Every finding on record at Nora Springs Care Center

Based on observation and interview, the facility failed to maintain kitchen equipment and clean dishes in a sanitary condition due to a white residue buildup. The facility reported a census of 39 residentsFinding includes:On 7/20/26 at 9:15 AM, an observation during an initial kitchen walkthrough revealed a buildup of white residue on the dishwasher and clean dishes. On 7/20/26 at 10:50 AM, an observation in the kitchen revealed the white residue remained on the dishes and in the dishwasher. On 7/21/26 at 11:05 AM, Staff E, Cook, reported facility staff attempted weekly descaling (removing mineral buildup) on the dishwasher, but dishes still retained the buildup. Staff E reported the Administrator held awareness of the issue. On 7/21/26 at 11:30 AM, the Dietary Manager (DM) reported facility awareness regarding the dishwasher issues, noting an ordered water softener remains on backorder. On 7/21/26 at 11:45 AM, the Administrator reported contacting the city in June regarding water usage to determine the required softener size, but received no response. The Administrator reported awareness regarding the buildup on the dishes and in the dishwasher. On 7/22/26 at 7:40 AM, Staff F, Dietary Aide (DA), reported the white residue on the dishwasher and dishes persisted for a long time. Staff F reported the Administrator held awareness without resolving the issue, noting several past and current residents disliked the buildup.

Based on record review and interview, the facility failed to ensure staff obtained a completed and signed Iowa Physician Orders for Scope of Treatment (IPOST) (end-of-life care order) from a physician for 1 of 8 residents (Resident #4) reviewed for advance directives. The facility reported a census of 39 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS score of 12, indicating moderately impaired cognition. A progress note dated [DATE] at 1:49 PM by Staff A, Social Worker (SW), documented leaving a message with Resident #4 Representative, asking Resident #4 Representative to call Staff A to sign Resident #4's Iowa Physician Orders for Scope of Treatment (IPOST) (end-of-life care order). The progress note documented Resident #4 maintained a Do Not Resuscitate (DNR) (no CPR) code status and noted the facility didn't have the original IPOST. Resident #4's care plan on [DATE] directed staff of an advance directive of DNR code status. An observation on [DATE] at 1:37 PM of Resident #4's Profile documented a code status of DNR. Resident #4's order summary documented a DNR order dated [DATE]. A progress note dated [DATE] at 1:31 PM documented Staff A reviewed the care plan and code status with Resident #4. Staff A reminded Resident #4 regarding seeking assistance at any time as needed and documented Preadmission Screening and Resident Review (PASRR) (mental health screening) in compliance. The note documented Resident #4's niece would call for a care conference on [DATE] at 11:30 AM to review code status and the care plan with Resident #4's niece. On [DATE] at 10:31 AM Resident #4 indicated she was a DNR. On [DATE] at 10:35 AM Staff A acknowledged the physician hadn't signed the IPOST and stated expecting the physician to sign the IPOST. On [DATE] at 12:33 PM Staff A indicated the Nurse Practitioner (NP) signed Resident #4's IPOST. On [DATE] at 12:34 PM an observation of Resident #4's record revealed the NP signed Resident #4's IPOST on [DATE].

Based on record review, resident and staff interviews, the facility failed to provide resident centered activities that incorporated the resident's interests and hobbies for 1 of 13 residents reviewed (Resident #29). The facility reported a census of 39 residents. Findings include:Resident #29's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #29 reported high importance regarding engaging in favorite activities, attending religious practices, keeping up with news, listening to music, and reading books, newspapers, and magazines. Resident #29's MDS documented diagnoses including anxiety (excessive worry) and depression (mood disorder). On 7/21/26 at 9:11 AM Resident #29 reported uncertainty if the facility offers activities. Resident #29 expressed wanting someone to read aloud and assist with a computer tablet to watch movies. Resident #29 stated staff members don't visit or engage in activities with Resident #29. Resident #29 reported lying in bed all day and hasn't gotten out of bed for some time, preventing participation in activities. A record review of Resident #29's Progress Notes and Electronic Health Record (EHR) showed a lack of documentation regarding provided activities beyond verbal encouragement to attend group activities. Resident #29's EHR showed no documentation of one-to-one or in-room activities offered to Resident #29. On 7/22/26 at 9:50 AM Staff A, Activity Director, stated not always having time to conduct one-on-one activities with residents remaining in rooms. Staff A reported not conducting any one-on-one activities with Resident #29. On 7/22/26 at 10:00 AM Staff B, Administrator, stated staff members need to offer one-on-one activities if a resident doesn't leave the room for group activities.

