Every finding on record at New Hampton Nursing & Rehab Center

Based on clinical record review, resident interview, family interview, staff interview, and facility policy/procedure review the facility failed to provide an environment free from physical assault and physical injury for 2 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 24 residents. Findings include: 1. A Minimum Data Set (MDS) form dated 10.24.24 indicated Resident #1 had diagnoses that included Cervical Spinal Fusion, Cervical Disc Disorder with Myopathy, malnutrition, Anemia, Heart Failure (HF), Coronary Artery Disease, and Atrial Fibrillation (AF). The assessment indicated the Resident had the ability to make himself understood and understand others, with a Brief Interview for Mental Status (BIMS) score of 7 out f 10 (severely impaired cognitive skills), no delirium/moods or behaviors, non-ambulatory, dependent on staff with lower body dressing and undressing and transfers, required substantial/maximum assistance of staff with toileting hygiene, dressing and undressing his upper body, and personal hygiene. A Care Plan identified the following Focus areas and Interventions as dated: a. Resident's ability for completion of activities of daily living (ADL's) deteriorated. (revised 12.31.20) 1. Assistance with morning (am) and evening (p.m.) cares. (initiated 3.23.21) b. At risk for skin breakdown related to incontinence, HF and malnutrition. (initiated 12.31.20 and revised 11.7.24) 1. History of skin tears. (revised 11.7.20) c. Resident with a skin tear of the right forearm, left 3rd finger and left elbow. (initiated and revised 11.7.24) 1. Inform/instruction to staff of causative factors and measures of prevention to skin tears. (initiated 11.7.24) An Incident Report form dated 11.5.24 at 8:45 p.m. indicated the nurse had been called to the resident's room by a Certified Nursing Assistant (CNA) as he received a skin tear to the right forearm in the shape of a U that measured 24 centimeters (cm) from one (1) end to the other. The resident also sustained a small skin tear to his left upper elbow that measured approximately 3 cm and a small skin tear to his left hand between the 3rd and 4th finger that measured approximately 1.3 cm. During an interview 1.3.24 at 2:46 p.m. Staff A, Certified Nursing Assistant (CNA) confirmed she worked 11.5.24 from 2 p.m. until 10 p.m. but had not been directly assigned to care for the resident. At approximately 3 ish she brought a snack to his room while she observed him positioned in his recliner. At that time he wore his short sleeved white t-shirt and plaid long sleeved shirt. That staff member could not recall if at that time had been when herself and Staff D, CNA or later transferred him to bed per an assistive lift device and laid him down, removed his pants and offered him his oxygen which he refused. The staff member indicated at no time during the transfer that occurred that evening the resident hit his arm, said ouch, and/or any blood had been noted on his person or the recliner chair. The staff member, Staff A, indicated the next time she had any contact with the resident had been around 8:30 p.m. when she went to look for the nurse to have retrieved a cream for another resident when she found the nurse, along with Staff E, CNA with the resident, still positioned in bed, covered up with a blanket to his waist, with the white t-shirt on but then with a bandage over his arm but denied any conversation about the resident's arm rather informed the nurse about the need for the cream and left the room. Staff A confirmed she worked with Staff E prior to the above stated event and observed an incident with Resident #2 approximately one (1) week prior at which time she knocked on the resident's door, entered, and observed Staff E as she held the resident's wrists because he had not wanted to get cleaned up by Staff F, CNA who also had been present. Staff A indicated it had been obvious the resident had not been happy about having his hands held because he tried to bite Staff E at which time she appeared mad as noted by her firm facial affect and how she talked to the resident with an elevated tone of voice. Staff A denied having heard any threats by Staff E however when she entered the room Staff E let go of the resident's wrists, grabbed the linens and left the room. Staff F and Staff A remained in the resident's room and covered his left arm with a towel due to the blood oozing from a noted new skin tear. The resident presented as upset related to what occurred with Staff E but showed no signs of having been combative with Staff E. The resident informed Staff A that Staff E twisted his wrist during the above stated encounter. Staff A confirmed from her experience Staff E failed to handle the situation correctly because when a resident refused cares staff had been directed to walk away and absolutely not grab and/or restrain a resident's wrists. During an interview 1.9.24 at 4:38 p.m. Staff D confirmed she assisted the resident to bed the night of the injury along with Staff A at which time he had not been combative at all. The staff members kept the resident in his clothes, she noted no signs of bleeding and the resident never complained of pain. Staff D then confirmed she worked with Staff E within days after the resident sustained his skin tear at which time the Resident yelled at Staff E. The staff member could not recall all that was said but he presented as upset because he said she was the one who caused the skin tear to his arm. During this interaction Staff E yelled back at the resident in an angry tone and verbalized it had not been her fault. During an interview 1.7.24 at 2:30 p.m. a family member indicated the resident told her three (3) nights in a row Staff E looked at the resident's bottom for sores. On the fourth night, the night of the election, the resident refused because he wanted to watch the results. The family member indicated the resident told her all of a sudden the staff member's face appeared viscous, further described as stern and she grabbed and twisted his arm and said your going to do this as she laid almost right on him. The resident confirmed she restrained him with her hands which made him angry and caused a feeling of helplessness. The resident indicated he yelled for help and said, no, and he went over all of the injuries he sustained during that encounter which presented as scars, showed the surveyor the scars. Per the family member she received a call on 11.5.24 at 11:27 p.m. at which time the night nurse apologized profusely because the male nurse should have called her at the time of the incident because the resident had been crying in pain. The family member arrived at the facility around 11:55 p.m. when the night nurse came into check the resident's blood pressure as he became combative and said Oh I thought you were that bitch coming after me. 2. An MDS assessment form dated 8.22.24 indicated Resident #2 with diagnoses that included a Traumatic Brain Injury (TBI), absence of a right hip joint, Osteoarthritis, Obesity, Combined Systolic and Diastolic Heart Failure, and Chronic Respiratory Failure. The assessment indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (cognitively intact) and with no Delirium, behaviors, or moods. The assessment indicated the Resident as non-ambulatory, dependent on staff with transfers and personal hygiene. A Care Plan addressed the following Focus areas and Interventions as dated: a. The Resident's ability to have completed ADL's had been deteriorated related to pain, a wound and a TBI. (revised 12.15.23) 1. Provision of assistance with a.m. and p.m. cares. (initiated 12.25.24) b. At risk for falls. (initiated 12.15.23 and revised 11.7.24) 1. Non-ambulatory. (initiated 1.12.24) 2. Transferred with 2 staff assistance and a sit and stand lift device. (initiated 12.15.23 and revised 1.9.25) An Incident Report dated 10.25.24 at 10:00 p.m. indicated the nurse was called to the Resident's room and found the resident positioned in bed with a skin tear on his left forearm. The staff reported the Resident had been hitting and verbally abusive during cares. The Resident reported the girls tried to kill him and asked why the facility hired staff like that as he had to defend himself. A Non-Pressure Skin Condition Report dated 10.25.24 indicated the Resident sustained a skin tear on his left wrist that measure five (5) cm in a Z form which contained a moderate amount of serosanguinous drainage. A Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7.2024 indicated the Policy Statement included the following: All residents had the right to have been free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.

