. d. Resident #1's roommate was moved on 7/25/23 into a private room. Patient medical doctor (MD) notified and placed on alert charting to monitor for signs and symptoms of a UTI. e. The medical director was notified on 7/26/23. f. Education to licensed nursing staff provided on 7/26/23 to include review of lab results, disease specific isolation guidelines/precautions for MRSA, PPE requirements and updating care plan and Kardex with isolation precautions. g. Education to nurse aides related to isolation precautions/PPE requirements for MRSA. h. Education to nurse management on updating the care plan/Kardex with isolation precautions. i. The Director of Nursing (DON) or designee will complete daily audits for 2 weeks to observe isolation/PPE guidelines are followed then daily Monday thru Friday for 2 weeks. j. The DON or designee will conduct daily audits for 2 weeks for urine/wound culture results and then daily Monday thru Friday for 2 weeks. k. Conserns or trends from monitoring will be taken through Quality Assessment and Assurance (QAA). The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 72 residents. The MDS dated [DATE] revealed Resident #1 had a diagnosis of renal insufficiency, obstructive uropathy, urinary tract infection (UTI) septicemia (blood poisoning by bacteria) and required extensive assistance of 1 person for personal hygiene. Resident #1 had a brief Interview for mental status (BMI) score of 12 indicating a slight impairment of cognition. The MDS identified Resident #1 had a clear comprehension and ability to express ideas and wants. The Care Plan dated 5/24/23 for Resident #1 identified an 18 French indwelling suprapubic catheter and directed staff to position catheter bag and tubing below the level of the bladder in a privacy bag, change monthly, as needed and monitor for signs and symptoms of a UTI. During an observation on 7/24/23 at 2:58 PM Resident #1 was alert and resting in bed on his right side, catheter drainage bag in a dignity bag on the floor next to the bed, yellow urine in tubing. Another resident shared the room and bathroom with Resident #1. The staff who came into the room did not wear personal protective equipment (PPE), there was no indication that Resident #1 was in an isolation precaution, as there was a lack of signage on the door. During an interview on 7/24/23 at 2:58 PM Resident #1 stated the nurses clean his catheter site at least 1 time a day and empty it 2 times a day. Resident #1 stated, The nurses are the ones who clean the catheter, the CNA's empty it. Document titled Weland Clinical Laboratories dated 7/21/23 indicated Resident #1 had an abnormal lab, organism identified as Methicillin-Resistant Staphylococcus Aureus (MRSA) (a contagious staph bacteria). Written on this lab form dated 7/21/23 per Staff I, Urologist, Macrobid 100 milligram (mg) PO (by mouth) BID (two times a day) for 7 days and Macrobid 100mg PO q d (every day) indefinite. A fax form attached identified sender as Harmony Cedar Rapids on 7/21/23 at 1:36 PM. The Progress notes for Resident #1 revealed: a. 7/19/23 at 1:03 PM Urine analysis was collected, clean catch of yellow thick urine. b. 7/21/23 Urine analysis culture result MRSA. c. 7/21/23 New order from the Urologist for Macrobid 100mg two times a day for 7 days then everyday day. During an interview on 7/25/23 at 2:32 PM, Staff H, Licensed Practical Nurse (LPN), stated she administered Macrobid to Resident #1 today for a UTI but was unaware the infection was MRSA therefore not using proper PPE. Staff H stated The urine has been leaking around the catheter at the suprapubic site and onto the sheets. During an interview on 7/25/23 at 3:12 PM, the Administrator stated the staff didn't need isolation, the MRSA is contained. During an interview on 7/25/23 at 3:18 PM, Staff G Registered Nurse (RN), stated he just became aware of the MRSA in report. Staff G stated he was told in report on 7/21/23 that Resident #1 had a UTI. During an interview on 7/25/23 at 3:20 PM Resident #1 stated he used the shared bathroom with his roommate. During an interview on 7/25/23 at 4:10 PM, the Administrator stated the staff placed Resident #1 in isolation at this moment and moved the roommate to a different room. During an interview on 7/25/23 at 4:12 PM Staff F, RN, responded to the question of PPE when nurses irrigate the urinary catheter, she stated if the urine splashed into their eyes, they can just flush it out. During an interview on 7/26/23 at 2:25 PM Staff D, Certified Nursing Assistant (CNA), stated she did not know about PPE or where to get it. During an interview on 7/26/23 at 3:44 PM, Staff E CNA, stated she was aware that the isolation gowns are in a supply closet down the hall it is locked and the nurse has the key. She stated she had worked last week with Resident #1 unaware of the MRSA, and was working on another unit. Staff E stated We float to other units. During an interview on 7/26/23 at 7:42 AM, Staff B, CNA, stated she had worked with Resident #1 and was not aware that he had MRSA. Staff B stated, The nurses usually tell us if we are going to need to were PPE. Staff B stated the PPE is in a locked room in another department and the nurses have the key. During an interview on 7/26/23 at 2:45 PM, Staff A, LPN, stated she had worked 7/22, 7/23/23 and 7/26/23 unaware of Resident #1's urine culture result that identified MRSA. Staff A stated the staff caring for Resident #1 should be wearing PPE. Staff A stated, We did not wear the PPE because we did not know about the MRSA. Staff A stated she was aware that Resident #1 had a UTI and was treated with an antibiotic. Staff A stated, I should have worn a splash guard because