Every finding on record at Lake Mills Care Center

Based on clinical record review, policy review, resident and staff interviews, the facility failed to separate any alleged abuser from a resident for 1 of 4 residents reviewed (Resident #1). Resident #1 had a bruise on the right inner arm. The facility reported a census of 49 residents.On July 2, 2026, the facility staff self-reported the incident to the Department of Inspections, Appeals and Licensing. The facility staff corrected the deficient practice on July 6, 2026 by taking the following step:Action Plan:Facility staff were re-educated on:*Abuse-Different types of abuse, reporting time frames, and who to report to when they suspect abuse.*Re-educated on resident rights and the right to refuse.*New staff will be educated prior to their first shift.Finding include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe impaired cognitive decisions and sometimes has the ability to be understood and understand others, and no behaviors or resisting of cares. Resident #1 required substantial to maximal assistance with oral and personal hygiene and was dependent on toileting hygiene, upper and lower body dressing and transfers. The MDS included diagnoses of Alzheimer's disease, Non-Alzheimer's Dementia, heart failure, anxiety and depression.The Care Plan Focus target dated 8/18/26, indicated Resident #1 had a history of rejecting care, medications, medical advice, increased confusion, and being accusatory of staff and then recanting these statements related to Alzheimer's and dementia. Interventions include: adjust grooming/bathing schedule as resident desires, at times, resident may become combative during routine care, not wanting to be cleaned, dressed, gotten up for the day, assisted with oral/personal hygiene. If/when resident becomes combative during routine care, leave resident in a safe position, call light within reach and re-approach at a later time or with alternative staff.An Incident Report dated 7/2/26 at 9:55 PM, documented late entry, notified of allegation of abuse with investigation to follow. Bruise to the right inner forearm 2.5 centimeters by 1.5 centimeters dark purple with petechial (tiny, round, flat red, purple, or brown spots) appearance.The General Progress Note dated 7/2/26 at 9:55 PM, documented an alleged report of abuse, Director of Nursing (DON) placed a phone call to this writer with alleged abuse concerns today 7/2/26 at approximately 11:15 AM. Initial state report submitted by the facility Administrator.The Communication with Resident at 7/2/26 at 11:07 PM, documented this nurse was instructed to conduct a head to toe assessment on Resident #1 due to an alleged report of physical abuse. This nurse entered the resident's room and greeted the resident. The resident was awake and smiling and stated Hi, oh there you are. The nurse asked the resident if she had a good day and the resident responded Oh yes . The nurse asked if anybody was rude or mean to the resident and the resident stated Oh, just one person. The nurse asked what happened? The resident proceeded to lift her right arm up and show the nurse a bruise. Bruise measured 2.5 centimeters by 1.5 centimeters. It is dark purple in color and has a petechial appearance. The nurse asked how that happened and the resident stated I do not know, she just got really mad at me, it was awful. The nurse asked if the resident knew who that person was and the resident stated Yes I do, I wish I could remember her name. The nurse asked if she had seen her before and the resident stated Yes many times. The nurse asked if the resident remembered what this person looked like and she responded over weight and kind of raggedy. The nurse asked the resident if she felt safe now and the resident responded Yes.The Investigation Summary dated 7/10/26, with date of incident being 7/2/26, that on 7/2/26 at 8:55 PM, the Director of Nursing received a phone call from Staff A, Certified Nursing Assistant (CNA) that Staff B, CNA, was rough with Resident #1 when providing cares today while getting Resident #1 up. Staff A, stated that Staff B, was rough rolling Resident #1 in bed and when providing peri cares, transfers, and grooming. Staff A went on to say that Staff B, pulled Resident #1 arm straight to get it through her shirt. Resident #1 began to holler out and Staff B, covered Resident #1 mouth with Staff B hand. A head to toe assessment on Resident #1 was completed and during the assessment a 2.5 centimeter by 1.5 centimeter dark purple discoloration was noted to the right forearm. Resident #1 is alert and orientated to person and place. Resident #1 is pleasantly confused with conversation but can be irritable and at times combative with care. Does not like to get up and out of bed. Preference is to remain in her bed and requires physical assistance with bed mobility, hygiene, peri cares and mobility. She transfers via Hoyer lift and two assists and is non ambulatory. On 8/14/26 at 12:30 PM, Staff C, Licensed Practical Nurse (LPN) was not aware of the incident that occurred on 7/2/26. Staff C, explained that if there is any type of allegation of abuse or accusations of abuse, staff are to notify the Director or Nursing or Administrator right away and if Staff C would of known about the allegation of abuse with Resident #1, Staff C would have separated the employee from the resident and other residents in the facility.On 8/14/26 at 4:00 PM, revealed Resident #1 sitting in a wheelchair in her room with a hoyer sling underneath her. Resident #1 explained that Staff B, CNA, was rough and grabbed her right arm and pulled it through her shirt and caused a bruise to my right inner arm and is fearful and scared of Staff B, CNA. Resident #1 proceeded to show where the bruise was on her right arm, for which no purple/red area was present. On 8/14/26 at 3:00 PM, the facility Director of Nursing confirmed and verified that the facility failed to follow the policy/procedure of Abuse Prevention by not separating the employee from the resident or other residents in the facility and that it is an expectation that staff follow the policy for separating the residents from the accused employee.On 8/18/26 at 11:30 AM, Staff D, LPN, explained that a note was left at the front nurses station for her to call the Director of Nursing right away when starting her shift on 7/2/26 from 10:00 PM-6:00 AM. Staff D was told by the Director of Nursing that an allegation of physical abuse had occurred approximately 11:15 AM, that morning and if Staff D would go and do a head-to-toe assessment on Resident #1. Staff D, stated that Resident #1 was lying in bed when she went into the room. Staff D explained to Resident #1 that she would like to do an assessment on Resident #1. Resident #1 held up her right arm and said oh you mean this area on my right arm, that a staff member grabbed and pulled my arm through my shirt and caused this. Staff D stated that she went and measured the area and reassured Resident #1 that no one would hurt her. Staff D, stated that Resident #1 did not remember anything else about the incident.On 8/18/26 at 1:30 PM, Staff A, CNA, explained that on 7/2/26 approximately 11:15 AM, Staff A and Staff B were assisting with cares for Resident #1. Staff B, said I have a bone to pick with Staff C, LPN, and I am pissed Staff B explained that Resident #1 never wants to get out of bed. Staff B, said to Resident #1, you are to get up. Resident #1 was holding super tight on to her blanket and said no. Staff B said I am not dealing with this and yanked the blanket violently from the resident's hands and threw the blanket across the room to the corner. Resident #1 shouted get out of my room. Staff B said nope. Resident #1 yelled again get out of my room and pointed to Staff B. Staff B then grabbed Resident #1 right wrist and slammed it against Resident #1 chest. Resident #1 had soiled herself and rolls better toward Resident #1 left side. Staff B rolled Resident #1 violently onto the left side of Resident #1 and cleaned her up harshly where Resident #1 was screaming ouch, ouch, ouch and stop. Staff B, responded to Resident #1 by stating if you want to be lazy and shit and piss yourself rather than use a bed pan then this is what we are going to do. Resident #1 began to swear at Staff B. Staff B then covered Resident #1 mouth with Staff B hand with enough force to press Resident #1 head into the pillow and screamed you are fucking with the wrong person, you will shut up and be quiet as Staff C is the reason I have to do this'. Staff B, then uncovered Resident #1's mouth and said you will not continue screaming, I am the wrong one today. Resident #1 continued to holler out. Staff B, told Resident #1 to knock it off. Staff A and Staff B were attempting to put on Resident #1 shirt and Resident #1 was not extending her arms. Staff B then extended Resident #1 right arm, forcing the shirt on, during this, Resident #1 was saying ouch, ouch, ouch,. Staff B, then yanked her arm up with Resident #1 screaming, and forced her arm into the sleeve. Resident #1 was not combative at all when Staff A and Staff B went into the room. Staff A, acknowledged that the Director of Nursing was not aware of the incident until 8:55 PM, that evening, after Staff A and Staff B finished their shift. Staff A, acknowledged that the expectation of the facility is if there is an allegation of abuse against an employee to separate the employee from the resident and other residents in the facility. Staff A, confirmed and verified that they had the Dependent Adult Abuse training. On 8/18/26 at 8:00 AM, the facility Administrator acknowledged that all staff are expected to report any allegations of abuse or accusations to the Abuse Coordinator right away and separate the resident from the alleged abuser according to facility policy/procedure.Review of the Patient Protection Guidelines for Abuse Prevention, Reporting and Investigation dated 9/2025, residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, family members friends or other individuals. All allegations of Resident abuse should be reported immediately to the charge nurse. Upon receiving a report of an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from the resident through the following or a combination of the following, (1) suspend the employee, (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility and in rare instances (3) separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents.

Based on observation, clinical record review, facility investigation, resident and staff interview along with review of policy and procedures, the facility failed to ensure all alleged violations of abuse involving mistreatment, neglect, verbal, and physical abuse, were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for 1 of 4 resident reviewed. (Resident #1). The facility reported a census of 49 residents.On July 2, 2026, the facility staff self-reported the incident to the Department of Inspections, Appeals and Licensing. The facility staff corrected the deficient practice on July 6, 2026 by taking the following step:Action Plan:Facility staff were re-educated on:*Abuse-Different types of abuse, reporting time frames, and who to report to when they suspect abuse.*Re-educated on resident rights and the right to refuse.*New staff will be educated prior to their first shift.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe impaired cognitive decisions and sometimes has the ability to be understood and understand others, and no behaviors or resisting of cares. Resident #1 required substantial to maximal assistance with oral and personal hygiene and was dependent on toileting hygiene, upper and lower body dressing and transfers. The MDS included diagnoses of Alzheimer's disease, Non-Alzheimer's Dementia, heart failure, anxiety and depression.The Care Plan Focus target dated 8/18/26, indicated Resident #1 had a history of rejecting care, medications, medical advice, increased confusion, and being accusatory of staff and then recanting these statements related to Alzheimer's and dementia. Interventions include: adjust grooming/bathing schedule as resident desires, at times, resident may become combative during routine care, not wanting to be cleaned, dressed, gotten up for the day, assisted with oral/personal hygiene. If/when resident becomes combative during routine care, leave resident in a safe position, call light within reach and re-approach at a later time or with alternative staff.An Incident Report dated 7/2/26 at 9:55 PM, documented late entry, notified of allegation of abuse with investigation to follow. Bruise to the right inner forearm 2.5 centimeters by 1.5 centimeters dark purple with petechial (tiny, round, flat red, purple, or brown spots) appearance.The General Progress Note dated 7/2/26 at 9:55 PM, documented an alleged report of abuse, Director of Nursing (DON) placed a phone call to this writer with alleged abuse concerns today 7/2/26 at approximately 11:15 AM. Initial state report submitted by the facility Administrator.The Communication with Resident at 7/2/26 at 11:07 PM, documented this nurse was instructed to conduct a head to toe assessment on Resident #1 due to an alleged report of physical abuse. This nurse entered the resident's room and greeted the resident. The resident was awake and smiling and stated Hi, oh there you are. The nurse asked the resident if she had a good day and the resident responded Oh yes . The nurse asked if anybody was rude or mean to the resident and the resident stated Oh, just one person. The nurse asked what happened? The resident proceeded to lift her right arm up and show the nurse a bruise. Bruise measured 2.5 centimeters by 1.5 centimeters. It is dark purple in color and has a petechial appearance. The nurse asked how that happened and the resident stated I do not know, she just got really mad at me, it was awful. The nurse asked if the resident knew who that person was and the resident stated Yes I do, I wish I could remember her name. The nurse asked if she had seen her before and the resident stated Yes many times. The nurse asked if the resident remembered what this person looked like and she responded over weight and kind of raggedy. The nurse asked the resident if she felt safe now and the resident responded Yes.The Investigation Summary dated 7/10/26, with date of incident being 7/2/26, that on 7/2/26 at 8:55 PM, the Director of Nursing received a phone call from Staff A, Certified Nursing Assistant (CNA) that Staff B, CNA, was rough with Resident #1 when providing cares today while getting Resident #1 up. Staff A, stated that Staff B, was rough rolling Resident #1 in bed and when providing peri cares, transfers, and grooming. Staff A went on to say that Staff B, pulled Resident #1 arm straight to get it through her shirt. Resident #1 began to holler out and Staff B, covered Resident #1 mouth with Staff B hand. A head to toe assessment on Resident #1 was completed and during the assessment a 2.5 centimeter by 1.5 centimeter dark purple discoloration was noted to the right forearm. Resident #1 is alert and orientated to person and place. Resident #1 is pleasantly confused with conversation but can be irritable and at times combative with care. Does not like to get up and out of bed. Preference is to remain in her bed and requires physical assistance with bed mobility, hygiene, peri cares and mobility. She transfers via Hoyer lift and two assists and is non ambulatory. On 8/14/26 at 12:30 PM, Staff C, Licensed Practical Nurse (LPN) was not aware of the incident that occurred on 7/2/26. Staff C, explained that if there is any type of allegation of abuse or accusations of abuse, staff are to notify the Director or Nursing or Administrator right away and if Staff C would of known about the allegation of abuse with Resident #1, Staff B would have been sent home and an investigation would have been started.On 8/14/26 at 4:00 PM, revealed Resident #1 sitting in a wheelchair in her room with a hoyer sling underneath her. Resident #1 explained that Staff B, CNA, was rough and grabbed her right arm and pulled it through her shirt and caused a bruise to my right inner arm and is fearful and scared of Staff B, CNA. Resident #1 proceeded to show where the bruise was on her right arm, for which no purple/red area was present. On 8/14/26 at 3:00 PM, the facility Director of Nursing confirmed and verified that the facility failed to report the allegation of abuse to the department of inspection and appeals and licensing (DIAL) with in the 2 hour time frame and it is an expectation of the staff to notify the Director of Nursing or Administrator upon an accusation or allegation of abuse. On 8/18/26 at 11:30 AM, Staff D, LPN, explained that a note was left at the front nurses station for her to call the Director of Nursing right away when starting her shift on 7/2/26 from 10:00 PM-6:00 AM. Staff D was told by the Director of Nursing that an allegation of physical abuse had occurred approximately 11:15 AM, that morning and if Staff D would go and do a head-to-toe assessment on Resident #1. Staff D, stated that Resident #1 was lying in bed when she went into the room. Staff D explained to Resident #1 that she would like to do an assessment on Resident #1. Resident #1 held up her right arm and said oh you mean this area on my right arm, that a staff member grabbed and pulled my arm through my shirt and caused this. Staff D stated that she went and measured the area and reassured Resident #1 that no one would hurt her. Staff D, stated that Resident #1 did not remember anything else about the incident.On 8/18/26 at 1:30 PM, Staff A, CNA, explained that on 7/2/26 approximately 11:15 AM, Staff A and Staff B were assisting with cares for Resident #1. Staff B, said I have a bone to pick with Staff C, LPN, and I am pissed Staff B explained that Resident #1 never wants to get out of bed. Staff B, said to Resident #1, you are to get up. Resident #1 was holding super tight on to her blanket and said no. Staff B said I am not dealing with this and yanked the blanket violently from the resident's hands and threw the blanket across the room to the corner. Resident #1 shouted get out of my room. Staff B said nope. Resident #1 yelled again get out of my room and pointed to Staff B. Staff B then grabbed Resident #1 right wrist and slammed it against Resident #1 chest. Resident #1 had soiled herself and rolls better toward Resident #1 left side. Staff B rolled Resident #1 violently onto the left side of Resident #1 and cleaned her up harshly where Resident #1 was screaming ouch, ouch, ouch and stop. Staff B, responded to Resident #1 by stating if you want to be lazy and shit and piss yourself rather than use a bed pan then this is what we are going to do. Resident #1 began to swear at Staff B. Staff B then covered Resident #1 mouth with Staff B hand with enough force to press Resident #1 head into the pillow and screamed you are fucking with the wrong person, you will shut up and be quiet as Staff C is the reason I have to do this'. Staff B, then uncovered Resident #1's mouth and said you will not continue screaming, I am the wrong one today. Resident #1 continued to holler out. Staff B, told Resident #1 to knock it off. Staff A and Staff B were attempting to put on Resident #1 shirt and Resident #1 was not extending her arms. Staff B then extended Resident #1 right arm, forcing the shirt on, during this, Resident #1 was saying ouch, ouch, ouch,. Staff B, then yanked her arm up with Resident #1 screaming, and forced her arm into the sleeve. Resident #1 was not combative at all when Staff A and Staff B went into the room. Staff A, acknowledged that the Director of Nursing was not aware of the incident until 8:55 PM, that evening, after Staff A and Staff B finished their shift. Staff A, acknowledged that the facility policy/procedure is to notify the charge nurse right away if suspected allegations of abuse and Staff A, had the Dependent Adult Abuse training. On 8/18/26 at 8:00 AM, the facility Administrator acknowledged that all staff are expected to report any allegations of abuse or accusations to the Abuse Coordinator right away and that the allegation needs to be reported within the 2 hour time frame.Review of the Patient Protection Guidelines for Abuse Prevention, Reporting and Investigation dated 9/2025, residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, family members friends or other individuals. All allegations of Resident abuse should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. Report all allegations of Resident abuse to the Iowa Department of Inspection and Appeals and Licensing immediately and not later than two (2) hours.