Based on observation, resident interview, family interview, staff interview, Resident Council Minutes, and facility policy review, the facility failed to answer resident call lights in a timely manner and within the required 15 minute time frame. (Resident #2, #4 and #5). The facility identified a census of 24 residents. Findings include: During an interview 1.9.25 at 4:05 p.m., Resident #4, identified by the facility as interviewable, indicated last night she timed her call light being on over one (1) hour as she used the clock on the wall in her room to watch the time which made her feel unwanted. During an interview 1.9.25 at 4:01 p.m., Resident #5, identified by the facility as interviewable, indicated he timed his call light being on for up to 1/2 hour as he used the clock on the wall in his room to watch the time which pissed him off. During an interview 1.3.24 at 3:38 p.m. a family member confirmed he timed the call light being on for Resident #2 for 45 minutes to 1 hour at various times but especially at meal times. During an interview 1.9.25 at 3:11 p.m., Staff A, Certified Nursing Assistant (CNA) indicated staff answered resident call lights within 15 minutes unless they were tied up in a residents room who required two (2) staff assistance. According to a form (not dated) the facility management staff identified 9 of 24 residents who required 2 staff to assist with personal cares. Review of the facilities Resident Council Minutes revealed residents verbalized concerns with slow staff response to call lights on 12.31.24. A Call Light Response policy effective 10.31.24 indicated the Objective as an assurance of a timely and efficient response to resident call lights which enhanced resident safety and satisfaction. The policy listed the response time as within 15 minutes of activation.

Based on clinical record review, resident interview, family interview, staff interview, and facility policy and procedures review the facility failed to provide an environment free from physical assault/physical injury and failed to report the suspected abuse to the State Agency in a timely manner as required for 2 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 24 residents. Findings include: A MDS assessment form dated 8.22.24 indicated Resident #2 with diagnosis that included a Traumatic Brain Injury (TBI), absence of a right hip joint, Osteoarthritis, Obesity, Combined Systolic and Diastolic Heart Failure and Chronic Respiratory Failure. The assessment indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (cognitively intact) and with no Delirium, behaviors or moods. The assessment indicated the Resident as non-ambulatory, dependent on staff with transfers and personal hygiene. A Care Plan addressed the following Focus areas and Interventions as dated: a. The Resident's ability to have completed ADL's had been deteriorated related to pain, a wound and a TBI. (revised 12.15.23) 1. Provision of assistance with a.m. and p.m. cares. (initiated 12.25.24) b. At risk for falls. (initiated 12.15.23 and revised 11.7.24) 1. Non-ambulatory. (initiated 1.12.24) 2. Transferred with 2 staff assistance and a sit and stand lift device. (initiated 12.15.23 and revised 1.9.25) An Incident Report dated 10.25.24 at 10:00 p.m. indicated the nurse as called to the Resident's room and found the resident positioned in bed with a skin tear on his left forearm. The staff reported the Resident had been hitting and verbally abusive during cares. The Resident reported the girls tried to kill him and asked why the facility hire staff like that as he had to defend himself. A Non-Pressure Skin Condition Report dated 10.25.24 indicated the Resident sustained a skin tear on his left wrist that measure five (5) cm in a Z form which contained a moderate amount of serosanguinous drainage. During an interview 1.7.25 at 1:11 p.m. Staff F, CNA confirmed she had been present during the situation with the Resident and she knew the incident had not been reported. The staff member confirmed she had been present with Staff E when the Resident sustained his skin tear as they assisted him with p.m. cares while positioned in his wheel chair but perineal cares had been performed while he stood in the lift device for the transfer. The staff member recalled as she cleaned him and Staff E controlled the lift device he said enough, enough as he routinely disliked the process due to pain. Staff F continued to clean him up due to the dried bowl movement on his buttocks. Staff F denied having known what Staff E said to him but she noted him as he swatted Staff E and eventually called her a Bitch. After proper cares had been performed the staff members positioned him in bed as Staff E said stuff to him like stop that verbiage and what would your family think in a really bad tone further defined as kind of yelling/loud and with a stern facial affect which upset the Resident more. As Staff F tried to clean the Resident's anterior perineal area Staff E stood by his head and he tried to swat at her again. Staff E then grabbed his forearms bilaterally and he said let go of me, let go of me. At this time he started kicking as she restrained his arms. At that time Staff A entered the room Staff F said they are done and Staff E left the room and that had been when they noted his arm as it bled. The Resident stated she scratched me, she scratched me. The staff members calmed him down, put a wet washcloth on it, situated him and left the room. Staff F described the skin tear (ST) as in a straight line which bled pretty good. Staff E tried to blame the ST on the lift device but that could not have been the case because they would have noted blood and when Staff F first observed the site it had just begun to bleed at a pretty good clip. Staff F indicated she would not have allowed Staff E to care for any of her family members due to her tone she used and confirmed she should not have restrained the Resident rather she should have stepped away. During an interview 1.9.25 at 1:04 p.m. Staff I, Registered Nurse (RN) confirmed she worked the evening the Resident sustained his ST when she received a walkie message from an unknown staff member who reported the Resident as combative and they required assistance. When she entered she noted the Resident as he yelled at Staff E and directed Staff I to remove her from his room with an adamant affect due to her physical behavior. Staff I requested Staff E to leave as she treated the ST. During an interview 1.7.25 at 3:49 p.m. the Director of Nursing (DON) indicated she never thought to report the skin tear injury from Resident #2 following the same type of injury to Resident #1 approximately 10 days later that both occurred by Staff E, CNA. The DON indicated when Staff G, RN and Staff H, LPN called her and reported the injury to Resident #1 they never gave any indication there would have been a suspicion for abuse. As the situation had been further described to the DON during the investigation the DON just shook her head up and down in the motion of yes and no but failed to directly answer the question. A Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7.2024 indicated the Training of Employees segment included the following: The training educated staff on: (a) activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (b) procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and (c) management of situations in which a higher risk for abuse to occur (i.e.: dementia, behaviors, mental health diagnoses, etc.) and resident abuse prevention.