we flush his catheter, it leaks all over the place and he's been in the dining room to eat. During an interview on 7/26/23 at 11:20 AM, the Director of Nursing (DON) stated she was the Infection Prevention Nurse and was not aware that Resident #1 had MRSA in his urine. The DON stated she had been on vacation and had not seen the lab results. The DON stated she was aware that Resident #1's suprapubic catheter leaked. The DON stated the site of the suprapubic catheter had been leaking since he returned from the hospital on 5/18/23. During an interview on 7/27/23 at 11:52 PM, Staff C, RN, stated, I received the order for the antibiotic for the urine infection on7/21/23 and I didn't see the MRSA at first, I sent it to the doctor and I thought the physician would give us an order of isolation. Staff C stated, When I saw the word isolation I thought it said encapsulated so I thought it was contained, so it was my fault he was not in isolation. Staff C stated the suprapubic catheter was leaking at the abdominal site and required to be flushed. During an observation on 7/27/23 at 7:40 AM, Staff A, LPN gowned in PPE, hand sanitized and put a splash guard on to protect her face. Resident #1's shirt was wet from urine that leaked from the suprapubic catheter site in the abdomen below his umbilicus. Staff A prepared to flush Resident #1's suprapubic catheter, took the catheter apart from the tubing that lead to the drainage bag, used a 50 milliliter (ml) syringe that contained normal saline, and applied pressure to the syringe to flush the catheter. The catheter flushed and fluid drained into the tubing after the LPN reconnected the closed system to the drainage bag. Policy titled Practice Guidelines dated 7/2021 revealed contact precautions: a. Wear gloves when in direct contact with a patient who is infected or colonized with organisms that are transmitted by direct contact (multi drug resistant organism's (MDRO's) such as MRSA). b. gloves and hand hygiene c. wear mask, eye protection to protect .eyes, nose, mouth during procedures and care likely to generate splashes or sprays of blood, body fluids, secretions and excretions. d. wear a gown .to protect skin and prevent contamination of clothing. e. PPE is to be donned (put on) prior to entering the room. f. signage notice posted on the door for any transmission-based precautions. g. consider all soiled laundry contaminated. During an interview on 8/2/23 at 11:21 AM, the DON stated the corporate provided the policies to follow, and followed the CDC guidelines. The DON stated the expectation was for the staff and administrator to follow the guidelines when she was on vacation. The DON stated, I would expect the nurses to call the doctor with lab results, note in progress notes, notify family, and if they are documenting in the progress notes, then the Infection Preventionist would know. The CDC webpage https://www.cdc.gov/mrsa/healthcare//index.html published 7/31/23 contained the following information regarding MRSA in a healthcare setting: a. MRSA is usually spread by direct contact. b. The only way to know if MRSA is the cause of an infection is to perform a culture (a laboratory test) of the bacteria. c. Successful MRSA prevention requires action both at the healthcare facility level, among healthcare providers and healthcare leadership. d. Based on the current evidence, CDC continues to recommend the use of Contact Precautions for MRSA-colonized or infected patients.

Based on clinical record review, observations, resident and staff interviews and policy review, the facility failed to ensure appropriate care and treatment to prevent urinary tract infections (UTI) leading to a resident suffering from septic shock and deep tissue pressure injury to the urethral meatus (tip of the penis) for 1 of 3 residents reviewed for catheter care (Resident #1). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 28, 2023 on July 26, 2023 at 12:15 p.m. The facility staff removed the Immediate Jeopardy on July 27, 2023 by implementing the following actions: a. Resident #1 resides in the center, head to toe assessment was completed and pain evaluation with interventions. b. Facility wide base line audit completed on 7/26/23 to identify residents with indwelling catheter or suprapubic catheter. c. Skin assessment completed on all patients identified on base line audit who have an indwelling/suprapubic catheter; and a whle house skin sweep completed by 7/27/23 to identify pressure ulcers. d. Braden assessments reviewed to validate high risk patients; a new Braden assessment completed completed if needed. Based on audit findings, interventions implemented with care plans/Kardex updated accordingly. e. Pain interviews/assessments completed on patients residing in the facility with pressure wounds. f. Medical Director notified on 7/26/23. g. Education to licensed nursing staff immediately 7/26/23 and will educate nurses prior to their scheduled shift on catheter care, skin practice guide, signs and symptoms of a UTI, pre-medicating/managing pain prior to dressing changes. h. Education to Certified Nursing Assistants (CNA) initiated immediately 7/26/23 and will educate aides prior to their scheduled shift on catheter care, signs and symptoms of UTI, skin (ORG) for aides. i. DON /designee will complete daily audits Monday - Friday x 4 weeks to observe catheter care and audit pain through observation of dressing changes and pain interviews. j. DON/designee will conduct weekly audits of pressure ulcer documentations and validate weekly skin assessment is completed. k. Concerns or trends from monitoring will be taken through Quality Assessment and Assurance (QAA). The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 72 residents. The MDS dated [DATE] revealed Resident #1 had a diagnosis of renal insufficiency, obstructive uropathy, urinary tract infection (UTI) septicemia (blood poisoning by bacteria) and required extensive assistance of 1 person for personal hygiene. Resident #1 had a brief Interview for mental status (BMI) score of 12 indicating a slight impairment of cognition. The MDS identified Resident #1 had a clear comprehension and ability to express ideas and wants. Care Plan dated 5/24/23 for Resident #1 identified an indwelling catheter placed on 5/9/23 and directed staff to change it monthly, as needed and monitor for signs and symptoms of a UTI. Care Plan dated 6/15/23 for Resident #1 revealed an open area to distal penis related to the Foley (indwelling) catheter tubing and directed staff to apply wound treatment as ordered by the physician, assess for pain, administer pain medication as ordered by the physician, observe for feedback and notify the physician as necessary. Document titled Discharge Summary dated 5/18/23 revealed Resident #1 was admitted to the ICU with septic shock secondary to UTI and obstruction. Resident #1 was on a ventilator for 4 days and returned to the nursing home on 5/18/23. It was recommended Resident #1 to have a Foley (indwelling) catheter indefinitely and to follow-up with the Urologist for possible prostrate surgery. Physician treatment order for Resident #1 dated May 2023 revealed: a. Body audits every Wednesday initiated on 4/12/23. b. Catheter Care every shift initiated on 5/24/23. c. Cleanse the urethral opening with normal saline and apply Bacitracin BID (two times a day) initiated 5/28/23. Treatment Administration Record (TAR) dated May 2023 revealed: a. Body audits were completed on May 3, 10, 17, 24, 2023. b. Catheter care documented as completed: 1. 5/24/23 two times 2. 5/25/23 three times 3. 5/26/23 three times 4. 5/27/23 four times 5. 5/28/23 three times c. Treatment with Bacitracin applied on 5/28/23. Nurse progress note dated 5/28/23 at 10:05 AM revealed Resident #1 complained of pain around his urethral opening where his catheter was, the skin was dark brown, crusted, and hard. The skin under the urethral opening was yellowish, slimy and peeling. Staff A, LPN called Staff J, Advanced Registered Nurse Practitioner (ARNP) and received an order for Bacitracin BID (2 times a day) to affected areas and continue to monitor. Nurse progress note dated 5/29/23 Resident #1 was unresponsive and was sent to the hospital. Document titled ED Provider Notes dated 5/29/23 revealed Resident #1 presented in the emergency department with an unresponsive episode, low blood sugar level and UTI. Document titled Progress Notes dated 6/11/23 revealed Resident #1 was readmitted to the hospital on 5/29/23 for pneumonia, UTI, bilateral PE (pulmonary Embolisms, blood clot in both lungs) and multiple soft tissue infections including on the glans of the penis due to pressure necrosis (death of a body tissue) likely from Foley catheter in place. Document titled Physician Progress notes date of service 6/2/23 at 4:40 pm signed by Staff I, Medical Doctor (MD) Urology revealed an assessment of wound Pressure Injury Penis Deep tissue. The examination revealed skin breakdown around the urethral meatus, exudate and sloughing of mucosa and 2 cm eschar. These findings are consistent with pressure ulcerations and breakdown likely from catheter on too much tension at the nursing home. Due to recurrent UTI and pressure necrosis from the Foley catheter, proceeded with the placement of a suprapubic catheter on 6/1/2023. Document dated 6/14/23 Staff M, MD, Hospitalist revealed the reason for Resident #1's continued hospitalization was due to the deep tissue injury of penis. Consult dated 6/12/23 at 4:34 PM Staff K, Certified Wound Ostomy Nurse (CWON) revealed Staff L, MD ordered the consult for Penile necrosis for Resident #1. The Staff K found the penis wound continues to be an unstageable pressure injury as the over half of the wound base remains covered and nonviable tissue. The ventral aspect (underside) of the penis is noted to have stringy adherent slough. Recommended to continuing with Triad hydrophilic wound paste and attempting to cover with a silicone bordered foam dressing. Wound progress notes on 6/15/23 at 11:43 AM Staff K, CWON revealed the assessment of Resident #1 penis wound, no dressing in place as ordered, thick dried layer of Triad hydrophilic over wound bed. Cleaned the wound with soapy water and used scissors and forceps to debride the eschar from the penis. Recommended impregnating (saturate) the 4x4 gauge with the Triad Hydrophilic and apply to wound and use tubular gauze to cover. A document titled HCR Manor Care Skin Alteration Record for Resident #1 revealed: a. 5/28/23 a 2 centimeter (cm) long by 2 cm wide slough (moist yellow or grey necrotic tissue) on his urethral opening (tip of penis), no pain identified. b. 5/29/23 Resident #1 was in hospital. c. 6/15/23 a 10 cm long by 1 cm wide scabbed pale pink tissue surrounded by red skin, identified that the wound was painful. d. 6/16/23 a 10 cm by 1 cm scabbed wound surrounded by reddened tissue, identified that the wound was painful. e. 6/20/23 no assessment f. 6/27/23 no assessment g. 7/5/23 a 5 cm by 0.2 cm eschar (thick, hard, black tissue) bottom of urethral opening, 1 cm by 0.4 cm eschar at 1 o'clock of urethral opening, identified that the wound was painful. h. 7/12/23 a 0.9 cm by 1.5cm by .15 cm deep slough on bottom side and .5 cm by .5 cm slough on top side, identified that the wound was painful. i. 7/19/23 no assessment During an observation on 7/24/23 at 2:58 