Based on observation, clinical record review, facility self-report investigation, staff and resident interview, along with facility policy/procedure, the facility failed to assure residents were free from physical abuse for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 49 residents.On July 2, 2026, the facility staff self-reported the incident to the Department of Inspections, Appeals and Licensing. The facility staff corrected the deficient practice on July 6, 2026 by taking the following step:Action Plan:Facility staff were re-educated on:*Abuse-Different types of abuse, reporting time frames, and who to report to when they suspect abuse.*Re-educated on resident rights and the right to refuse.*New staff will be educated prior to first shift. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe impaired cognitive decisions and sometimes has the ability to be understood and understand others, no behaviors or resisting of cares. Resident #1 required substantial to maximal assistance with oral and personal hygiene and was dependent on toileting hygiene, upper and lower body dressing and transfers from staff. The MDS included diagnoses of Alzheimer's disease, Non-Alzheimer's Dementia, heart failure, anxiety and depression.The Care Plan Focus target dated 8/18/26, indicated Resident #1 had a history of rejecting care, medications, medical advice, increased confusion, and being accusatory of staff and then recanting these statements related to Alzheimer's and dementia. Interventions include: adjust grooming/bathing schedule as resident desires, at times, resident may become combative during routine care, not wanting to be cleaned, dressed, gotten up for the day, assisted with oral/personal hygiene. If/when resident becomes combative during routine care, leave resident in a safe position, call light within reach and re-approach at a later time or with alternative staff.An Incident Report dated 7/2/26 at 9:55 PM, documented late entry, notified of allegation of abuse with investigation to follow. Bruise to the right inner forearm 2.5 centimeters by 1.5 centimeters dark purple with petechial (tiny, round, flat red, purple, or brown spots) appearance.The General Progress Note dated 7/2/26 at 9:55 PM, documented an alleged report of abuse, Director of Nursing (DON) placed a phone call to this writer with alleged abuse concerns today 7/2/26 at approximately 11:15 AM. Initial state report submitted by the facility Administrator.The Communication with Resident at 7/2/26 at 11:07 PM, documented this nurse was instructed to conduct a head to toe assessment on Resident #1 due to an alleged report of physical abuse. This nurse entered the resident's room and greeted the resident. The resident was awake and smiling and stated Hi, oh there you are. The nurse asked the resident if she had a good day and the resident responded Oh yes . The nurse asked if anybody was rude or mean to the resident and the resident stated Oh, just one person. The nurse asked what happened? The resident proceeded to lift her right arm up and show the nurse a bruise. Bruise measured 2.5 centimeters (cm) by 1.5 centimeters. It is dark purple in color and has a petechial appearance. The nurse asked how that happened and the resident stated I do not know now she just got really mad at me, it was awful. The nurse asked if the resident knew who that person was and the resident stated Yes I do, I wish I could remember her name. The nurse asked if she had seen her before and the resident stated Yes many times. The nurse asked if the resident remembered what this person looked like and she responded over weight and kind of raggedy. The nurse asked the resident if she felt safe now and the resident responded Yes.General Progress Note dated 7/3/26 at 11:25 AM, documented, Resident is alert and oriented. She knows her name and town. She denies pain at this time. She refuses to get out of bed for breakfast this morning. She does have a bruise on her right forearm, measured at 2.5 x 1.5 centimeters, I inquired how she got that and she responded she hurt me was her response. Bruise in purple in color, not tender to touch. General Progress Note dated 7/4/26 at 3:45 PM, Skin assessment completed prior to resident getting up in a wheelchair to head out for coffee time. No new skin concerns noted upon assessment. Assessed bruise to the right inner forearm and asked the resident, how did you get this bruise?. Resident #1 stated, a lady here, she just brought me to a boil. General Progress Note dated 7/5/26 at 9:27 PM, Resident has been up per usual. Purple bruising to the right posterior forearm is intact. When the resident asked if it hurt she stated it was only tender when touched, otherwise she denies any pain. An Encounter note dated 7/6/26 and signed 7/7/26 at 3:20 PM, follow-up on incident, Resident #1 is seen on rounds today for evaluation of a reported bruise to her upper right extremity. The resident reported to the provider that another resident hit her in the right upper arm. However, nursing documentation indicates a 3 x 5 x 7.2 sonometer purple and yellow bruise to the right inner forearm. When staff asked how Resident #1 sustained the bruise the resident stated one of the ladies that works here, but was unable to to identify the individual and stated she had not seen her in a few days. On examination today, no significant bruising was appreciated by the provider, although the resident reported mild tenderness with palpation of the upper right arm. Right upper extremity contusion\ecchymosis.General Progress Note dated 7/6/26 at 1:45 PM, followed up with Resident #1 at this time regarding bruising to the right inner forearm. She pulled her sleeve up and allowed the writer to measure. Bruise measures 3.5cm X 7.2cm purple & yellow in color - bruise itself is scattered amongst her normal aging spots. Asked the resident if she was having any pain or discomfort; she said no then she touched the bruise area and said, oh this one, it doesn't hurt. Asked resident how did you get that bruise? She states, one of the ladies that works here but I don't know her name and haven't seen her in a few days. She is in pleasant spirits and readily communicates with this writer.General Progress Note dated 7/8/26 at 10:28 AM, This nurse went to assess the residents right arm. The resident stated, Who is asking? This nurse explained that I was her nurse today and I just needed to check on the area that hurt. The resident then pulled up her right sleeve and presented her right inner arm. This nurse lightly palpated the area and the resident states My arm really hurts. This nurse asked the resident what happened and the resident stated There was a lady and she hit me. This nurse apologized and provided the resident with reassurance that she is safe and that if anything happens again to please tell me so I can report it immediately.The Investigation Summary dated 7/10/26, with date of incident being 7/2/26, that on 7/2/26 at 8:55 PM, the Director of Nursing received a phone call from Staff A, Certified Nursing Assistant (CNA) that Staff B, CNA, was rough with Resident #1 when providing cares today while getting Resident #1 up. Staff A, stated that Staff B, was rough rolling Resident #1 in bed and when providing peri cares, transfers, and grooming. Staff A went on to say that Staff B, pulled Resident #1 arm straight to get it through her shirt. Resident #1 began to holler out at Staff B, and then Staff B proceeded to cover Resident #1 mouth with Staff B hand. A head to toe assessment on Resident #1 was completed and during the assessment a 2.5 centimeter by 1.5 centimeter dark purple discoloration was noted to the right forearm. Resident #1 is alert and orientated to person and place. Resident #1 is pleasantly confused with conversation but can be irritable and at times combative with care. Does not like to get up and out of bed. Preference is to remain in her bed and requires physical assistance with bed mobility, hygiene, peri cares and mobility. She transfers via Hoyer lift and two assists and is non ambulatory. On 8/18/26 at 1:30 PM, Staff A, CNA, explained that on 7/2/26 approximately 11:15 AM, Staff A and Staff B were assisting with cares for Resident #1. Staff B, said I have a bone to pick with Staff C, LPN, and I am pissed Staff B explained that Resident #1 never wants to get out of bed. Staff B, said to Resident #1, you are to get up. Resident #1 was holding super tight on to her blanket and said no. Staff B said I am not dealing with this and yanked the blanket violently from the resident's hands and threw the blanket across the room to the corner. Resident #1 shouted get out of my room. Staff B said nope. Resident #1 yelled again get out of my room and pointed to Staff B. Staff B then grabbed Resident #1 right wrist and slammed it against Resident #1 chest. Resident #1 had soiled herself and rolls better toward Resident #1 left side. Staff B rolled Resident #1 violently onto the left side of Resident #1 and cleaned her up harshly where Resident #1 was screaming ouch, ouch, ouch and stop. Staff B, responded to Resident #1 by stating if you want to be lazy and shit and piss yourself rather than use a bed pan then this is what we are going to do. Resident #1 began to swear at Staff B. Staff B then covered Resident #1 mouth with Staff B hand with enough force to press Resident #1 head into the pillow and screamed you are fucking with the wrong person, you will shut up and be quiet as Staff C is the reason I have to do this'. Staff B, then uncovered Resident #1's mouth and said you will not continue screaming, I am the wrong one today. Resident #1 continued to holler out. Staff B, told Resident #1 to knock it off. Staff A and Staff B were attempting to put on Resident #1 shirt and Resident #1 was not extending her arms. Staff B then extended Resident #1 right arm, forcing the shirt on, during this, Resident #1 was saying ouch, ouch, ouch,. Staff B, then yanked her arm up with Resident #1 screaming, and forced her arm into the sleeve. Resident #1 was not combative at all when Staff A and Staff B went into the room. Staff A, acknowledged that the Director of Nursing was not aware of the incident until 8:55 PM, that evening, after Staff A and Staff B finished their shift. Staff A, acknowledged that the facility policy/procedure is to notify the charge nurse right away if suspected allegations of abuse and Staff A, had the Dependent Adult Abuse training. On 8/14/26 at 11:45 AM, the facility Administrator acknowledged that all residents are to be free from any types of abuse, including physical injury.On 8/14/26 at 12:30 PM, Staff C, Licensed Practical Nurse (LPN), acknowledged that all residents are to be free from any types of abuse including physical.On 8/14/26 at 3:00 PM, the facility Director of Nursing confirmed and verified that all residents are to be free from any types of abuse including physical injury.On 8/14/26 at 4:00 PM, revealed Resident #1 sitting in her wheelchair in her room, and proceeded to show where the bruise was on the right inner arm. Observation revealed no bruise/red area was present.On 8/14/26 at 4:00 PM, Resident #1 explained that Staff B, CNA, grabbed her right arm and pulled the arm through the sleeve of her shirt and caused the bruise on the right inner arm and that Resident #1 is scared and fearful of Staff B. On 8/18/26 at 11:30 AM, Staff D, LPN, acknowledged that residents are to be free from any types of abuse including physical.The Patient Protection Guidelines for Abuse Prevention, Reporting and Investigation dated 9/25, stated that the purpose is to provide professional care and services in an environment that is free from abuse, neglect and exploitation. Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, friends, family or other individuals. Physical Abuse-includes hitting, slapping, pinching, and kicking.

Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to protect residents from pathogens when they stored food in an unhygienic manner and when they assisted residents with eating using unsanitary practices. The facility reported a census of 39. Findings include: The Minimum Data Set (MDS) for Resident #29, dated 02/07/2026, documented the following relevant diagnoses: Alzheimer's disease, Non-Alzheimer's dementia, Dysphagia Oropharyngeal Phase (difficulty swallowing). It documented the resident required substantial/maximal assistance in eating. The MDS for Resident #33, dated 03/06/2026, documented the following relevant diagnoses: Non-Alzheimer's dementia. It documented the resident required supervision or touch assistance while eating. The MDS for Resident #41, dated 03/10/2026, documented the following relevant diagnoses: Dysphagia Oral Phase (difficulty swallowing). It documented the resident required supervision or touch assistance while eating. The initial kitchen observation on 04/12/2026 at 12:25 PM revealed the following: A container of cheese slices was unsealed and open to the air of the refrigerator. A smell resembling spoiled milk was immediately noted upon entering the refrigerator. A sticky, smelly substance was observed covering a box of sealed yogurt containers. A direct observation of dining service on 04/13/2026 at 08:46 AM documented the following:At 08:59 AM Staff A, Certified Medication Aide (CMA), began assisting two residents with eating, identified as Resident #29 and Resident #33. Both residents were directly fed by Staff A, and no hand sanitation was witnessed leading up to feeding. During the observation starting at 08:59 AM and ending 09:24 AM Staff A frequently alternated from one resident to another, often using the same hand to feed both residents. At no point in time during the observation did Staff A wash or use hand sanitizer. At 09:06 AM Staff A took a straw wrapped in paper, unwrapped the item, and touched both drinking ends of the straw before giving it to a resident. The resident then used the straw to drink. At 09:23 AM Staff A picked up Resident #41's toast with ungloved hands, appeared to butter and jelly the toast, and then allowed Resident #41 to eat it. It was not until after this encounter that Staff A finally sanitized her hands. In an interview on 04/14/2026 at 01:28 PM with Staff A, CMA, she stated she frequently feeds two residents at the same time. She confirmed she is supposed to sanitize her hands between each bite a resident takes before moving on to another resident. She agreed she did not perform hand sanitation during the observation the day before. She was unsure if she could touch feeding surfaces that go directly in the mouth like a straw. She confirmed she used ungloved hands to pick up the resident's food and put jelly on it for the resident, but she was unsure if that was an acceptable practice. In an interview on 04/15/2026 at 10:22 AM with Staff B, CMA, she stated there are a number of things to avoid when assisting residents with eating. She stated it was not appropriate to touch a residents food with ungloved hands, not appropriate to touch the ends of straws or other surfaces a resident would eat or drink off of. She stated she can feed multiple residents at the same time but confirmed she was required to sanitize her hands in between each resident. In an interview on 04/15/2026 at 10:36 AM with Staff C, Licensed Practical Nurse (LPN), she confirmed staff members have to refrain from touching resident's food with their bare hands. She stated staff members should not feed multiple residents at the same time as it can be a hazard. She stated if you are feeding two residents at the same time you should sanitize your hands in between each bite given to a different resident. In an interview on 04/15/2026 at 10:38 AM with Staff D, Certified Nurses Aide (CNA), she stated it is never acceptable to directly handle a resident's food. If you have to touch a resident's food she stated you should wear gloves. She confirmed that when feeding two residents at the same time staff members must wash or sanitize their hands between each bite if you're alternating between residents. In an interview on 04/14/2026 at 03:15 PM with the Assistant Director of Nursing (ADON), she stated her expectation is that staff members do not directly handle a resident's food, that they use gloves if they have to. She confirmed her expectation is for staff members to sanitize their hands frequently during meal service and between each bite when assisting two residents with feeding. She stated it is her expectation staff members do not directly touch surfaces a resident may eat off of or drink from. Review of a facility provided document titled Food Handling, with a revision date of 10/2023, documented the following: 1. Employees must perform hand hygiene prior to handling food. 2. Ready-to-eat foods must not be touched with bare hands. 3. All foods prepared in operation must be covered and labeled with date of preparation prior to storage in refrigerators and freezers.4. Upon receiving, check products for condition, possible contamination, and temperature.

Based on record review, policy review and staff interviews, the facility failed to promptly identify, intervene and notify the provider of an acute change in a resident's uncontrolled pain following a fall on 7/21/25 for 1 of 3 residents reviewed (Resident #1). On 7/21/25 at 4:00 AM, Resident #1 had a witnessed fall. When the nurse assessed her, she reported pain to her leg but had range of motion to her legs. After transferring the resident to the bed, the resident reported an increase in pain reporting it was the worst pain ever. The nurse faxed the physician instead of sending her for evaluation. The resident continued to put her call light on seven times between 4:50 AM to 5:15 AM reporting to staff severe pain. The nurse said she just needed to wait for the Tylenol to kick in, because it isn't quick acting. At 7:15 AM the next shift nurse sent the resident to the hospital Emergency Department (ED) due to yelling out in pain. The hospital ED records noted the resident had a comminuted left acetabular fracture with protrusion of femoral head in the pelvis. The facility reported a census of 48 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS include diagnoses of hypertension (high blood pressure), anxiety and monoplegia (paralysis of a single limb) of the upper limb affecting the left nondominant side. Resident #1's Care Plan with a focus area for pain documented an intervention dated 5/29/25 directed staff to notify the physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain. Resident #1's Incident Report for the fall on 7/21/25 at 4:15 AM documented she complained of hip pain but kept switching left or right side. Resident #1's Pain Score in the Electronic Health Record at 4:32 AM documented a score of 10 on a scale of 1 to 10, 10 being the worst pain. On 10/14/25 at 4:25 PM Staff B, Licensed Practical Nurse (LPN) verbalized on the early morning of the fall she was working as an aide. Staff B reported Staff A, LPN came over the walkie and said she would need help getting Resident #1 up due to having to lower her to the floor. Staff B reported when she got to the room, Resident #1 was by the bathroom door on the floor. Staff B reported the resident was complaining of lots of pain at the time. Staff B reported when Staff A and her got Resident #1 up she was in pain but did take steps. She verbalized they got her in bed and she still was in pain. Staff B reported she asked Staff A if she was going to send her out and Staff A said she could not due to it being a different provider (meaning doctor) for the Resident #1. On 10/15/25 at 10:38 AM Staff D, LPN stated prior to Resident #1's fall, Staff D could not recall her ever complaining of pain. On 10/15/24 at 1:33 PM Staff C, Certified Nurses Aide (CNA) reported Resident #1 kept hitting her call light every 5 minutes or so because she was in so much pain. Staff C verbalized she reported it to Staff A. Staff C reported roughly 45 minutes after Resident #1 got into bed she finally settled down. Review of Resident #1's call light log documented she put her call light on seven times between 4:50 AM and 5:15 AM. On 10/15/24 at 2:40 PM Staff A, LPN reported the bed alarm was going off for Resident #1 and she heard it from the nurses station. Staff A reported Resident #1 was 3 feet away from the bed and the walker and wheelchair were next to the bed. Staff A verbalized she tried to get Resident #1 to wait but she wouldn't wait. Staff A reported Resident #1 was unsteady walking so she went right to her. Staff A reported she was walking behind Resident #1 on the left side and Resident#1 turned quickly toward the bathroom. Staff A reported she couldn't get behind Resident #1 and Resident #1 slipped and fell back against the door and facing Staff A. Staff A verbalized as Resident #1 was sliding to the floor she was supporting Resident #1's head. Staff A reported a little ways off the floor Resident #1 lost her footing and dropped to the floor about 2 feet from the floor. Staff A verbalized Resident #1 dropped to her left side with legs facing toward the bathroom. Staff A reported she can't remember for sure if Resident #1's legs were bent or not. Staff A reported Resident #1 sat herself up and leaned her back against the door. Staff A reported Staff B came in and Staff A talked about the machine to get Resident #1 up and Resident #1 started to try and get herself up. Staff A verbalized prior to Staff B coming in Staff A assessed range of motion on Resident #1. Staff A reported Resident #1 complained of pain to her legs. Resident #1 could lift and rotate her legs. Staff A reported she asked Resident #1 to point to where it hurt and Resident #1 pointed to the leg. Staff A reported Resident #1 could not rate the pain. Staff A reported no shortening noted at the time. Staff A reported she knew Resident #1 hit her leg. Staff A reported the pain was not a lot when moving Resident #1 and once in bed she rated it worse. Staff A reported Resident #1 verbalized it as the worst pain ever. Staff A reported that is why she documented the pain score at a 10. Staff A reported at the time of the fall the facility did not call the doctor with every fall. Staff A reported she gave Resident #1 tylenol and around 5:15-5:30 AM Resident #1 was sleeping. Staff A reported Resident #1 was putting her call light on once Staff A gave her the tylenol and she kept asking for medication. Staff A reported she does not remember staff reporting pain for Resident #1. Staff A verbalized Resident #1 had aches and pain but the pain had not been localized. Staff A reported it is per nursing discretion for calling the doctor. On 10/16/25 at 9:30 AM The Director of Nursing verified the facility did not do education on pain, assessment of pain and when to notify the physician with falls. She reported she was not aware of Resident #1 having the severe pain that was reported by the staff working. On 10/16/25 at 12:02 PM Staff E, LPN reported she got a report at 6AM on 7/21/25 and then got her medication cart ready. Staff E reported she went down west hall and started a medication pass when she heard yelling at around 6:45 AM coming from room [ROOM NUMBER] window side (Resident #1's bed). Staff E reported Resident #1 was yelling out Help me! Help me! I'm in so much pain. Staff E reported Resident #1's eyes were red and she was facial grimacing so Staff E knew it was really bad. Staff E reported she forgot to chart in her documentation that Resident #1's left leg was abducted out and wouldn't let Staff E move her. Staff E verbalized she called the son because he visits frequently and told him Resident #1 needed to go to the hospital to be checked out because she was in a lot of pain and the staff could not move her. Staff E then sent Resident #1 by ambulance to the hospital Emergency Department (ED) to be further evaluated. Staff E reported Resident had mild aches and pains but never acted like how she was with the severe pain. On 10/16/25 at 1:05 PM Spoke with Staff F, CNA reported on 7/21/25 when she did walk through at 6 AM, Resident #1 was sleeping in bed. At around 6:45 AM Staff F went in to see if Resident #1 would want to get up for breakfast. Staff F reported Resident #1 began yelling out she was in pain. Staff F reported she could tell it in her eyes she was in pain. The nurse came in right away when she started yelling. The facility policy titled Fall Occurrence with a revised date of February 2024 lacked direction for staff in relation to pain with falls, what to do for the pain and when to notify the physician in relation to the pain.