Based on clinical record review, resident interview, family interview, staff interview, and facility policy and procedures review the facility failed to provide an environment free from physical assault/physical injury and investigate potential abuse as required by Federal regulations for 2 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 24 residents. Findings include: 1. A Minimum Data Set (MDS) form dated 10.24.24 indicated Resident #1 had diagnoses that included Cervical Spinal Fusion, Cervical Disc Disorder with Myopathy, malnutrition, Anemia, Heart Failure (HF), Coronary Artery Disease, and Atrial Fibrillation (AF). The assessment indicated the Resident had the ability to make himself understood and understand others, with a Brief Interview for Mental Status (BIMS) score of 7 out f 10 (severely impaired cognitive skills), no delirium/moods or behaviors, non-ambulatory, dependent on staff with lower body dressing and undressing and transfers, required substantial/maximum assistance of staff with toileting hygiene, dressing and undressing his upper body, and personal hygiene. A Care Plan identified the following Focus areas and Interventions as dated: a. Resident's ability for completion of activities of daily living (ADL's) deteriorated. (revised 12.31.20) 1. Assistance with morning (am) and evening (p.m.) cares. (initiated 3.23.21) b. At risk for skin breakdown related to incontinence, HF and malnutrition. (initiated 12.31.20 and revised 11.7.24) 1. History of skin tears. (revised 11.7.20) c. Resident with a skin ear of the right forearm, left 3rd finger and left elbow. (initiated and revised 11.7.24) 1. Inform/instruction to staff of causative factors and measures of prevention to skin tears. (initiated 11.7.24) An Incident Report form dated 11.5.24 at 8:45 p.m. indicated the nurse had been called to the resident's room by a Certified Nursing Assistant (CNA) as he received a skin tear to the right forearm in the shape of a U that measured 24 centimeters (cm) from one (1) end to the other. The resident also sustained a small skin tear to his left upper elbow that measured approximately 3 cm and a small skin tear to his left hand between the 3rd and 4th finger that measured approximately 1.3 cm. During an interview 1.3.24 at 2:46 p.m. Staff A, Certified Nursing Assistant (CNA) confirmed she worked 11.5.24 from 2 p.m. until 10 p.m. but had not been directly assigned to care for the resident. At approximately 3 ish she brought a snack to his room while she observed him positioned in his recliner. At that time he wore his short sleeved white t-shirt and plaid long sleeved shirt. That staff member could not recall if at that time had been when herself and Staff D, CNA or later transferred him to bed per an assistive lift device and laid him down, removed his pants, and offered him his oxygen which he refused. The staff member indicated at no time during the transfer that occurred that evening the resident hit his arm, said ouch, and/or any blood had been noted on his person or the recliner chair. The staff member indicated the next time she had any contact with the resident had been around 8:30 p.m. when she went to look for the nurse to retrieved a cream for another resident when she found the nurse, along with Staff E, CNA with the resident, still positioned in bed, covered up with a blanket to his waist, with the white t-shirt on but then with a bandage over his arm but denied any conversation about the resident's arm rather informed the nurse about the need for the cream and left the room. The staff member confirmed she worked with Staff E prior to the above stated event and observed an incident with Resident #2 approximately one (1) week prior at which time she knocked on the resident's door, entered, and observed Staff E as she held the resident's wrists because he had not wanted to get cleaned up by Staff F, CNA who also had been present. Staff A indicated it had been obvious the resident had not been happy about having his hands held because he tried to bite Staff E at which time she appeared mad as noted by her firm facial affect and how she talked to the resident with an elevated tone of voice. Staff A denied having heard any threats by Staff E however when she entered the room Staff E let go of the resident's wrists, grabbed the linens and left the room. Staff F and Staff A remained in the resident's room and covered his left arm with a towel due to the blood oozing from a noted new skin tear. The resident presented as upset related to what occurred with Staff E but showed no signs of having been combative with Staff E. The resident informed Staff A that Staff E twisted his wrist during the above stated encounter. Staff A confirmed from her experience Staff E failed to handle the situation correctly because when a resident refused cares staff had been directed to walk away and absolutely not grab and/or restrain a resident's wrists. During an interview 1.9.24 at 4:38 p.m. Staff D confirmed she assisted the resident to bed the night of the injury along with Staff A at which time he had not been combative at all. The staff members kept the resident in his clothes, she noted no signs of bleeding and the resident never complained of pain. Staff D then confirmed she worked with Staff E within days after the resident sustained his skin tear at which time the Resident yelled at Staff E. The staff member could not recall all that was said but he presented as upset because he said she was the one who caused the skin tear to his arm. During this interaction Staff E yelled back at the resident in an angry tone and verbalized it had not been her fault. During an interview 1.7.24 at 2:30 p.m. a family member indicated the resident told her three (3) nights in a row Staff E looked at the resident's bottom for sores. On the fourth night, the night of the election, the resident refused because he wanted to watch the results. The family member indicated the resident told her all of a sudden the staff member's face appeared viscous, further described as stern and she grabbed and twisted his arm and said your going to do this, as she laid almost right on him. The resident confirmed she restrained him with her hands which made him angry and caused a feeling of helplessness. The resident indicated he yelled for help and said, no, and he went over all of the injuries he sustained during that encounter which presented as scars, showed the surveyor the scars. Per the family member she received a call on 11.5.24 at 11:27 p.m. at which time the night nurse apologized profusely because the male nurse should have called her at the time of the incident because the resident had been crying in pain. The family member arrived at the facility around 11:55 p.m. when the night nurse came in to check the resident's blood pressure as he became combative and said Oh I thought you were that bitch coming after me. 2. A MDS assessment form dated 8.22.24 indicated Resident #2 with diagnoses that included a Traumatic Brain Injury (TBI), absence of a right hip joint, Osteoarthritis, Obesity, Combined Systolic and Diastolic Heart Failure, and Chronic Respiratory Failure. The assessment indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (cognitively intact) and with no Delirium, behaviors, or moods. The assessment indicated the Resident as non-ambulatory, dependent on staff with transfers and personal hygiene. A Care Plan addressed the following Focus areas and Interventions as dated: a. The Resident's ability to have completed ADL's had been deteriorated related to pain, a wound and a TBI. (revised 12.15.23) 1. Provision of assistance with a.m. and p.m. cares. (initiated 12.25.24) b. At risk for falls. (initiated 12.15.23 and revised 11.7.24) 1. Non-ambulatory. (initiated 1.12.24) 2. Transferred with 2 staff assistance and a sit and stand lift device. (initiated 12.15.23 and revised 1.9.25) An Incident Report dated 10.25.24 at 10:00 p.m. indicated the nurse was called to the Resident's room and found the resident positioned in bed with a skin tear on his left forearm. The staff reported the Resident had been hitting and verbally abusive during cares. The Resident reported the girls tried to kill him and asked why the facility hired staff like that as he had to defend himself. A Non-Pressure Skin Condition Report dated 10.25.24 indicated the Resident sustained a skin tear on his left wrist that measure five (5) cm in a Z form which contained a moderate amount of serosanguinous drainage. During an interview 1.7.25 at 3:49 p.m. the Director of Nursing (DON) indicated she never thought to report the skin tear injury from Resident #2 following the same type of injury to Resident #1 approximately 10 days later that both occurred by Staff E, CNA. The DON indicated when Staff G, RN and Staff H, LPN called her and reported the injury to Resident #1 they never gave any indication there would have been a suspicion for abuse to be investigated. A Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7.2024 indicated the Key Definitions segment included the following: A physical injury to, or injury at a variance with the history given of the injury, or unreasonable confinement, unreasonable punishment, or assault of a dependent adult which involved a breach of skill, care, and learned ordinarily exercised by a caretaker in similar circumstances. Assault of a dependent adult meant the commission of any act which generally intended to cause pain or injury to a dependent adult, or which generally intended to result in physical contact which would had been considered by a reasonable person to have been insulting or offensive or any act which intended to have placed another in fear of immediate physical contact which would have been painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.

Based on observation, staff interview, resident interview, and facility policy review, the facility failed to maintain call lights in reach for 1 of 4 residents reviewed (Resident #2). The facility identified a census of 24 residents. Findings include: An observation and interview 1.3.25 at 1:30 p.m. revealed Resident #2 positioned in his wheel chair in his room as he called out for assistance. Upon entry the resident requested to go to bed at which time an observation revealed one (1) call light wrapped around the bottom of a positioning bar on the left side of his bed. The other call light positioned across the cushion and under an unknown item of his easy chair. The Surveyor turned on the call light. At 1:40 p.m. Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA responded and confirmed the cal lights were out of reach. During an interview 1.3.24 at 3:38 p.m. a family member confirmed during his regular visits to Resident #2 he observed the call lights out of reach on several occasions.