Based on record review, policy review and staff interviews, the facility failed to follow professional standards for reconciling controlled drugs (medication with a high potential for abuse) for 1 of 3 residents reviewed (Resident #36). The facility reported a census of 39 residents. Findings include:Based on observation, record review, and interview, the facility failed to ensure staff members accurately counted and reconciled controlled medications (narcotics), and failed to immediately report a narcotic count discrepancy for 1 of 1 resident (Resident #36) reviewed for medication administration. Resident #36's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #36's MDS documented diagnoses including malignant neoplasm of the bladder (cancerous growth on the bladder). Resident #36's MDS documented hospice care (end-of-life care). On 7/20/26 at 1:55 PM Staff A, Registered Nurse (RN), and Staff B, Licensed Practical Nurse (LPN), conducted a narcotic count for shift change. Staff B held the narcotic count book, reading the count numbers aloud while Staff A looked at the narcotics. Neither staff member compared the physical narcotic count to the count sheet to verify accuracy. On 7/21/26 at 10:42 AM the Administrator stated nurses or a nurse and a Certified Medication Aide (CMA) count the cart whenever keys transfer. The Administrator stated staff must verify the physical narcotic count matches the narcotic count sheet. A record review of a facility-reported incident summary dated 7/10/26 at 6:06 AM showed staff notified the Director of Nursing (DON) of a narcotic count discrepancy for Resident #36's liquid morphine sulfate (controlled pain medication). The count sheet documented 29.25 milliliters (ml) should remain in the bottle, but staff measured 24 ml. Further incident investigation documented 29 ml should remain in the bottle when staff measured 24 ml. The facility couldn't determine the location of the missing morphine. On 7/22/26 at 9:27 AM Staff B stated working second shift the previous night without Staff G, CMA, reporting a count discrepancy. Staff B reported returning for the 6:00 AM to 2:00 PM shift the next morning and noticing a count discrepancy with Resident #36's morphine. Staff B reported immediately notifying the DON, who investigated the discrepancy. On 7/22/26 at 10:31 AM Staff H, LPN, reported the narcotic count appeared correct upon arriving for shift early morning on 7/9/26. Staff H reported the 2:00 PM count on 7/9/26 measured 29 ml, noting a minor discrepancy might exist due to liquid holding in the syringe insertion area during counting with Staff G. On 7/22/26 at 10:38 AM Staff G stated noticing a count discrepancy of 24 ml in the bottle during a count with Staff H, but felt unsure of the exact volume. Staff G stated Staff H reported the count as correct, so staff continued counting. Staff G stated failing to report the discrepancy to anyone other than Staff H at time of discovery. Staff G reported attempting to administer morphine to Resident #36 using a syringe larger than 1 ml, possibly 5 ml, but couldn't measure 0.25 ml accurately. Staff G reported receiving help from another CMA to obtain a different syringe, noting a small amount of morphine possibly remained in the discarded syringe tip. Staff G reported counting narcotics at 10:00 PM with Staff I, LPN, noting Staff I didn't question the count. Staff G reported Staff B identified the missing morphine on the morning of 7/10/26 and notified the DON. Staff G reported the facility provided instruction regarding the importance of narcotic documentation and reporting. On 7/22/26 at 11:34 AM Staff I reported failing to notice the initial count discrepancy due to incorrectly viewing the bottle. Staff I reported becoming aware of Resident #36's missing morphine on the morning of 7/10/26 while counting with Staff B, and immediately notified the DON. The Controlled Medication Storage and Count Policy dated October 2023 directed staff to immediately report any narcotic count discrepancy to the DON.