PM Resident #1 was alert and resting in bed on his right side, the catheter drainage bag in a dignity bag on the floor next to the bed, yellow urine in tubing. During an interview on 7/24/23 at 2:58 PM Resident #1 stated the catheter that was in his urethra hurt for a week or two and the nursing staff was aware. During an interview on 7/25/23 at 12:24 PM, Staff M, Certified Nursing Assistant (CNA) stated the CNA's provide catheter care and empty the drainage bag at the end of each shift and for the suprapubic catheters the CNA's only empty the bags. During an interview on 7/26/23 at 2:45 PM Staff A, Licensed Practical Nurse (LPN), stated no one informed her of the scab on Resident #1 urethral opening before 5/28/23. Staff A stated on 5/28/23 a CNA (unable to remember who it was) notified her that Resident #1 complained of pain in his penis, There was a dark scab on it and I don't remember the catheter being too tight. Staff A stated she had worked with Resident #1 a week before 5/28/23 and the dark scab was not there. Staff A stated, The CNA's were doing the catheter cares and emptying the catheter bag. The Policy titled Catheter Care-indwelling catheter directed staff to: a. Examine skin for signs of inflammation, skin breakdown or discharge during the procedure. b. Notify the nurse if anything is abnormal. c. Secure the catheter to the patient's leg using a securement device or Velcro tag strip to prevent traction on the urethra. d. Check to be sure that tubing and bag are off the floor. e. Policy Lacked a procedure to empty the catheter bag. During an interview on 7/27/23 at 7:05 AM Resident #1 stated he was in pain 8/10 in his penis. I feel weak and it hurts. I just want to get out of here. It hurts almost every day. During an interview on 8/2/23 at 11:21 AM the Director of Nursing (DON) stated that she would expect her nursing staff to follow the policies and procedure for catheter care and to notify the physician if there are skin issues. The DON stated, If we don't know where it (skin issue) came from, we need an investigation and notify family and doctor, but if we know where it came from then we don't do an incident report.

Based on resident and staff interviews, observation and record review, the facility failed to manage pain for 1 of 3 residents reviewed for dressing changes (Resident #1). Resident #1 stated he had experienced pain during daily dressing changes for 6 weeks. The facility reported a census of 72 residents. The MDS dated [DATE] revealed Resident #1 had a diagnosis of renal insufficiency, obstructive uropathy, urinary tract infection (UTI) septicemia (blood poisoning by bacteria) and required extensive assistance of 1 person for personal hygiene. Resident #1 had a brief Interview for mental status (BMI) score of 12 indicating a slight impairment of cognition. The MDS identified Resident #1 had a clear comprehension and ability to express ideas and wants. Care Plan dated 6/15/23 for Resident #1 revealed an open area to distal penis related to the Foley (indwelling) catheter tubing and directed staff to apply wound treatment as ordered by the physician, assess for pain, administer pain medication as ordered by the physician, observe for feedback and notify the physician as necessary. Document titled Discharge Summary dated 5/18/23 revealed Resident #1 was admitted to the ICU with septic shock secondary to UTI and obstruction. Resident #1 was on a ventilator for 4 days and returned to the nursing home on 5/18/23. It was recommended Resident #1 to have a Foley (indwelling) catheter indefinitely and to follow-up with the Urologist for possible prostrate surgery. Physician treatment order for Resident #1 dated May 2023 revealed: a. Body audits every Wednesday initiated on 4/12/23. b. Catheter Care every shift initiated on 5/24/23. c. Cleanse the urethral opening with normal saline and apply Bacitracin BID (two times a day) initiated 5/28/23. Treatment Administration Record (TAR) dated May 2023 revealed: a. Body audits were completed on May 3, 10, 17, 24, 2023. b. Catheter care documented as completed: 1. 5/24/23 two times 2. 5/25/23 three times 3. 5/26/23 three times 4. 5/27/23 four times 5. 5/28/23 three times c. Treatment with Bacitracin applied on 5/28/23. Nurse progress note dated 5/28/23 at 10:05 AM revealed Resident #1 complained of pain around his urethral opening where his catheter was, the skin was dark brown, crusted, and hard. The skin under the urethral opening was yellowish, slimy and peeling. Staff A, LPN called Staff J, Advanced Registered Nurse Practitioner (ARNP) and received an order for Bacitracin BID (2 times a day) to affected areas and continue to monitor. Nurse progress note dated 5/29/23 Resident #1 was unresponsive and was sent to the hospital. Document titled Progress Notes dated 6/11/23 revealed Resident #1 was readmitted to the hospital on 5/29/23 for UTI and multiple soft tissue infections including on the glans of the penis due to pressure necrosis (death of a body tissue) likely from Foley catheter in place. Document titled Physician Progress notes date of service 6/2/23 at 4:40 pm signed by Staff I, Medical Doctor (MD) Urology revealed an assessment of wound Pressure Injury Penis Deep tissue. The examination revealed skin breakdown around the urethral meatus, exudate and sloughing of mucosa and 2 cm eschar. These findings are consistent with pressure ulcerations and breakdown likely from catheter on too much tension at the nursing home. Due to recurrent UTI and pressure necrosis from the Foley catheter, proceeded with the placement of a suprapubic catheter on 6/1/2023. Document dated 6/14/23 Staff M, MD, Hospitalist revealed the reason for