Every finding on record at Hawkeye Care Center Dubuque

Based on staff interviews, facility record review and facility policy review the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey and cited in previous surveys. The facility reported a census of 71 residents.Findings include:The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 12/22/22 reflected deficiencies identified for infection control.The CMS 2567 form dated 9/12/24 reflected deficiencies identified for infection control .During the current recertification and complaint dated 9/18/25, the team identified same deficiency, Infection Control (F880).On 9/18/25 at 11:22 AM the Infection Preventionist, Registered Nurse (RN) stated she did attend quarterly quality assurance meetings. They discussed what infections were in the building and how many people were on antibiotics in the past quarter. Enhanced barrier precautions was not really discussed, and it was something the Infection Preventionist said should add to their report. She revealed she was unsure if they covered personal protective equipment in skills lab this year, and she would have to check with the Director of Nursing. Per the Infection Preventionist, after the infection control deficiency last year facility educated on laundry. The problem was found in the laundry area. On 9/18/25 at 11:32 AM the Director of Nursing (DON), RN stated had a full staff meeting in August, and talked about enhanced barrier precautions. The DON explained talked about the different types of isolation precautions and different types of personal protective equipment in that meeting, and she could not recall in the recent past that they had done any quality assurance on isolation or enhanced barrier precautions. She stated did not do anything with personal protective equipment during facility's skills fair this year. On 9/18/25 at 11:38 AM, the Administrator confirmed there were concerns with the pattern of same deficiency, and thought at this point would have more frequent audits, and had started the education related to the problem. The facility provided the Quality Assurance/Process Improvement (QAPI), undated, that included facility will monitor adherence to quality standards via site visits and ongoing review of complaints, adverse events and deficiencies. Audits will be performed to review clinical and administrative protocols/procedures, and clinical records to ensure we are in compliance with protocol procedures and rules and regulations. Appropriate corrective action will be taken with any noted inconsistencies until our goals are met.

Based on observation, record review, interviews, and policy review the facility failed to update a resident's code status change in a timely manner to ensure their right to refuse medical treatment was respected for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 71 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The MDS revealed Resident #5 had diagnoses of cancer, non-Alzheimer's dementia, stage 3 chronic kidney disease, and hypertensive heart disease with heart failure.A review of the resident's Electronic Health Record (EHR) on [DATE] at 8:43 AM revealed the resident's code status as CPR (Cardiopulmonary Resuscitation), which indicated the resident wanted life sustaining measures performed if his heart and/or breathing were to stop. This was included on the admission record page and at the top of the EHR tab pages.During paper chart review on [DATE] at 10:01 AM, the resident's paper chart contained code status documents that contradicted each other. A document labeled CODE STATUS for: (Resident #5) signed by the resident and a witness on [DATE] indicated the resident wanted Cardiopulmonary Resuscitation (CPR) performed. The physician line labeled I HEREBY ISSUE A FULL CODE ORDER was signed [DATE]. The physician line labeled I HEREBY ISSUE A DO NOT RESUSCITATE ORDER (DNR) was signed [DATE].Another document titled Iowa Physician Orders for Scope of Treatment (IPOST) dated [DATE] and signed by the resident's Power of Attorney documented the resident's status as DNR/Do Not Attempt Resuscitation. Medical interventions identified comfort measures only and declined artificially administered nutrition. The Nurse Practitioner signed the IPOST [DATE].On [DATE] at 10:06 AM Staff B, Licensed Practical Nurse (LPN) reached for the paper chart when asked where he would look for code status. He showed the surveyor the CODE STATUS document, and pointed to the DNR line signature. When asked about the conflicting information on that document, he checked the code status in the computer and stated the resident wanted CPR. When showed the IPOST, the LPN stated that was confusing and called the Assistant Director of Nursing (ADON).At 10:12 AM on [DATE] the ADON pointed out the dates on the documents and said that whoever got the new IPOST did not enter it into the EHR. During a follow up at 11:02 AM, the ADON stated they needed to go through the charts to remove tabs, stickers, and documents that would be confusing. She indicated they made adjustments to the resident's record to correct the error.During a follow up review of the chart on [DATE] at 10:54 AM the resident's Profile tab listed the resident's code status as DNR at the top of the page. Under the Custom Information section, the advance directive was listed as CPR.A policy titled Resuscitative Measures re-reviewed and updated 11/2024 documented CPR will be initiated and emergency personnel summoned by calling 911 in the event that a resident has a cardiopulmonary arrest, unless (1) there is the presence of obviously clinical signs of irreversible death (dependent lividity or rigor mortis); or (2) the resident or surrogate has indicated that resuscitation is not desired and the physician has issued a do not resuscitate (DNR) order which is located in the resident's clinical record.

Based on observations, clinical record review, staff and resident interviews and facility policy review the facility failed to use Personal Protective Equipment (PPE) as directed for two out of five residents reviewed (Resident #43 and Resident #66). The facility reported a census of 71 residents. Finings include: 1.The Brief Interview for Mental Status (BIMS) assessment for Resident #66 dated 7/9/25 reflected a score of 15 out of 15, which indicated intact cognition. The Medical Diagnoses list dated 9/17/25, included diagnoses of personal history of Methicillin-resistant Staphylococcus aureus (MRSA) infection, pressure ulcer, sepsis, and urinary tract infection (UTI). Review of Hospital Medicine History and Physical paperwork for the resident dated 9/1/25 revealed the following for the resident: significant past medical history or recurrent UTI, multiple drug-resistant organism infections in the past. The Medication Administration Record (MAR) dated 9/2025, directed Cefepime HCl Intravenous (IV) Solution 2 GM 2 gram three times a day for UTI/Sepsis for 13 Days. The Care Plan for Resident #66 dated 9/16/25 identified compromised skin areas related to Intravenous (IV)s and lab draws and cellulitis. The Intervention dated 9/16/25 revealed, Provide Enhanced Barrier Precautions (EBP) outlined by CMS (Centers for Medicare and Medicaid Services). The sign posted on Resident #66's room door read, Stop Contact Precautions Everyone Must: clean their hands, including before entering and when they leave the room. Providers and staff must also: Put on gloves before room entry the room and discard gloves before exiting the room. Put on a gown before room entry and discard gown before exiting the room. On 9/16/25 at 8:58 AM, Staff A, Registered Nurse (RN) nurse entered Resident #66's room, gave her medications and failed to use a gown or gloves. Staff A gloved touched the resident face and administered eye drops to both eyes and exited the room went back to the medication cart. On 9/16/25 at 9:38 AM, Staff A gloved as she entered Resident #66's room. Staff A appeared to move around the left arm and provide care to the left arm. Staff A failed to wear a gown. On 9/16/25 at 10:44 AM, Resident #66 wore an elastic net over her left elbow area. Resident #66 confirmed the net held her IV. On 9/18/25 8:34 AM Resident #66's room door continued to hold the sign that identified contact precautions. Resident #66 reported not all the staff put on the gown, and gloves when they come in to help her. She reported it depended on who it was. On 9/18/25 at 10:26 AM, the Infection Preventionist reported Resident #66 needed Enhanced Barrier Precautions (EBP) and contact precaution related to her the infection in her urine and the IV line. The IP identified Resident #66's history of multidrug-resistant organism, (MDRO)s. She reported she expected the staff with hands on contact they needed to put on the personal protective equipment (PPE) that the sign directed. The IP reported the facility had provided the education to the staff. 2. The MDS for Resident #43 dated 6/26/25 documented diagnoses of ulcerative (chronic) pancolitis, Crohn's disease of the large intestine, and non-Alzheimer's dementia. Her Brief Interview for Mental Status score of 13/15 indicated intact cognition. On 9/11/25 a focus area was added that the resident was on contact isolation for C-diff (Clostridium difficile, a bacterium that can cause an infection of the colon/large intestine) and received Vancomycin (antibiotic). The goal was to remain on isolation precautions as long as she had symptoms and was still on medication for C-diff. The Intervention dated 9/11/25 revealed, Staff to wear proper PPE when taking care of [Resident #43]. On 9/16/25 at 9:40 AM signs observed on Resident #43's door for contact precautions and enhanced barrier precautions. The contact precautions sign documented everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also put on gloves before room entry and discard them before room exit; put on a gown before room entry and discard gown before room exit; and use dedicated or disposable equipment. Staff were directed not to wear the same gown and gloves for the care of more than one person. There was a white cart outside the door which contained red hazard bags, white gowns, 2 packets of germicidal cleaning wipes, and regular garbage bags. The cart did not contain gloves, hand sanitizer, or masks. During an interview on 9/16/25 at 9:45 AM Resident #43 stated she had an infection but could not explain it. She said that she mostly kept to her room due to the infection. Room observations on 9/16/25 included: At 10:06 AM the resident was seated in her wheelchair in her doorway. Staff came out of another resident's room, heard her ask for help ,and entered Resident #43's room to turn on her call light. At 10:07 AM Staff D, Certified Nurses Aide (CNA) went in to the resident's room to turn her call light off without gown or gloves and brushed up against the resident's wheelchair when passing her. At 10:09 AM Staff D and Staff E, CNA used hand sanitizer available on the white cart, gowned, wore masks they were already wearing, and then took the resident in to her room. They did not put gloves on outside of the room. At 10:14 AM while Staff D and Staff E were providing cares, Staff C, CNA entered the resident's room to see if she needed ice water. She left the room, went to the cart to get the water, and re-entered the resident's room with ice water. Staff C did not wear gown or gloves. She did not wash her hands with soap and water. At 11:52 AM Staff E entered the resident's room to answer her call light without a gown or gloves. Observation revealed there were not gloves in the cart. She did not wash her hands with soap and water. During an interview with Staff C on 9/17/25 at 10:49 AM, she stated she knew C-diff was a bacterial infection of the colon that was contagious and required enhanced barrier precautions for all cares. She stated the facility provided education and that staff entering Resident #43's room should have a gown, mask, and gloves before going in. Staff C stated they should wash their hands or sanitize them when coming out of the room. She stated she was told that anyone going into Resident #43's room should wear a gown and gloves because they could carry C-diff out with them. She acknowledged that she had seen staff enter the room without proper PPE. Staff B stated on 9/17/25 at 11:01 AM the Director of Nursing (DON) provided staff training about C-diff and the Assistant Director of Nursing (ADON) stocked the carts. He again stated staff should gown and glove no matter their reason for entering the room.During an interview on 9/17/25 at 11:09 AM the ADON stated she and the DON worked together to receive and provide training about enhanced barrier precautions and contact precautions. She reported the process for entering the resident's room was to wash with soap and water, wear gowns and gloves, and to dispose of them before exiting the room. She was aware that some of the staff didn't gown and glove to answer the call light or bring the resident water. The facility policy titled Infection Control Manual revised 4/2025 documented contact precautions should be used for residents who are known or suspected to be infected or colonized with epidemiological organisms. Barriers included gloves when entering the room and gowns when entering the room if contact with the resident, environmental surfaces, or items in the resident's room were anticipated. The policy noted contact precautions may be considered for Clostridium difficile (C-Diff). The policy section on Clostridium Difficile (also known as C. Difficile or C. Diff) revealed, Gloves should be worn to enter the room of a resident who has diarrhea caused by C. Difficile. A gown is needed to enter the room of a resident who has diarrhea caused by C. difficile if substantial contact with the resident or the environmental surfaces is anticipated. Gloves and gown should be removed before leaving the resident's room and hands must be washed immediately with an antiseptic soap.

