Every finding on record at Mount Ayr Health Care Center

Based on observations, interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with food service safety for general practices of mealtime service. The facility reported a census of 24 residents. Findings include: Observed during the initial kitchen visit on 4/11/26 at 9:10 AM the following:The Cook's Refrigerator had an incomplete temperature log with missing data for 4/8 and 4/10/26.The bottom of the upright freezer contained a milky white frozen substance and crumbs across the bottom. The freezer contained a 5 gallon container of ice cream on the top shelf and frozen meats on the bottom shelf. Observed during the meal service on 4/12/26 at 11:50 AM Staff D, Dietary Aide, complete the following:The staff donned gloves without hand hygiene.Staff D used the right hand to cut the pie and load the sliced pie onto the pie server.Using the left gloved hand Staff D obtained dessert plates, placed them on the counter and touched the pie slices moving them off the pie server onto the dessert plates. Staff D obtained a bowl with the left gloved hand from a different part of the kitchen, placed it on the counter, and continued touching the pie slices while moving them onto a dessert bowl and plates from the pie server.Staff D completed the process of using the left hand to touch dessert plates and the slices of pie while removing them from the pie server for 16 pieces of pie.Staff D removed gloves and washed her hands.On 4/11/26 at 9:20 AM the Food Service Supervisor when asked about the incomplete temperature logs stated she expected the staff to complete the log(s) as required and had spoken with the staff about this task.On 4/12/26 at 1:00 PM the Food Service Supervisor stated when serving pie the staff should use a pie server and a fork to move the pie from the pie pan to the serving dishes. The Food Service Supershould not touch the pie with gloved or non-gloved hands. When looking at the bottom of the upright freezer, the Dietary Manager acknowledged that melted ice cream was on the bottom and should have been cleaned up. 4/12/26 at 1:15 PM the Administrator concurred that cleaning of kitchen appliances and logging of temperatures needed to be completed; as well as staff should not be touching food and serving dishes with the same gloved hand. The facility's Food Service Hand Hygiene and Glove Use Policy, dated 4/9/25, revealed that hand washing should occur for at least 20 seconds before and after glove use. The document provided that gloves should be changed when touching contaminated surfaces and after any interruption. The facility's Chest Freezer Policy signed 2/11/12 revealed the kitchen chest freezer should be cleaned monthly consisting of unplugging one freezer at a time, moving items to another freezer, defrosting, washing with hot detergent water, rinsing, sanitizing , air drying/wiping with clean dry cloth, plugging in the freezer, cooling to zero and replacing the food. The facility's General Cleaning Guidelines signed 2/11/12 revealed all items should be cleaned after use, immediately as possible using basic cleaning rules of washing, rinsing and sanitizing unless specified otherwise. The facility's Refrigeration Equipment Temperature Policy revealed temperatures should be taken and recorded daily on all refrigeration equipment to ensure food was stored at appropriate temperatures.

Based on clinical record review, staff interviews, and policy review, the facility failed to notify the Long-Term Care State Ombudsman of a transfer to the hospital for 2 of 2 residents (#13, #28). The facility reported a census of 24 residents.Findings include:1.Resident #13's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of high blood pressure, coronary artery disease (heart blood vessels), diabetes mellitus, thyroid disorder, and non-Alzheimer's dementia. It revealed the resident was dependent with shower transfers, required maximal assistance with bathing, setup assistance with eating and oral hygiene, supervision with all other Activities of Daily Living (ADLs), and was independent with all other mobility.A Health Status Progress Note dated 3/03/26 at 10:56 PM revealed the resident sustained a fall and was transferred to the hospital for an evaluation. A subsequent Health Status Progress Note dated 3/04/26 at 1:30 AM revealed the resident returned to the facility. The Care Plan dated 3/04/26 included a fall intervention regarding the resident's room environment.An undated Notice of Transfer Form to Long-Term Care Ombudsman document did not include Ombudsman notification of Resident #13's transfer to the hospital on 3/03/26.2. Resident #28's Discharge MDS dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses diabetes mellitus and hypothyroidism. It revealed the resident was dependent with tub and shower transfers, required moderate assistance with bathing, supervision with car transfers, setup assistance with eating, dressing, and personal hygiene, and was independent with all other ADLs and mobility. It also revealed that 3/28/26 was the resident's planned discharge date .A Health Status Progress Note dated 3/28/26 at 8:17 AM indicated Resident #28 was discharged home with family. An undated Notice of Transfer Form to Long-Term Care Ombudsman document did not include Ombudsman notification of Resident #28's discharge home on 3/28/26.On 4/12/26 at 9:05 AM, the Administrator stated he wasn't aware Resident #13's transfer required Ombudsman notification due to the short amount of time she was away from the facility. He also stated he overlooked Resident #28's discharge Ombudsman notification because it occurred on a weekend day.An undated policy titled Transfer Discharge Notification Policy indicated it was the responsibility of the facility to notify the long term care ombudsman monthly of the transfer to hospital and discharges that may occur.