Based on observation, clinical record review, policy review, resident and staff interviews, the facility failed to appropriately provide assessment and interventions for 1 of 3 residents (Resident #1) reviewed for anticoagulation (blood thinning medication) therapy. The facility failed to recognize that an international normalized ratio (INR, blood test to determine how long it takes to blood to clot) had not been done from the time of admission until 35 days later when the resident exhibited symptoms of having blood that was too thin. The facility reported a census of 40 residents. Findings include: Resident #1's Minimum Data Set (MDS), dated [DATE], documented the resident was admitted to the facility on [DATE]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) of 10, indicating moderate cognitive impairment. The MDS listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident needed limited assistance of 1 person for bed mobility, transfers, walking, dressing, toilet use and hygiene. The MDS included anticoagulation medication had been taken on 7 of 7 days prior. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress notes written on 9/20/22 at 6:00 PM, revealed Staff A reached out to the hospital for clarification orders including questioning the [MEDICATION(S)] 10 mg daily order and when the next INR was to be checked. At 6:36 PM, Staff A received a call from the nurse at the hospital stating [MEDICATION(S)] 10 mg daily and INR will be done on follow up day in a week. On 9/21/22 the facility received an order sheet signed by the resident's physician. The order sheet included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders were noted by Staff B on 9/21/22. Progress Note written on 9/22/22 at 8:19 AM by Staff C documented the clinic called to remind the facility the resident had a follow up appointment scheduled for 9/27/22 at 11:00 AM. Progress note written on 9/27/22 at 3:12 PM by Staff D documented, per physician, no changes at this time. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders did not include an INR order or results from the INR that was to be done at the clinic. Progress Note written on 10/25/22 at 9:48 AM by Staff B noted the resident had dark colored bloody stools. His abdomen was nontender with active bowel sounds in all 4 quadrants. The facility nursing staff sent Resident #1's physician a fax about Resident #1's condition and current medication list. At 1:42 PM, Staff B sent a second fax to the physician requesting an INR. At 5:23 PM, Staff E documented a fax was sent to the physician notifying the physician the resident's [MEDICATION(S)] was being held due to dark red blood in the resident's urine. At 9:17 PM, the physician called the facility and ordered an INR for the next morning. Progress Note written on 10/26/22 at 7:49 AM by Staff F documented the resident was having blood in his stool and urine. At 8:15 AM, Staff F notified the resident's wife of his condition. The wife was agreeable to sending the resident to the hospital. The ambulance was called and the resident left the facility. At 9:40 AM, Staff F received the INR results, which showed Resident #1's INR was 13.56 (critically high, indicating Resident #1 had a very high likelihood of excessive bleeding). This information was called and faxed to the emergency department. At 10:19 AM, Staff F received a verbal order from the physician to send the resident to the emergency department. The resident returned to the facility at 12:48 PM. At 12:57 PM, Staff F received report from the hospital. The resident received Vitamin K for the INR over 13 and a liter of fluids. The resident was in CHF and had crackles in lungs and 2-3+ pitting [CONDITION(S)] (significant swelling in the lower legs, indicating impaired cardiac function) in bilateral lower extremities. He had petechia (pinpoint, round spots on the skin as a result of bleeding) to his forehead, face and areas on his body and tested positive for a GI bleed. At 2:58 PM, Staff A received an order to hold the [MEDICATION(S)], continue Aspirin and check the INR daily for 3 days. At 8:58 PM Staff E documented the resident had blood in the toilet and coughed up black phlegm. Progress note written on 10/27/22 at 7:26 AM Staff F documented the resident incontinent of bloody stool, she noted the smell of blood in stool. The resident was shaky, confused and unable to walk at this time. At 1:30 PM Staff F documented the resident had 3 more bloody stools, had an INR of 1.61, hemoglobin of 8.9 (moderately anemic) and a red blood cell count of 2.9. His [MEDICATION(S)] was on hold until 10/31 and would be restarted at 5 mg daily. He had crackles half way up his lung fields, 2-3+ [CONDITION(S)] in lower legs, was weak and confused. At 2:07 PM Staff F sent a condition report to the physician. The physician requested the resident be sent to the emergency department. The ambulance contacted and transported resident. At 2:08 PM Staff F notified the resident's wife. At 3:54 PM Staff E documented the wife called the facility and the resident was being admitted to the hospital for 24 hours. At 4:19 PM the Director of Nursing (DON) documented the hospital called the facility and stated they were keeping resident for observation, his vitals were stable and labs were being drawn. Progress Note written on 10/28/22 at 9:12 PM Staff E documented the resident returned to the facility via private car accompanied by his wife. His lungs clear, he had 3+ [CONDITION(S)] to bilateral lower extremities and multiple scattered bruises. Facility policy titled Lab Tracking, dated 8/1/17, directed staff to monitor labs from the time of the order until results were received. During an interview on 11/2/22 at 3:52 PM, Resident #1 explained he is feeling better now. He stated his blood was so thin it was going right through me. He further explained he spent 24 hours in the hospital where his medication was changed and he feels pretty good. During an interview on 11/8/22 at 12:43 PM, the DON stated she did not have labs that were drawn on 10/29/22. She stated the lab was faxing the results since they were done at the clinic. She stated she did not know if the clinic received the results and why the facility did not have the results. She stated her expectation was the lab would fax results and it was the responsibility of the charge nurse and DON jointly to follow up on missing lab results. During an interview on 11/8/22 at 2:04 PM, the physician confirmed he saw the resident in the clinic on 9/27/22 for a post hospitalization follow up appointment. He explained there was not an INR done at that visit, as the resident had and INR done on 9/19/22. That INR was therapeutic and no changes were made, so anther INR on 9/27/22 was unnecessary. The physician explained in this case, the resident was in the nursing home, so he went a month without a visit which was very unusual for the physician. During an interview on 11/8/22 at 2:48 PM, the DON stated she would expect staff to follow policy and procedure. She stated she would expect a lab tracking sheet to be completed and same day follow up with the lab for results not received by the facility. She further stated she would expect the nurse to follow up with the clinic if labs were drawn at the clinic to ensure a copy was received by the facility.

Based on observation, interviews, and dryer manual review the facility failed to keep access panels to two (2) dryers closed when running the dryers to dry clothing and linens. The facility reported a census of 38 residents. Findings include During an observation on 08/03/22 at 08:45 AM of the facilities laundry room revealed two (2) dryers one (1) running with a very well contained orange fire inside the machines. The access panel open with the keys in the lock. During an interview on 08/03/22 at 08:45 AM with the Laundry Supervisor revealed the access panels to the dryers are closable by lock and key but the heat goes out when they are closed, so they are kept open for air flow. She then revealed the lint traps are cleaned after every load with a broom and also cleaned with a shop vac monthly. During an interview on 08/03/22 at 10:12 AM with the facilities dryer servicing company revealed the following information. The whole point of the dryer access panel lock is for it to be locked when the dryer is in use. The access panel is used for maintenance purposes only. If they are having issues with airflow then they need to have that looked at and get adjusted or we would fix the switch. The access panel should be shut to keep the air flow coming in from the bottom of the machine and working up, keeping the panel open affects that. The dryers could get too and potentially not trip the three (3) safety's built into the machine. The flames should be blue in color. If the flames are orange the flame could ignite the burners causing a serious dryer fryer. The orange flame is concerning because its getting to much air flow and those safety's would not trip. During an interview on 08/03/22 at 12:40 PM with the Maintenance Supervisor revealed last month he completed cleaning of the lint vent/trap with a shop vac on the underneath inside the dryer, backside if the dryer, and vents. During interview and observation on 08/03/22 01:08 PM with Laundry Supervisor revealed the dryers typically have orange flames that stay on and once it gets hot enough they turn blue. Flames were observed by the Laundry Supervisor as orange in color during the observation while the machine was running During an interview on 08/03/22 at 01:11 PM with the Laundry Supervisor revealed the access panels have been vented since she has been working here and that is greater than 9 years. Dryers were observed running with access panels open. During an interview on 08/04/22 at 11:14 AM with the facilities Administrator revealed the dryers are not serviced on a regular basis just when needed. During an interview on 08/04/22 at 11:17 AM with the facilities Administrator revealed they have closed the access paned and they will stay stay closed now. Record review of and undated laundry cleaning check list instructed the facility to daily: a. Clean dryers after each use b. clean dryer lint traps after each load Record review of the facilities dryer manual provided by the facility dated December 2016 instructed the facility to: a. WARNING: Never start the tumbler with any guards/panels removed. b. Control panel and access panel MUST be reinstalled after inspection or servicing of the tumble dryer is completed