Based on observation, staff interviews, and policy review the facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items. The facility reported a census of 72 residents. Findings include: In an interview on 9/10/24 at 8:50 AM Staff A, Laundry aide explained dirty laundry comes in bags. Whites are separated as are personal items. Laundry from isolation rooms comes in a red bag and they get washed by themselves in the washer. Staff wear gloves and an apron for isolation laundry, and only gloves for regular dirty laundry. In an observation on 9/10/24 at 9:17 AM Staff A put on gloves, took the cover off the soiled laundry bin, and placed soiled linens into two washers without donning a gown. She shook out the soiled pads prior to placing them in the washer. She then closed the washer doors and started the machines. Staff A then removed her gloves. In an interview on 9/11/24 at 8:50 AM the Housekeeping Supervisor explained she expected staff to always wear a gown and gloves and then place soiled linens in the washer. The facility policy titled Infection Control Manual: Laundry, revised 11/2023 documented laundry personnel must wear gown and gloves when handling any soiled linens.

Based on observation, record review, and staff interview the facility failed to update the Care Plan for 1 of 2 residents with a pressure sore (Resident #33) and 1 of 5 residents with psychotropic medications ( Resident # 21). The facility reported a census of 73 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #33 indicated a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. It further indicated diagnoses including: anemia, heart failure, and hypertension. The MDS indicated Resident #33 needed partial to moderate assist of staff for transfers, bathing, dressing, and personal hygiene. The MDS indicated Resident #33 had a Stage 3 pressure ulcer and an unstageable pressure ulcer. The MDS indicated the resident was at risk for pressure ulcers. The facility provided a Risk Management assessment dated [DATE] which indicated a possible deep tissue injury to bilateral heels. Review of the Progress Notes dated 5/24/24 revealed the nurse found possible deep tissue areas on both heels. Right heel 1.5 centimeters (cm) by 1.2 cm. Area is flat, intact, with no drainage, purplish gray in color, non tender to the touch. Surrounding skin is dark pink and blanchable. Left heel 1 cm x 1 cm. Area is slightly raised with fluid filled intact blister. Purplish gray in color with surrounding skin dark pink and blanchable. Review of the Care Plan failed to address the bilateral heel pressure ulcers until 6/19/24. On 09/10/24 at 11:33 AM observed Resident #33 sitting in her wheelchair in the main dining room waiting for lunch to be served both lower extremities have heel protector boots in place. On 09/10/24 at 2:15 PM observed Resident #33 in bed both heels floating with bilateral heel protectors in place. On 09/11/24 at 10:32 AM observed Resident #33 in her room in her wheelchair and she had bilateral heel protectors in place she stated she is not having any pain. 09/12/24 at 9:48 AM the Assistant Director of Nursing (ADON), Registered Nurse (RN) stated once the pressure ulcer is identified the Care Plan should be updated. We are notified so once a skin issues is identified the staff do a risk management, the MDS coordinator is responsible to update the Care Plan. The Care Plan should be updated weekly at the Care Plan meeting when something is added or changed. On 09/12/24 at 9:57 AM Staff B, Licensed Practical Nurse (LPN), MDS Coordinator, stated if someone develops a pressure ulcer the Care Plan should be updated immediately. We have a meeting once a week and pressure ulcers are discussed in the clinical meetings. It looks like on 5/7/24 Resident #33 had 'at risk for pressure ulcer' on the Care Plan and on 6/20/24 I added the actual pressure ulcers to the Care Plan and I am not sure why I added them then because they were supposed to be on there but were not. They should have been added right away. On 09/12/24 at 10:04 AM the Director of Nursing (DON), RN stated the interventions should be put on the Care Plan as soon as the change is noted. I would have expected to see it back in May when the pressure ulcer was identified to be on Resident #33's Care Plan. The facility provided a policy titled Care Plan Development Process, updated 11/2023, instructed the following: The Comprehensive Care Plan must be developed no later than 21 days after admission, and will specifically address the following needs: a. Medical b. Nutritional c. Psychological d. Physical e. Functional f. Social g. Educational h. Spiritual i. Condition Impairments j. Disability/Disease 6. Each team member needs to review and revise their portion of the Care Plan in order to prepare for the meeting and to keep Care Plan meeting times concise. The Care Plan will be reviewed and amended as needed. 8. The MDS Coordinator is responsible for ensuring that each portion of the Care Plan is up to date. 9. The Care Plan is reviewed and updated quarterly or with any change in the resident's condition. 49976 2. The MDS dated [DATE] for Resident #21 documented a BIMS score of 15/15 indicating no cognitive impairment. It further indicated diagnoses including: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and depression. The Medication Administration Record for September, 2024 noted the following medication orders: a. Aripiprazole oral tablet 5 milligrams (mg) - give 1 tablet by mouth one time a day related to other specified depressive episodes b. Escitalopram oxalate oral tablet 10 mg - give 1 tablet by mouth one time a day related to other specified depressive episodes c. Venlafaxine HCl ER oral capsule 150 mg - give 2 capsules by mouth one time a day for depression d. Buspirone HCl oral tablet 15 mg - give 1 tablet by mouth three times a day related to other specified depressive episodes The facility Care Plan updated 8/13/24 lacked documentation regarding medication side effects, emotional triggers, and behavior monitoring related to depression.