Based on clinical record review, staff interviews, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #5), who was diagnosed with a new mental disorder diagnosis since admission to the facility. The facility reported a census of 24 residents.Findings include:Review of the facility provided document Pre-admission Screening and Resident Review (PASRR) completed on 12/29/21 identified the following: Diagnoses of major depression (current), anxiety disorder (current) and mental retardation. No substance related disorder, diagnosis of dementia/neurocognitive disorder.No known mental health symptoms affecting the individual's ability to think through or complete tasks which she should be physically capable of completing. No known recent or current mental health symptoms.No mental health services now or in the past.Medications of Abilify 30 mg for depression, Clonazepam 1.5 mg for anxiety and Sertraline 150 mg for depression. Level I Positive, No Status Change. No Level II required at this time, no status change. Level II was completed on 10/21/21 with a non-time limited approval which will remain valid. Level II not currently required. If exacerbation related to mental illness or discrepancy in reported information then status change should be submitted.The clinical record census disclosed Resident #5 was admitted to the facility on [DATE].The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS recorded no mood or behaviors during the reporting period. The MDS documented diagnoses that included: anxiety disorder, depression and psychotic disorder. The MDS documented the resident received antipsychotic, antianxiety and antidepressant medication on 7 out of 7 days of the assessment reference period. The MDS assessment dated [DATE] for Resident #5 recorded the resident displaying other behavioral symptoms not directed toward others for 1 to 3 days over the last 14 days. The document revealed diagnoses of anxiety disorder, depression and psychotic disorder. The MDS documented the resident received antipsychotic, antianxiety and antidepressant medication on 7 out of 7 days of the assessment reference period.The MDS assessment dated [DATE] for Resident #5 recorded no mood or behaviors during the reporting period. The MDS documented diagnoses of anxiety disorder and depression. The MDS documented the resident received antipsychotic, antianxiety and antidepressant medications during the last 7 days of the assessment reference period. The Care Plan revised 11/11/25 identified the resident had a behavioral problem due to delusional disorder which she exhibits paranoia likely related to mild intellectual disorder (revised 5/26/25). The Care Plan identified staff interventions of therapy for mood/behaviors monthly and target behaviors including thoughts of having no friends, no one likes her or others are picking on her - paranoia. The clinical record's medical diagnoses included: Delusional disorder (paranoid) dated 5/13/25 during stay.Generalized anxiety disorder dated 10/25/21 admission.Major depressive disorder dated 10/25/21 admission.Mild intellectual disabilities dated 10/25/21 admission. The clinical record's physician orders included:Clonazepam .5 mg. 1 tablet three times daily (TID) related to generalized anxiety disorder 4/9/26.Aripiprazole (Abilify) 12.5 mg. 1 tablet daily (QD) related to delusional disorder 5/14/25.Aripiprazole 10 mg. 1 tablet QD related to delusional disorder revised 5/13/25.Sertraline 50 mg. Give 2.5 tablets QD for generalized anxiety disorder, major depressive disorder, recurrent, mild. The clinical record's progress note titled Health Status Note on 5/13/25 at 4:39 PM revealed nursing would like to review options for other medications if possible for anxiety, mood swings and temper tantrums. The entry included medication and diagnosis list reviewed and updated with diagnosis of paranoid delusional disorder.The clinical record's progress note titled Consulting Pharmacy Note on 5/13/25 at 2:52 PM included the primary care physician documented approval for a gradual drug reduction of Abilify to 10 mg AM and 12.5 mg PM with a diagnosis of paranoid delusions as the resident had a history of paranoia. The document included acknowledgement by the pharmacy of updating the new diagnosis. In an interview on 4/12/26 at 2:45 PM the Director of Nursing (DON) stated she completed the PASRR for the facility. The DON concurred that the most recent PASRR was completed on 12/29/21 and the diagnoses and non-treatment/identification of mental health symptoms contained within it. When reviewing the current physician orders and diagnoses, the DON admitted that a new PASRR should have been completed with the additional diagnosis of delusions. The DON stated a new PASRR should be completed with medication and diagnosis changes, severe behaviors that would trigger a Level II or if a resident was no longer demonstrating previously identified behaviors. In an interview on 4/13/26 at 9:30 AM the Administrator acknowledged he was made aware of the missed PASRR and that one should have been completed with the addition of a new mental health diagnosis. The facility policy titled Preadmission Screening and Resident Review (PASRR) dated 4/12/26 directed staff that a new PASRR evaluation must be initiated when there is a significant change in condition including a new diagnosis of mental illness, intellectual disability or related condition and recommendation for specialized services. The document disclosed the interdisciplinary team was responsible for identifying these changes and notifying the appropriate staff to initiate a PASRR review.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access by leaving 2 residents' information accessible when staff walked away from the Electronic Health Record (EHR) laptop. The facility reported a census of 24 residents. Findings include: On 4/11/26 at 11:44 AM, Staff A, Licensed Practical Nurse (LPN) walked away from the medication cart located in the lobby to get a cup for a resident. The laptop was open and Resident #16's medication list was visible on the screen. Resident #6 was continuously wandering around the lobby.At 11:46 AM, Staff A returned to the medication cart and stated she usually closes the laptop but thought her task would be completed quickly.At 11:57 AM, Staff A walked away from the medication cart in the lobby to administer medications to a resident in the dining room. The laptop was open and Resident #10's medication list was visible on the screen. A policy titled Securing Resident Records Policy dated 9/12/25 indicated it was the policy of the facility to ensure the confidentiality, security, and integrity of all resident records, including both electronic and paper records, in accordance with CMS regulations, HIPAA requirements, and facility standards. It also indicated All staff are responsible for protecting resident information from unauthorized access, use, or disclosure at all times.On 4/13/26 at 1:52 PM, the Director of Nursing (DON) stated staff should've locked the laptop screen before leaving the medication cart.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to implement infection control practices by manipulating a catheter drain spigot with gloves previously used during resident transfer (Resident #1). The facility reported a census of 24 residents.Findings include:Resident #1's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderately impaired cognition. It included diagnoses of cancer, benign prostatic hyperplasia (BPH - enlarged prostate), kidney failure, and neurogenic bladder (bladder dysfunction caused by nerve damage). It indicated the resident required setup assistance with eating, maximal assistance with oral hygiene, showering, and turning in bed, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It also indicated the resident had an indwelling catheter (urinary catheter) in the 7-day look-back period.An Orders-Administration Progress Note dated 2/26/26 revealed the resident's indwelling urinary catheter was changed due to decreased urine output. It indicated the catheter would be changed monthly and as needed.The Care Plan revised 12/24/25 indicated the resident had an indwelling catheter and directed staff to wear a gown and gloves when performing high-contact resident care activities.During a continuous observation on 4/12/26 that began at 8:41 AM, Staff B, Certified Nurse Aide (CNA) and Staff C, CNA transferred Resident #1 in a mechanical lift from his wheelchair to his recliner. After the resident was seated in his recliner, Staff B used the same gloves and grabbed the urine measuring cylinder in a plastic bag, raised the resident's right pant leg, held the cylinder in her left hand, unscrewed the urine drainage bag spigot with her left hand, and emptied the urine into the cylinder. Staff B wiped the spigot tip with an ETOH pad, closed the spigot, and emptied the urine into the toilet. Hand hygiene nor a glove change were performed throughout the observed process.At 8:46 AM, Staff C stated Staff B should have performed hand hygiene and changed her gloves prior to accessing the resident's urinary catheter bag.At 9:05 AM, Staff B stated she didn't feel she missed a hand hygiene or glove change opportunity throughout the transfer and accessing the urinary drainage bag process. She also stated touching reusable equipment and resident linen or clothes with gloved hands does not contaminate the gloves.A policy titled Catheter Care Procedure - Indwelling or Suprapubic Catheters dated 8/28/25 indicated it was the policy of the facility to provide catheter care at least twice daily and directed staff to always use standard precautions and hand hygiene.A policy titled Facility Wide Infection Control reviewed 1/20/23 indicated standard precautions will be implemented in the following manner:HandwashingWash hands after touching blood, body fluids, secretions, excretions, and contaminated items, regardless of whether gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients and environment. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination of different body sites. (Refer to handwashing procedures.)A plain soap will be used for routine handwashing, unless otherwise specified.On 4/13/26 at 1:48 PM, the Director of Nursing (DON) stated staff should've performed hand hygiene and changed gloves prior to accessing the resident's urinary drainage bag.