Resident #1's continued hospitalization was due to the deep tissue injury of penis. Consult dated 6/12/23 at 4:34 PM Staff K, Certified Wound Ostomy Nurse (CWON) revealed Staff L, MD ordered the consult for Penile necrosis for Resident #1. The Staff K found the penis wound continues to be an unstageable pressure injury as the over half of the wound base remains covered and nonviable tissue. The ventral aspect (underside) of the penis is noted to have stringy adherent slough. Recommended to continuing with Triad hydrophilic wound paste and attempting to cover with a silicone bordered foam dressing. Wound progress notes on 6/15/23 at 11:43 AM Staff K, CWON revealed the assessment of Resident #1 penis wound, no dressing in place as ordered, thick dried layer of Triad hydrophilic over wound bed. Cleaned the wound with soapy water and used scissors and forceps to debride the eschar from the penis. Recommended impregnating (saturate) the 4x4 gauge with the Triad Hydrophilic and apply to wound and use tubular gauze to cover. A document titled HCR Manor Care Skin Alteration Record for Resident #1 revealed: a. 5/28/23 a 2 centimeter (cm) long by 2 cm wide slough (moist yellow or grey necrotic tissue) on his urethral opening (tip of penis), no pain identified. b. 5/29/23 Resident #1 was in hospital. c. 6/15/23 a 10 cm long by 1 cm wide scabbed pale pink tissue surrounded by red skin, identified that the wound was painful. d. 6/16/23 a 10 cm by 1 cm scabbed wound surrounded by reddened tissue, identified that the wound was painful. e. 6/20/23 document lacked the wound assessment and pain assessment f. 6/27/23 document lacked the wound assessment and pain assessment g. 7/5/23 a 5 cm by 0.2 cm eschar (thick, hard, black tissue) bottom of urethral opening, 1 cm by 0.4 cm eschar at 1 o'clock of urethral opening, identified that the wound was painful. h. 7/12/23 a 0.9 cm by 1.5cm by .15 cm deep slough on bottom side and .5 cm by .5 cm slough on top side, identified that the wound was painful. i. 7/19/23 document lacked the wound assessment and pain assessment The Medication Administration Record (MAR) for Resident #1 revealed: a. June 2023 pain medication was not administered. b. July 1, 2023 Tramadol 50 mg was given for pain. c. July 2, 2023 through July 26, 2023 pain medication was not administered. During an interview on 7/24/23 at 2:58 PM, Resident #1 stated he remembered the catheter that was in his urethra. Resident #1 stated, It hurt for a week or two and the nursing staff was aware. Staff interview on 7/25/23 at 2:32 PM, Staff H, Licensed Practical Nurse (LPN) stated His penis is painful to him, this morning he didn ' t want the dressing changed. When the surveyor asked if pain medication was administered, Staff H stated, No, he didn ' t ask. During an interview on 7/26/23 at 2:45 PM Staff A, LPN stated on 5/28/23 a CNA (unable to remember who it was) notified her that Resident #1 complained of pain in his penis, There was a dark scab on it and I don't remember the catheter being too tight. Staff A stated she had worked with Resident #1 a week before 5/28/23 and the dark scab was not there. Staff A stated Resident #1 was cooperative with dressing changes. Staff A stated I ' m careful, it hurts him. During an interview on 7/27/23 at 7:05 AM Resident #1 stated he was in pain 8/10 in his penis. I feel weak and it hurts. I just want to get out of here. It hurts almost every day. During an interview on 7/27/23 at 7:01 AM, Staff A, LPN, stated a pain assessment was completed on 7/26/23 for Resident #1, who complained of pain from his wound on his penis, and had received an order for Lidocaine spray. Staff A stated the pharmacy informed the facility the Lidocaine spray was unavailable for delivery until 7/29/23. Staff A stated she offered Resident #1 an oral pain medication which Resident #1 refused and claimed all pills are giving him dirrhea. The Policy titled Pain directed staff to: a. If pain medication is needed, medications will be given per order. After the administration of prn pain medication, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident ' s physician will be notified. b. During the treatment procedure, the resident will be assessed for pain. Pain medication will be administered per order and patients will receive pain medication prior to treatment procedure if indicated. If medication given prior to treatment is not effective and the patient continues to complain about pain or exhibit signs of pain; staff will stop the treatment procedure and notify the physician. During an interview on 7/27/23 at 10:16 AM, The DON stated she called the pharmacy and they could not deliver the pain medication that was ordered on 7/26/23 until 7/29/23. The DON stated the nurses were documenting 0 for pain when Resident #1 stated he was in pain almost every day, He told me he hurts during dressing changes only and maybe the nurses assess his pain level at a different time. During an observation on 7/27/23 at 7:45 AM Staff F, RN Unit manager stated the DON had obtained the Ladocaine spray from a local pharmacy and gave Ladocaine spray to the Staff A. During an interview on 7/27/23 at 7:58 AM, Staff A, LPN stated she applied the Ladocaine to Resident #1 ' s wound before the dressing change and within minutes the resident stated it felt better. During an interview on 7/27/23 at 8:20 AM, Resident #1 said the spray was working, he smiled and shook the surveyor's hand, and stated, Thank you. During an interview on 8/2/23 at 11:21 AM, The DON stated she would expect that the nurse would notify the doctor if the currently offered medication is refused or is ineffective and if delayed delivery from the pharmacy.