Based on observation, record review, and staff interview, the facility failed to provide care consistent with professional standards to prevent a pressure ulcer, and failed to provide the necessary treatment and services to promote healing for 1 resident with a pressure ulcer (Resident #2). The facility reported a census of 52 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident was dependent for transfer, toileting, putting on/taking off footwear, and did not walk. The resident required substantial/maximal assist with rolling left to right. The resident's diagnoses included non-Alzheimer's dementia and Multiple Sclerosis (MS).The resident had risk for pressure ulcers, but had no pressure ulcers. The resident had a pressure reducing device for the bed, and a pressure reducing device for the chair. According to the MDS assessment dated [DATE], Resident #2 scored 6 on the BIMS indicating severe cognitive impairment. The resident had an unstageable pressure injury presenting as a deep pressure injury. In addition to pressure reducing devices to the bed and chair, the resident had a turning and repositioning program and nutrition or hydration interventions to manage skin problems. The Care Plan with a goal target date of 6/29/25 identified the resident at risk for alteration in skin integrity related to (r/t) a history of pressure ulcer to right inner buttocks and left buttocks and had the potential for pressure ulcer development r/t the history of pressure ulcers, impaired skin integrity r/t impaired mobility, incontinence, cognitive impairment, MS, and tremors. 2/1/25 dark purple non blanchable deep tissue injury right heel, encourage heel lift boots to bilateral feet. At times resident chose not to lay down in the morning, but usually laid down in the afternoon. 4/8/25 Resident's physician was okay with her wearing tennis shoes to her right foot if that was what she desired. The interventions included: a. Administering medications as ordered. b. Administering treatment per physician orders. c. Applying bilateral heel lift boots when in bed as tolerated (after the pressure ulcer developed). d. Encouraging good nutrition and hydration in order to promote healthier skin. e. Encouraging to reposition. f. Following facility policies/protocols for the prevention/treatment of skin breakdown. g. Observing skin condition with care. h. Pressure reducing device on bed. i. Pressure reducing device on chair. j. Providing preventative skin care. k. Using pillows/positioning devices as needed. The Progress Notes dated 1/29/25 at 6:14 p.m. documented the resident had cold symptoms and an emesis. The Progress Notes dated 1/30/25 at 5:42 a.m. documented the resident's head of the bed elevated throughout the shift and would encourage fluids with each contact. The Progress Notes dated dated 1/30/25 at 8:45 a.m. documented the resident experienced a change in condition. The resident had a large emesis undigested food light tannish in color, and no foul odor. The resident did feel nauseated, but better since vomited. Skin pink in color and warm to touch, and nasal drainage and congestion noted. Questioned with fever, urinary incontinence, and significant history of Urinary Tract Infection (UTI), if they could obtain a straight catheter urine sample for Urinalysis (UA) and Culture and Sensitivity (C&S). At 9:10 a.m. the resident received Tylenol for a temperature of 100.6 degrees. At 1:54 p.m. the facility received an order for a UA and C&S. At 9:26 p.m. the resident remained on isolation due to cold symptoms. Noted with occasional nonproductive cough, and poor appetite. Fluids encouraged and offered with each contact. The Progress Notes dated 1/31/25 at 10:17 a.m. documented the resident had been more lethargic, confused, with increased needs in assistance. The resident's Oxygen (O2) saturation (sat) 85% (norm 92-100%) and O2 placed per nasal prongs at 2 liters. She denied dysuria (pain with urination) but had some episodes of shaking, possibly chills. At 12:31 p.m. O2 sat 89% on 4 liters of O2. At 6:38 p.m. the resident had been resting in bed and said she felt better, but may have been unreliable due to her poor cognition. The Progress Notes dated 2/1/25 at 12:31 p.m. documented the resident noted with dark purple, non-blanchable area to the right heel measuring 1.8 by 2.7 cm. The intact area did not appear tender with assessment. The resident had a recent change in condition on 1/30/25 and continued isolation precautions. Staff anticipated and met all the resident's needs, including repositioning every 2 hours and as needed. Staff encouraged the resident to wear heel protector boots at all times as tolerated. Questioned if considering the location and characteristics if it would be a deep tissue pressure injury. The Progress Notes dated 2/4/25 at 11:27 a.m. documented call to family regarding recommendation of hospice services per the physician. The family member voiced understanding and stated she would call the physician and her other family members to discuss the recommendation and would get back to them. At 12:20 p.m. a return fax received, signed by the physician citing the wound was likely a deep pressure injury. It would be reasonable to proceed with the Wound Care consult. Family has been contacted regarding/ Hospice referral. Can we hold off on wound care consult at this time until family makes a decision? Wound will still be assessed weekly by the facility's wound care certified skin nurse. The Progress Notes dated 2/6/25 at 10:41 a.m. documented a return fax received, signed by the physician, citing he thought it was reasonable to wait until the family decided how they would like to proceed. The Progress Notes dated 2/12/25 at 2:01 p.m. documented the resident's family member stated they would not go with hospice services. The clinical record lacked documentation the facility set up a wound care consult. The Progress Notes dated 2/26/25 at 2 a.m. documented a Certified Nursing Assistant (CNA) reported an area on the resident's right heel. The area was first documented on 2/1/25. They were waiting on family to decide on hospice care before coming up with a treatment plan. The area was intact but had gotten bigger. On 2/1/25 the area measured 1.8 x 2.7 cm. Then the area is measured 2.2 x 3.7 cm, dark purple almost black, and nonblanchable. The note questioned if they should move forward with a wound clinic consult. At 5:45 p.m. received a fax from the physician stating please proceed with Wound Care Consult. The resident likely had a pressure ulcer due to her failing health and would likely worsen over time. The clinical record lacked documentation the facility attempted to get the resident seen for a wound care consult. The Progress Notes dated 3/5/25 at 10:18 p.m. documented receipt of a fax from the physician following up on the Skin Evaluation Pressure Wound Assessment stating: wound care nurse evaluation please, and thank you. Order put in. The clinical record lacked any documentation the facility attempted to make an appointment for a wound care nurse evaluation. The Progress Notes dated 4/1/25 at 2:56 p.m. documented receipt of a return fax from the physician regarding the:Pressure Wound assessment. Received the order, the resident would benefit from wound care intervention. He would recommend a consultation with the Wound Nurse or at the Wound Care Clinic of her choice. The resident's family notified and requested a specific wound clinic. Request placed to set up appointment. The Progress Notes dated 4/2/25 at 8:30 a.m. documented a call placed to to the wound clinic the family chose. The earliest appointment available 4/21/25. The family called and fine with any wound clinic available. The Progress Notes dated 4/3/25 at 15:26 p.m. documented the facility faxed the order to the wound clinic and they were unable to schedule an appointment until the order was entered in the system. The Progress Notes dated 4/4/25 at 1 p.m. documented the resident's physician replied he would be happy to order the consult, and requested the facility let him know where the wounds were located so he could enter an accurate referral. The Progress Notes dated 4/7/25 at 8:25 a.m. documented receipt of a call from the wound clinic and they could make an appointment because the order was in the system. The 1st available on 4/14/25 at 2:45 p.m. On 4/7/25 at 4:54 p.m. the resident sat in her wheelchair in her room and allowed a Certified Nursing Assistant (CNA) to remove her right slipper and sock to reveal dry black eschar to the right interior heel. On 4/8/25 at 8:59 a.m. the resident sat in her wheelchair in her room. The resident wore tennis shoes. At 11:10 a.m. the resident still had shoes on. On 4/9/25 at 8:04 a.m. the resident was dressed and wore slippers on in the dining room. On 4/8/25 at 11:54 p.m. the facility Wound Nurse stated they did not have an order for the resident to not wear shoes. In an email dated 4/8/25 the Provisional Administrator responded to the request for policy on pressure ulcer care, that they would follow the standard of care. On 4/8/25 at 12:55 p.m. the Provisional Administrator and previous Administrator stated the resident may want to wear her shoes, and they allowed resident's choice. The clinical record lacked any documentation the facility addressed the the resident's footwear in relation to the pressure ulcer. On 4/8/25 at 4:15 p.m. the Director of Nursing (DON) asked the MDS Coordinator if there were any additional assessment or interventions when the resident was ill (the end of January), and the MDS Coordinator named interventions they put in place after the resident developed the pressure ulcer, including the boots and dietary. The DON acknowledged the lag time in getting the resident seen after the pressure sore developed. She said they made many calls to the wound center, but they would not make an appointment until the doctor made a proper referral. She said she knew if it wasn't documented it wasn't done. The DON said the resident liked to be dressed and that included shoes. She didn't know if they encouraged the resident to wear her slippers. The National Pressure Injury Advisory Panel (NPIAP), Pressure Injury Prevention Points directed repeating risk assessments with any change in condition. Repositioning and mobilization included keeping the heels free from the bed.

Based on record review, staff interview the facility failed to create a comprehensive Care Plan with appropriate goals and interventions for 1 of 2 residents (Resident #43) for anticoagulants (also known as blood thinners, medications that prevent blood clots from forming or growing and can cause increased risk of bleeding, which can manifest as excessive bruising, prolonged nosebleeds, or even internal bleeding) and diuretics (medications that increase urine production, helping the body eliminate excess salt and water and can cause negative side effects such as dehydration, dizziness, fatigue, muscle cramps, headache) and 1 of 3 residents for diabetes and insulin (Resident #50). The facility reported a census of 52 residents. Findings include 1. The Minimum Data Set (MDS) for Resident #43 dated 2/5/25 documented she admitted to the facility on [DATE] with diagnoses of heart failure, hypertension, deep vein thrombosis (the formation of a blood clot in a deep vein, this clot can potentially travel to the lungs, causing a pulmonary embolism), and respiratory failure. The MDS also documented she takes anticoagulants and diuretics now and prior to admission. Record review of Resident #43 Order Summary Report dated 3/12/25 documented orders for apixaban (anticoagulant medication) 5 milligrams (mg) twice a day for acute embolism and thrombosis, torsemide (diuretic medication) 20mg daily for heart failure, and spironolactone (diuretic medication) 25mg daily for heart failure. Record Review of Resident #43's current Care Plan on 4/8/25 did not include goals and interventions for anticoagulant and diuretic medications. 48003 2. Resident #50's MDS dated [DATE] documented a BIMS score of 15 indicating intact cognition. The MDS documented Resident #50 diagnosis of diabetes. The MDS further documented she received insulin (diabetic medication) during the 7 day look back period. Review of Resident #50's Care Plan lacked documentation of the diabetes, insulin medication or any interventions for the high risk medication. During an interview on 4/8/25 at 2:45 PM, the MDS coordinator reported she writes down what medications residents are on and make sure the ones needed on the care plan are on it. She reported she missed the insulin and diabetes on the care plan for Resident #50.