Based on clinical record review, staff interview, guidance from the Centers for Disease Control and Prevention (CDC) and facility policy review, the facility failed to offer the recommended pneumococcal vaccine to 4 of 8 residents reviewed for vaccines (#06, #11, #23, and #29). The facility reported a census of 34 residents. Findings include: 1) The vaccine record of Resident #06 indicated the resident had not received or refused the appropriate pneumococcal vaccine. The Electronic Health Record (EHR) revealed an 8/14/50 date of birth. 2) The vaccine record of Resident #11 indicated the resident had not received or refused the appropriate pneumococcal vaccine. The Electronic Health Record (EHR) revealed a 4/03/26 date of birth. 3) The vaccine record of Resident #23 indicated the resident had not received or refused the appropriate pneumococcal vaccine. The Electronic Health Record (EHR) revealed a 5/16/46 date of birth. 4) The vaccine record of Resident #29 indicated the resident had not received or refused the appropriate pneumococcal vaccine. The Electronic Health Record (EHR) revealed an 7/19/47 date of birth. On 4/08/25 at 3:11 PM, the Assistant Director of Nursing (ADON) stated the physicians haven't addressed it yet and there was no rationale for why residents didn't get offered the pneumonia vaccine. She added the facility had focused on COVID 19 and influenza vaccinations. On 4/09/25 at 8:48 AM, the Administrator stated staff should have coordinated an interdisciplinary approach to identify residents who meet criteria to receive appropriate vaccinations. The CDC document titled Adult Immunization Schedule Notes, dated 11/21/24 documented the following: Age [AGE] years or older who have: Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21. If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose. Previously received only PCV13: 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PCV13 dose. Previously received only PPSV23: 1 dose of PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose. An undated facility policy titled Policy and Procedure for Pneumovacs, Flu, & COVID Vaccinations indicated the following: It is the policy of our facility that upon admission, new residents will be screened for their last pneumovac when admitted to our facility. If the resident is unable to specify date of pneumovac, their family and/or physician may be asked. If it is found that the resident had not had the pneumovac, the physician will be contacted to see if the wants the resident to have the injection or if it is medically contraindicated. If the physician orders for the resident to have the pneumovac, the resident and/or family will be educated on the benefits and potential side effects of the pneumovac through information provided by public health. If the resident and/or family choose for the resident to receive the vaccination it will be obtained from their primary care physician and note din the chart. If the resident and/or family refused the pneumovac, the refusal will be noted in the chart. For residents at high risk for pneumonia or whom are frequently contracting respiratory illnesses, should the doctor feel a booster or 2nd pneumovac needed, it will be given per his direction.

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to perform hand hygiene between touching non-food items and handling raw food in the kitchen. The facility reported a census of 34 residents. Findings include: On 4/08/25 at 8:25 AM, a kitchen observation revealed the Certified Dietary Manager (CDM) opened several packages of raw pork chops, grabbed a can of cooking spray with her gloved right hand and sprayed the grill. She then grabbed a bottle of Olive Oil blend with the same hand and poured some on the grill. Afterward, she grabbed a pork chop in each hand, gloved right hand and ungloved left hand, and placed them on the grill. She repeated this process for eight (8) pork chops. At 8:42 AM, a second observation revealed the CDM donned gloves, grabbed the Olive Oil blend with her right hand and poured oil on grill then handled more raw pork chops. At 12:20 PM, the CDM stated she was told touching raw food with bare hands was permitted. She acknowledged she didn't perform hand hygiene and change gloves after handling non-food items. On 4/09/25 at 9:01 AM, the Administrator stated staff should have performed hand hygiene and donned new gloves between touching non-food items and handling food. An undated document titled Hand Washing & Glove Usage indicated: 4) Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. 5) Gloves are to be used whenever direct food contact is required. 6) Hands are washed before donning gloves and after removing gloves.

Based on clinical record review, staff and resident interviews, and policy review, the facility failed to provide follow-up assessment and intervention for 1 of 1 diabetic resident blood sugar (BS) result of 30 milligrams/deciliter (mg/dL) (#19). The facility reported a census of 34 residents. Findings include: On 4/06/25 at 10:57 AM, Resident #19 stated his blood sugar level dropped below 41 mg/dL within the last few days. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of peripheral vascular disease, diabetes mellitus (DM), non-Alzheimer's dementia, paraplegia, anxiety, and depression. It also revealed the resident required setup assistance with eating and oral hygiene, required moderate to maximal assistance with personal hygiene, dressing, bathing, and mobility, and was dependent with toileting and putting on and removing footwear. The Electronic Health Record (EHR) included a physician's order dated 7/14/24 that staff may check BS using accu-check fingerstick as needed when Dexcom not available. It also included a physician's order dated 3/31/25 for 10-day sensor Dexcom 6: change sensor every 10 days per instructions. apply to abdomen, back of arms, upper chest. blood sugar monitor for collection of blood sugar readings for SSI results every day shift every 10 day(s) for facility quality control. There was no physician order that identified a resident specific low BS level. It directed staff to follow the Care Plan as written. Blood Sugar Summary dated 4/01/25 at 4:28 PM revealed the resident's blood sugar result was 30 mg/dL and was signed by Staff B, Licensed Practical Nurse (LPN). The Medication Administration Record (MAR) dated April 2025 for the resident's sliding-scale insulin (SSI) indicated the resident's BS was 30 (mg/dL) on 4/01/25 at 5:00 PM. It referred to the EHR Progress Notes. The Progress Notes included an entry dated 4/01/25 at 4:28 PM that indicated the resident BS was 30 on our glucometer and 57 on his meter. No subsequent progress notes or BS results were entered on 4/01/25. The Nutrition Amount Eaten Response History indicated the resident ate 76%-100% of his lunch at 12:51 PM and 26%-50% of his dinner at 9:52 PM on 4/01/25. The Nutrition Snack Response History indicted the resident did not receive a snack on 4/01/25 until 9:52 PM. The Care Plan revised 7/14/24 directed staff that resident may have BS checked using Accu-Check Finger stick when machine isn't functioning due to resetting during changes, or when a questionable BS is obtained. On 4/07/25 at 2:46 PM, Staff C, LPN stated if a resident's BS is low, staff should get them some carbohydrates such as a peanut butter sandwich or some quick-acting sugar such as orange juice, or protein. She further stated staff should document the intervention in the progress notes and recheck the resident's BS one (1) hour later to ensure it is increasing. If it was still low, the nurse would repeat the food intervention and notify doctor. On 4/09/25 at 7:19 AM, Staff D, Registered Nurse (RN) stated the facility does not have a protocol identifying low blood sugars. She stated nurses are to document interventions in the nursing notes. She confirmed she uses the facility blood sugar results if there is a discrepancy between the resident's Dexcom and the glucometer. She further stated follow up blood sugar checks should be documented in the progress notes. Staff B, LPN was not available for an interview. On 4/09/25 at 8:27 AM, the Director of Nursing (DON) stated staff should have provided an intervention and rechecked the BS 30 minutes after. An undated document titled Blood Sugar Monitoring directed staff to utilize the American Diabetic Association (ADA) suggested treatment for hypoglycemic events (low BS). The ADA defines hypoglycemia as blood glucose levels below 70 mg/dL.