Based on clinical record review, policy review, and staff and family interviews the facility failed to provide adequate supervision and assistance with transfers which led to a fall that caused a resident harm for 1 of 3 residents reviewed (Resident #29). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #29 documented the presence of short and long-term memory impairment. The MDS indicated the resident required assistance of 2 staff for toileting. It documented diagnoses including osteoporosis (lack of bone density), right leg below knee amputation, and generalized muscle weakness. The resident's Care Plan initiated 8/18/23 identified a focus area for dependence on staff for transfers. It directed staff to provide an assist of 2 with transfers. On 11/17/23 the intervention changed and directed staff to transfer with a Hoyer lift and assistance of two staff. The Fall Incident Note dated 11/8/23 at 8:53 AM indicated Staff B, Registered Nurse (RN) was called to the resident's room where the resident was found on the floor with her left leg in front of her, leaning back against her wheelchair with Staff C, Certified Nursing Assistant (CNA). Staff C reported she eased the resident to the ground during a transfer to the toilet. The resident complained of pain in the lower left leg. Staff B assessed the resident and noted a 9 cm x 5 cm hematoma (pooling blood under the skin) on the lower left leg and a 1 cm x 2 cm skin tear on top of the hematoma. The Emergency Department report dated 11/08/23 at 12:19 PM documented the resident had significant swelling and pain in the left lower leg. The hematoma measured 10 cm x 8 cm. Staff were instructed to elevate and ice the leg. The Fall Follow-up Note dated 11/09/23 at 4:46 AM documented the hematoma was dark red, black, and purple with bruising around the width of the leg. It measured 14 cm x 10 cm beginning at the lower leg to the top of the ankle. The skin tear was dark red in color and the area surrounding it swollen. The Non-pressure Skin Assessment v2 dated 11/17/23 documented the skin tear as 2.5 cm x 2.0 cm. The hematoma was 10 cm x 12 cm. The resident complained of tenderness to the area when standing and with touch. The Physician's Order Note dated 11/20/23 by the Wound Nurse documented the wound as a necrotic (dying) scab that measured 1 cm x 2 cm with a raised wound measuring 4 cm x 6 cm and very tender to the resident. She referred the resident to the Primary Care Provider or Surgeon for further evaluation and treatment. The Surgeon's Note dated 11/30/23 documented the resident complained of leg pain during the assessment. A 4 cm x 4 cm x 2 cm area was surgically debrided (removal of damaged tissue) and a large clot was removed. The wound was then packed and wrapped. The resident was placed on an antibiotic for 7 days. The Health Status Note dated 12/3/23 documented the resident had a remaining hematoma above the surgical site that measured 3 cm x 4 cm. The note dated 12/6/23 documented an abrasion above the hematoma. The Change of Condition Form v1 dated 12/11/23 documented the shin had two open areas. The top portion had two open areas measuring less than 5 cm with white/yellow exudate (leaking fluid) with a large black area on top. The bottom portion was quarter sized, open, with white/yellow exudate and black tissue encircling the area. The Health Status Note dated 12/18/23 documented a follow-up appointment with the surgeon on that date, again on 1/25/24, and 3/25/24 with instructions to return as needed. The Non-Pressure Skin assessment dated [DATE] documented the surgical site measured 0.6 cm x 0.5 cm. The skin was pink with no active drainage. An observation of the resident on 4/30/24 at 12:55 PM revealed her attempting to self-propel in the wheelchair down the hallway with her left leg. The dressing was present on her left lower leg. During an interview on 4/30/24 at 12:50 PM Staff B reported Staff C was with the resident when she fell . Staff C was transferring her alone and lowered her to the floor during the fall. Staff B did a full head-to-toe assessment and notified the doctor & family. She noted the resident was sent to the surgeon to debride it and one small open area remains but the bottom one is healed. She noted the resident only complained of pain with dressing changes and was premedicated with Tylenol. Dressing changes were daily then changed to twice a day. She reported the skin areas are measured weekly until completely healed, and the top wound is still receiving treatment. During an interview with the Director of Nursing (DON) on 4/30/24 at 2:17 PM she produced a signed statement from Staff B that documented she knew she looked in the wrong place for resident transfer status and did not ask questions about it. She knew where to look and looked at the resident name above Resident # 29 instead. The document titled Fall Witness Statement completed by Staff C reported she attempted to transfer the resident to the toilet by herself. The resident's knees wobbled and she hit her leg on the side of the toilet. She started to fall back and Staff C eased her to the floor. She documented she needed to verify the resident was an assist of two but read the transfer sheet incorrectly and attempted an assist of 1. During an interview on 5/01/24 at 2:26 PM the DON explained her expectation is for staff to keep up to date on the Kardex (care guide) to make sure and follow the right transfer status. She further expected staff to be aware of the transfer status listed on the communication board in the Electronic Health Record and use gait belts for transfers. She expected staff to follow facility policies. The facility policy titled Use of Transfer Belt/Gait belt, updated 10/23 instructed staff to always follow the resident's interim or comprehensive care plan as more than one staff may be needed for assistance.

Based on record review and staff interview the facility failed to submit Payroll Based Journaling (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) as required for the quarter of October 1 through December 31, 2023. The facility reported a census of 70 residents. Findings include: The CMS PBJ Staffing Data Report for Federal Year (FY) Quarter 1 2024 (October 1- December 31) triggered for failure to submit data for the quarter. During an interview on 4/30/24 at 11:40 AM, the Administrator confirmed the corporate office did not submit the data. The corporate office submits the data to CMS. This time the corporate office was waiting for additional information from a 3rd party and submitting the facility data slipped her mind. The Administrator was not aware the data was not submitted until 4/29/24.

Based on observation, document review and staff interview the facility failed to keep hands off of the drinking rim of cups for 2 of 3 dining rooms observed and failed to contain hair during meal preparation and serving for 2 of 5 staff observed. The facility reported a census of 70 residents. Findings include: During an observation of the noon meal on 4/29/24 from 11:17 AM through 11:53 AM in the Transitional Care Unit (TCU), Staff D, Dietary Aide was noted to have hair outside her hairnet on the side in front of her ears. She was serving residents food and drink from the steam table. During the same observation, Staff D was observed serving 18 cups to 11 residents while touching the drinking rim of the cups. During an observation on 5/1/24 at 11:49 AM Staff E, Dietary Aide, did not have his facial hair contained or covered while preparing and serving food. During an interview on 5/1/24 at 12:06 PM, the Dietary Manager explained the cups could not be touched at the top, where the resident would drink, the cups needed to be handled by the side or the bottom. She further explained hair nets are to be worn from the beginning to the end of the shift and all facial hair should be covered. 49976 2. During an observation of the noon meal on 4/29/30 at 11:04 AM Staff A, Dietary Aide served 5 glasses with her hand on the side of the glass and fingers touching the drinking rim surface of the glass. She served 4 glasses with her hand over top of the glass and fingers touching the drinking rim surface of the glass. This affected 9 residents.

Based on record review, staff interview and facility policy review the facility failed to follow up with interventions for a skin problem for 1 out of 3 residents with pressure sores (Resident #16). The facility reported a census of 70 residents. Findings include: The Minimum Data Set, dated dated dated [DATE] revealed Resident #16 had a Brief Interview for Mental Score (BIMS) of 6 which indicates severe cognitive impairment. The MDS indicated resident required substantial to moderate assistance with repositioning in bed and transfers. Review of the Progress Notes dated 4/24/24 at 4:57 AM revealed Resident #16 had a 4 centimeter (cm) by 5 centimeter (cm) open blister on left lateral ribs 6-8. Superficial wound bed, pink with clear drainage. Covered area with non-adherent dressing and mepilex dressing. The nurse practitioner was notified via facsimile. The family needs notification. Review of the Change in Condition report sent to the nurse practitioner 4/24/24 revealed the facility notified the nurse practitioner of a 4 cm by 5 cm open blister on left lateral ribs. The nurse practitioner signed the report but did not include an order for treatment of the wound. During an interview on 05/02/24 at 10:05 AM the Director of Nursing (DON) stated when a wound is found staff should fill out the skin sheet and notify physician and family. We would review myself or admission nurse would review the skin sheet. The admission nurse follows all the skin areas on the transitional care unit. I am wondering if it could have been more of a friction area from the gait belt. It typically is reviewed at the morning meeting. I saw Resident #16 wound in the report the morning it was identified, looking back I am not sure what happened in the morning meeting. The nurse should fax the physician the wound information and typically as in this case they should clarify if there is no treatment. I would expect staff to obtain a treatment for a new wound. During an interview on 05/02/24 at 10:13 AM Staff F, Licensed Practical Nurse (LPN), Admissions Nurse stated she is responsible for skin issues in the transitional care unit. She stated she does remember something about Resident #16 and a skin issue on his side. She stated usually the nurse that finds it gets an immediate treatment and then from there I just monitor it weekly. I did not look at the area or assess it. I just make sure they have an order to check/measure the wound every week and make sure there are no changes. On a new admission I will get new orders. The nurse who found the wound will do the assessment. The nurse should start a risk management. We check the risk management every morning, if its a skin issue we don't look for an order for a treatment, I assume the floor nurse did it because that is their job. I put it on the Care Plan and when they heal I remove it. I also make sure weekly measurements are being done. The facility provided an undated policy titled Skin Assessments which directed staff all impairments will be noted and addressed by the facility and resident physician.