Based on observation, staff interviews and policy review the facility failed to keep the facilities oven and convection oven free of black and brown buildup. The facility reported a census of 38 residents. Findings include During an observation on 08/01/22 from 9:20-9:40 AM revealed the facilities kitchen oven with black build up noted to stove. The facilities convection oven also observed with black buildup and brown exterior buildup. During an interview on 08/01/22 from 9:20-9:40 AM with the Dietary Manager revealed she would like the ovens cleaner, but unable to with staffing levels right now. Record review of a undated kitchen cleaning policy, titled Cleaning of Kitchen Items documented the following instructions: a. Stove 1. Daily, wipe up any spills with warm soapy water. 2. If large spill occurs pray with oven cleaner, allow time to sit and scrub clean. 3. Some spill may clean up by sending through dish machine: do at the end of doing dishes 4. Weekly: The grates must be scrubbed clean and put through dish machine. Also while grates are off stove remove burners and place upside down on another burner. Turn flame on to burn carbon off for 5-10 minutes, remove burner, handle with potholders (to prevent burning yourself), replace. Monthly: The pipes should be scrubbed/clean. You can spray with oven cleaner if needed. Remember to use personal protective equipment. b. Oven 1. Remove racks and place in large sinks. 2. Spray oven cleaner on racks and inside the oven. 3. Allow time to sit and soak. 4. wipe with wet rag. 5. Wipe with rag twice and use clean rag second time. 6. Recipe with wet rag if white spots remain, wipe dry.

Based on clinical record review, facility document review and staff interview, the facility failed to notify the physician of a missing [MEDICATION(S)] patch for 1 of 4 resident (Resident #11) reviewed. The facility identified a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #11 with a Brief Interview for Mental Status (BIMS) score of 99, with long/short term memory loss and severely impaired daily decision making. The Resident required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #11. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A Health Status Note dated 7/24/2022 at 10:04 a.m. documented by Staff A, RN documented she checked Resident #11 for a [MEDICATION(S)] (Patch) placement and no patch noted on her left lateral deltoid; patch was changed last evening. Torso checked and no patch noted. Staff A checked the resident's clothing that she wore; no patch. She asked the Resident Care Technician (RCT) if she saw a [MEDICATION(S)] patch on resident left upper arm when doing morning cares and she says she did not see a patch. Staff A checked the resident's bedding and found no patch. Staff A documented she spoke to Staff B, RCT, in laundry to see if she had seen a patch and Staff B responded no, but she would monitor the laundry and let her know. Staff A called the on-call nurse and informed her of missing [MEDICATION(S)] patch as well as the Assistant Director of Nursing (ADON). The July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #11. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 0.25 ml by mouth every 2 hours as needed for shortness of breath or pain. Administered: a. 7/25/22 at 00:03 a.m., pain level 9 on 1-10 scale; b. 7/25/22 at 5:41 p.m., pain level 5 on 1-10 scale; c. 7/26/22 at 8:05 a.m., pain level 9 on 1-10 scale; d. 7/26/22 at 5:55 p.m., pain level 4 on 1-10 scale; The July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 mg by mouth every 2 hours as needed for restlessness. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. 7/24/22 at 8:54 a.m. b. 7/24/22 at 3:06 p.m. c. 7/25/22 at 00:001 a.m. d. 7/25/22 at 11:38 a.m. e. 7/25/22 at 5: 41 p.m. A review of the Progress Notes from 7/24/22 thru 8/03/22 and a review of the Resident's paper medical chart lacked documentation of notification to the physician via call or facsimile regarding the missing [MEDICATION(S)] Patch. During an interview on 9/04/22 at 9:27 a.m. the Hospice Nurse reported Staff A notified her the same day the [MEDICATION(S)] Patch went missing. She stated she had been in the facility for another resident; she didn't actually see Resident #11 that day and did not contact any physician on the missing pain medication. The Hospice Nurse stated she assumed the facility put on another [MEDICATION(S)] patch for pain and did not address it with the facility; Staff A never asked her about additional pain medication. During an interview on 9/04/22 at 9:33 a.m. Staff A reported the Hospice Nurse had been in the facility to see another resident and she had informed her of Resident #11's missing [MEDICATION(S)] patch. Staff A reported she had been really busy addressing the care of another resident and she did not notify Resident #11's physician or address if another [MEDICATION(S)] Patch should have been applied. She stated that Resident #11 did have as needed (PRN) [MEDICATION(S)] for pain and she remembered giving the PRN [MEDICATION(S)] for pain that day and probably should have notified the physician. During an interview on 8/04/22 at 10:57 a.m. the Assistant Director of Nursing (ADON) reported she didn't know the facility's policy on physician notification regarding to missing medications, but she would have expected someone, either the charge nurse or the Hospice nurse to notify the physician of the missing [MEDICATION(S)] patch and address pain medication needs if another patch needed to be applied. It should have been addressed with the physician by someone. The Physician Notification Policy, undated, provided by the facility listed a Procedure that included: 1. Physicians will be notified promptly of the following: A. Any accident or unusual incident. B. Any accident or incident which results injury which may require physician intervention. C. A significant change in resident condition which is life threatening. D. A significant change in resident condition which has potential for clinical complication. E. A change in condition which requires a significant alteration in treatment. F. Death of a resident. G. Discharge or transfer of a resident. 2. Same Day Fax notification may be utilized for condition changes, transfer, discharges, accident and incidents, and other events which do not require immediate attention.