Based on observations, clinical record review, resident and staff interview, and facility policy review, the facility failed to follow the comprehensive care plan for 1 of 12 residents reviewed (Resident #13). Additionally, the facility failed to fully develop a comprehensive, resident centered care plan for 2 residents (Resident #28, Resident #12). The facility reported a census of 34 residents. Findings Include: 1. The Minimum Data Set (MDS) of Resident #13, dated 2/27/25 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented diagnoses that included anxiety disorder and depression, neurocognitive disorder with Lewy bodies and borderline personality disorder. The Care Plan, last reviewed 3/2/25, identified a Focus area of All About Me - Care/ADL (Activities of Daily Living) Preferences. Interventions included: - I like to nap often, usually in the morning and early afternoon then more of a night owl - This helps me feel better when I am upset: To talk to somewhat about what is bothering me The Care Plan identified a Focus area of chronic anxiety and depression, insomnia related to chronic health problems/pain, dementia and a stressed relationship with family. Interventions included: - Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.). Resident refuses at this time. January 2023- Resident agreed to try Encounter Telehealth for mental health services but refuses appointments when approached. To see Advanced Registered Nurse Practitioner (ARNP) for med management and tele talk therapy - with Licensed Social Worker but refuses every time - Facility Designated Social Service staff doing weekly visits - revision date 12/7/24. Observations on 4/6/25 at 11:21 am and 4/6/25 at 1:06 pm, resident was observed to be in her room with the lights off, lying in bed under the covers, appearing to be sleeping. On 4/7/25 at 9:20 am, resident was again observed in bed under the covers with the lights off. On 4/7/25 multiple residents were observed participating in group activities in the common area of the facility beginning at 10:00 am. Staff were observed going room to room inviting residents to attend. No observation was seen of any staff inviting Resident #13 to see if she desired to participate. On 4/7/25 at 11:41 am, Resident #13 was observed still in bed prior to lunch trays arriving. On 4/7/25 at 11:44 am, Staff A, Certified Nurse Aide (CNA) delivered a lunch tray to Resident #13. After exiting the room, Staff A stated Resident #13 will sit on the side of the bed to eat but she generally is in bed all day and all night. On 4/7/25 at 4:12 pm, the Director of Nursing (DON) stated this was the time of day that Resident #13 normally starts to wake up. She stated she prefers to keep the lights off all the time but she gets more awake around 4:00 or 4:30 in the afternoon and stays up most of the night. Review of the Social Services Notes for the care planned weekly visits revealed visits were documented on 12/4/24, 1/9/25, 2/6/25, 2/27/25 and 3/14/25. On 4/7/25 at 4:39 pm, the Social Service designee stated she was instructed to make notes of when Resident #13 refused the weekly visits but she stated she had failed to do that. She stated the weeks of no documentation were all times the resident had refused visits. She also stated she had completed a visit the week prior but had not yet documented that visit. She stated she thought Resident #13 did have depression, and felt she had been this way most of her life but it was better prior to her retirement. On 4/8/25 at 4:20 pm, Resident #13 stated she has cataracts in both of her eyes and the lights bother her. She stated she likes to lay down a lot and have her eyes closed but she is not necessarily asleep. She stated she has dealt with depression for many years but it was much worse when she was younger and still raising her children. She stated spending her time laying down in bed is more about her eyes than about depression. She added there are only two other residents in the building who she knows and she just prefers to be alone in her room. She stated a lot of residents like to spend their days out in the common area but she doesn't know them and she felt there was an age difference as well. She stated she had gotten divorced nearly [AGE] years ago and was used to being alone and she didn't find it challenging to be alone. Resident #13 stated the Social Services designee came to visit her probably once a month or so. She said she wears many hats in the facility and also assists with housekeeping in the facility. She stated they did visit when she was cleaning her room but they weren't sit down visits. She denied ever refusing a visit. She said the Social Services designee also works in the facility's Assisted Living area and is busy. On 4/9/25 at 10:28 am, the ADON stated they had spoken with the Social Services designee about the visits with Resident #13. She stated it was reiterated to document all visits including if the resident refused a visit. 2. The MDS of Resident #28, dated 3/27/25 identified a BIMS score of 0, which indicated severe cognitive impairment. The MDS documented the resident exhibited behavioral symptoms not directed toward others on 1 to 3 days of the 7-day look back period. The MDS documented diagnoses that included non-Alzheimer's Dementia and cancer. The MDS documented the resident received antipsychotic and antidepressant medications during the 7-day lookback period. The Care Plan, last reviewed 4/2/25, identified a Focus area of the resident having dementia. Interventions included: -Administer Seroquel (an antipsychotic medication) and Zoloft (an anti depressant medication) for dementia behaviors. Monitor for effectiveness. The Care Plan failed to identify any target behaviors for the medications. Review of Progress Notes revealed the following: -10/6/24 - A CNA reported to a nurse the resident was making several sexual comments towards her and laughing about it including asking her to climb into bed with him. -10/6/24 - An additional note of the resident attempting multiple times to touch young female staff members on their breasts and groin areas along with sexual verbal comments. -10/7/24 - Note of increasing sexual comments towards staff and attempts to inappropriately touch staff. Note stated due to his dementia, the resident does not remember these episodes a few minutes after they happen. The note stated the resident had also become very disruptive during activities calling other people stupid, telling them to shut up and using the F*** word. The note detailed the resident also expressed the same behaviors towards his hospice staff during a visit. -10/8/24 - Noted resident to be yelling and disruptive to other residents -10/9/24 - Noted outburst during church service, yelling and cursing at the pastor. When staff removed the resident from the area, he continued to be loud from down the hall. -10/23/24 - Noted the resident continued to be disruptive during activities, yelling at the activity director, calling other residents derogatory names and continued sexual behaviors towards female staff. -11/15/24 - Noted the resident was awake all night, yelling, pulling his alarm. Was noted he was being disruptive to other residents and was attempting to grab female staff inappropriately. -1/17/25 - Noted resident was alert, continuously hitting staff and claiming staff were bad people. The resident was mocking other residents and attempting to trip them. Resident taking spoons off of the medication cart and mixing the clean and dirty spoons together, and knocking clean cups off of the medications cart. While in the dining room, pounding his fists on the table. -1/23/25 - Noted increased behaviors. Resident screaming help me continuously for no apparent reason, wheeling himself around the facility and into the rooms of other residents, going through their belongings. Opening the shower door while it was in use. Trying to get other residents riled up. -1/26/25 - Noted resident to be combative, groping female staff, offering staff money for sexual favors. Resident also mocking staff and calling them derogatory names. -2/1/25 - Noted resident had been yelling, hitting and kicking. Threw water at a nurse. Removed alarm box off of the bedside stand and threw it into the bathroom. -2/7/25 - Grabbed a staff member's neck firmly when staff was providing cares. Another staff member had to assist to remove his hands and the resident attempted to hit the staff. -2/8/25 - Resident combative with staff, grabbing a staff member's hand and bending fingers backwards. -2/9/25 - Yelling at staff, swinging arms and hitting and then kicking the staff -2/25/25 - Multiple occurrences of grabbing female staff in inappropriate places during the shift. Review of the Comprehensive Care Plan performed on 4/8/25 failed to reveal documentation of the resident's sexual inappropriateness, combativeness, or other disruptive behaviors. On 4/8/25 at 4:17 pm the Assistant Director of Nursing stated she would add the behaviors to the resident's care plan. She stated the nurse aides chart behaviors on their daily tasks charting but she could add to the care plan to make it more specific. On 4/8/25 at 5:19 pm, the Administrator stated the staff does a good job of communicating with one another and all staff are aware of the Resident #28's behaviors. He stated if things come up, staff talk to one another about it. 47079 3. On 4/06/25 at 10:45 AM, Resident #12 was observed lying in her bed with her head at the footboard. The MDS of Resident #12, dated 4/03/25 revealed a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of Chronic Kidney Disease (CKD), Non-Alzheimer's Dementia, unspecified dementia moderate with anxiety, depression, and insomnia. It also revealed the resident received antipsychotic (AP), antianxiety (AA), and antidepressant (AD) medications during the last 7 days. The Electronic Health Record (EHR) included the following physician's orders: a) Escitalopram oxalate oral tablet 10 mg dated 1/02/25; Give one (1) tablet by mouth in the evening related to unspecified dementia moderate with anxiety. b) Lorazepam oral tablet 0.5 mg dated 9/26/24; Give one (1) tablet by mouth four (4) times a day related to unspecified dementia moderate with anxiety. c) Seroquel oral tablet 25 mg dated 4/03/25; Give one (1) tablet by mouth one (1) time a day related to unspecified dementia moderate with anxiety. The Progress Notes included an entry dated 8/28/24 that identified the behaviors for lorazepam as resident is anxious/restless. Pacing up and down hallways, reports unable to sleep. A progress note dated 9/30/24 identified the resident's behavior for Seroquel as hallucinations. Another progress note dated 7/25/24 identified the resident's behavior for escitalopram as sleeping late and refusing to eat. The Care Plan revised 1/10/25 included the resident's antidepressant, antianxiety, and antipsychotic medication use but did not include the resident's individualized target behaviors for staff to monitor nor the non-pharmacological interventions for staff to attempt if the behaviors were observed. On 4/08/25 at 4:07 PM, Staff E, Licensed Practical Nurse (LPN) stated she didn't know if the behaviors should be in the resident's care plan but stated the care plan is what the facility used to drive the resident's care. On 4/09/25 at 9:30 AM, the Assistant Director of Nursing (ADON) stated the target behaviors should have been included in the resident's Care Plan. A policy titled Admission and Comprehensive Care Planning reviewed 4/08/25 included the following: This care plan must be individualized and developed with interdisciplinary input, incorporating information from the initial assessment, resident preferences, family input (if applicable), and medical documentation. The comprehensive plan must address, but is not limited to: o Fall risk and prevention strategies o Skin integrity and wound care o Nutrition and hydration needs o Activities of Daily Living (ADLs) and functional support o Discharge planning, including goals o Code status and advanced directives o Pain management o Psychosocial and activity interests o Behavioral and emotional health needs o Trauma history or trauma-informed care planning o Medical diagnoses that significantly impact care delivery