Based on record review, staff and policy review the facility failed to promptly implement and ensure physician notification and response for 1 of 1 residents with new onset of Urinary Tract Infection (UTI) signs and symptoms resulting a delay in care and unresolved pain (Resident #20). The facility also failed to notify 1 of 2 residents physician timely for elevated blood sugar levels (Resident #8). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #20 dated 12/30/24 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented diagnoses of diabetes mellitus, heart failure and renal failure. The MDS showed she needed substantial/maximal assistance with lower body dressing, showering/bathing, and toileting. The MDS also documented she was not on a toileting program and was always continent of bowel and bladder. Record review of a Change in Condition Assessment auto generated system Progress Note dated 4/6/2025 at 4:34 PM documented Resident #20 has experienced the following change in condition: complaining of frequency, urgency, burning, and increased incontinency with urination and cranberry juice was given. A fax was sent to her Doctor to address in the morning. During an interview with Resident #20 on 4/7/25 at 9:30 AM revealed she thinks she has a UTI and it started 4/4/25 (Friday) in the late afternoon. She informed she has had pain, burning, urgency and incontinence all weekend, and has told all of the nurses and asked them to do something about it but the weekend was coming and she knew nothing would get done, so she has dealt with the burning and pain all weekend. She revealed she has told nurses and one took her blood pressure and checked her over but nothing has happened, she then informed they need to get her urine checked this morning so she doesn't have to live with this for another night. Record review of a Progress Note dated 4/7/25 at 2:53 PM documented Resident #20 Doctor was updated about possibility of a UTI and ongoing symptoms and an order was received for Resident #20 to have a UA with Culture and Sensitivity (C&S) urine labs completed. Record review of a Progress Note by Staff E, Licensed Practical Nurse (LPN) dated 4/7/25 at 1:50 PM documented Resident #20 continues with pain/burning with urination, urgency, and increased incontinence. Resident #20 does not have a fever and has no changes in cognition, and reports I can't go on like this. Is there any way we can get an order sooner for a urine sample? Resident is also on a fluid restriction so fluid intake cannot be increased. Record review of a Progress Note dated 4/7/25 at 9:26 PM documented Resident #20 continues with complaints of painful urination and will collect urine lab sample in the morning. Unable to encourage fluids due to fluid restriction. During an observation and interview on 4/8/25 at 7:46 AM with Resident #20 and Staff E, Certified Medication Aid (CMA) administering medications, Resident #20 was sitting on the toilet, and said she was having a terrible time with a UTI. During a follow up interview with Resident #20 on 4/8/25 at 2:19 PM reconfirmed her UTI symptoms of pain, burning, urgency and incontinence started on Friday (4/4/25) in the evening and continued on Saturday and Sunday but nothing was done. She then informed on Monday they had to get the clearance from the Doctor and she does not know what happened, but it didn't happen, but the facility finally managed to get the urine sample this morning (4/8/25). She revealed she has talked to all the nurses, but there wasn't anything they could do. She revealed she does not want to blame anyone here at the facility because for the most part it is very good staff. She then informed on Saturday (4/5/25) afternoon a nurse took her vitals and they haven't done anything since then. She stated urine burned all day Saturday, Sunday, and Monday, and she gets a sharp sharp pain, on a 0-10 pain scale (10 being the worst) it was over 10 many times when urinating. She stated all weekend she kept thinking she just wanted it to be Monday, cause it hurt so bad. She informed she suggested to a nurse (could not recall the nurses name) on Saturday maybe she should go to the emergency room (ER) and try to get some help for this, and the nurse told her that is not what the emergency room (ER) is for. She then revealed she has had UTI's in the past, but none like this, and this is the worst she has ever had. Record review of Resident #20 Urinalysis (UA) dated 4/8/25 at 17:35 documented the following significant results found in her urine: Blood, occult at 2+ (should not have any) Protein Stix at 1+ (should not have any) Leukocyte at 3+ (should not have any) White Cells are greater than 100 (normal range 0-5) Red Cells 11 to 25 (normal range 0-2) Record review of Resident #20 Pending Urine Culture lab dated 4/8/25 at 6:09 PM documented the following: Urine culture at 80,000 CFU/mL Colony Forming Units per milliliter (CFU/mL) probable: Proteus species (a bacterial count of 80,000 CFU/mL in a urine sample, with a probable identification of a Proteus species, is considered high and suggests a potential urinary tract infection (UTI). The presence of 100,000 CFU/mL or more of a single bacterial species is a common threshold for diagnosing a UTI). Record review of Resident #20's Assessments in her EHR on 4/9/25 at 9:26 AM documented no further assessments completed by nursing since her Change in Condition assessment on 4/6/25. Record Review of Resident #20's Vital Signs in her Electronic Health Record (EHR) on 4/9/25 at 9:27 AM revealed her last temperature was taken on 4/6/25 at 97.4 degrees Fahrenheit (F), and last blood pressure was taken on on 4/6/25 at 132/74 millimeters of mercury (mmHG), and last documented pain level assessment was on 4/4/25 at a 2 on 0-10 pain scale. During an interview on 4/9/25 at 9:41 AM with Staff C, Certified Nurse Aide (CNA) informed she works at the facility full time and Resident #20 will call when she needs assistance and she has been having some complaints of UTI symptoms since 4/8/25. During an interview on 4/9/25 at 9:50 AM with Staff D, LPN revealed she collected a urinalysis (UA) lab and sent it to the clinic for Resident #20 on 4/8/25 and she has not seen results faxed back. During an interview on 4/9/25 at 9:56 AM with Staff E, Certified Medication Aide (CMA) revealed she has worked with Resident #20 on 4/7/25 and 4/8/25 and stated she complained she might have a UTI and the nurses were aware. During an interview on 4/9/25 at 10:06 AM with Staff B, LPN revealed Resident #20 is still having pain with urination and urgency and she has not called yet today for lab results. She revealed she worked Monday 4/7/25 and Resident #20 was having pain, burning, and urgency with urination and increased incontinence. She then stated on 4/7/25 she got an order from Resident #20's Doctor for her urine to be tested and sent to the lab, but it was too late in the day to get her urine to the lab so they waited till Tuesday 4/8/25 to get her urine and she has not heard anything back yet. She stated if a nurse completes a Change of Condition Assessment related to a possible urinary tract infection they are supposed to chart vital signs and document on urine characteristics for three (3) days every shift. During an interview on 4/9/25 at 10:47 AM the Director of Nursing (DON) revealed she would expect nursing staff to notify Resident #20's Doctor timely if concerns regarding UTI symptoms were present and a change in condition assessment was completed. During an observation and interview on 4/9/25 at 11:02 AM, Staff B, LPN provided Resident #20's pending urine culture lab and completed urinalysis (UA) lab, when asked if the urinalysis was back yet, she proceeded to go through the fax book and found Resident #20's UA lab results timed stamped from the fax machine as received on 4/8/25 at 6:14 PM, Staff B informed no one has sent the results to the Doctor, she informed she was not aware it was here. UA results were taken to the DON and informed nothing has been done, the DON stated she will take care of it and contact Resident #20's Doctor now. During an interview on 4/9/25 at 6:08 PM with Staff A, Advanced Registered Nurse Practioner (ARNP) revealed the last call she received from the facility regarding Resident #20 was in September 2024 and it was regarding low back pain. She informed she is only able to see the on call screen, and it only shows if the facility called on a resident between 6:00 PM and 6:00 AM and informed nothing has been called in since September 2024 for Resident #20. Record review of Resident #20's current Care Plan on 4/9/25 documented the following: Resident is at increased risk of developing skin impairment and UTI's her goal is to remain free of complications related to incontinence and intervention is to monitor skin and report abnormal findings to practitioner and therapy consult as needed. 2. The MDS dated [DATE] for Resident #8 documented diagnoses of diabetes mellitus, hyponatremia (when the level of sodium in your blood is lower than normal), and hypertension. The MDS also documented daily insulin injections. Record review of Resident #8's current Care Plan dated 8/8/25 instructed to monitor blood sugar levels as ordered and report to Doctor per parameters, dated 10/18/24. The Care Plan lacked resident #8 parameters. Record review of an After Summary Visit orders from the local hospital dated 3/10/25 lacked blood sugar parameters. Record review of Resident #8's Blood Sugars in his EHR documented the following: On 3/10/25 at 8:53 PM 486 milligrams per deciliter (mg/dL) (For most adults with diabetes, a target range for blood sugar is typically 80 to 130 mg/dL before meals and less than 180 mg/dL one to two hours after meals) On 3/10/25 at 9:54 PM 474 mg/dL On 3/11/25 at 7:08 AM 366 mg/dL On 3/11/25 at 11:08 AM 374 mg/dL Record review of Resident #8's Progress Notes lacked documentation of Doctor notification regarding elevated blood sugars on 3/10/25. Record review of Resident #8 Miscellaneous documents in his EHR lacked documentation of Doctor notification regarding elevated blood sugars on 3/10/25. During an interview on 4/9/25 at 10:47 AM the DON revealed she would expect the nurses to call if a blood sugar was obtained outside of parameters and on 3/10/25 she revealed blood sugars for Resident #8 were outside parameters and his Doctor should of been notified at that time. She then informed he was seen the following day by his provider on 3/11/25. An e-mail provided by the Provisional Administrator on 4/8/25 at 4:19 PM provided the following information the facility follows when asked for facility policy and/or procedures related to Physician Notification and Change of Condition/Assessment: Physician Notification Policy In our facility, we maintain timely and appropriate communication with physicians regarding residents' changes in condition, lab results, or other clinically relevant findings. Our nursing staff is trained to use their clinical judgment and follow internal protocols to determine when to notify the physician, always prioritizing resident safety and well-being. Notifications are documented per policy, and any updates or directives received are incorporated into the plan of care as needed. Change of Condition/Assessment Policy Our team is trained to recognize both acute and subtle changes in a resident's condition-whether physical, cognitive, behavioral, or functional. A change in condition may be identified through routine monitoring, staff observation, resident or family reports, or during cares. When a change is suspected, the nurse performs a thorough assessment, which may include reviewing vital signs, performing a head-to-toe physical assessment, evaluating mental status, pain, fluid intake/output. The nurse uses clinical judgment in conjunction with the resident's baseline status to determine if the change is significant. Based on the findings, the physician is notified per facility protocol, and any new orders or interventions are implemented promptly. The care plan is updated as appropriate, and documentation reflects the assessment, actions taken, and resident response. Communication with the resident, family, and interdisciplinary team is also part of the process to ensure continuity of care

Based on observations, facility document review and staff interviews, the facility failed to post staff daily posting with the census and staffing data required. The facility reported a census of 52 residents. Findings include: An observation on 4/6/25 at 10:10 AM noted the facility staff post did not have resident census, total hours worked for each category nor identify if the nurse was a Licensed Practical Nurse (LPN)or Registered Nurse (RN) each shift. An observation on 4/6/25 at 3:00 PM noted the facility staff post did not have resident census, total hours worked for each category nor identify if nurse was an LPN or RN each shift. An observation on 4/7/25 at 8:30 AM noted the facility staff post did not have resident census, total hours worked for each category nor identify if nurse was an LPN or RN each shift. An observation on 4/7/25 at 1:00 PM noted the facility staff post did not have resident census, total hours worked for each category nor identify if nurse was an LPN or RN each shift. During an interview on 4/7/25 at 1:15 PM, the MDS Coordinator reported she was not sure why the staff posting does not have the census on it and would check into it. During an interview on 4/7/25 at 1:29 PM, the Provisional Administrator reports the staff postings changed on December 1st. She is unsure why the census is not on it and it should be. Acknowledged the staff posting should also identify the categories of nursing department for identifying RN, LPNs and CNAs.

Based on observations, interview, record review and policy review the facility failed to ensure that the kitchen was maintained in a sanitary manner for 49 out of 49 residents. Failure to keep sanitary conditions in the kitchen has the potential to spread foodborne pathogens among residents. Specifically, food items in the kitchen and storage areas were expired, unlabeled and/or undated and kitchen equipment was coated in a white residue. Findings include: Review of the facility's policy titled, Refrigerated Food Storage dated [DATE], revealed, Refrigerated foods received, stored, prepared and served, will be properly labeled, dated and used or discarded according to the regulatory requirements and maintenance of food quality. On [DATE] at 01:39 PM the Dietary Consultant (DC) came to the conference room and stated that the facility did not have policies on dry storage, labeling or the ice machine. The initial kitchen inspection was conducted on [DATE] at 10:24 AM through 11:10 AM with the Dietary Manager (DM). The following concerns were noted: In the Cooler a 114-ounce opened container of ketchup was observed. The container had no lid and was covered loosely around the neck of the container with aluminum foil. There was a date on the top of the aluminum foil [DATE]. The DM stated they must have misplaced the lid. A large container of cooked rice was noted with a date of [DATE] and a use by date of [DATE], the DM stated that the rice was for a renal resident. An opened package of ham was observed in a clear plastic storage container that was labeled as came out of the freezer ,d+[DATE]. It was noted with an amber colored liquid on the bottom of the container. The DM stated the liquid is from the ham defrosting and stated that they should have put a discard date on the box. An opened package of sliced turkey was observed in a clear plastic storage container, open date ,d+[DATE], no use by date noted. In the Dry storage section of the kitchen, there was an open, undated package of instant dry milk. The ice machine was observed with what appeared to be hard water, lime scale and/or mineral deposits in several areas of the ice machine including the front area above the bin dispenser door and around the side of the machine. The DM stated that maintenance comes once a year to clean the ice machine. There was no cleaning log available for the ice machine. During a follow-up kitchen observation on [DATE] at 10:02 AM the following concerns were noted: The 114-ounce opened container of ketchup was still observed in the cooler. The DM stated that the ketchup is not covered in a manner that would prevent foodborne pathogens from growing and she stated that she would train the staff on that. The tin foil is probably not keeping it safe from foodborne pathogens. The ham and turkey that were previously in the cooler were no longer observed. The DM stated that she discarded them and there should have been a discard date on them. The DM stated that the allowable amount of time to keep deli meat is 7 days. In the Dry storage section of the kitchen instant dry milk is observed a second time, it remained open and undated. The DM stated that she didn't want to discard it because they didn't know when they received it. The ice machine exterior was visibly cleaner but now the floor around the ice machine has dirt and debris. During an interview with the Maintenance Director (MD) on [DATE] at 10:14 AM, he stated that their ice machine was serviced every three months, and its next service is due on [DATE]. When asked if there was a cleaning log, he showed a small sticker inside of the machine that said: Ice wand: Date installed [DATE] and replace in 90 days [DATE]. The MD opened the ice machine and showed the inside area where the water comes down, it appears clean. The MD stated that there was an issue with the water softener, and they do not keep a log of the cleaning. He revealed that is the responsibility of the kitchen to maintain the outside of the ice machine, but he understood that the DM is new. He stated that the previous DM was not as diligent about cleaning the machine as well. The last time the machine was cleaned was [DATE], though he did not have any documentation of such. He stated the external of the machine became dirty because the ice runs out of the machine, and that it has always been like that. That morning he ran a cleaner through the machine. When he opened the machine, he stated that it did have some lime build up on the inside as well. He predicted it would not be a problem as long as the softener keeps working. He stated that the lime away in the kitchen was old and when they got a new one it came off much easier, but he also had to use a butter knife to scrape it off. The debris on the floor was a result of his scraping the residue off the machine. At 10:25 AM the freezer was observed. There are two portable coolers on the floor containing the ice which was removed from the ice machine due to cleaning earlier in the morning. An opened five-pound bag of precooked sausage was observed with no opened or use by date and there is a sticker on the package that says Tuesday and a date is scratched out. The DM states she will talk to the staff about why the date is scratched out. An opened four-pound bag of fajita vegetables is noted to have melted and refrozen into one large frozen chunk of vegetables. The bag is labeled as Opened on [DATE]. The DM stated it must have thawed out and the staff refroze it and stated that's not in keeping with correct temperature controls on the food.