Based on record review, staff interview and facility policy review the facility failed to notify a family of an area of skin breakdown in 1 of 3 residents reviewed for pressure sores (Resident #16). The facility reported a census of 70 residents. Findings include: The Minimum Data Set, dated dated dated [DATE] revealed Resident #16 had a Brief Interview for Mental Score (BIMS) of 6 which indicates severe cognitive impairment. The MDS indicated the resident required substantial to moderate assistance with repositioning in bed and transfers. Review of the Progress Notes dated 4/24/24 at 4:57 AM revealed Resident #16 had a 4 centimeter by 5 centimeter open blister on left lateral ribs 6-8. Superficial wound bed, pink with clear drainage. Covered area with non-adherent dressing and mepilex dressing. The nurse practitioner was notified via facsimile. The family needs notification. During an interview on 05/02/24 at 8:39 AM the Director of Nursing (DON) stated she did not find any documentation that family was notified of the change in skin condition for Resident #16. There was documentation of communication with the family on the chart but nothing specific to the new skin area. My expectation is they would notify family of any change in condition including any new skin areas. During an interview on 05/02/24 at 8:50 AM Staff E, Registered Nurse (RN) stated Resident #16 had an open area of skin on his side by his ribs. I know the nurse before me had told me she had found an open skin area on his rib. Usually if you find a skin area you do a risk management for new skin area and then notify the nurse practitioner and the family. I did not see the area or do an assessment. I did not talk to the family about it at all. Usually the person who finds it notified the family, even if it is on third shift. The facility provided an undated policy titled Nurse Notification of Physician, Resident and Representative of Changes, it directed staff it is the responsibility of licensed nurses employed at this facility to notify the resident's physician/designee, the resident and the representative if/when the resident's clinical condition may require or requires physician intervention to consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; any significant change in the resident's physical, mental or psychosocial status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility. When making notification, the facility will ensure that all pertinent information is available and provided upon request to the physician, the resident and/or the resident's representative.

Based on observation, policy review, and staff interviews the facility failed to maintain sanitary conditions due to inadequate dishwasher temperatures, food temperatures and a lack of monitoring systems. The facility reported a census of 76 residents. Findings include: 1. During an observation on 12/19/22 at 10:07 AM the main kitchen dishwasher wash cycle temperature read 140 degrees Fahrenheit (F), with a rinse cycle temperature of 160F. The Model CMA-180 VL Installation and Operation manual, page 4 specified 155F as the minimum temperature for the wash cycle, and 180F the minimum rinse cycle temperature During an interview on 12/19/22 at 10:09AM, Staff D, Cook, stated she had not done any breakfast dishes and would inform a maintenance staff of the low temperatures. Staff D stated the staff document the wash and rinse temperatures in a log book three times a day. Staff D could not present the log book after two requests. During an observation on 12/21/22 at 8:18 AM the main kitchen dishwasher rinse cycle after a warm up cycle read 174F. During an interview on 12/21/22 at 8:20 the Food Services Director (FSD) stated she would get a maintenance staff to adjust the temperature. Upon request, the FSD presented a dishwasher temperature log for December 2022. All temperatures for the wash and rinse cycle were within the recommended manufacturer perimeters. When asked for previous months dishwasher temperature logs, the FSD stated she does not keep logs more than several days. When asked if the staff consistently document dishwasher temperatures daily, the FSD stated they do, but she does not keep the logs. During an interview on 12/21/22 at 12:46 PM Staff F, Dining Services Aide stated she does document temperatures when there is a log sheet available. When asked if there is always a log sheet available Staff F stated no, there is not. Staff F stated she services meals on the [NAME] Unit and would use the dishwasher in the unit, however it is out of order. The staff stated since the machine is out of order she used the kitchen dishwasher. During an observation on 12/21/22 at 12:47 PM, after several cycles completed by Staff F, Dining Services Aide, the kitchen dishwasher rinse cycle read 174 F. When asked to use a test strip to measure the of the dishwasher, Staff F stated test strips are not used. During an interview on 12/21/22 at 12:54 PM, the FSD stated the kitchen dishwasher temperatures have been a concern and maintenance regularly makes adjustments to bring up the temperature to the recommended minimum. When asked about the December 2022 dishwasher temperature log, the FSD stated the logs were made up results. The DM stated she did this for all operational unit dishwashers. When asked how sanitation is maintained, the FSD stated Martin Brothers services the all kitchen equipment monthly and sends a report. A dining observation completed on 12/21/22 at 11:11 AM, revealed dietary staff used washable dinner plates, small salad bowls, coffee cups, plastic 8 ounce cups, and silverware to service the noon meal to 13 residents in the [NAME] dining room. During an interview on 12/21/22 at 2:00 PM, the Administrator stated she had been unaware the dishwasher temperature logs were documented, and logs maintained. The Administrator stated she would expect staff to document dishwasher temperatures after each meal, and logs maintained since the last annual recertification. The Administrator stated the facility does not have a policy for dishwashing temperatures, and would use the Model CMA-180 VL Installation and Operation manual for guidance. 2. A record review of the December 2022 facility food logs on the [NAME], Penn and TCU units revealed the results to be the same for each food item, for each meal, for each day documented from breakfast on December 1, 2022 thru lunch on December 19, 2022. The daily temperature log for TCU lacked documented temperatures for the supper meal on 12/19/22, and 12/20/22, and breakfast and lunch meals on 12/21/22. The daily temperature log for Penn lacked documentation for all meals after supper on 12/10/22. During an interview on 12/21/22 at 12:00 PM, Staff G, Certified Nursing Assistant and Dietary Aid on the Penn Unit stated she did not take food temperatures prior to serving the noon meal. An observation on 12/21/22 at 12:07 PM, revealed seven lunch trays plated with beef stroganoff, buttered noodles, carrots and pea salad. Each tray sat on a cart, uncovered. The beef stroganoff appeared dried out. During an interview on 12/21/22 at 12:08 PM, Staff H, Certified Nursing Assistant stated she prepared the plates to be delivered to rooms five minutes ago and had been unable to find plate covers. Staff H could not find a food thermometer in the unit kitchenette when asked to take the food temperatures. Staff H stated she is a CNA, but had recently started serving meals. Staff H denied completing any training requirements, and did not know she needed to take food temperatures, or to document the results. At 12:17PM, the Administrator arrived at the unit and agreed the trays cannot be served to residents. At 12:19PM the results of food temperatures taken with the Administrator present. Hot items: beef stroganoff 130 degrees Fahrenheit (F), buttered noodles 78F, carrots 85 F Cold items: pea salad 70F. At 12:30PM, the Administrator reviewed the December 2022 food logs for each unit. During an interview on 12/21/22 at 12:35 PM, the Administrator stated the food logs are a problem and she can see they are the same. The Administrator stated she is very disappointed. The Administrator stated she would expect food temperatures for each item served during a meal are taken, and documented. The Administrator stated she would expect the logs to be kept from recertification year to recertification year. During an interview on 12/21/22 at 12:54 PM, the Food Services Director stated she and a co-worker filled out the log sheets and made two copies. The FDS stated she placed a copy in a binder and put one binder on each unit. The FSD stated staff take food temperatures but due to being short staffed they have not been documenting the temperatures. An undated facility policy, titled Food Temperatures - Serving Line procedure stated: A. Hot foods are maintained at or above 135F, so that items arrive at approximately at or above 120F when serviced. B. Cold foods are maintained and serviced at 41F or less. C. Temperatures are taken prior to each service to ensure hot foods and cold foods are maintained at the specified temperatures D. Temperatures are recorded on the Food Temperature form and kept on file for 1 year.

Based on clinical record review, observation, staff interview and facility policy review, the facility failed to follow physician orders to provide the correct amount of fluids and to perform an enteral (feeding) tube placement check according to current standards of practice for 1 of 1 residents reviewed who required an enteral tube (Resident #1). The facility identified a census of 76 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive loss. Resident #1's diagnoses included cerebral palsy, seizure disorder. The resident required total assist of one staff for eating. The MDS documented the resident utilized a feeding tube for fifty one percent (%) or more of her total calories and 501 cubic centimeters (cc's) per day or more of fluid while residing at the facility. The order summary report dated active orders as of 11/28/22 directed staff to provide four ounces of cranberry juice with eight ounce of water four times daily. The orders also directed staff to provide enteral feed order four times a day related to cerebral palsy give 237 milliliter Promote with fiber via gastronomy tube four times a day for supplement and flush with eight ounces of water with administration. The care plan intervention dated 2/18/18 directed staff to administer four ounces of cranberry juice with eight ounces of water per the gastronomy tube. The interventions also directed staff to check placement verification prior to feedings and medications with a date initiated 2/18/18. During an observation on 12/20/22 at 10:02 AM Staff B, Licensed Practical Nurse (LPN) entered Resident # 1 room resident sitting in wheelchair he opened the resident's [NAME] button (stomach tube for nutrition) and connected syringe with tubing. He provided 90 cc cranberry juice then administered fiber 1.0 cal 8 ounces by gravity and then followed with a 2 ounce water flush. Staff B failed to aspirate for residuals or check for placement of the tube. During an interview on 12/21/22 at 1:22 PM Staff B, LPN stated prior to doing the tube feeding staff should check for residuals. He admitted he did not do it 12/20/22 for Resident # 1 prior to initiating her tube feeding. During an interview on 12/21/22 at 01:24 PM Director of Nursing (DON) stated for a tube feeding the expectation is follow the physician order to give the appropriate fluids. She would expect staff prior to administering feeding to check for residual or placement. They should follow physician order on what to administer for residents tube feeding. The facility provided a policy dated 2/20/16 titled Enteral Feeding which directed staff to verify physicians order for bolus feeding and to check tube placement per policy.