Based on observations, clinical record review, staff interviews, and facility policy review the facility failed to update the infection control policy and failed to maintain infection control practices for catheter cares for 1 of 2 residents reviewed (Resident #4). The facility reported a census of 33 residents. Findings include: 1. Review of the facility policy titled Infection Control Policy, revealed it was last reviewed and dated on 4/8/20 by Staff D and the Director of Nursing (DON). On 6/26/24 at 7:56 AM Staff A, the current DON/Infection Preventionist (IP) stated the infection control policies were reviewed annually at the first Infection Control Committee/Quality Assurance and Performance Improvement (QAPI) meeting. Staff A concurred the facility Infection Control Policy was dated as last reviewed on 4/8/20. The staff stated the facility did not use signature sheets to indicate policies were reviewed. On 6/27/24 at 7:14 AM the Administrator stated the facility policies were reviewed annually but may not have signatures indicating they were reviewed within the past year. 40905 2. A Minimum Data Set (MDS) assessment for Resident #4, dated 5/30/24, included diagnosis of renal insufficiency and documented resident had an indwelling catheter (tube to drain bladder). The MDS documented a Brief Interview for Mental Status score of 15, indicating no cognitive impairment for decision making. Observation on 6/26/24 at 9:25 AM, with the Director of Nursing (DON) observing, Staff B, Certified Nurse Aide (CNA) and Staff C, CNA applied gowns and gloves and entered Resident #4's room. Staff C proceeded with her gloved hands and touched the door, cabinet and pulled a curtain and with the same gloved hands proceeded to cleanse the catheter bag drainage port tube with an alcohol swab, empty the catheter bag into the measuring graduate, cleanse the port again, and empty and rinse the graduate. Staff C then removed her gloves and gown and sanitized her hands. Facility policy, Closed System Drainage Bag and Leg Bag Procedure reviewed 10/2/19, directed staff to wash hands and apply gloves, empty the drainage bag into appropriate receptacle. Interview on 6/26/24 at 9:30 AM, the DON confirmed she observed Staff C touch contaminated items with gloves prior to catheter care with the same gloves and stated expectation for staff to use clean gloves prior to emptying the catheter and not touching other contaminated surfaces with gloves prior to providing care of the catheter.

Based on clinical record review, resident interviews and staff interviews, the facility failed to include the resident in the care plan participation conference for two (Residents #4 and #12) of twelve residents reviewed. The facility reported a census of 33 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] for Resident #4, documented the resident admitted on [DATE] and a Brief Interview for Mental Status (BIMS) score of 15 indicated no cognitive impairment for decision-making. The Care Plan Conference Note dated 6/6/24 documented the resident attended the meeting. Interview on 6/25/24 at 10:01 AM, Resident #4 stated she had never been invited to or attended a care conference and she would attend if invited. 2. A MDS assessment dated [DATE] for Resident #12, documented the resident admitted on [DATE] and a BIMS score of 11 indicated mild cognitive impairment for decision-making. The Care Plan Conferecne Note dated 4/18/24 documented the resident attended the meeting. Interview on 6/24/24 at 1:57 PM, Resident #12 stated she was unsure of attending any care plan conferences. Interview on 6/25/24 at 1:40 PM, Staff B, Certified Nurse Aide stated resident care conferences are on Thursday afternoons and the residents and families do not attend as they are only for the staff. Interview on 6/25/24 at 1:47 PM, Staff B stated she misunderstood and the residents are invited but do not want to attend and when asked again if residents or families attend, Staff B stated no the families don't want to come either. Interview on 6/25/24 at 3:35 PM, the Activity Director stated she attends residents' care conferences, sometimes the staff are not all together at the same time, the facility does not have conferences on a specific day, and the residents are not at their care conference. Interview on 6/26/24 at 3:49 PM, Staff A, Director of Nursing stated they do meet with the residents and discuss if everything is going ok and confirmed the team doesn't meet with the resident and whole care plan team at the same time. Staff A also stated the facility does not have a care conference policy.