Based on record review and interview, the facility failed to ensure staff administered insulin according to physician orders and failed to notify the physician when holding or altering insulin doses for 2 of 5 residents reviewed (Residents #30 and #22). The facility reported a census of 39 residents. Findings include:1. Resident #30's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2, indicating severely cognitively impaired. Resident #30's MDS included a diagnosis of diabetes (high blood sugar). Resident #30's insulin orders as of 4/7/26 documented Lantus (long-acting insulin used to manage blood sugar levels) 35 units in the morning, Novolog (rapid-acting insulin used to control high blood sugars) 10 units at lunch and 8 units at supper. On 6/30/26 a physician order documented Novolog 8 units in the morning. Resident #30's Progress Notes documented the following times nurses held insulin orders without notification or orders from the physician from 5/1/26 through 7/11/26: 5/4/26 at 12:54 PM held Novolog 10 units of insulin 5/10/26 at 5:07 PM held Novolog 8 units of insulin 5/11/26 at 11:35 AM held Novolog 10 units of insulin 5/16/26 at 4:58 PM held Novolog 8 units of insulin 5/18/26 at 1:18 PM held Novolog 10 units of insulin 5/19/26 at 12:27 PM held Novolog 10 units of insulin 5/20/26 at 12:49 PM held Novolog 10 units of insulin 5/28/26 at 5:22 PM held Novolog 8 units of insulin 6/10/26 at 12:37 PM held Novolog 10 units of insulin 6/27/26 at 9:08 AM held Lantus 35 units of insulin 7/8/26 at 8:53 AM held Novolog 8 units of insulin 7/8/26 at 11:35 AM held Novolog 10 units of insulin 7/11/26 at 6:18 PM held Novolog 8 units of insulin On 7/22/26 at 11:25 AM Staff A, Registered Nurse (RN), reported nurses don't adjust insulin doses but can hold insulin per nursing judgment per staff discretion. Staff A reported staff should send a fax to the physician and document in progress notes notifying the physician. Staff A reported nurses didn't verify with the doctor at the time, noting facility training instructed this practice. Staff A reported staff don't always notify the physician, but documented notifications in progress notes if completed. On 7/22/26 at 12:23 PM Staff B, Licensed Practical Nurse (LPN), reported nurses can't adjust the dose. Staff B reported a meeting where the former Director of Nursing (DON) told nurses staff could hold insulin per nursing judgment. Staff B reported a few residents had hold orders. On 7/22/26 at 12:29 PM Staff C, LPN, reported the former DON told staff nurses can't adjust dosing but can hold per nursing judgment. Staff C reported receiving instruction staff needed to document reasons for holding insulin without needing to call the physician. On 7/22/26 at 12:56 PM Administrator reported nurses per nursing judgment can hold insulin and should pass information at shift change and notify the physician. On 7/22/26 at 1:05 PM Nurse Consultant reported nurses can hold insulin if parameters exist for holding; otherwise, staff need to contact the doctor for directions. On 7/22/26 at 1:30 PM the DON reported nurses must call the physician if staff feel insulin needs holding or immediate adjusting. The DON reported staff must clarify with the physician what to do for insulin per physician direction. The DON reported some residents have hold parameters with orders from the doctor. On 7/22/26 at 2:20 PM Staff D, LPN, reported holding insulin per nursing judgment. Staff D reported not calling the physician to confirm insulins and receiving instruction nurses don't need to notify the physician. The Medication Administration-Medication Pass policy revised May 2023 directed staff to administer medications according to physician orders. 