Based on clinical record review, resident and staff interviews and facility policy review the facility failed to complete pre and post dialysis assessment for 1 out of 1 residents reviewed (Resident #124). The facility reported a census of 76 residents. Findings included: The Minimum Data Set (MDS) assessment for Resident # 124 dated 12/12/22, included diagnoses of end stage renal disease (ESRD) and hypertension. The MDS reflected Resident's 124's Brief Interview for Mental Status (BIMS) as 15 (intact cognition). The Care Plan for Resident # 124 dated 12/19/22, directed dialysis days: Monday-Wednesday-Fridays. Nursing will complete an assessment prior to leaving and upon return from dialysis. The Clinical Assessments in the Electronic Health Record (EHR) dated 12/9-17/22, lacked pre and post dialysis assessments. The Health Status Note dated 12/16/22, Friday lacked dialysis pre and post assessment. The Health Status Note dated 12/14/22 at 2:59 PM, read Resident # 124, returned from dialysis, with no new orders. The Health Status Note dated 12/14/22 failed to include a pre dialysis assessment. The Health Status Note dated 12/12/22 failed to show a post dialysis assessment. The Health Status Note dated 12/9/22 failed to show a pre and post dialysis assessment. On 12/21/22 at 8:42 AM, Staff D Registered Nurse, (RN) reported she is expected to complete dialysis pre and post assessment for the resident that go to dialysis and they are documented in the resident Progress Notes. On 12/21/22 at 11:38 AM, the Director of Nursing, (DON) reported she expected the nurses to complete pre and post dialysis assessment and document them in the Progress Notes. The facility provided a policy titled Standards and Processes, Pre and Post Dialysis Assessments and Documentation of the Dialysis Resident dated 11/22, directed to assess for and evaluate any changes of condition related to the residents physical condition prior to dialysis and upon return after receiving Dialysis treatment. The Process directed; 1. Obtain a set of vitals signs (VS) prior to leaving the facility and upon return to the facility- (report any abnormalities from resident's normal range to the physician. 2. Assess residents physical condition prior to leaving the facility and upon returning (skin temperature- does resident complain (c/o) of feeling cold- c/o pain- alertness-level of lethargy c/o nausea. 3. Assess residents vascular site- reporting any bleeding swelling- document condition pf the site and/or dressing dry and intact. 4. Administer any medications as ordered. 5. Re-assess resident's physical conditions and VS as warranted with any change in condition and report to the resident's Physician or physician on call. 6. Document VS and assessment in the Progress Notes- report to physician any abnormalities and report to the on-coming Nurse to ensure follow up. Document any contact with the Physician and /or family members. 7. If dialysis report sheets are not received upon return to the facility, notify Dialysis unit to send to the facility or notify the DON.

Based on observations, policy reviews and staff interviews the facility failed to implement infection control standards for intravenous antibiotic therapy and straight catheterization for 1 of 1 resident (Resident #33). The facility reported a census of 76 residents. 1. The Minimum Data Set (MDS) assessment tool, dated 10/27/22, listed diagnosis for Resident #33 included: Type 2 diabetes mellitus, neurogenic bladder (lack control), and muscle weakness. The MDS stated the resident required extensive assistance with one staff for toilet use, and personal hygiene. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 99, indicating a severe cognitive impairment. A record review revealed escherichia coli (a common bacteria that causes urinary tract infections) found in residents' urine during a hospitalization on [DATE]. On 12/16/22 the resident discharged from the hospital with a physician's order to receive IV (temporary tubing placed in a vein for delivery of liquid medication) antibiotic therapy twice daily. The physician placed an order for the antibiotic Imipenem-Cilastatin 500 mg. The resident had a midline IV catheter placed in her right arm prior to returning to the facility. During an observation on 12/20/22 at 6:00 AM, Staff E, Registered Nurse began the process to administer the IV medication. During the process, Staff E could not remove the cap on the IV tubing. In the process of attempting to remove the cap, Staff E twisted and handled the IV tubing after touching the resident's bed, and touching her face with gloved hands. At 6:11 AM, Staff E removed the cap from the IV tubing. Staff H used an alcohol prep to clean the resident ' s IV line connection tip, and then without scrubbing the IV tubing connected the tubing to the midline. During an interview on 12/20/21 at 1:52 PM, Staff E stated the connectors on the midline IV and the IV tubing needs to be scrubbed for 30 seconds with an alcohol prep. Staff E stated the cap of the IV tubing had been difficult to see and she had difficulty getting it off. Staff E stated she should have scrubbed the IV tubing connector. During an interview on 12/21/21 at 2:00 PM, the Director of Nursing (DON), stated when staff administer an IV medication she expects they will scrub the connector to the resident IV before connecting the IV tubing. When asked if the IV tubing should be scrubbed after being handled for 11 minutes due to difficulty with the cap, the DON stated yes, the IV tubing connector should be scrubbed under the circumstance. The facility lacked a policy on the use of intravenous supplies. 2. The Minimum Data Set (MDS) assessment tool, dated 10/27/22, listed diagnosis for Resident #33 included: Type 2 diabetes mellitus, neurogenic bladder (lack of control) and muscle weakness. The MDS stated the resident required extensive assistance with one staff for toilet use, and personal hygiene. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 99, indicating a severe cognitive impairment. A record review revealed a physician order for a straight catheterization (catheter in to drain bladder and then removed) three times daily due a neurogenic bladder. During an observation on 12/20/22 at 1;25PM , Staff E , Registered Nurse (RN) applied left sterile glove by placing her right hand under the cuff on the outside of the glove. Staff E ' s bare hand touched the outside of the glove. At 1:29 PM, while waiting for the urine to completely drain into the catheter bag, Staff E placed her clean left glove hand on the resident's bed three times. Staff E used her left hand to manipulate the catheter tubing in and out of the urethra in an attempt to ensure complete drainage of the bladder. During an interview on 12/20/22 at 1:56 PM, Staff E stated she did not realize she put her bare right hand under the outside cuff of the left glove. Staff E stated she should have placed her hand on the inside of the glove to put it on. Staff E stated she did place her left hand on the bed and then manipulated the catheter tubing to ensure complete drainage. During an interview on 12/21/22 at 2:05, the Director of Nursing (DON0 stated a straight catheterization is a sterile procedure, She stated she would expect the staff to put on gloves by placing their clean hand on the inside of the glove, never touching the outside. The DON stated during a catheterization she would expect staff to keep their clean hand off the bed as that is a source of contamination. The facility policy, reviewed and updated 11/2022, titled Straight Catheter Protocol staff are directed to don (put on) sterile gloves. The protocol does not address maintaining a clean hand during the procedure.

Based on observation, clinical record review and staff interview, the facility failed to ensure the comprehensive care plan included all services required to ensure the medical and nursing needs were met for 3 out of 3 residents with incidents of coffee being spilled onto skin (Resident #10, # 29 and #45). The facility census was 76 residents. Findings include: 1.)The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognitive status. Resident #45 's diagnoses included anemia, hypertension and renal insufficiency. The MDS indicated Resident #45 was independent with eating. Review of the incident report dated 9/13/22 at 3:09 PM revealed Resident #45 was outside with husband and spilled coffee on her lap. Resident received burn to right and left inner thigh. Review of the care plan failed to reveal any interventions to prevent further incident of spilling coffee until 12/20/22 after surveyor requested information. Intervention added to provide my coffee in a sturdy coffee cup on 12/20/22. 2.) 1.)The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive status. Resident #29 's diagnoses included coronary artery disease and hypertension. The MDS indicated Resident #29 required set up help with eating. Review of the incident report dated 11/13/22 at 11:10 AM revealed Resident # 29 spillled coffee down the right side of her hip and received a two centimeter blister. During an observation on 12/20/22 at 11:43 AM Resident # 29 ate meal independently in the main dining area. She drank from insulated coffee cup with a lid on it. Review of the care plan failed to reveal any interventions to prevent further incident of spilling coffee until 12/20/22 after surveyor requested information. Intervention added to require a lidded cup for my coffee on 12/20/22. 3.) The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12 indicated mild cognitive impairment. Resident #10 's diagnoses included coronary artery disease, hypertension and heart failure. The MDS indicated Resident #10 required set up help with eating. Review of the incident report dated 11/15/22 at 1:19 PM revealed Resident # 10 spilled hot coffee on his left upper leg. There was a 6 inch by 2 inch red area with some blistering. Review of the care plan for Resident #10 failed to reveal any interventions to prevent further incident of spilling coffee until 12/20/22 after surveyor requested information. Intervention added to require a lidded cup for my coffee on 12/20/22 to prevent spilling. During an observation on 12/20/22 at 11:40 AM Resident #10 fed self independently in the main dining room. He drank from glasses without incident and no spillage. Resident #10 did have coffee in front of him in insulated cup no lid on the cup. During an interview on 12/21/22 at 1:30 PM with the Director of Nursing she stated the incidents with coffee spilled on residents would be addressed by staff would notify myself or the administrator or designee if someone is on call then we would discuss with our clinical meetings in the morning. Typically we would do care plan updates with any changes and then communicated to the kardex to inform staff. The interventions to the care plan should have been added at the time of the intervention and when the coffee was spilled to prevent any further incidents. The facility provided a policy dated 2/20/16 titled Care Plan Frequent Update, it directed staff the resident care plan will be updated whenever there is a change in the plan of care. The process directed staff whenever a change in physician orders and/or nursing interventions occur, the care plan is to be reviewed for an update to reflect the change.