Based on observation, interviews, and facility policy review, the facility failed to ensure the facility consistently maintained a clean environment in the kitchen. The facility reported a census of 25 residents. Findings include: During an observation on 02/07/22 at 12:30 PM, a fan blew on the dust-covered wiring, motor, and other electrical equipment on top of the 3 door refrigerator. The wall behind the motor of the refrigerator also contained a build-up of dust. The fan also circulated air throughout the kitchen. In an interview on 02/07/22 at 12:30 PM, Staff A reported maintenance put the fan on the refrigerator to blow on the motor and keep it cool, but had not removed the dust first. On 02/08/22 at 12:38 PM, the Administrator stated that he placed fan on top of the refrigerator to ensure the 3 door refrigerator did not over heat, although they have had a new compressor on order to replace the current one. He added he knew that the dust had built up, but feels the grease in the air in the kitchen prevents the dust from flying. He reported they cleaned and replaced the cover over the wiring and motor of the refrigerator this morning and had an electrician to replace the part that just arrived. In a subsequent interview on 02/09/22 at 08:25 AM, the Administrator reported the electrical company will come to the facility today to replace the compressor so they don't need a fan to cool refrigerator. At 12:35 PM, the administrator said he guessed the fan was up for about a week. In an interview on 02/09/22 at 12:40 PM the Dietary Manager stated she thought the fan had been in place for maybe more than 2 weeks. She reported the kitchen staff clean their fan 2 times a week, but since maintenance had put it there she did not clean the fan over the 3 door refrigerator. A facility kitchen policy dated 3/30/09 directed staff to disassemble the fans in the kitchen and wash, air dry, and reassemble the blades every Sunday and Wednesday. The policy also directed maintenance will blow dust from motor as needed. An undated kitchen checklist documented staff cleaned the kitchen fan on Sunday 02/06/22.

Based on clinical record review and staff interview, the facility failed to refer residents with a negative Level I result for the Pre-Admission Screening and Resident Review (PASRR), with a possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 of 1 residents reviewed (Resident #12). The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 12/9/21, Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #12 scored 13 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, indicating the resident demonstrated mild cognitive impairment. The MDS also documented Resident #12 required assist of 1 staff for bed mobility, transfers, and toilet use, and set-up assist of assist of 1 staff for dining. The MDS revealed the resident took anti-depressant, anti-anxiety, and antipsychotic medications 7 of 7 days during the lookback period. The Preadmission Screening and Resident Review (PASRR) dated 1/08/2020, documented a negative level one outcome and indicated the individual did not have a major mental illness. On 5/27/20, Resident #12 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's Care Plan initiated 1/9/20, revealed Resident #12 displayed behavioral problems related to [CONDITION(S)] causing hallucinations, anxiety, paranoia, and [CONDITION(S)]. The Care Plan directed staff to administer medications as ordered and monitor for side effects and medication effectiveness. During an interview on 2/8/22 at 11:20 a.m., the Assistant Director of Nursing reported Resident #12 changed psychiatric providers while living at the facility and added she was unsure if the facility resubmitted the PASRR with a new diagnosis. During an interview on 2/8/22 at 1:39 p.m., the Director of Nursing reported she resubmitted Resident #12's PASRR and he qualified for a Level II PASRR. .