Based on interviews and record reviews, the facility failed to develop and implement a medication regimen review (MMR) policy and procedure with time limits for steps in the Medication Regimen Review (MRR) process with the steps the pharmacist must take when an irregularity requires urgent action. The facility's deficient practice increased the 49 residents residing at the facility's risk of medication errors/adverse medication consequences. Findings include: Review of Haloperidol .[NAME] Pharmaceuticals, Inc . on the website National Library of Medicine revealed .Warning: Increased Mortality in Elderly Patients .Haloperidol tablets are indicated for use in the management of manifestations of psychotic disorders .Haloperidol tablets are contraindicated .Parkinson's disease . Review of R29's undated Admission Record under the Profile tab located in her Electronic Medical Record (EMR) revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include Parkinson's disease, anxiety disorder, headache, restless leg syndrome, mild cognitive impairment, nausea, chronic kidney disease, sleep disorder, heart failure, major depressive disorder, and history of falling without diagnosis of cancer. R29 was elderly. Review of R29's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/23 and located in her EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating she is cognitively intact, had no potential indicators for psychosis, did not exhibit physical or verbal behaviors or reject care, Parkinson's, depression disease and without a diagnosis of cancer. The MDS further indicated R29 was administered an antipsychotic for 7 out of 7 days, during the look back period, without Gradual Dose Reduction (GDR) attempted, antidepressant for 7 out of 7 days. There was no indication the resident was receiving chemotherapy and/or had a diagnosis of cancer. Review of R29's Physician's Orders under Orders tab located in her Electronic Medical Record (EMR) revealed .Haloperidol Tablet 0.5 MG (milligram), Give 1 tablet by mouth one time a day for nausea related to Anxiety . dated 10/13/22. Further review of the physician orders revealed there were no orders for palliative care. Review of R29's Medication Administration Record (MAR) under the Orders tab located on her EMR revealed: a. 04/23 Haloperidol Tablet 0.5 MG, give one tablet by mouth, one time a day for nausea related to anxiety disorder with staff initials for 04/01/23-04/30/23 indicating the tablet was administered. b. 05/23 Haloperidol Tablet 0.5 MG, give one tablet by mouth, one time a day for nausea related to anxiety disorder with staff initials for 05/01/23-05/02/23 indicating the tablet was administered. Review of R29's comprehensive Care Plan under Care Plan tab located in her EMR revealed .I use psychotropic medications r/t [related to] DX [diagnosis] of anxiety .Monitor/document/report PRN[as needed] any adverse reactions of Psychotropic medications: unsteady gait, tardive dyskinesia, EPS[Extrapyramidal side effects] (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person . Further review of R29's care plan revealed there was no intervention for palliative care. Review of R29's Pharmacy Review under the Assessment tab located in her EMR revealed: a. 08/17/22 Pharmacist General Recommendation .Haldol-current diagnosis on file is Nausea which does not qualify for antipsychotic use per CMS ., Physician Response .DX [diagnosis] nausea. Decrease in Haldol was ordered . b. 10/26/22 Physician Response .Nausea and vomiting associated with cancer or cancer chemotherapy .Nausea is the diagnostic reason she is on this. We are attempting a palliative approach to see if this helps again . c. 03/28/23 Pharmacy Review Assessment .GDR X[times] 2 SENT .using dronabinol for nausea .Haldol 0.5 QD .GDR 03/23 .GDR request for psychotropic Medication . without Physician Response. During an observation on 05/02/23 at 10:35AM, R29 was sitting on her recliner in her room. R29 had a washcloth on her head. R29 stated she was nauseous and had a headache. R29 had a breakfast meal on her bedside table that was untouched. During an observation /interview on 05/03/23 at 9:37AM of R29 being provided AM care by Certified Nursing Assistant (CNA)2. R29 stated she had a headache. CNA2 told her she would get her some ginger ale and a washcloth when they were done. CNA2 stated R29 was forgetful and confused at times and may have a little dementia. CNA2 stated R29's displayed behaviors were, she was sick a lot. CNA2 stated R29 used her sickness as an excuse to miss scheduled appointments at times. CNA2 verified R29's bedsheet and pillowcase had a small amount of blood on it. CNA2 stated R29 got anxious at night and bit her tongue and slept on one side and the blood ran out of her mouth. CNA2 asked R29 are you ready for breakfast and R29 replied yes. CNA2 used her walkie talkie to call the kitchen and request R29's meal tray. During an interview on 05/04/23 at 9:20AM with Licensed Practical Nurse (LPN)1 stated R29 did not have behaviors. LPN1 stated R29 complained daily with headaches and nausea. LPN1 stated R29 started having headaches in the past year. LPN1 stated R29 had a nodule to the left side of her tongue. LPN1 stated R29 nodule was discovered by one of the other nurses back in March 2023. LPN1 stated R29's tongue nodule could not cause nausea. LPN1 stated R29 bit the nodule when she was sleeping, and she woke up with dried blood. LPN1 stated R29 had a diagnosis of dementia but not too advanced. LPN1 stated she was oriented to person and place, and she knew who her kids were. LPN1 stated R29 took Haldol for depression. LPN1 stated Haldol was a psychotropic medication. LPN1 stated she observed for R29's side effects of headaches, constipation, light headiness (drowsiness) and some can cause nausea. LPN1 stated she did not document the headache and nausea as a side effect related to her Haldol. LPN1 stated she had been on the Haldol since she started at the facility 2 years ago. LPN1 stated she did not know what the black box warning was for Haldol. LPN1 stated she did not use a drug reference for the medication information prior to administering. LPN1 stated if she had questions, she would look on the internet for answers but normally she does not. LPN1 stated she would call the pharmacist if she had questions related to the resident's medications. During an interview on 05/04/23 at 3:19 PM with the Pharmacy Consultant (PC) confirmed R29 was administered the antipsychotic medication Haldol for a diagnosis of nausea since 07/22 at the same dose. The PC stated R29's Haldol black box warning had an increased risk of death with elderly patients. The PC stated Haldol manufacture's label or FDA (Food and Drug Administration) approval did not indicate the use of Haldol for nausea. The PC stated there were other medications the facility could order for nausea that were not antipsychotic and with less risks. The PC stated he made a recommendation to stop R29's Haldol on 03/23 and the provider had not entered a response in her EMR yet. The PC stated R29 continued to complain of nausea and headaches. The PC stated he tried to get the physician to discontinue R29's Haldol but the physician had not. The PC stated the provider's response to his recommendation regarding R29's Haldol should be timely, but he was being realistic there were a lot of documents for the provider to review. The PC stated he considered sixty days as a timely period for R29's provider response to the pharmacy recommendation. During an interview on 05/04/23 at 8:02 PM the Director of Nursing (DON) confirmed R29 was elderly. The DON verified R29 had an order on her EMR for an antipsychotic medication for nausea. The DON verified the black box warning for Haldol was increased risk of death with the elderly. The DON stated R29's Haldol was not ordered for an indication of use per the manufacture's guideline of FDA approval. The DON confirmed R29 continues to have chronic nausea. The DON stated she did not have an expectation for the time limit the physician respond to the pharmacy consultant recommendation regarding antipsychotics. The DON stated the facility did not have policy for medication regimen review and the PC was at the facility monthly. The DON stated the facility did not have a policy that stated the PC was at the facility monthly. During an interview on 05/04/23 at 6:14 PM the Medical Director stated R29's Haldol (antipsychotic) physician order for her diagnosis of nausea was entered in an error by someone. The Medical Director stated he expected R29's provider to respond to the PC recommendations within a month.

Based on interviews and review of the records, the facility failed to ensure the Medical Director implemented resident care policies for activities of daily living (ADL), nail care, personal hygiene, range of motion, contractures, splints, braces, medication storage, medication regimen review and speech therapy. The facility's deficient practice increased the 49 residents residing at the facility risk of improper care/inadequate quality of care. Findings include: A request was made for the facility's Medical Director's job description. The facility provided the document titled CMS Manual System .State Operations Provider Certification 11/28/05 revealing .The medical director is responsible for- .Implementation of resident care policies . and did not provide the facility's Medical Director's job description. A request was made to Resident Care Coordinator (RCC)2 for the following facility policies for review: Nail Care, ADL and/or Personal Hygiene. On 05/02/23 at 5:04 PM the RCC2 stated the facility did not have the policies for resident's personal hygiene, nail care or ADL care. The facility did not provide a policy for speech therapy for review as requested from the Speech Therapist (ST). The facility did not provide a policy for splints, braces, or contractures for review as requested from Resident Care Coordinator (RCC)3 on 05/03/23 at 10:29 AM. RCC3 provided CMS[Centers for Medicaid and Medicare Services] Form 20120 .Positioning, Mobility & Range of Motion (ROM) Critical Element Pathway 05/17 (pages one through nine) and stated the facility used the pathway for their policy for residents with limited range of motion or contractures. RCC3 stated she was unsure if the facility developed policies. During a brief interview on 05/02/23 at 5:02 PM the Director of Nursing (DON) stated the facility did not have a Medication Storage policy or a Medication Refrigerator policy. During an interview on 05/04/23 at 6:10 PM the Medical Director stated he reviewed the facility's policies and procedures at the facility quarterly with the facility leadership. The Medical Director stated policies and procedures were used to guide the staff on how to care for the residents at the facility. The Medical Director stated he was responsible for ensuring the facility implemented the facility's policies and procedures. The Medical Director stated the last time he reviewed policies and procedures at the facility was two months ago. The Medical Director stated he did not see a policy for nail care, change in condition, notification of physician, ADL, splints, braces, or contractures for the residents at the facilities. During an interview on 05/04/23 07:29 PM the DON stated the facility did not review the resident care policies and procedures. The DON stated the facility's policy and procedures were reviewed by the cooperate office. The DON stated the facility does not have specific policies or procedures for a lot of the resident care areas like ADL care or nail care. The DON stated she was unsure if the facility should have policies and procedures for specific care areas for the residents. The DON stated she did not review the facility's policies. The DON stated the resident care policies were guidance for the facility staff. During a brief interview on 05/04/23 at 8:02 PM the DON stated the facility did not have a policy for Medication Regimen Review.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure one of one medication room, did not store one medication bottle with faded, and unreadable label, contained twenty-three expired syringes with needles, and the medication refrigerator temperatures were logged/documented properly. The facility deficient practice increased the 49 residents residing at the facility at risk of medication errors. Findings include: Review of the facility's policy titled Drug Labeling dated ,d+[DATE] revealed to assure appropriate drug labeling procedures .Floor stocked nonprescription medication containers must identify at minimum brand name or genic name and manufacturer, strength, lot number and expiration date . During an observation/interview on [DATE] at 2:45 PM of the facility's medication room with the Director of Nursing (DON), and Licensed Practical Nurse (LPN)2 the following were identified: a. One medication bottle with a faded label (unreadable) with the word Famotine handwritten on the lid that was ,d+[DATE] full of small tablets and was stored in the upper cabinet with the facility's stocked medications. b. Twenty-three unopened Monoject 1 milliliter (ml) Tuberculin Safety syringes with needle, with an expiration date of [DATE], were in the upper cabinet with unexpired medical supplies/syringes. The DON verified the needles were expired and should not be stored in the cabinet and should be destroyed per manufacture guidance. During an observation/interview on [DATE] at 2:59 PM, the DON verified the medication bottle's label was faded and difficult to read. DON stated she would request a new label from the pharmacy to replace the label.The DON stated the tablets were the facility's stocked medications stored in the cabinet with the facility's stocked medications for the residents. Review of the facility provided document titled Record of Med Room Temperatures dated ,d+[DATE], revealed missing entry of medication refrigerator temperature for [DATE]. During a brief interview on [DATE] at 2:55 PM the DON verified the Record of Med Room Temperatures was blank for [DATE] and should have the refrigerator's temperature entered, and did not. During a brief interview on [DATE] at 5:02 PM the Director of Nursing (DON) stated the facility did not have a medication storage policy or a medication refrigerator policy.