Based on clinical record review, facility document review, staff interviews and facility policy review, facility staff failed to report to the Department of Inspection and Appeals a missing [MEDICATION(S)] patch for one resident (#11) and failed to report an allegation of verbal and physical abuse in a timely manner for another resident (#14) of five residents reviewed for abuse prevention. The facility identified a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #11 with a Brief Interview for Mental Status (BIMS) score of 99, with long/short term memory loss and severely impaired daily decision making. The resident required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #11. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Health Status Note dated 7/24/2022 at 10:04 a.m. documented by Staff A, RN documented she checked Resident #11 for a [MEDICATION(S)] (Patch) placement and no patch noted on her left lateral deltoid; patch was changed last evening. Torso checked and no patch noted. Staff A checked the resident's clothing that she wore; no patch. She asked the Resident Care Technician (RCT) if she saw a [MEDICATION(S)] patch on resident left upper arm when doing morning cares and she says she did not see a patch. Staff A checked the resident's bedding and found no patch. Staff A documented she spoke to Staff B, RCT, in laundry to see if she had seen a patch and Staff B responded no, but she would monitor the laundry and let her know. Staff A called the on-call nurse and informed her of missing [MEDICATION(S)] patch as well as the Assistant Director of Nursing (ADON). During an interview on 8/02/22 at 2:18 p.m. the Administrator reported the missing patch was not reported into the Department of Inspection and Appeals (DIA) as she had not known about it. The Administrator learned of the incident that day. The Administrator stated she had not been able to get into the DIA on-line reporting system and would have expected the incident to have been reported to DIA. During an interview on 8/02/22 at 2:35 p.m. the Assistant Director of Nursing (DON) reported she received a call from Staff A when the [MEDICATION(S)] Patch went missing. She had inquired if Staff A had informed the on-call nurse and told her to follow what the on-call nurse had informed her to do what the on-call nurse, Staff C, Licensed Practical Nurse (LPN) said to do. The ADON reported it was a Sunday and she and the DON were both off on Monday so she texted the MDS Coordinator and told her to check and be sure that everything had been followed up on Monday. During an interview on 8/2/22 at 3:09 p.m. the MDS Coordinator reported when she came in on Monday she pulled the schedules, face sheet, and medication sheets for the investigation. She did not know if the incident was reported to DIA, but she did not report it. The MDS Coordinator stated the Administrator was usually the one that reported incidents into DIA. Usually someone will text the Administrator when something occurs that needed to be reported, but there was so many hand in the pot that she didn't ask any questions. The MDS Coordinator didn't ask if anyone had reported the incident. During an interview on 8/02/22 at 3:44 p.m. the DON reported she completed an investigation on Resident #11's missing patch when she had returned to work on Tuesday 7/26/22. The DON stated she did not report the missing [MEDICATION(S)] Patch to DIA and had not thought about reporting. She reported she would have to check the facility policy as to what it directed on reporting. During an interview on 8/03/22 at 12:30 p.m. the Administrator stated she had not reported the incident into DIA since the surveyors were already on site and looking at the incident. A Missing Narcotic (Patch/tab/liquid) Protocol, dated 7/27/22, provided by the facility and signed by the DON listed the following steps: 1. The staff will notify the nurse manager on call. 2. No staff leave the facility until statements are taken and search is completed. 3. The DON/Administrator must be notified. 4. Pull schedules to see who worked the shift before as staff members not at the facility at the time of the missing narcotic noticed may also need to be questioned. All staff being interviewed must be asked the same questions. It is easier to go with yes/no questions. 5. When instructing staff, please make sure you have dates/times on the statements of when the questioning is being done but also when last time seen, etc. 6. Make sure the physician is being notified. 7. Instruct the nurse to not enter anything into the nurses notes. The note will be entered after all information is gathered/investigation completed. 8. If any questions please call DON or if not available contact the corporate nurse. The protocol lacked any direction on reporting to DIA. The Nursing Facility Abuse Prevention, Identification, Investigating and Reporting Policy, dated July 2019, provided by the facility, defined abuse of Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Resident's belongings or money without the Resident's consent. This includes misappropriation or diversion of resident medications. The Policy Reporting requirements state allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator, or designated representative. All allegations of Resident abuse shall be reported to the Iowa Department of Inspection and Appeals not later than two (2) hours after the allegation is made. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspection and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. 2. The MDS assessment dated [DATE] documented Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident possessed severely impaired memory and cognition, as evidenced by a BIMS score of six. The assessment documented the resident required the assistance of two staff with transfers, walking in her room and toilet use and the assistance of one staff with personal hygiene. The MDS documented Resident #14 had no behavioral symptoms or refusal of care during the assessment period. Review of Resident #14's Confidential Incident Report documented an incident of alleged abuse that occurred on 05/22/2022 at 12:30 PM. The DIA Intake Submission time documented Resident #14's allegation of abuse as submitted on 05/23/22 at 11:08 AM. During an interview on 08/03/22 at 10:55 AM, the prior Administer stated he worked as the Administrator of the facility at the time of the incident on 05/22/22 with Resident #14. He stated he was informed right way by the DON on a Sunday and believed he reported it to DIA first thing on Monday. During an interview on 08/04/22 at 11:12 AM with the Administrator revealed she was not working at the facility during the incident with Resident #14 on 05/22/22 but would have reported the alleged abuse to DIA within two (2) hours.

Based on clinical record review and staff interview, the facility failed to notify the Long-Term Care Ombudsman of residents discharging the facility for one of four residents reviewed (Resident #14). The facility reported a census of 38 residents. Findings include 1. Record review of Resident #14's Minimum Data Set (MDS) log documented a discharge on 05/04/2022. Record review of Resident #14's MDS log documented a reentry to the facility on [DATE]. Record review of the facility's May 2022 Ombudsman Notification logs revealed no notification to the Ombudsman that Resident #14 discharged on [DATE]. During an interview 8/2/22 at 3:15 PM the facility Administrator verified that the LTC Ombudsman office had not been notified of the transfer to the hospital for Residents #14 and there had been a miscommunication about this requirement but it has been corrected and will be done going forward.

Based on observation, staff interviews and record review the facility failed to provide 1 of 38 residents (Resident #9) with their physician prescribed diet. The facility reported a census of 38 residents. Findings include The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident#9 had diagnoses including stroke, and gastro-[CONDITION(S)] reflux disease. The MDS documented that the resident had impairment of one upper extremity, and required meal set up assist of one staff member. Record review of a document titled Diet Type Report, dated 08/01/2022 documented Resident #9 is to received a mechanical soft diet. Record review of Resident #9 current Care Plan documented and intervention of; provide with diet as ordered, initiated on 11/24/2015 and last revised on 12/15/2016. Record review of Resident #9 Orders documented a diet of: General diet, Mechanical Soft texture, Regular consistency, with a start date of 10/07/2019. During an observation on 08/03/22 at 12:38 PM of a Certified Nursing Assistant (CNA) providing regular diet to Resident #9. During an observation on 08/03/22 at 12:42 PM the Dietary Manger realized Resident #9 received the wrong diet. Observed Resident #9 consumed approximately 1/4 of the regular. The Dietary Manager removed the regular diet plate of food and provided the correct diet of mechanical soft to Resident #9. During an interview on 08/04/22 at 10:45 AM with the Assistant Director of Nursing (ADON) revealed she would expect residents to receive the correct diets.

Based on record review, staff interviews, and policy review the facility failed to provide as needed (PRN) diuretic medication as directed by the physician for 1 of 1 residents reviewed for diuretic PRN medication (Resident #36). The facility reported a census of 38 residents. Findings include: The Five Day Scheduled Minimum Data Set (MDS) dated [DATE] documented that Resident#36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented that the resident had taken diuretic medication the last seven days. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . weight gain, continue until weight back to normal. Record review of a document titled Weights and Vitals Summary for Resident #36 documented: 05/15/22 weight 206 lbs. 05/16/22 weight 207 lbs. and 210 lbs. Record review of Resident #36 May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a document titled Weights and Vitals Summary for Resident #36 documented: Record review of Resident #36 07/15/22 wight 195 lbs. 07/16/22 no weight documented 07/17/22 weight 203 lbs. Record review of Resident #36 July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #36 current Care Plan instructed staff on the following: Focus: Resident receives diuretic therapy related to Heart Failure, date initiated: 01/26/22 Goal: Resident will receive diuretic as ordered and be free from medication side effects, revised on: 01/26/22 Intervention: Administer diuretic as ordered, date initiated: 01/26/22 During an interview on 08/04/22 at 11:14 AM with the Administrator revealed she would expect for PRN diuretic medication to be given if it met the order criteria and did not constitute a reweigh. Record review of a policy titled, Medication Administration, dated 10/10/2019 instructed the facility on the following: Whenever medications are administered on an as needed (PRN) basis, the staff administering the dose is responsible for documenting the administration. The nurse will be responsible for assessing the need and effectiveness of the PRN medication.

Based on document review, policy review and staff interview the facility failed to have the Medical Director in attendance at least quarterly for the Quality Assurance and Performance Improvement (QAPI) meetings. The facility identified a census of 38 residents. Findings include: A review on 8/03/22 of the QAPI Meeting Attendance Signature Sheets, provided by the facility, showed from October 1, 2021 thru June 30th, 2022 the Medical Director had not signed in and attended any of the QAPI meetings. The July 2022 QAPI Meeting Attendance Signature Sheet showed the Medical Director did attend the July 2022 meeting. During an interview on 8/03/22 at approximately 12:27 PM the Administrator reported they had switched Medical Directors and the previous Medical Director had not attended the QAPI Meetings. She stated they are working to correct that. Her expectation is that the Medical Director would attend and participate in the QAPI meetings. The QAPI Plan, undated, provided by the facility documented all department managers, the administrator, the director of nursing, infection control and prevention officer, medical director, consulting pharmacist and up to three additional staff members will provide QAPI leadership by being on the Quality Assurance Assessment (QAA) Committee. The New [NAME] Nursing and Rehab Center QAPI meeting schedule, provided by the facility documented the facility planned to have QAPI meetings for the following dates with the Medical Director in attendance: 1. July 21, 2022 2. August 18, 2022 3. September 15, 2022 4. October 20th 2022 5. November 17, 2022 6. December 15, 2022