Based on Pre-Admission Hospital Record review, facility clinical record review, State of Iowa Certificate of Death review, Medical Director and staff interviews, and facility document review, the facility failed to complete a thorough assessment, contact the resident's physician timely to request transport to the hospital for provision of treatment for 1 of 5 residents reviewed (Resident #2), when a serious change in condition noted for the resident. This failure resulted in the resident not being transported to the emergency room (ER) in a timely manner to receive medical interventions/treatment and subsequently the resident found in bed at the facility without a pulse or respirations, therefore causing an Immediate Jeopardy to the health and welfare of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 1:45 p.m. The facility staff removed the Immediate Jeopardy on [DATE] by implementing the following actions: A house wide audit completed to include baseline assessment and vital signs of current resident. Based on assessment findings, interventions were put in place and actions taken to address needs for residents when applicable. Doctor (MD) and Family Notifications completed for any changes in condition identified. Medical Director was made aware. Education to Licensed Nursing Staff was initiated [DATE] to include education on change in condition, assessment/intervention care paths. The Director of Nursing/Designee will complete Audits to validate documentation of assessments/interventions of any changes in condition. The scope lowered from J to D at the time of the Survey after ensuring the facility implemented staff education and procedures. The facility reported a census of 79 residents. Findings Include: The Pre-Admission Hospital Record documented diagnoses including COVID, acute cough, hematemesis, esophageal varices, and Grade D (severe) esophagitis. The hospital record documents the resident presented to the Emergency Department (ED) on or around [DATE] after his daughter observed coffee ground emesis. Resident #2's Minimum Data Set (MDS) dated [DATE], documented an admitted [DATE]. The Electronic Health Record (EHR) Medical Diagnosis Section documented admission medical diagnosis including esophageal varices without bleeding and secondary esophageal varices with bleeding. The Progress Note written on [DATE] at 5:55 PM documented the resident was admitted from a local Hospital by a transportation service. He was in the facility for strengthening. The resident was oriented to his room, call light, and TV remote. Medication orders were faxed to the Pharmacy and the Doctor (MD) was aware of the admission. The clinical record lacks a Progress Note, vital signs, any nursing documentation or physician documentation for [DATE]. The Progress Note written on [DATE] at 5:53 AM, documented the resident had a quiet night, was COVID positive with intermittent cough. His respirations were even without distress. The Progress Note written on [DATE] at 8:23 PM, documented the resident's lungs sounds were clear and diminished and his abdomen had active bowels sounds in all 4 quadrants. The Progress Note written on [DATE] at 4:46 AM, documented the resident was resting peacefully with his eyes closed. His respirations were even and no distress observed. The resident had an intermittent cough. The Progress Note written on [DATE] at 9:48 AM, documented the resident was vomiting and refused (his medications). The clinical record lacked documentation of a physical assessment, vital signs or Physician notification at that time. The Progress Note written on [DATE] at 11:15 AM, documented the nurse entered the resident's room at 10:30 AM. The resident was making retching noises and had an emesis basin with spit and a tinge of blood. The resident asked the nurse if he was going to die that day and began to get worked up and breath heavy. The nurse encouraged the resident to deep breath through his nose and out through his mouth as he was exhibiting signs of an anxiety attack. His pulse was 102 beats per minute and his oxygen saturation was 100 % on room air. The nurse called the resident's daughter to ask medical questions as the resident did not appear to be an accurate historian. The daughter requested the resident be sent to the emergency room (ER) immediately. The nurse documented she told the daughter this was not an emergency situation, he was just anxious. The resident was given Zofran (medication given for nausea) and water, covered with a blanket and the nurse told the resident she would be back to see if the Zofran helped. At 11:05 AM, the nurse entered the resident's room to see the resident with a blank stare, pupils fixed, his mouth and chin were blood stained. He did not have a pulse or respirations. The nurse documented an overhead page was made for the Code Blue and chest compressions were started. The nurse, another nurse and the Activity Assistant rotated compressions and the Ambu bag (to provide breaths to resident). At 11:06 AM, the Assistant Director of Nursing (ADON) called 911. At 11:13 AM, the ambulance crew arrived and took over care. At 1:00 PM, the Medical Examiner called and reported the cause of death to be ruptured esophageal varices. The State of Iowa Certificate of Death documented the date and time of death as [DATE] at 11:45 AM. The immediate cause of death is listed at exsanguination (sever blood loss) secondary to