Based on observations, interviews, and review of records, the facility failed to provide one resident's (R) 23) of one resident sampled for communication, proper care, and treatment to maintain or improve her communication. The facility's deficient practice increased R23's risk of poor communication. Findings include: Review of Iowa code 2023, Professional Licensure .Speech pathologist and Audiologists . provided by the Occupational Therapist Assistant (OTA) stating, it was the facility's policy for speech therapy, revealed no information for resident's care for speech therapy. Review of LSVT[[NAME] Voice Treatment] LOUD program: Speech Therapy for Parkinson's Disease . undated documents provided by ST revealed .LSVT LOUD is an effective speech treatment for people with Parkinson's disease (PD) and other neurological conditions .Key to the treatment is helping people recalibrate their perceptions so they know how loud or soft they sound to other people and can feel comfortable using a stronger voice at a normal loudness level .add up to highly effective program that improves communication in everyday life .improves communication by helping you speak with a voice and volume that's easy for others to hear and understand. The treatment is built on tailored exercises that strengthen the voice box . and speech system .Another key is working with an LSVT LOUD Certified speech-language pathologist whose professional skills and training will ensure that you improve your voice in a healthy way . Review of R23's undated Admission Record located in her Electronic Medical Record (EMR), under the Profile tab, revealed, the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses to include Parkinson's disease, dementia without behavioral disturbances, speech disturbance, life management difficulty, unspecified voice and resonance disorder [Resonance Disorders are not voice disorders, although they are often mislabeled as such. Resonance disorder results from too much or too little nasal and /oral sound energy in the speech signal. They can result from structural or functional (e.g., neurogenic causes and occasionally are due to mislearning . according to American Speech-Language-Hearing Association website under heading Resonance Disorders]. Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/23 and located in her EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) with a score of 14 out of 15 indicating R23 is cognitively intact. Further review of the MDS revealed R23 has unclear speech-slurred or mumbled words, and diagnosis of Parkinson's. Review of R23's Physician's Orders 05/23, under Orders tab located on her Electronic Medical Record (EMR) revealed R23 did not have an order for speech therapy or voice therapy evaluation or treatment. Review of R23's comprehensive Care Plan under Care Plan tab located on her EMR revealed .Sometimes I have problems communicating r/t [related to] Expressive Aphasia, Weak or absent voice .I will be able to understand simple verbal choices and communicate by either pointing to things or word cards. Target Date: 06/01/2023 .It is hard for me to speak because of my Parkinson's. I can say a few words at times, I do have a 3-ring binder in my room that has common words of things that I may need, I can point to words and tell you what I'm needing .Refer to speech therapy for evaluation and treatment as ordered or requested by myself, or my family . initiated 11/17/21. There were no interventions for voice therapy evaluation or treatment. During an interview on 05/02/23 at 3:21 PM, R23 responded by saying her name. R23's speech was slow. R23 answered questions non-verbally with nodding her head up and down or shaking her head from side to side. During an interview on 05/02/23 at 3:51 PM with Certified Nursing Assistant (CNA)1, CNA1 stated, she had trouble communicating with R23, and some days it was very difficult. CNA1 stated, R23 pointed at things, and she tried to figure out what R23 wanted. CNA1 stated, she did not know if the facility provided R23 with speech therapy. During an interview on 05/03/23 at 2:38 PM with Restorative Coordinator (Aid) (RC) stated, she communicated with R23 with sticky notes or sometimes she guessed and used R23's physical cues to determine what R23 would like. RC verified R23's care plan interventions for communication were three ring binder in her room that has common words of things that she may need, she can point to words and tell them what she was needing initiated on 11/11/21. RC verified R23 had a referral for speech therapy as needed or requested by herself or her family, initiated on 11/11/21. RC stated there was no information on R23's task regarding communication and it would be helpful to include her task on her EMR for the staff. RC verified R23's assessment under therapy alert did not include an assessment regarding her communication or deficiency of her communication and there should be a note from speech therapist. During an interview on 05/04/23 at 10:12 AM with Licensed Practical Nurse (LPN)1 stated R23 had trouble communicating. LPN1 stated R23 had a notebook with pictures and was able to write notes of what she wanted. LPN1 stated at times R23 wanted to talk to her daughter and called her daughter on her phone and handed LPN1 the phone. LPN1 stated there were times when she got frustrated because she cannot speak/communicate. LPN1 stated she used her finger to point at things also. During an interview on 05/04/23 at 10:30 AM the Speech Therapist (ST) stated R23 has a Parkinson's diagnoses, it had gotten worse, affecting her speech and her swallowing. ST stated she implemented a communication binder. ST stated R23 could verbally communicate if she wanted to, and the resident has control over her ability to communicate. ST stated R23 verbally communicated when she was frustrated. ST confirmed R23 had a diagnosis of speech disturbances, dysphagia and voice and resonance disorder. ST stated voice treatments [LSVT [[NAME] Silverton Voice Treatment] LOUD program was performed by a certified speech therapist at another location for residents with Parkinson diagnosis. ST stated she did not refer R23 for voice treatment because R23 does not like to leave the facility, and she thought that R23 would not be open to leaving for speech therapy/voice. ST stated she did not specifically ask R23 if she wanted to do voice treatment. ST stated she should have asked R23 if she wanted voice treatment or to be evaluated for voice treatments. ST stated the facility did not send R23 for a voice treatment and should have sent her for an evaluation and treatment. ST stated the voice treatments could help her communicate better.

Based on staff interviews and record review, the facility failed to ensure an antibiotic for a urinary tract infection (UTI) was provided timely for one of one resident (Resident (R) 18) reviewed for timely medication administration. There was a total sample of 14 residents. Findings Include: 1) Review of R18's Admission Record in the Electronic Medical Record (EMR) under the Resident tab revealed R18 was admitted on [DATE]. Diagnoses included UTI, nondisplaced fracture of first cervical vertebra and dementia. Review of R18s Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/16/23, located in the EMR, under the MDS tab, revealed R18 had a Brief Interview of Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. R18 required extensive assistance for most activities of daily living (ADL). Review of R18's Care Plan dated 04/11/23 in the EMR under the Care Plan tab, revealed R18 I have mixed bladder incontinence related to activity intolerance, impaired mobility, history of UTI. R18's goal was to Experience adequate management of UTI's discomfort and incontinence. Interventions included Encourage me to drink fluids of choice during the day and in the early evening to help prevent dehydration and UTIs .Watch and report if I show the following s/sx (signs/symptoms) of UTI. Review of R18's Progress Notes revealed R18: -On 02/06/23 UA (urinalysis) results received per fax. Results faxed to ARNP (Advanced Registered Nurse Practitioner). -On 02/08/23 Return urinalysis received from ARNP with Awaiting Sensitivity. -On 02/11/23 Final urine culture results returned and placed in (physician) folder for review . -On 02/14/23 Received signed orders on UA C&S (Culture and Sensitivity) per ARNP to begin Macrobid (antibiotic) 100 mg (milligrams) po (by mouth) BID (twice per day) x (times) 7 days. During an interview with the Director of Nursing (DON) and the Resident Care Coordinator (RCC) for the East Hall, on 05/04/23 at 12:57 PM, the DON stated the facility did not have a policy for staff to communicate with the physician for timeliness on lab results and follow-up. The DON and the RCC for the East Hall agreed the medication took too long to be administered based on the positive UA results and nursing staff should have followed up with the physician to determine if an antibiotic should be ordered. During an interview with Licensed Practical Nurse (LPN)1 on 05/04/23 at 11:07 AM, she stated if she received lab results for a resident that indicated the resident had a UTI, she would fax the results to the physician. She stated if she did not hear from the physician during her shift or at the end of her shift, she would contact the physician to ensure the results were received and determine if the physician had any further orders. During an interview with LPN2, on 05/04/23 at 11:12 AM, she stated she would want the physician to respond during her shift. She stated if she had not heard from the physician before the end of her shift, she would pass it on to the next nurse at shift change. She stated three days to wait to hear from the doctor was too long to wait.

Based on observations, interviews, and review of records and the facility's policy, the facility failed to determine one resident (Resident #11) of one resident sampled, was assessed as being clinically appropriate to safely self-administer their own medications. The facility's deficient practice increased Resident #11's risk of medication errors and unsafe medication administration. Findings include: Review of the facility's policy titled Self-administration of Medications 10/05 provided by the facility revealed .Each resident has the right to self-administer medications after the Interdisciplinary Team has assessed the resident and determined the resident can safely complete the task .If a resident expresses a desire to self-administer medications the DON [Director of Nursing] and Interdisciplinary Team must be notified prior to allowing the resident to self-administer the medication .This request will be documented in the Interdisciplinary Notes of the resident's medical record .A physician's order .allowing .self- administration of medications will not be honored until the Interdisciplinary Team has assessed the resident for ability to administer the medication (s) safely Medications will be administered by the licensed nurse or certified medication aide until the Interdisciplinary Team determines the resident can safely store and /or self-administer medication (s) in a safe manner . Review of Resident #11's undated Admission Record located in his Electronic Medical Record (EMR), under the Profile tab, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including diabetes, cognitive communication deficit, and problems related to life management difficulty. Review of Resident #11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/23 and located in his EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15, indicating R11 is cognitively intact, and was administered insulin injections 7 out of 7 days. Review of Resident #11's Physician's Orders 05/23 under the Orders tab located in his EMR revealed there was no order for self-administration of his insulin. Review of Resident #11's Medication Administration Record (MAR) 05/23 under the Orders tab located in his EMR revealed there was no order for self-administration of his insulin. Review of Resident #11's comprehensive Care Plan under Care Plan tab located in his EMR revealed .prefer to take my insulin with me when I go out to eat with family and friends. I am able to self-administer my insulin independently target date 06/11/23 . Review of Resident #11's Self-Administration of Medication assessment dated [DATE], under the Assessment tab located in his EMR revealed The Resident can correctly administer subcutaneous injections with an entry indicating that this does not apply. During a medication administration observation on 05/03/23 at 10:30 AM of Licensed Practical Nurse (LPN)1 prepping Resident #11's medication at the North Medication Cart, LPN1 withdrew 7 units of Resident #11's Novolog insulin vial into a syringe. LPN1 stated, Resident #11 wanted to take his insulin with him (out of the facility) and self-inject it. LPN1 placed Resident #11's medication (syringe with insulin) in his left front shirt pocket with the safety cap down and plunger hanging out of his pocket and an alcohol prep. LPN1 stated, he was going out of the facility that day, and was taking his insulin with him. During an interview on 05/03/23 at 11:04 AM with LPN1, LPN1 verified Resident #11 did not have a physician's order to self-administer his insulin and should have an order to do so. LPN1 verified Resident #11's self-administer assessment revealed it was not applicable for him to self-administer his medication. LPN1 verified Resident #11 had a care plan intervention to self-administer his insulin. LPN1 stated, Resident #11's care plan interventions and physician's orders should be consistent, and they were not consistent. During an interview on 05/04/23 at 7:24 PM the Director of Nursing (DON) stated, the nursing staff were responsible for administering Resident #11's medications, including his insulin. The DON stated she was aware Resident #11 was given his insulin syringe to take out of the building with him, so he could self-administer his medication, and should not have. The DON confirmed, the facility failed to ensure Resident #11 had an assessment for self-administration of his insulin or a physician's order to self-administer his insulin and should have ensured he had the assessment and order. The DON confirmed Resident #11 does have a care plan intervention to self-administer his insulin.

Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two residents (R6 and R31) of 14 residents selected for care plan review. Specifically, for R6's diuretics/dehydration, and R31's exit seeking and wandering behaviors. Findings include: 1) Review of R6's Admission Record, located under the Profile tab of the electronic medical record (EMR) indicated R6 was admitted to the facility on [DATE] had diagnoses of chronic systolic (congestive) heart failure, chronic kidney disease, stage 3, retention of urine and constipation. Review of R6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/11/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated the resident was severely cognitively impaired and that R6 had been on diuretics on seven of the last seven days of the assessment period. Review of R6's Progress Notes dated 04/10/2023 at 11:21 AM and located under the Progress Notes tab of the EMR indicated R6 runs a low BP at times. Today it was 95/41, pulse 88. The only med that affects BP is the Torsemide [a loop diuretic (water pill) that is used to treat fluid retention (edema) in people with heart failure, liver disease, or kidney disease.] 20 milligrams (mg) daily. He rarely has any edema, lungs clear. Would you consider decreasing the dose to 10mg daily or discontinuing it? Review of R6's undated Care Plan located under the Care Plan tab of the EMR revealed no care plan specific to diuretics or dehydration. During an interview with the Director of Nursing (DON) on 05/03/23 at 2:00 PM the DON stated that the Resident Care Coordinators (RCC) do the care plans, RCC1 is the RCC for the North Unit [where R6 is located]. During an interview with RCC1 on 05/04/23 at 9:48 AM, she stated that for residents who are on a diuretic, they do not necessarily need to have a care plan or monitoring for the diuretic. She stated that R6 is a hospice patient, and for them they don't typically do weights or labs. She stated that Torsemide is more for comfort for him, and that dehydration is part of the dying process. During end-of-life (EOL) care, it is better if you are dehydrated. She stated that they do monitor him with the weekly end of life assessments, and she stated he did not trigger for dehydration on his last one [MDS] because that is section V. After reviewing EOL assessments, they put an additional note in their assessment like a summary, there is the weekly hospice assessment that addresses dehydration and skin turgor. He is on10mg [of Torsemide]. I'm not saying he doesn't need one, but it depends on the situation of the individual, and she stated that in weekly monitoring and EOL assessments that the diuretics were being addressed. This writer referenced one other hospice resident from the same unit who did have a care plan for diuretics and RCC1 stated it was probably because he was on two different diuretics and that is why he triggered it. RCC1 stated that R6 was being adequately monitored. During an interview with DON on 05/04/23 at 2:01 PM she revealed that R6 was a hospice patient. Dehydration would trigger an end-of-life assessment, they [Hospice] are here at least once a week, they [Hospice] complete at least three full assessments, it [to have a care plan for diuretics or dehydration] wouldn't be appropriate. She stated that R6 was admitted on hospice and that expectation would include watching it[diuretics/dehydration] nearly as closely, it [diuretics/dehydration] didn't necessarily need to be care planned for him as opposed to someone else. It wasn't appropriate. She stated that it depended on the individual and the expectations of his care. She stated that she didn't feel like it needed to be in the care plan in this instance. 2) Review of the facility's policy titled Baseline Care Plan Guidelines dated 12/10/18, provided by the facility revealed no information related to the development of the ongoing care plan. This was the only policy the facility provided related to care plans. Review of R31's undated Resident Face Sheet in the Electronic Medical Record (EMR) under the Resident tab, revealed R31 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, senile degeneration of the brain, and difficulty in walking. Review of R31's quarterly Minimum Data Set (MDS) in the EMR, under the MDS tab, with an Assessment Reference Date (ARD) of 03/24/23, revealed R31 was unable to complete the Brief Interview for Mental Status (BIMS) indicating R31 had severe cognitive impairment. The staff assessment revealed R31 had difficulty concentrating on things and being short-tempered. R31 had delusions and verbal behavior directed towards others. R31 was independent with all Activities of Daily Living (ADL). Review of R31's Progress Notes in the EMR, under the Progress Note tab, revealed six attempts to exit seek or wander into other resident's rooms. These attempts were documented on 04/14/23, 04/17/23, 04/19/23, 04/24/23 and twice on 04/26/23. Review of R31's Care Plan in the EMR, under the Care Plan tab revealed no documentation related to exit seeking behaviors and/or wandering. During an interview with Licensed Practical Nurse (LPN)2, on 05/03/23 at 12:15 PM, she stated exit seeking and wandering should be on the care plan. She confirmed R31's care plan did not include any exit seeking or wandering behaviors. During an interview with the Director of Nursing (DON) on 05/03/23 at 1:54 PM, she stated that exit seeking, wandering and all interventions should be included in the care plan. The DON confirmed R31's care plan did not include this information but should.