Based on observation, record review, and staff interview the facility failed to ensure proper sanitation of kitchen utensils and dishware used for preparation and serving resident meals. The facility census was 35 residents. Findings include: During kitchen observation 5/25/21 at 9:56 am the surveyor observed the automatic chemical sanitizing dishwasher in use and asked Staff A to perform a test of the sanitizer concentration, Staff A used the facilities test strips and there was no color change to the test strip which should have turned blue if the sanitizer concentration had been at the required level. Staff A cycled the dishwasher again and performed another test with the same result, Staff A checked the bucket of chemical sanitizer that the dishwasher draws from for the sanitizing rinse cycle and verified the sanitizer was empty, on visual examination the tubing that delivers the sanitizer to the dishwasher had mostly air with only a few drops of sanitizer that would not flow to the dishwasher. Staff A then replaced the sanitizer with a new, full bucket and ran the dishwasher through another cycle and retested the sanitizer concentration, the test strip still did not change color, Staff A ran the dishwasher through 4 more cycles and retested the sanitizer and still no color change, at that time staff primed the sanitizer line until liquid could be seen running through the line all the way to the dishwasher then ran the dishwasher through another wash/rinse cycle and tested the sanitizer concentration which did turn blue indicating the concentration was at least 100 PPM (parts per million). Continued observation on 5/25/21 at 9:56 am revealed the manufacturer's tag on the dishwasher stated that the sanitizer concentration needed to be at least 50 PPM to be effective, review of the daily sanitizer testing log on the wall across from the dishwasher showed that the sanitizer concentration is tested by staff 3 times daily around each meal time and it had been tested at breakfast time the morning of 5/25/21 with a result documented at 100 PPM, with no way of knowing exactly when the sanitizer would have become empty after breakfast Staff A stated the dishes from this morning would be rewashed.

Based on observation and staff interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The facility reported a census of 40. Findings include: 1. During an observation on 9/24/20 at 1:45 p.m. revealed the Center Hall Shower Room in use. During an observation on 9/24/20 at 2:00 p.m., the Center Hall Shower baseboard contained a build up of a black/brown substance. The 2 vents contained a build up of dust, dirt and debris. The electric fan positioned on the floor contained a build up of dust, dirt and debris. During an interview 9/24/20 at 3:00 p.m., the Director of Nursing stated did not know what the substances was and she asked the Maintenance Staff who rubbed on the substance and described it as a build up of dirt, shampoo and gunk. 2. During an observation on 9/24/20 at 1:50 p.m., of West Lounge area outside the Nurse's Station/Office revealed two heat vents. The vents contained a build up of dust, dirt and debris. The vents passed air on the medication cart. During an interview 9/24/20 at 1:52 p.m., the Maintenance Staff confirmed the build up of dust, dirt and debris on the heat vents and cleaned the vents.

Based on observation, record review and staff, physician and resident interviews, the facility failed to adequately assess and prevent the development of pressure ulcers (Resident #5). The facility identified 1 of 54 residents with pressure ulcers. Findings include: Resident #5 had a MDS (Minimum Data Set) assessment with a reference date of 11/1/16. The MDS identified [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance of 2 staff members for bed mobility and depended upon 2 staff members for transfers. The BIMS (Brief Interview for Mental Status) indicated a score of 15. A score of 15 represented no cognitive problems for daily decision making. The MDS indicated the resident at risk for the development of pressure ulcers but had no pressure ulcers present. The MDS identified no diabetic, venous nor arterial ulcers present. A document titled Braden Scale for Predicting Pressure Sore Risk, dated 10/25/16, identified the resident at risk for the development of pressure sores. The Progress Notes (nurse's notes) dated 11/21/16 identified an air cast/boot to the right ankle. The nurse removed the boot for a skin assessment. The incision to the right ankle mostly healed and staples had been removed. The nurse document she noted 2 open areas to the inner right ankle that appeared to be from pressure. The first pressure sore measured 0.6 by 0.9 by less than 0.1 cm (centimeters) and located on the upper right inner ankle. The second pressure sore measured .04 by 0.5 by less than 0.1 cm located on the inner lower right ankle. The skin surrounding the open areas are intact and pink in color. The area blanched. The nurse identified the right 3rd toe had a reddened area that measured 1 cm by 1 cm. The area blanched. The Wound/skin healing record identified the right upper ankle sore as a stage II pressure ulcer. The surround skin color had a normal skin color. Wound record 11/21/16 recorded these as Stage II pressure areas. Resident # 5's Care Plan, initiated on 4/11/13, identified the resident at risk for impaired skin integrity related to incontinence, limited mobility, and [DIAGNOSES REDACTED]. On 5/27/15, the resident needs assistance into and out of bed. Assist (the resident) with repositioning. On 4/11/13, the facility placed a pressure relief mattress on the bed. On 10/19/16 the facility placed a pressure reduction cushion in the chair. On 11/2/16 the resident wears ace wrap/air cast to right lower extremity at all times as tolerates, Resolved 12/13/16. After the pressure area discovered on 11/21/16, the following interventions were added to the resident's Care Plan. On 11/23/16 Skin treatment as ordered. On 11/23/16 assess the pressure ulcers for location, stage, size (length, width, depth), presence and absence of granulation tissue and epithelization, and condition of surrounding skin weekly. On 11/23/16 monitor skin during cares. Report any further skin breakdown (sore, tender, red or broken areas) On 11/23/16, turn and reposition every 2 hours. On 11/29/16 may remove boot while in bed and for bathing biweekly. The facility fax to the physician dated 11/28/16 identified an unstageable right heel pressure area which measured 0.5 by 0.7 cm. The area had a brown scab covering the area. The right walking boot in place at all times per the physician after the surgical repair of the right ankle fracture. The nurse documented she would fax the physician to request boot removed when in bed. The Care Plan intervention dated 11/29/16 indicated the staff may remove the boot while in bed and for bathing biweekly. On 1/24/17 at 1:00 pm Resident #4 was interviewed and stated just since yesterday (1/23/17) when staff discovered a new pressure ulcer. The facility just then began putting the right lower extremity up on a pillow when she/he is in bed. On 1/26/17 at 10:00 am, the DON was interviewed and stated a wound nurse consult was scheduled for today due to the Wound Clinic only open on Thursdays. The DON stated she asked the resident on 1/24/17 (day after another pressure sore had been found) if she would wear a boot and the resident declined (No documentation of this or education was provided or able to be found in the clinical record). On 1/26/17 at 10:15 am Staff C, Registered Nurse (RN), was interviewed and stated after the first pressure ulcer was discovered on the right inner ankle, she received new orders to remove the boot when not in use and implemented a reposition program every 2 hours. There was no physician recommendation for a Wound Clinic and have now scheduled an appointment for today 1/26/17 since she has developed another pressure ulcer. On 1/26/17 at 12:11 pm the resident's primary physician was interviewed. The physician verified a heel protector boot may have prevented the pressure ulcer.

Based on observation and staff interview, the facility failed to maintained a quaternary solution at the appropriate level to ensure kitchen equipment was properly sanitized. The facility census was 54 residents. Findings include: 1. During observation on 1/24/17 at 10:59 a.m., Staff A, Dietary Aide used a cloth from a plastic bucket in the kitchen to sanitize a plastic rolling cart used to transport dishes and other items throughout the dining room. At the time the Dietary Manager verified the bucket contained quaternary sanitizer. The surveyor asked the Dietary Manager to check the sanitizing solution level. The Dietary Manager dipped a strip in the solution for ten seconds and the strip did not change color. The Dietary Manager stated the solution was no good and it needed to be changed. The Dietary Manager made fresh solution and it measured 300 parts per million. On 1/26/17 at 7:00 a.m., the Dietary Manager stated there was no record of staff checking the quaternary solution or ever documenting results and they were in the process of developing a policy.