esophageal varices with other significant conditions being COVID-19. During an interview on [DATE] at 1:59 PM, the Director of Nursing (DON) explained if a resident or family member was requesting a resident be sent to the ED, she would expect an assessment to be completed, the Doctor be notified and made aware of the request and assessment findings. She further explained the nurse would get the order to send at that time. She would expect that information to be documented. She explained that if it isn't documented that doesn't necessarily mean it wasn't done. If there was an emergency or something it could have slipped the nurses mind. During an interview on [DATE] at 8:49 AM, Staff B, Licensed Practical Nurse (LPN) explained if a family member requested a resident go to the ER she would do an assessment, vitals and notify the Doctor. During an interview on [DATE] at 8:52 AM, Staff C, LPN explained if a family member or resident was requesting the resident go to the ED she would do an assessment and notify the Doctor. During an interview on [DATE] at 8:58 AM, Staff D, Registered Nurse (RN), explained if a resident was requesting to go to the ER she would do an assessment, call the Doctor and would send the resident to the ER. She explained if a family member was requesting the transfer, the resident gets transferred, the request can't be declined. During an interview on [DATE] at 9:15 AM, Staff A, RN explained the passed away on her last day working in this facility. She recalled the resident wasn't feeling well and had a little blood in his mouth. She explained the resident was anxious that day ([DATE]) and he was in the facility for COVID. The resident felt nauseated and she gave him a Zofran. He did not vomit but spit up. She called the daughter from the resident's cell phone with his permission. She remembers the cell phone recording they talked for 13 minutes. The resident was spitting up pink tinged sputum and the daughter thought he should go to the emergency room . Staff A explained to the daughter that he was anxious, this was not an emergency and she was calling to get a better picture of his previous history and background. The daughter gave that picture. Staff A explained she left the resident with an emesis basin as he was feeling nauseated and his call light and went to tend to another resident. When she was done with the other resident, she went back to check on the resident and found him with a blank stare, pupils fixed. She stated she shouted his name and felt for a pulse. She did not find one. She explained she knew he was a Full Code (wanted life saving measures), she called the code overhead and called for the crash cart and began compressions. She reported bright red blood clots were coming out of the resident's mouth with compressions. She stated she was not aware the resident had esophageal varices at that time. During an interview on [DATE] at 11:42 AM, Staff F, RN, Unit Manager explained she was working in another part of the building when she heard the code page. She explained 2 nurses were doing Cardiopulmonary Resuscitation (CPR) when she got to the room. She recalled she ran and grabbed the suction machine and took it into the room and called 911. She went back in the room to get the suction machine going and the ambulance crew was there very quickly. She recalled the resident had blood coming from somewhere on or near his face. His color was completely pale. She explained she called the resident's daughter and notified her the resident was on his way to the hospital. Staff F explained if a family member requested the resident be sent to the ER the Doctor should be notified and she would get a Doctor's Order to send the resident to the hospital. When asked about a nurse refusing to call the Doctor, she stated That would be wrong. She stated the nurse needed to put forth the effort to call the Doctor and let the Doctor know and decide what would happen next. During an interview on [DATE] at 11:59 AM, the DON acknowledged Staff A had received a request from the resident's daughter for the resident to go to the ER but she received that information later. She explained it would not be appropriate for the nurse in the facility to tell the family no, this is not an emergency and refuse to send the resident or even call the Doctor. During an interview on [DATE] at 4:12 PM, the Medical Director explained when a resident or family member requests to go to the ER we send them. That's standard, we don't refuse to send them. He further explained if it is an emergent situation they can call 911 and send the resident to the ER, get them taken care of and then notify us (himself and his team). If it's not emergent we like to be notified ahead of time so we can give the order and be aware. He explained he would expect a new set of vitals and an assessment from the nurse's interaction with the resident, that is standard. If they call and don't have that information he would ask them to get that information and call back. The facility document titled Change in Condition, dated ,d+[DATE] directed staff to consult with the resident's Physician for any need to alter treatment or a decision to transfer the resident from the facility. The document further directed staff to immediately notify the Physician for any symptom, sign or apparent discomfort that is acute or sudden onset and a marked change in relation to usual symptoms and signs.