Based on observations, interviews, and record reviews the facility failed to ensure one resident (R)35) of two sampled residents reviewed for activities of daily living (ADL) received assistance with nail care. The facility's deficient practice increased R35's risk of poor personal hygiene. Findings include: The following facility policies for review: Nail Care, ADL and/or Personal Hygiene were requested from the Resident Care Coordinator (RCC)2. On 05/02/23 at 5:04 PM the RCC2 stated, the facility does not have policies for resident's personal hygiene, nail care or ADL care. Review of R35's undated Admission Record located in her Electronic Medical Record (EMR), under the Profile tab, revealed she was initially admitted to the facility on [DATE] with diagnoses including cognitive communication deficient, delusional disorder, depressive disorder, anxiety disorder, and sleep disorder. Review of R35' s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/23 and located in her EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) with a score of 14 out of 15 indicating R35 is cognitively intact. Further review of the MDS revealed R35 was delusional (potential indicators of psychosis), had no verbal or physical behavior towards others, did not reject care or wander and required one person assistant with personal hygiene. Review of R35's comprehensive Care Plan under Care Plan tab located on her EMR revealed . I need assistance with my ADL's related to: Limited Mobility, Stroke with left upper & lower extremities flaccid, Weakness, expressive aphasia, left field visual deficit, fracture, hx. [history] endometrial cancer, HTN [hypertension] .Personal Hygiene/Oral Care: I require substantial assistance to maximize my independence . with a target date of 07/23/23. During an observation on 05/01/23 at 3:42 PM R35's right hand fingernails were observed to be long and unclean/dirty with brown particles. During a second observation and concurrent interview on 05/02/23 at 02:30 PM of R35's right-hand unclean/dirty fingernails with R35's Family Member (FM)1. FM1 confirmed the resident's right-hand fingernails were dirty. During a brief interview on 05/02/23 at 3:28 PM Certified Nursing Assistant (CNA)1 stated the facility expected the CNA staff to clean the resident's nails daily, and as needed and did not expect resident's nails to be dirty. CNA was assigned to the West Hall, where R35 is located. During a third observation on 05/02/23 at 3:30 PM of R35's right hand, CNA1 confirmed the resident's nails were unclean/dirty. CNA1 stated R35's fingernails were not clean, and she expected them to be clean and not dirty. During an interview on 05/02/23 at 4:35PM, RCC2 stated, the nursing staff were responsible for trimming resident's nails. RCC stated, the CNA staff were responsible for cleaning the resident's fingernails as needed. RCC stated, her expectation was for the resident's nails to be clean and not dirty. During an interview on 05/03/23 at 10:01AM with CNA2, CNA2 stated, she provided nail care including cleaning and filing the resident's nails daily with the resident's AM [morning] care every day and documented on the resident's EMR. CNA2 stated the nursing staff were responsible for cutting the resident's nails. During an interview on 05/04/23 at 6:02 PM with the Director of Nursing (DON) stated, she expected her aids to provide resident's nails care including cleaning the resident's fingernails in the morning when they provide ADLS, and on shower days. The DON stated she expected the resident's nails to be clean and not dirty. The DON stated the facility did not have a policy regarding resident's nail care. The DON stated the staff were guided in new employee orientation to provide nail care as needed and on the resident's shower days.

Based on clinical record review, policy review and interviews the facility failed to perform Medication Regiment Review (MRR) to review resident's medical records for medication irregularities during the months of June through October for 1 of 5 Residents (Resident # 31). The facility reported a census of 47. Findings included: The admission Minimum Data Set (MDS) dated [DATE] for Resident #31 reported she admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe impairment of cognition. The MDS included diagnoses of hypertension and Alzheimer's disease and received antipsychotic and antidepressant 7 out of 7 days during the look back period. The 5 day MDS dated [DATE] for Resident #31 reported her to be severly impaired for cognitive skills of daily decision making. The MDS reported diagnosis of hypertension and Alzheimer's disease and received antipsychotic and antidepressant 6 out of 6 days during the look back period. Resident #31's Care Plan with a target date of 12/22/21 included a focus area for the use of [CONDITION(S)] medications and had a goal to not have adverse side effects form the use of [CONDITION(S)] medications. The Care Plan had interventions to discuss with the doctor, and family regarding ongoing need for the use of medication and to monitor, document and report any adverse reaction of [CONDITION(S)] medication. The Medication Administration Review (MAR) for Resident #31 for June through October included the following; a. [MEDICATION(S)] (an antipsychotic) tablet 2 mg, give 1 tablet by mouth one time a day with a start date of 6/16/21. b. [MEDICATION(S)] (an antidepressant) tablet 50 mg, give 1 tablet by mouth one time a day for mood with a start date of 6/16/21. c. [MEDICATION(S)] (an antidepressant and sedative) tablet 50 mg by mouth one time a day with a start date of 6/15/21. Resident #31 Order Recap Report dated 12/9/21 for the dates 6/15/21- 11/12/21 included the following; a. [MEDICATION(S)] (an antipsychotic) tablet 2 mg, give 1 tablet by mouth one time a day with a start date of 6/16/21. b. [MEDICATION(S)] (an antidepressant) tablet 50 mg, give 1 tablet by mouth one time a day for mood with a start date of 6/16/21. c. [MEDICATION(S)] (an antidepressant and sedative) tablet 50 mg by mouth one time a day with a start date of 6/15/21. The facilities undated policy titled Drug Regimen Review included the following: Policy * The consultant pharmacist performs a Drug Regimen Review (DRR) review of each resident's medical chart at least monthly. * The DRR included evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings recommendation and irregularities are reported to the director of nursing, the attending physician, the medical director and if appropriate the administered. Procedures * The facility assures that the consultant pharmacist has access to resident and the resident' medical records; provider pharmacy's resident medication profiles, if requested; the facility's records of medication receipt and disposition; medication storage areas; and controlled substances record and supplies. The facilities undated policy titled Documentation and Communication of Consultant Pharmacist Recommendations included the following: Policy * The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding resident's medication therapy are communicate to those with authority and or responsibility to implement the recommendation and responded to in an appropriate and timely fashion. Procedures * A record of the consultant pharmacist's observations and recommendation is made available in an easily retrievable form to nurses, physician and the care planning team. That should include: a. The consultant pharmacist document potential or actual review findings appropriate for prescriber, medical director and or nursing review. b. This procedure may be altered for interim medication regiment reviews conducted off-site between routine monthly consultant pharmacist visits. During an interview on 12/09/21 at 11:31 AM the Administrator explained she had talked to corporate about surveyor access and not being able to see MMR reviews for Resident # 31. The Administrator acknowledged the MMR for Resident #31 did not show on her computer either yesterday when she had shown the screen, only thing that appeared would have been the November review. During a subsequently interview on 12/09/21 at 11:48 AM the Administrator explained on admission the family choose a different pharmacy not the facilities primary pharmacy. After she called corporate and then electronic record company they had a filter that needed changed so all residents medication would be reviewed. The Administrator explained Resident # 31 became covid positive on 10/26/21 and placed on skilled services so the facilities primary pharmacy reviewed her medications in November. The Administrator acknowledged Resident #31's medications were not reviewed June -October 2021.

Based on clinical record review, observation, staff interview, and facility pericare policy, the facility failed to provide incontinence cares in a manner to minimize the risk for cross-contamination and potential infection for one of three residents observed for incontinence cares (Resident #21). The facility reported a census of 47 residents. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had impaired short-term and long-term memory and severely impaired decision making skills. The MDS revealed the resident required extensive assistance of two persons for bed mobility, transfers, toileting and dressing, and limited assistance of one person for personal hygiene. The MDS coded the resident had bladder and bowel incontinence. The Care Plan revised 11/5/21 identified the resident had bladder incontinence and required assistance with activities of daily living related to impaired mobility, confusion, and muscle weakness. The Care Plan documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff directives included extensive assistance of one staff for dressing, bed mobility, and personal hygiene, check and change the resident every 2-3 hours and as needed (PRN), don a pull-up brief during the day and a brief at night, and watch and report any signs or symptoms of [CONDITION(S)]. Observations on 12/08/21 at 9:52 AM revealed Resident #21 lying in bed. Staff A, Certified Nursing Assistant (CNA) washed her hands and donned a pair of gloves. Staff B, Licensed Practical Nurse (LPN) had gloves and a gown on when the surveyor entered the residents room. Staff B placed a plastic bag with a package of Tena disposable wipes and gloves on a folding chair by the bed. Staff A uncovered the resident, removed the tabs on the resident's brief, and pushed the brief back toward the scrotal and buttocks area. Staff A used her gloved hand and opened the lid on the Tena disposable wipes and removed a disposable wipe from the package. Staff A took the disposable wipe and cleansed the tip of the resident's penis. Staff A stated the wastebasket not in reach and requested Staff C, temporary aide (in training), place the wastebasket closer. Staff A threw the soiled wipe toward the wastebasket but missed the wastebasket and the soiled wipe landed on the carpet next to the folding chair. Staff A took another disposable wipe and cleansed the penis, then removed her gloves, sanitized her hands, and donned a pair of gloves. Staff A took disposable wipes and cleansed the resident's groin, then changed gloves again. Staff A took a disposable wipe and cleansed the right buttock in a downward motion from back to front twice. Staff B and Staff A assisted the resident to roll onto his right side. Staff A took a disposable wipe and cleansed his left buttock in a downward motion. Staff A and Staff B changed gloves, hand sanitized, and donned clean gloves. Staff A tucked the soiled wet brief under the resident's bottom, then placed a clean brief under the resident's bottom, rolled the resident onto his right side again, removed the soiled brief, then pulled the clean brief up and between his legs. At 10:33 AM Staff B used her bare hand and picked up the soiled disposable wipe lying on the floor and placed the wipe in the wastebasket, then bagged up the trash. Staff B took the bag to a lidded hamper in the hall alcove, and hand sanitized. The Assistant Director of Nursing (ADON) stood in the room and observed during cares. In an interview 12/08/21 at 4:20 PM, the ADON reported the facility didn't have a policy or staff competency for pericare or incontinence cares. The ADON stated they just used the standard of care for pericare/incontinence cares that CNA's received during the CNA training course. The ADON reported she was uncertain when a skills fair held, but usually covered pericare during their skills fair. The ADON acknowleged she stood in Resident #21's room when staff performed cares on 12/8/21 but reported her faceshield fogged up and she had trouble seeing when staff performed incontinence cares. The ADON reported she expected staff used one wipe for each area cleansed, and cleansed front to back. The ADON stated no staff audits performed for pericare/incontinence care. The ADON stated she did not see Staff B pick up the soiled disposable wipe on the floor in Resident #21's room with her bare hand after cares completed on Resident #21. In an interview on 12/08/21 at 4:40 PM, the Administrator reported the facility didn't have a CNA competency or policy for incontinence cares or pericare. The facility used the Standard of Care Practice, which was part of the CNA course and skills testing. The Administrator reported the Nurse Managers performed spot audits and watched staff perform cares/incontinence cares. In an interview 12/09/21 at 1:20 PM, the Director of Nursing reported CNA class held through community college for their CNA's to obtain CNA certification. In an interview 12/09/21 at 2:02 PM the Administrator reported Staff A told her she became very nervous when surveyor watched her perform cares for Resident #21 on 12/8/21, and things spiraled out of control. The Administrator stated Staff A was upset she didn't do well and voiced concern she trained new staff to do things wrong. A facility's Pericare Review revealed the following steps: a. Wash hands b. Assemble supplies c. Apply gloves d. Remove soiled pads and clothing e. For males, cleanse tip of penis by pulling foreskin back f. Wash penis and scrotum g. Cleanse groin and upper pelvic area h. Turn onto side and cleanse buttocks front to back, and upper thighs i. Turn onto opposite side and cleanse hip areas j. Remove gloves and hand sanitize