Based on observations, record review, staff and resident interviews, the facility failed to ensure staff wore their Person Protective Equipment (PPE) according to guidance from the Centers for Disease Control and Prevention (CDC) during cares. Staff members that worked on both of the facility's COVID-19 units failed to always wear eye protection appropriately while on the units. Staff A Certified Nursing Assistant (CNA) entered 2 rooms with her eye protection on top of her head. Staff B CNA remained in 1 room with her eye protection on top of her head. Staff C CNA delivered 7 resident lunch trays to their rooms with her eye protection resting on her forehead. The facility reported a census of 31 residents. Findings include: Observation on 1/7/21 at 10:45 AM revealed the East Hall had been blocked by a wood barrier and door. Staff A and Staff B were working on the East Hall. Both staff members had N95 masks, gowns, gloves and eye protection on top of their head. Staff A wore personal glasses. Staff A walked the hall, entered and exited room [ROOM NUMBER], and then entered room [ROOM NUMBER] with her eye protection on top of her head. Staff B walked out of room [ROOM NUMBER] and stood in the doorway with her eye protection on top of her head. Staff B noticed the surveyor, stepped back into room [ROOM NUMBER] and then stepped back to the doorway with her eye protection covering her eyes. Observation revealed signs on resident doors that instructed staff how to don and doff PPE. The facility had posted signage on the outside of the wooden barrier (and visible prior to entering the East Hall) that directed : -Attention: Droplet Precaution Disposable gown, gloves, face shield or goggles, N95 mask After you leave the room, dispose of gown and gloves. -How to Don and Doff PPE -PPE Required in COVID-19 Area: N95 with face shield or PARP system, gown, gloves, shoe covers (optional) Observation on 1/7/21 at 11:50 AM revealed the facility used the North Hall as an isolation unit. Staff C distributed lunch trays while wearing an N95 mask, her personal eye glasses, gloves, and gown, with her eye protection on her forehead. Staff C entered and exited rooms 2, 4 and 6 twice, and 8 and 10 as she passed lunch trays. During that time her eye protection remained on her forehead. Posted outside of room [ROOM NUMBER] there was a note that read: Isolation. The other other rooms contained a note that read: COVID . The following signage was noted to be at the start of the North Hall: -Isolation area: face shield or goggles, face mask N95 or higher, one pair of clean nonsterile gloves, and isolation gown to be worn beyond this point. Review of the facility resident list by hall, which the facility presented to the surveyor on 1/7/21, revealed the North Hall had 6 residents with positive COVID-19 tests and 3 residents that were isolated because they had been exposed. The East Hall had 13 residents with positive COVID-19 tests and no residents that were isolated due to exposure. Review of the facility's COVID Outbreak Flow Sheet dated 12/28/2020, which the facility presented on 1/11/21 revealed the following information: -Resident #1 tested positive for COVID-19 on 1/11/21 and displayed mild symptoms -Resident #2 tested positive for COVID-19 on 1/11/21 and was asymptomatic -Resident #3 tested positive for COVID-19 on 12/31/20 and displayed moderate/severe symptoms -Resident #4 tested positive for COVID-19 on 1/1/21 and displayed mild symptoms -Resident #5 tested positive for COVID-19 on 1/1/21 and displayed mild symptoms -Resident #6 tested positive for COVID-19 on 1/4/21 and asymptomatic -Resident #7 tested positive for COVID-19 on 1/4/21 and moderate/severe symptoms -Resident #8 tested positive for COVID-19 on 1/6/21 and displayed mild symptoms -Resident #9 tested positive for COVID-19 on 1/4/21 and displayed mild symptoms -Resident #10 tested positive for COVID-19 on 1/4/21 and displayed mild symptoms -R11 tested positive for COVID-19 on 1/11/21 and displayed mild symptoms -R12 tested positive for COVID-19 on 1/4/21 and displayed mild symptoms During an entrance conference on 1/7/21 at 9:50 AM, the Director of Nursing (DON) stated they had 19 residents and 6 staff members that tested positive for COVID-19. During an interview on 1/7/21 at 11:40 AM, the DON verified Staff A and B were not wearing their eye protection during the observations made on the East Hall. She stated the facility noted that also and educated them at that time regarding wearing eye protection when working. When asked if staff could forgo eye goggles if they wore their personal glasses, she replied, no, staff need to wear the proper eye protection; face shield, or goggles. In an interview on 1/8/21 at 12:23 PM, Staff D Licensed Practical Nurse (LPN) was asked about proper PPE to wear when working on the COVID-19 units, she stated a mask, gloves, gown, paper mask, goggles, or face shield. Staff D stated staff still need a face shield or goggles even with personal glasses. Staff D said she did not notice that Staff C wore her goggles on her head on 1/7/20. During an interview on 1/8/2021 at 1:53 PM, the DON stated reported the county positivity rate was 13.5% according to the CMS website from 12/17/21 - 12/18/21 (print date 1/4/21). After informing the DON Staff C was not wearing the appropriate eye protection while working on a COVID-19 unit, she stated she would make note of this and reeducate her on this again. The DON added the last time she spoke to Staff C she assured the DON she had worn them correctly. During a staff interview on 1/8/21 at 3:03 PM, Staff A stated she only worked on the COVID-19 unit because she already had COVID-19. She stated she stays on the East hall when she works. When asked if she wears goggles, she stated all day. When it was brought to her attention the surveyor noted she did not have them on during observations, she stated her issue is when she does charting she lifts them so she can see to chart. She stated she couldn't see through because they are scratched. Staff A thinks she had them on her head while charting then heard an alarm and she goes to help not realizing they are on top of her head. In an interview on 1/8/21 at 3:13 PM Staff D, stated she did have her goggles over her glasses on 1/7/2020. When it was brought to her attention that her goggles had been on her forehead while she served lunch trays, she stated she honestly thought she had them on because of her glasses. She stated she works on the West hall with the COVID-19 residents. On 1/12/21 at 10:51 AM, the Assistant Director of Nursing (ADON) stated Resident #1 and Resident #2 were in isolation because their roommates had both tested positive for COVID-19. When asked where they obtained guidance once they had their first positive COVID 19 case(s), she stated they use IDPH guidelines, CMS guidelines, and action plans from their corporate office. She stated guidance contained information on proper PPE usage. The ADON was asked what PPE are to be worn when working on the 2 COVID-19 units, she stated gown, gloves, a N95 or papper. If staff chose to wear a N95 they are to wear goggles or a face shield. According to the Center for Disease Control and Prevention (CDC) Infection Control Guidance that was updated 12/14/2020: healthcare providers working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with COVID-19 infection. If COVID-19 infection is not suspected in a patient presenting for care (based on symptom and exposure history), healthcare providers should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters.

Based on observations, record review and staff interview the facility failed to ensure all staff working as an aide become certified within 4 months. The facility reported a census of 36 residents. Findings include: During dining room observation on 12/9/19 at 11:40 AM observed the Administrator apply a gait belt to Resident #36 and provided assistance with standing and walking the resident out of the dining room by himself. The Nurse Aide Roster, updated by the facility on 12/9/19, lacked documentation that the Administrator is a Certified Nursing Assistant. The personnel file for the Administrator lacked documentation that he is certified as an aide. The quarterly Minimum (MDS) data set [DATE], documented Resident #36 as extensive assist of 1 for transfers. During interview on 12/11/19 at 11:15 AM, the Administrator stated he is not certified as an aide and never has been. He reported it is normal practice for him to help the girls with cares on the floor and that he had done skills training.

Based on observations and staff interview the facility failed to serve food under sanitary conditions for 6 of 12 residents reviewed, (Residents #20, #33,# 3,# 6,# 31 and #9). The facility identified a census of 36 residents. The findings include: On 12/9/19 at 11:40 AM observed Staff C assist Resident #33, #20 and #6 with their meals. Staff C did not sanitize her hands between the residents and she was observed pushing her glasses up and pushing her hair back from her face in between assisting them. On 12/10/19 at 11:55 AM observed Staff D assist Resident #33 and #20 with their meal. Resident #33 coughed and Staff D used the resident's napkin to wipe her mouth and resumed assisting Resident #33 and Resident #20 without washing her hands or using hand sanitizer. Interviewed the Clinical Director on 12/11/19 at 11:19 AM and she stated it is her expectation that staff wash their hands or use hand sanitizer between assisting residents with their meal especially after wiping a resident mouth from coughing. 2. Observation on 12/9/19 at 11:52 AM revealed Staff C, CNA assisted residents at the assisted dining table. Staff C assisted Resident #20 with his drink then cut up Resident #6's meat. Staff C failed to perform hand hygiene in between assisting these residents. Observation on 12/10/19 at 11:43 AM revealed Staff D, CNA touched her face with her left hand, then held Resident #31's dinner plate while she scooped up food in his spoon. She then assisted Resident # 9 by moving her plates and picking up her coffee thermos, then assisted Resident #31 by feeding him his lunch. Once Staff D saw this surveyor she then asked Staff F, Licensed Practical Nurse (LPN) for hand sanitizer and used it. Observation on 12/10/19 at 11:46 AM revealed Staff D, CNA had fed Resident #33 with her right hand. Staff D then touched her glasses with her left hand, moved Resident #3's plate with her right hand, then continued to assist her with her meal and assisted Resident #16 with his meal. Staff D failed to perform hand hygiene in between assisting residents and touching her glasses. Staff D touched her hair with her right hand, assisted Resident #6 with the silverware he was using, assisted Resident #33 and Resident #3 with their meals; going back and forth between the two. She again failed to perform proper hand hygiene between assisting the residents.