Based on observation, record review and staff interview the facility failed to provide tubi grips to a resident per the physician order for 1 out of 1 residents reviewed (Resident #34). The facility reported a census of 76 residents. Findings include: Minimum Data Set (MThe DS) assessment dated [DATE] recorded Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognitive status. Resident #34's diagnoses included hypertension, diabetes, stroke, and depression. He required limited assistance of one staff with bathing and dressing. The treatment administration record for December 2022 revealed an order for tubi grip stockings to both lower extremities on in the AM and off at bedtime. Hand wash and hang to dry two times a day. The physician order sheet dated 11/28/22 revealed an order dated 9/7/22 for tubigrips bilateral lower extremites on in the AM and off at bedtime, hand wash and hang to dry. The care plan with a date initiated of 7/1/22 failed to address the tubi grip stockings. During an observation on 12/19/22 at 11:54 AM Resident #34 at lunch in his wheelchair in the main dining room and no tubi grip noted to both lower extremities. During an observation on 12/19/22 at 3:30 PM Resident #34 in the main dining area of unit playing cards with other residents sitting in his wheelchair and no tubi grip on both lower extremities. During an observation on 12/20/22 at 7:49 AM propelling self to breakfast in wheelchair and no tubi grip on both lower extremities. During an observation on 12/21/22 at 8:58 AM Resident # 34 in bed with both lower extremity regular socks on and does not have any tubi grips on both lower extremities. He states he is not aware of any kind of special socks that he wears but would have to ask the staff. During an interview on 12/21/22 at 1:19 PM with Staff A, Certified Medication Aide (CMA) states she is not aware of Resident #34 having tubi grips but I am not assigned to this hall very often. During an interview on 12/21/22 at 1:19 PM Staff B, Licensed Practical Nurse ( LPN) states Resident #34 needs to have tubi grips on dally and off at bedtime. I think he is using them because of edema. The certified nurses aides put them on in the morning and take them off at night . I sign them off on the treatment administration record. I typically see them when he comes out for breakfast. During an interview on 12/21/22 at 1:28 PM the Director of Nursing (DON) states she would expect staff to follow physician order and by signing the treatment administration record it would indicate the treatment is completed . On 12/21/22 at 3:05 PM the DON stated they do not have a policy for following physician orders but she would expect the nurse to follow as written by the physician.

Based on observation, record review and staff interview the facility failed to provide adequate catheter cares for 2 out of 2 catheter cares observed, (Resident #5 and Resident #6). The facility reported a census of 67 residents. Findings include: 1.) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #5 scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognitive status. The resident needed extensive assist of 1 staff with transfers, personal hygiene, dressing and toileting. The MDS indicated the resident had an indwelling catheter. The Care Plan dated 7/1/22 indicated Resident #5 had a catheter due to [CONDITION(S)]. The interventions directed staff to provide catheter cares twice a day and as needed. Review of the Medication Review Report dated 9/5/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/21/22 at 7:54 AM Staff D, Certified Nursing Assistant (CNA) used a gait belt and assist of one to ambulate and transfer resident into bathroom to have resident sit on toilet. Staff D removed a soiled brief from resident and provided catheter cares while resident sat on the toilet. The only care Staff D provided was to wipe the catheter tubing and dry the tubing. Staff D failed to cleanse the abdominal folds, the groin area, the penis or the buttocks. Staff D placed a brief back on the resident and assisted to change his shorts and assisted Resident #5 back to his recliner chair in his room. 2.) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident needed extensive assist of 2 staff with transfers, personal hygiene, dressing and toileting. The MDS indicated the resident had an indwelling catheter. Review of the Care Plan dated 8/30/22 Resident #6 had a catheter related to incontinence. The interventions directed staff to provide catheter cares twice a day and as needed. During an observation on 9/21/22 at 7:40 AM with Staff H, CNA and Staff I, CNA provided catheter cares to Resident #6. The resident had bowel movement on buttocks. Staff I assisted to clean the buttocks and then rolled the resident onto back to provide catheter cares. Resident #6 had continued to have bowel movement when providing cares to the groin area. Staff rolled the resident onto right side and proceeded to wipe buttocks in back to front motion. Staff I dried the area wiping the same direction. During an interview on 9/21/22 at 11:03 AM with the Director of Nursing regarding catheter cares she stated she would expect staff to follow the standard of care process. They should change surface of wipe and wipe front to back and wipe the bacteria away from the person and cleanse the tubing. The areas to be cleansed would the groin, the penis and head of the meatus but adding cleaning the tubing. The facility provided a policy titled Foley Catheter Care undated which directed perineal care is to be given twice daily in the morning and evening. Perineal care consists of washing the perineal area and catheter with clean, warm, soapy water or disposable cleansing wipes followed by rinsing the area.

Based on record review, staff interview and facility policy review the facility failed to proovide a dignified dining experience for 1 of 3 residents reviewed, (Resident #3). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #3 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognitive status. The resident needed extensive assist of 2 staff with transfers, personal hygiene, dressing and toileting. The MDS indicated the resident required supervision and set up help for eating. Review of the Incident Report dated 4/30/22 revealed staff reported the resident was seen seated at the dining room table. Per a Certified Nursing Assistant (CNA) report another CNA made statements to resident, stated to the resident I don't like you The CNA made comments about resident being mean. The CNA stood at the residents table and stated Hit me multiple times. The resident stated he was not going to hit her. The CNA stated that's right you can't because you had a stroke. The Termination Worksheet dated 5/20/22 for Staff A, CNA revealed she was terminated due to misapproriate communciation with resident which resulted in company self report. Last day worked May 9; suspension followed, termed May 9 by Administrator by phone with Human Resources present. During an interview on 9/15/22 at 12:36 PM with Staff B, CNA stated the incident occurred during the evening meal on 4/30/22 around 5:00 PM. Staf A encouraged Resident #3 to hit her and when he said no she said yeah it's because you have had a stroke and can't use your arms. It was not a very nice interaction. Tone of her voice was very aggressive and mean. She was going back and forth between two tables assisting two other ladies while they were eating. There were comments back and forth while he was sitting at the table about him taking a shower. During an interview on 9/19/22 with Staff C, Dietary Aide stated was working in the dining room when the incident with Resident #3 occurred. Staff A, CNA made rude comments to the resident. I can not remember specifically what she said to the reident. I know Staff A from school and she told me about it afterwards. She stated she was talking to Resident #3 and made rude comments and got fired for it. She was across the table from him so she was kind of loud. Resident #3 looked offended by what she was saying . I didn't really hear what she was saying, I just knew it was rude by how she was saying it and how the resident looked. He looked upset. During an interview on 9/21/22 at 10:58 AM with the Director of Nursing (DON) she stated after completing the investigation and speaking with other staff members in the dining room and we concluded because of the things she mentioned in her statement and she admitted to arguing with Resident #3, but did not admit to making the statement. The facility did terminate her due to these statements. DON stated would expect staff to speak to residents in a respectful manner and would expect if there was a situation where they are uncomfortable they neeed to notify their supervisor and if residents has a raised voice they need to walk away from the situation. During an interview on 9/21/22 atg 1:12 PM with the Administrator she stated spoke to Staff A immediately and had her leave the building. Told her she would be suspended pending the investigation. She basically denied making the statements, we told her another staff member had overheard the conversation and had concerns. She basically denied. She stated Staff A had told her the interpretation was more of them joking around and then it rose to a level that was not acceptable. We terminated her over the phone for misconduct. It was an allegation of abuse. I felt after talking to other staff it was the one staff member based on the words on what she said and was very specific. I felt it did occur. The Administrator stated she does not expect the staff to talk down to resident and bring up the disability to them. It is very unacceptable I would expect staff to be respectful and compassionate to the residents.