Based on record review and staff interviews, the facility failed to ensure one of four residents received adequate supervision and assistance to prevent a fall which resulted in a sprained finger for Resident #1. The facility reported a census of 60 residents. Findings Include: According to documentation in the clinical record, Resident #1 entered the facility on 11-30-12 and had [DIAGNOSES REDACTED]. Review of the facility Minimum Data Set (MDS) assessment form dated 05-19-2016 indicated Resident #1 scored 15 of 15 points on the Brief Interview for Mental Status (BIMS) indicating no cognitive decline. The assessment also described Resident #1 as requiring extensive staff assistance with bed mobility, transferring, ambulation in the room and corridor, dressing, toilet use and bathing. The individual plan of care identified the problem of Resident #1 needing assistance with activities of daily living (ADL's) and directed staff to assist Resident #1 with two staff and gaitbelt for transfers and assist of two staff with cane and gaitbelt for ambulation. According to documentation in the facility Confidential Incident Report when staff pulled the wheelchair next to the resident, Resident #1 sat on the edge of the wheelchair and slid down and hit his/her head on the floor. The physical assessment indicated Resident #1 had some swelling and bruising on the left forehead and a skin tear on the left hand. According to documentation in the nurse's notes dated 06-17-16, staff notified Resident #1's physician at 9:20 p.m. and received orders to send Resident #1 to the emergency room . Documentation on 06-18-16 at 12:57 a.m. indicated Resident #1 returned to the facility with new orders for ice for 15-20 minutes 3 to 4 times a day for 2 to 4 days to right thumb for sprain. During an interview on 07-26-16 at 9:03 a.m. Staff A stated she and another resident care technician (RCT) had transferred Resident #1 from the wheelchair to the toilet the evening of 06-17-16. Staff A stated Resident #1 had used the call light to alert staff that he/she needed assistance with transferring again. Staff A responded to Resident #1's call light and called one time, via walkie talkie, for assistance in transferring Resident #1 from the toilet back to the wheelchair. Staff A stated she told Resident #1 one time that they needed to wait for extra help, and that the other staff was busy at the moment. Staff A stated she was aware that the care plan was for two staff to assist Resident #1 in all transfers and admitted she transferred Resident #1 without a second staff present. During an interview on 07-25-16 at 1:24 p.m. with the Director of Nursing, she stated on 06-17-16 Resident #1 sustained a fall after being transferred from the toilet to the wheelchair with one staff assisting. During the transfer, Resident #1 fell and sustained a minor sprain. The Director of Nursing stated the staff had been educated on referring to the care card for direction on proper transferring of Resident #1 but apparently thought he/she could transfer Resident #1 alone.

Based on observation, staff interview and review of the facility menu, the facility failed to provide the correct serving size for each of 40 residents observed who received the general diet entree at one of one evening meal observed. The facility reported a census of 58 residents. Findings include: A review of the facility menu for the evening meal on 2/1/16, revealed the planned entree as a one cup serving of cheesy tomato soup. During observation of the meal service on 2/1/16 at 6:00 p.m., Staff H, Cook used a #12 (1/3 cup) scoop and a #8 (1/2 cup) scoop to serve 40 residents who received the cheesy tomato soup. Upon completion of the meal observation, Staff H verified they had used a #12 and #8 scoop. When the surveyor showed staff the menu called for a one cup serving, Staff H stated they should have used two #8 scoops to equal the one cup serving the menu specified. Staff H stated they did not know why they had not done that. On 2/3/16 at 2:00 p.m., the Director of Nursing provided the surveyor with a list of six residents who had a significant weight loss, five on a general diet.

Based on observation, record review and staff interview, the facility failed to serve a therapeutic diet as prescribed by the physician and failed to follow the physician orders [REDACTED]. The facility reported a census of 59 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment for Resident #10 with a reference date of 11/8/13 reflected the resident could eat independently with set up help only. The MDS identified the resident had short and long term memory problems and a BIMS (Brief Interview for Mental Status) could not be determined due to cognitive decline. The Physician order [REDACTED]. A nutrition/dietary note dated 11/14/13 at 2:57 p.m., documented the residents daughter had indicated the resident had been allergic to strawberries and barley. The note reflected the strawberries and barley caused the resident to have a rash. The plan of care dated 11/14/13, included a problem of altered nutrition related to [MEDICAL CONDITION] some loss of independence in dining. The problem included an intervention to provide a general diet as ordered. The bottom of the care plan included a section for allergies [REDACTED]. Review of the facility menu for 12/3/13, revealed the listed dessert for the lunch meal to be berry shortcake. During observation of meal service on 12/3/13 at 12:00 p.m., Staff A (Cook) served the main course to the residents in the West dining room from a steam table. At 12:15 p.m., Staff A completed service of the main course in the West dining room and wheeled the steam table back to the kitchen to serve the main course to residents in the East dining room. At 12:40 p.m., observation revealed a wheeled cart being taken from table to table in the east dining room with strawberry shortcake on the cart. At that time, the surveyor asked the dietary manager about desserts for the west dining room and they stated the dessert had already been served by Staff B (cook). The surveyor then asked what Resident #10 would have been served for dessert since the resident had a directive for no strawberries. The dietary manager stated the resident would have been served an alternate. At that time the dietary manager agreed to accompany the surveyor to the west dining room. Observation revealed the resident remained at the dining table with an empty dessert plate resting on the table in front of him/her. The dietary manager stated the resident had received the shortcake. The dietary manager asked the resident if they had eaten strawberries and the resident replied yes. The dietary manager immediately notified Staff C (Licensed Practical Nurse). The dietary manager then went to the kitchen and informed Staff B the resident should not have been served strawberries. Staff B verified they had served the resident the strawberries and stated they had given it to the resident because the resident had asked for the strawberries. The dietary manager then informed Staff B the resident would not have been able to make an appropriate choice. The surveyor then asked the dietary manager what system had been in place for servers to double check resident diet orders as they are served, as observation revealed no tray cards used. The Dietary Manager stated there had been a Rolodex on their desk in the back of the kitchen, and staff usually remembered resident diets. The Progress Notes dated 12/3/12 at 1:01 p.m., identified vital signs (blood pressure, pulse, respirations, temperature) had been taken while the resident had been sitting at the lunch table, taken back to room where another set of vitals performed; phone call placed to emergency room and spoke with Advanced Registered Nurse Practitioner (ARNP). The ARNP gave an order to give the resident [MEDICATION NAME] (anti-[MEDICATION NAME]) 25 milligrams and give it right away. The Assistant Director of Nursing (ADON) gave an Epi-pen ([MEDICATION NAME], used for severe allergic reaction) injection to hip, 1 dose as per package, The resident ' s daughter was notified and the daughter stated the resident ' s eyes would swell shut and would have a rash. The resident ' s eyes began to water, increased labored breathing and drooling was present. At 3:00 p.m., the Dietary Manager provided the surveyor with a revised seating arrangement which included diet orders and allergies [REDACTED]. The signs of symptoms of being allergic to strawberries, identified in LIVESTRONG.com identified the first symptom of an allergic reaction to strawberries occurs in the mouth and throat and face. A tingling and burning sensation in the lips, mouth, throat and palate. Swelling of the throat and tongue can obstruct the airways leading to the lungs and impair oxygen uptake in the lungs. An [MEDICATION NAME] may occur which results in a rapid drop in blood pressure, diarrhea, impaired breathing, vomiting, dizziness and loss of consciousness. [MEDICATION NAME] is considered a life-threatening condition that requires immediate medical attention.