Based on clinical record review, staff interviews, and facility policy the facility failed to ensure one of four residents reviewed received medication according to the physician's orders [REDACTED]. (Resident #2) The facility reported a census of 78 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented the resident admitted to the facility on [DATE]. The resident identified with no cognitive impairment and required extensive assistance of two staff to transfer. [DIAGNOSES REDACTED]. The MDS documented the resident received a diuretic (fluid pill) for seven days during the last seven days. The resident's Discharge Instructions from the hospital dated 9/10/2019 included a Physician order [REDACTED]. The facility Order Summary Report for September, 2019 included an order for [REDACTED]. Resident #2's September, 2019 Medication Administration Record [REDACTED]. daily from 9/11 through 9/19/2019. Progress Notes dated 9/11/2019 revealed Resident #2 complained of intermittent nausea. Progress Notes dated 9/12/2019 revealed staff administered [MEDICATION NAME] for nausea and vomiting with effective results Progress Notes dated 9/12/2019 revealed Staff A, Nurse Practitioner (NP), ordered labs for the resident and an IV (intravenous) for 1000 ml (milliliters) of fluid. Staff A ordered Resident #2's vitamins and supplements be put on hold, and [MEDICATION NAME] (diuretic) be held for three days. Progress Notes dated 9/19/2019 revealed the resident complained of feeling weak, having nausea and chills. Staff B, Registered Nurse (RN) assessed the resident and notified Staff A, NP who ordered labs and an IV. Staff had difficulty starting the IV fluids and discharged the resident to the emergency room for further evaluation. Lab results dated 9/19/2019 revealed Resident #2 with abnormal results including low potassium and sodium and a urinalysis determined the resident had a UTI (Urinary Tract Infection). The Emergency Department (ED) Notes dated 9/19/2019 revealed Resident #2 transferred from the facility due to low blood pressure and low oxygen saturation while there. The ED noted the resident had [DIAGNOSES REDACTED] (low potassium) and required a work up. The ED Notes reported the resident felt generalized weakness with a decreased appetite, not eating or drinking well and battling a urinary tract infection for the last few weeks. Will check labs and UA (urinalysis). The History and Physical dated 9/19/2019 documented Resident #2 with a positive UTI and received an IV antibiotic. It also revealed the resident had [DIAGNOSES REDACTED], acute and unstable in spite of taking potassium daily, possibly related to excessive diuresis (fluid loss) with daily use of [MEDICATION NAME] ([MEDICATION NAME]) rather than the prescribed dose of once weekly as indicated by the cardiologist notes. The resident documented with Acute Kidney Injury (AKI), likely secondary to excessive dosing of [MEDICATION NAME] compared to what was intended by the cardiologist. New orders included hold both [MEDICATION NAME] and [MEDICATION NAME] and resume both medications when resolved, with resuming the [MEDICATION NAME] once weekly dosing rather than the once daily dosing. During an interview on 10/2/2019 at 11:00 a.m., Staff C, Director of Nursing (DON), reported Resident #2's family member told the facility they had a medication error involving the resident. The facility took it seriously and notified the physician, corporate office and gave education to all staff and began monitoring all residents admitted on a diuretic. Staff B, RN entered the medication orders into the pharmacy system and the facility failed to have another nurse and the Unit Manager verify the orders transcribed correctly when entered. During an interview on 10/2/2019 at 2:30 p.m., Staff B, RN revealed he/she received Resident #2's admission paper work and entered the medications in the pharmacy tab. It was a human error that he/she documented [MEDICATION NAME] 5 mg. to be given daily versus weekly. The night shift nurse and the Unit Manager were to double check the orders. Staff B received education about making sure to double check orders and to also have another nurse verify them. On 9/19/2019, Staff B worked the evening shift and asked the resident how he/she felt at approximately 2:00 p.m The resident asked if he/she could get another IV because it helped and he/she had been feeling nauseous and weak. Staff B notified the physician, assessed the resident and determined the resident had low blood pressure. Staff B administered [MEDICATION NAME] for nausea. The physician ordered labs and an IV, however the resident had difficult veins and Staff B sent the resident to the Emergency Department. During an interview on 10/2/2019 at 12:15 p.m., Staff D, RN, Unit Manager, revealed upon admission the nurse on duty enters the orders to the pharmacy and Staff B entered [MEDICATION NAME] daily versus weekly and staff did not catch the mistake. All staff were educated about triple checking the orders and Staff D personally received education. The next shift nurse and the Unit Manager are to double check the orders. The physician or Nurse Practitioner check the orders when the facility receives physician orders [REDACTED].#2's orders that day and approved them. The resident admitted to the facility directly from the hospital. During an interview on 10/2/2019 at 1:00 p.m., Staff A, Nurse Practitioner, PhD, revealed he/she saw Resident #2 and reviewed the medications. The resident took a lot of vitamins and supplements which may have caused the nausea. Staff A ordered labs and ordered staff to hold off on administering some of the medications with a wait and see approach to see if the symptoms improved. The goal was to help with the nausea and help the resident's appetite. The resident had a medication error with the [MEDICATION NAME] but co-morbidities also worked together to make bad stuff happen. The 9/19/2019 labs revealed the resident had a UTI which can also cause nausea, vomiting, pain and dehydration. During an interview on 10/2/2019 at 2:00 p.m., Staff E, Nurse Practitioner revealed he/she checked and approved the medication list when Resident #2 admitted to the facility from the hospital. The resident had a lot of digestive issues as well and a UTI. Review of the facility Admission Policy dated 12/2009 included: a. Notify physician of admission and obtain and verify orders b. Fax admission orders [REDACTED]. Review of the facility Medication Administration: Medication Pass policy included: Purpose: To safely and accurately prepare and administer medication according to the physician order [REDACTED]. The facility corrected the deficient practice on September 23, 2019 by conducting inservice training to the facility nurses regarding transcribing physician orders [REDACTED].