Based on record review and staff interview the facility failed to provide appropriate care for a dementia resident for one out of one residents reviewed with physical aggressive behaviors, (Resident #1). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognitive status. The resident needed extensive assist of 1 staff with transfers, personal hygiene, dressing and toileting. The MDS failed to address Resident #1 had behaviors. The Progress Note on 9/9/22 at 1:18 AM stated Resident #1 in the evening at 9:50 PM had an incident of physical aggression, throwing items in his room and being physically aggressive towards staff. Resident #1 had a firm grip on a gait belt and refused to let go of it. Staff was able to administer as needed antianxiety medication. Staff noted skin tears on both upper and lower arms. Interventions such as snack, drink and toileting were ineffective. Resident #1 was still upset but did allow nurse to dress the wounds but unable to measure wounds at the time due to non-compliance. The Care Plan failed to address physical behaviors as a problem or interventions until 9/14/22 after the incident had occurred on 9/8/22. During an interview on 9/19/22 at 1:50 PM Human Resource brought an additional list of inservices assigned to Staff E, Certified Nursing Assistant with a due date 9/29/22. She stated they are assigned on hire and they have 30 days to complete initial training. The facility uses computer based training modules. Review of training for Staff E revealed Dementia Training: Behavior Management and Abuse Prevention, Activities for Persons with Dementia, Understanding Dementia, Philosophy of Care, Family and Staff Issues, Ethical Issues, Activities of Daily Living, Medications and Nutrition, and Communication had been assigned on 8/30/22 and Staff E had not completed the training. During an interview on 9/18/22 at 8:43 AM Staff E, Certified Nursing Assistant (CNA) stated on the evening of 9/8/22 Resident #1 was in the COVID unit and was agitated. Resident #1 was attempting to get out of the unit and he would not allow him out. He was attempting to stand up from his wheelchair and then became agitated and pulled a white board and a gait belt off the wall. Staff E stated he was unable to redirect the resident. He attempted to remove the gait belt and white board from the front of the resident and when he was unable to do this he went around the back of the resident. Staff E put his arms around the resident and used his arms to encircle him and held him down with his hands with the gait belt in both their hands. He then put the call light on and waited 5-7 minutes for help to arrive while holding the resident. He noticed there was blood from the skin tear. During an interview on 9/19/22 at 6:00 PM Staff F, Licensed Practical Nurse (LPN) stated Resident #1 was in COVID area and she heard staff yell for assist and when she got to the COVID area where his room was located he had gait belt in his hand wrapped around it and there was blood on his hands and on the floor. So with a lot of slow and patient redirection she got the gait belt out of his hands. Staff F left and got dressings for his hands and then dressed the skin tears on his hands. When she got done dressing his hands he said my arms hurt. Staff F stated she thought he had reopened other skin tears on his arm so we slowly took off his sweat shirt and both of his arms had several new skin tears. Another coworker nurse came to the room and he assisted with dressing the wounds. He assisted with one arm and she did the other arm for the dressing change. The CNA stated he had been throwing things and he does get agitated. During an interview on 9/19/22 at 7:08 PM Staff G, Registered Nurse (RN) stated he did not see what happened with Resident #1 on 9/8/22. When arrived to the room Staff E and Staff F stated he had an incident where he was very angry and he can become aggressive. Recently we had an incident for 4 hours where Resident #1 was trying to throw a coke bottle. Staff G stated you should not restrain a resident with behaviors. I would never try to hold him down. Staff could try to walk him sometimes that will help. Staff G stated he assisted the other nurse to put the dressings on. Resident #1 had calmed down by then. Staff F said she had administered a antianxiety medication. He was calm during the dressing change. Staff G stated he did the dressings on the right arm and there was one skin tear on the hand and 2 on the upper arm, front and back with 2 skin tears on the forearm. They were pretty large but we did not measure the skin tears. Staff F stated she would do it later. Staff G stated he would never restrain a resident with behaviors. During an interview on 9/21/22 at 11:03 AM the Director of Nursing (DON) stated she would not expect staff to physically hold a resident down if combative. She stated she was aware there were no interventions for physically aggressive behaviors on the care plan and stated she would expect the care plan to address behaviors for a resident with aggressive behaviors. The DON stated she was aware Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Administrator on 9/21/22 at 1:12 PM she stated the care plan should have interventions to address the behaviors for combative residents. The facility provided a standards and processes dated 2/20/16 titled Behaviors-Disruptive which directed the process when a disruptive behavior is noted staff should consult care plan for interventions specific to the resident. Update as warranted.

Based on observation, record review, and staff interview, the facility failed to lock the med carts prior to the administration of medication and failed to prime the needle of the [MEDICATION(S)] Kwikpen prior to the administration of insulin to one resident (Resident #38) in three different observations. The facility reported a census of 56 residents. Findings include: Observations during the medication pass task revealed the nurses failed to lock the medication cart prior to the administration of medications at the following dates and times: 6/15/21 at 6:50 AM, Staff A, LPN did not lock before she left unattended 6/15/21 at 7:10 AM, Staff A, LPN did not lock before she left the medication cart unattended in the hallway, entered a resident's room, and closed the door to check the resident's blood sugar. 6/15/21 at 7:20 AM, Staff A, LPN did not lock before she entered the resident's room to administer medications 6/15/21 at 7:37 AM, Staff B, LPN, dialed [MEDICATION(S)] Kwik pen to 15 units, placed the needle on pen, did not prime the needle, did not lock med cart, left one of the drawers partially open, and walked down the hall to the resident's room at the end of the hall. She administered the insulin without priming the needle. 6/15/21 at 7:42 AM, Staff B, LPN did not lock cart before she walked down the hall to the dining room to administer medications. 6/15/21 9:28 AM, Staff B, LPN did not lock before leaving it. 6/15/21 at 11:35 AM, Staff B, LPN removed a [MEDICATION(S)] Kwik pen from med cart (which had already been unlocked), attached the needle, did not prime needle, dialed pen to 10 units, used AHR, did not lock med cart, walked all the way to end of hall to the resident's room and administered the insulin without priming the needle. 6/16/21 at 7:15 AM, Staff C, RN removed a [MEDICATION(S)] Kwikpen from medication cart and locked the cart (pen dated as opened 6/11/21), entered the resident's room, placed a needle on pen, dialed to 15, however, did not prime needle first before she administered the insulin. A review of the patient information insert from the manufacturer for [MEDICATION(S)] Kwik Pen (copyright 2020) revealed the following: Instructions for priming your pen a. Prime before each injection b. Priming your pen means removing the air from the needle and the cartridge that may collect during normal use and ensures that the pen is working correctly c. If you do not prime before each injection, you may get too much or too little insulin. d. To prime your pen, turn the dose knob to select 2 units In an interview on 6/16/21 at 8:42 AM, Staff C, RN reported she should lock the medication cart before she prepared to administer medications and before she gave insulin with a flex pen, she would clean her hands, clean the pen, and clean the site with alcohol. In an interview on 6/16/21 at 9:16 AM, Staff G, RN reported that she should lock the medication cart before she prepared to administer medications, and before she gave insulin with a flex pen, she would check the orders on the MAR (medication administration record), dial the pen to the dose ordered, wipe area with alcohol and administer dose ordered. In an interview on 6/16/21 at 3:11 PM, the DON (director of nursing) reported she would expect the nurses to lock the medication cart before they leave to administer medications and would expect the nurses to follow the guidelines, which say that they are going to prep the pen as per manufacturer's guidelines and standards of care. A review of the facility policy dated 2021 titled, Assisting with Insulin Pens, documented the following: a. Prime the pen by releasing a few drops (2 units) of insulin into the air to remove any air bubbles. If nothing comes out of the needle, the needle may not be screwed on properly, or the pen may not have enough insulin. -