Based on observations and record review the facility failed to complete a significant change assessment within 14 days of determining the status change was significant for 1 of 12 residents reviewed, (Resident #20). The facility reported a census of 36 residents. Finding include: The admission Minimum Data Set ((MDS) dated [DATE] coded Resident #20 as extensive assist of 1 staff for bed mobility, transfers and toileting and minimal assist of 1 staff for dressing, eating and hygiene. The MDS was marked as no indwelling catheter present. The Progress Note dated 10/28/19 at 11:32 AM, documented Resident #20 was admitted to an acute behavioral unit in the hospital. The MDS tab of the electronic record for Resident #20 indicated a discharge MDS was completed on 10/28/19 and an entry MDS was completed on 11/11/19. It did not indicate any other MDS had been done since 11/11/19. The Progress Note dated 11/11/19 at 10:20 AM, documented Resident #20 would be returning to the facility with an indwelling foley catheter in place due to [MEDICAL CONDITION]. The resident required extensive encouragement to eat and drink, had many medication changes and new [DIAGNOSES REDACTED]. The Progress Note dated 11/11/19 at 2:16 PM, documented the nurse practitioner had been here on daily routine rounds and reviewed orders from the behavioral health unit. New orders received for the resident for physical and occupational therapy to treat for a decline in activities of daily living and strengthening. The Progress Note dated 11/12/19 at 11:37 AM, documented the plan of care reviewed and completed with changes made to focus, goals and interventions after returning to facility from behavioral health stay. The Physical Therapy Evaluation for Resident #20 dated 11/12/19, documented a certification period 11/12/19 to 2/8/20 due to recent decline in ability to stand for transfers and ambulation due to weakness. The Occupational Therapy Evaluation for Resident #20 dated 11/12/19, documented a certification period 11/12/19 to 12/8/19 due to a decline in general strength, balance and activity tolerance after being admitted and treated at a behavioral unit. Resident now required extensive assist with activities of daily living and required increased assist with transfers. The ADL Coding form dated 11/12/19 to 11/18/19, documented Resident #20 as extensive assist of 2 staff for transfers, and extensive assist of 1 staff for dressing, eating and hygiene. On 12/9/19 at 11:40 AM observed Staff C assisting Resident #20 with his meal. The resident was fed by the aide during the majority of the meal. On 12/10/19 at 11:55 AM observed Staff D assisting Resident #20 with his meal. The resident was fed by the aide. On 12/10/19 at 1:30 PM observed Staff D and Staff [NAME] walk Resident #20 to the bathroom to attend to his toileting needs. The resident required extensive assist of 2 staff for the transfer. During interview with the Assistant Director of Nursing on 12/11/19 at 2:45 PM, she stated she would do a significant change in assessment if there was a decline in activities of daily living that was significant.

Based on observation, record review and staff interviews the facility failed to safely transfer a resident, (Resident #8). The facility reported a census of 36 residents. Findings include: Review of an annual Minimum Data Set (MDS) with assessment reference date of 9/19/19, revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 6, indicating mild cognitive impairment. The resident required extensive assistance of 2 staff for mobility and transfer and utilized a wheelchair. Review of Resident #8's Care Plan revealed she is able to transfer and ambulate short distances with extensive assistance of 1-2 staff. The Care Plan also stated she used a wheelchair for longer distances and is able to propel herself using her feet and staff assistance as needed. The Care Plan indicated she is not always willing to keep her feet up on the foot pedals and she is willing to self propel while holding staff hands as they walk beside or slightly in front of her. During initial tour on 12/9/19 at 9:54 AM, Staff A, Certified Nursing Assistant (CNA) assisted Resident #8 down the hall to the west hall bathroom. Staff A pushed Resident #8 in her wheelchair with no foot pedals on as her feet were touching the floor. During a staff interview on 12/11/19 at 11:21 AM, Staff F, Licensed Practical Nurse (LPN) and Staff G, Registered Nurse (RN) stated it is not acceptable to assist a resident in a wheelchair without foot pedals. They were asked what if the resident was able to hold their legs up, would they still need foot pedals and Staff G said yes because they could still drop their feet on the ground. During a staff interview on 12/11/19 at 12:20 PM, the Assistance Director of Nursing (ADON) stated staff are not to push residents in their wheelchairs without foot pedals on. When asked if a resident is capable of holding their feet up, do they need foot pedals when in their wheelchairs, the Clinical Director RN stated yes all residents need them. She stated they work on re-educating staff members on using foot pedals for all residents when pushing them in their wheelchairs. She stated they even have to remind family members. She stated for Resident #8 in particular they need to remind staff because they can hold her hand, walk with her down the hall but staff forget about getting the foot pedals. The Clinical Director RN stated Resident #8 is one that will put her feet down, while in the wheelchair, when she does not want to do something. She stated a nurse observed this and let the facility know so education could be provided.

Based on observation, record review, and staff interview the facility failed to use professional standards during the medication administration task. A nurse dropped a pill on the medication cart, picked it up with her bare hand, and placed it in the medication cup with the rest of Resident #12's morning medications. The facility reported a census of 36 residents. Findings include: Observation on 12/10/19 at 8:00 AM revealed Staff B, Licensed Practical Nurse (LPN) had dispensed Resident #12's medications in to a medication cup that sat on top of her medication cart. Resident #12's [MEDICATION NAME] (antidepressant) pill fell out of the bubble packet and landed on the medication cart. With her bare hands, Staff B picked up the pill and placed it in the medication cup with 8 of his other medication pills. Staff B then went in to the dining room to administer his medications. An Order Summary Report dated 12/10/19, revealed Resident #12 had an order for [REDACTED]. During a staff interview on 12/11/19 at 1:41 PM, the Assistant Director of Nursing stated if a pill falls out of a pill packet on to the medication cart it needs to be destroyed because it is considered dirty at that time.

Based on record review and staff interview the facility failed to accurately complete a resident assessment. Resident #21's last 2 quarterly Minimum Data Set (MDS) assessments indicated she had received an anticoagulant but she is prescribed and antiplatelet. The facility reported a census of 36 residents. Findings include: According to a quarterly MDS with a reference date of 10/24/19, Resident #21 had a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS listed a stroke as one of her diagnoses. The MDS also indicated she received an anticoagulant for 7 days during the 7 day review period. According to a quarterly MDS with a reference date of 7/25/19, Resident #21 had received an anticoagulant for 7 days during the 7 day review period. Review of Resident #21's Care Plan, with a revision date of 11/22/19, revealed staff are to administer both aspirin and [MEDICATION NAME] (antiplatelet) as ordered for further prevention of a [MEDICAL CONDITIONS]. Review of Resident #21's signed Order Summary Report, with a date of 12/4/19, revealed she had the following medication orders [REDACTED] -Aspirin Tablet 81 milligrams (mg) one time a day with a start date of 6/24/18. -[MEDICATION NAME] Bisulfate ([MEDICATION NAME]) 75mg one time a day with a start date of 6/26/18. During a staff interview on 12/11/19 at 1:30 PM, the Assistant Director of Nursing (ADON) stated she did not think Resident #21 was on an anticoagulant but would have to check. During a follow up interview at 1:45 PM the ADON stated Resident #21 received [MEDICATION NAME] which is a blood thinner. After it was discussed that [MEDICATION NAME] is an antiplatelet, she stated she would get the MDS updated.