Based on record review and staff and family interviews, the facility failed to supervise Resident #1 to ensure against hazards from self and the Health Facility Supervisor failed to revise and supervise the written health care plan to ensure the resident ' s needs are met with the use of call light. The staff person left the resident unattended to obtain additional assistance to transfer the resident to the bed. The resident did not have access to a call light and attempted to transfer self to the bed. The resident fell and fractured the left hip. The sample consisted of 4 residents and the facility reported a census of 66 residents. Findings Include: 1. The MDS (Minimum Data Set) assessment with a reference date of 11/05/2012 reported Resident #1 had moderately impaired cognitive skills for daily decision making, transferred from one surface to another with extensive assistance of two staff, had [DIAGNOSES REDACTED]. The Care Plan identified Resident #1 had impaired functional mobility and needed assist with transferring and ambulating with the goal of having no falls with injury requiring hospitalization initiated 05/12/2012. The Care Plan directed staff to transfer the resident with the assistance of two staff, do a full assessment if the resident fell , use a wheel chair for distances and supply an elevated toilet seat in the bathroom. The Care Plan documented the resident had a bed alarm and wheel chair alarm, but were discontinued. The care plan did not direct staff to ensure the resident had access to the call light The physician's orders [REDACTED]. The Progress Notes revealed on 12/18/2012 at 7:45 p.m. a CNA (Certified Nurse's Aide) summoned Staff B, LPN (Licensed Practical Nurse) to Resident #1's room. Staff B noted the resident's wheel chair tipped over to the left with the resident lying on the floor, alert and oriented and complained of pain to the left upper and lower extremities with skin tears to the left elbow, forearm, left leg and an abrasion and bruise to the forehead. Staff B assessed the resident and reported no signs or symptoms of fracture. The resident stated "they didn't come back so I tried to go to bed", and resident unable to reach call light on bed. Staff B reported the accident to the physician and family and placed the call light within reach. The Fall Investigation dated 12/18/2012 at 7:45 p.m. reported Resident #1 fell during an attempted self-transfer from wheel chair, the call light was not on. Staff A left the resident to summon help to assist with the transfer, and before Staff A returned, within fifteen minutes, the resident fell from the wheel chair. Care Plan changes: encourage staff to put the resident to bed as soon as possible after supper meal, or encourage resident to remain in living room for a short while. The Major Injury Determination Form dated and signed by the physician on 12/19/2012, indicated the resident sustained [REDACTED]. Hospital Records included: Emergency Department: 12/19/2012 Radiology: Suspect subcapital femoral neck fracture History and Physical: Patient fell yesterday afternoon, now with left hip pain. Patient tried to get to his walker and reports the wheel chair got in the way. The assessment revealed acute traumatic left hip fracture, history of osteopenia with radiographic findings on prior x-rays indicating osteopenia, accidental fall, hypertension, major depression, dementia and chronic obstructive pulmonary disease. Discharge Summary: discharged to Heritage Manor Nursing Home. Procedure: Bipolar endoprosthesis (repair) of the left hip on 12/19/2012. During a phone interview on 01/14/2013 at 3:15 p.m., Staff A (Certified Nursing Assistant) reported working at the facility part time and worked the evening Resident #1 fell . Staff A revealed the resident remained in the dining room (dining room, assisted dining room, lounge and chapel are all combined areas) for an evening activity following supper on 12/18/2012. Staff C (activities person) returned the resident to his/her room. Staff A assisted the resident with evening cares and left the resident to find Staff D to assist with transferring the resident from the wheel chair to the bed. When Staff A exited the resident's room, he/she observed another resident next door requiring immediate assistance. Staff A returned to Resident #1's room within fifteen minutes and found the resident on the floor. Staff A observed the call light on the bed, not within reach. Staff A assumed he/she failed to give the resident the call light since it lay on the bed. Usually, Staff A left the call light in the resident's hand, but intended to return immediately. Now staff uses walkie talkies to communicate with one another. During an interview on 01/14/2013 at 3 p.m., Staff B reported working the evening shift on 12/18/2012, when Resident #1 fell at approximately 7:30 p.m. When Staff B heard a call for help, he/she entered Resident #1's room and observed the resident on the floor with Staff A present. The resident lay parallel to the bed with the wheel chair nearby and the tray table near the head. The resident stated he/she wanted to go to bed, and staff said they'd be right back; they didn't come, so he/she tried to go to bed. Staff B observed the call light looped on the bed with the button between the wall and bed mattress, covered with blankets. The resident had skin tears but no signs or symptoms of fracture. During an interview on 01/14/2013 at 4:20 p.m., Staff C (activities person) reported working the evening of 12/18/2012. Resident #1 remained in the living room after supper for the activity. Staff C returned the resident to the room and thought he/she looped the call light through the wheel chair arm rest. During an interview on 01/15/2013 at 9:15 a.m., Staff E (CNA) reported working the day shift for three years. Staff E worked 12/19/2012, the day after Resident #1 fell , assisted another staff to transfer the resident from the bed to wheel chair for breakfast. The resident had difficulty bearing weight and complained of pain. Staff E reported the findings to the nurse, assisted in placing the resident back to bed until the ambulance came to transfer the resident to the hospital. Staff E said the resident could use the call light if placed in his/her hand, or pinned to the shirt. During an interview on 01/15/2013 at 9:00 a.m., Staff F, CNA reported working the evening Resident #1 fell . Staff F heard Staff A's call for help, and Staff F observed the resident on the floor with skin tears to the arm and leg. Staff F didn't observe the call light but reported the resident could use it if within reach. During an interview on 01/15/2013 at 8:00 a.m., Staff G (CNA) reported working the night shift after Resident #1 fell . The resident complained of pain in the left hip with repositioning that night, though he/she slept well. Staff G reported the findings to the night shift nurse. Staff G indicated the resident did use the call light on the night shift. During an interview on 01/15/2013 at 4:15 p.m. Staff H (CNA) reported working second shift for over three years. Resident #1 had anxious behaviors and therefore Staff H put the resident's call light on and remained with the resident while waiting for staff to assist with the transfer from bed to wheel chair. Staff H had observed the resident attempt to self- transfer in the past, and the resident could put the call light on. During an interview on 01/14/2013 at 4:10 p.m., Staff I, (CNA) reported working at the facility [AGE] years. Staff I indicated the resident had no attempts to self- transfer, rarely attended activities and preferred to go to bed right after supper and could use the call light. Staff I stated it acceptable to leave Resident #1 in the room in the wheel chair with the call light for short amounts of time. Now staff use walkie talkies to summon help. During an interview on 01/15/2013 at 2 p.m., Staff J (LPN) reported Resident #1 could remain in the room in the wheel chair, and he/she never observed the resident use the call light. During an interview on 01/15/2013 at 2:15 p.m., Staff K (LPN) reported working second and third shift. Resident #1 had anxious behaviors and could use the call light and frequently requested an antianxiety or pain pill. During an interview on 01/15/2013 at 10:00 a.m., Staff L, LPN reported working the day shift, assessed the resident on 12/19/2012 prior to staff assisting the resident from the bed to wheel chair and observed no signs or symptoms of fracture. Staff L had never observed the resident use the call light, had alarms upon admission but discontinued them. The resident told Staff L tried to put self to bed. During an exit on 12/15/2013 at approximately 3 p.m., the DON (Director of Nursing) reported staff knew to give the call lights were to be within reach, and they review it at every CNA meeting. During a phone interview on 01/15/2013 at 10:30 a.m., the resident's family member expressed Resident #1's desire to eat and go to bed. The resident used the call light, and staff hooked it close by.

Based on clinical record review and staff interviews, the facility failed to ensure each resident received adequate supervision and implementation of assistive devices to prevent accidents and failed to implement the health care plan as directed for one of five residents reviewed with a history of falls. (Resident #5) The facility census was 67 residents. Findings include: 1. A facility care plan dated 12/20/2011, documented Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had some cognitive deficit, with a BIMS (Brief Interview For Mental Status) score of 7 (out of a total of 15). The MDS assessment described the resident as independent with bed mobility, transferring, ambulating in his/her room and corridor and eating. The resident required supervision with dressing, toilet use, personal hygiene and extensive assistance with bathing. A physician progress notes [REDACTED]. The notation indicted the resident frequently had falls, likely related to a decrease in his/her vision and a referral was made to an ophthalmologist. The nurse progress notes dated 3/13/12, documented staff found the resident sitting on the floor along side his/her bed at 6:00 p.m. The resident indicated he/she had been dizzy at the time. Documentation indicated the resident experienced a second fall on 3/15/2012 at 12:31 a.m., and was sent to the emergency room for an evaluation. On 3/15/2012 at 3:30 p.m., the resident returned to the facility with physician orders. The emergency room Treatment Report dated 3/15/2012 directed staff to start new medications (Meclizine (for dizziness) 25 milligrams every 6 hours; QID and Celebrex (anti-inflammatory medication) 100 milligrams each day; continue prior medication orders, all transfers to be assisted and to obtain " bed alarm " for patient. The document indicated the resident ' s [DIAGNOSES REDACTED]. The nurse progress notes dated 4/8/12 at 10:15 p.m., documented staff heard a thump and found the resident lying on the floor on his/her left side with pants around his/her ankles and complained of pain in the left groin/left thigh. The nurse ' s notes indicated staff sent the resident to the emergency room at 10:20 p.m. The x-ray reports dated 4/9/2012 indicated the resident sustained [REDACTED]. On 4/10/2012 at 1:58 p.m., Staff C, Certified Nurse Aide, was interviewed and stated she was assigned to the resident the evening of 4/8/2012. Staff C stated when she assisted the resident to bed, she noted an alarm cord on the resident's bed, but did not see an alarm box. Staff C stated nothing they read indicated the resident had an alarm. Staff C did not apply an alarm and stated things change day to day and the prior shift did not report anything about an alarm either. Staff C indicated she referred to a facility "hall sheet" dated 11/23/2011. Information for the resident included anti roll back breaks, but did not indicate the use of a bed alarm. On 4/10/2012 at 3:47 p.m., Staff B, Licensed Practical Nurse, was interviewed and stated she tried to update the "hall sheets" as quickly as she could and attempted to complete them on a weekly basis. Staff B stated she did not and have not been changing the date, and indicated the date of 11/23/2011, would not have been correct. Staff B stated they were aware the resident had a bed alarm but was not aware it was not added to the "hall sheet". Staff B stated she would recommend to staff that they look and check the "hall log books" before relying on the "hall sheets". Staff B did state she added the bed alarm for the resident to the hall sheet on 4/9/2012 or one day after the fall. The DON (Director of Nursing) was interviewed on 4/11/2012 at 9:09 a.m. The DON stated the hall sheet is updated one time per week and impossible to do each day. The DON stated the care plans are accessible to nursing assistants (located in each resident ' s chart). The DON stated the " hall book " contained a list of residents on the walk to dine program, snack list, residents with alarms, diets and a log of intake and output. The DON stated she would have expected the nursing assistants to be oriented to the nurse aide book and alarm sheet.