2. Resident #2's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #2's MDS documented diagnoses of diabetes (high blood sugar) and adult failure to thrive (unintentional weight loss and functional decline). The Transfer Orders signed by the physician on 1/20/26 documented orders for Basaglar (long-acting insulin) inject 8 units under the skin 1 time each day in the morning and insulin Aspart (rapid-acting insulin) inject 8 units under the skin 3 times a day before meals. Resident #22's Progress Notes documented the following times nurses held insulin orders per nursing judgment without notification to the physician: 1/23/26 at 3:32 PM insulin Aspart 8 units held 1/26/26 at 4:18 PM insulin Aspart 8 units held 1/28/26 at 4:52 PM insulin Aspart 8 units held 1/29/26 at 5:07 PM insulin Aspart 8 units held 1/30/26 at 5:02 PM insulin Aspart 8 units held and administered only 4 units per nursing judgment 1/31/26 at 5:14 PM insulin Aspart 8 units held 2/1/26 at 4:24 PM insulin Aspart 8 units held 3/7/26 at 4:49 PM insulin Aspart 8 units held 3/12/26 at 5:32 PM insulin Aspart 8 units held 3/15/26 at 4:42 PM insulin Aspart 8 units held 3/19/26 at 4:58 PM insulin Aspart 8 units held 3/20/26 at 5:42 PM insulin Aspart 8 units held 3/23/26 at 5:11 PM insulin Aspart 8 units held 3/26/26 at 5:16 PM insulin Aspart 8 units held 3/29/26 at 5:08 PM insulin Aspart 8 units held 4/1/26 at 12:48 PM insulin Aspart 8 units held 4/8/26 at 4:59 PM insulin Aspart 8 units held 4/14/26 at 5:03 PM insulin Aspart 8 units held 4/16/26 at 4:59 PM insulin Aspart 8 units held 4/17/26 at 5:08 PM insulin Aspart 8 units held 5/3/26 at 5:13 PM insulin Aspart 8 units held 5/7/26 at 4:59 PM insulin Aspart 8 units held 5/8/26 at 11:37 AM insulin Aspart 8 units held 5/12/26 at 4:56 AM insulin Aspart 8 units held 5/28/26 at 5:12 PM insulin Aspart 8 units held 5/31/26 at 4:52 PM insulin Aspart 8 units held 6/2/26 at 4:58 PM insulin Aspart 8 units held 6/3/26 at 5:08 PM insulin Aspart 8 units held 6/8/26 at 8:15 AM insulin Aspart 8 units held 6/12/26 at 5:12 PM insulin Aspart administered only 4 units per nursing judgment 6/18/26 at 5:11 PM insulin Aspart 8 units held 6/23/26 at 1:32 PM insulin Aspart 8 units held 6/26/26 at 5:26 PM insulin Aspart 8 units held 6/27/26 at 4:55 PM insulin Aspart 8 units held 7/1/26 at 11:57 AM insulin Aspart 8 units held 7/4/26 at 5:08 PM insulin Aspart 8 units held 7/5/26 at 5:52 PM insulin Aspart 8 units held 7/11/26 at 5:07 PM insulin Aspart 8 units held Resident #22's Care Plan with a target date of 9/22/26 documented Resident #22 receives diabetic oral hypoglycemic (blood sugar lowering) medication and injectable insulin to maintain glucose (blood sugar) levels within normal limits. Interventions directed staff to administer medication as ordered, provide diet as ordered, request dietitian consult as needed, encourage compliance with medication and diet regimen, monitor blood sugar as ordered, and monitor for signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). On 7/21/26 at 3:48 PM Staff J, LPN, indicated receiving instruction staff could hold insulin per nursing judgment. Staff J indicated staff should fax the physician and document in a progress note. On 7/22/26 at 2:26 PM Staff B, LPN, indicated holding Resident #22's insulin because blood sugars dropped in the afternoon, especially if Resident #22 didn't eat much or had only a snack. Staff B indicated staff didn't call the physician and used nursing judgment without adjusting the dosage of insulin.

Based on clinical record review a, policy review and staff interviews, the facility failed to notify the physician of an omission of a medication for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 47 residents. Findings include: Resident #5's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of adult failure to thrive, diabetes and cancer. Resident #5's October 2025 MAR listed the zinc order. Documentation directed to see progress notes from 10/4/26-10/9/26. The Orders-Administration Note 10/4/25 - 10/9/25 listed Zinc Sulfate as unavailable.The Progress Notes lacked documentation of the facility notifying the provider that Resident #5 didn't receive the Zinc Sulfate as order. On 4/14/26 at 11:50 AM the Administrator reported she couldn't find documentation of the physician being notified for the zinc not given for Resident #5. The facility policy titled Medication Administration-Medication Pass revised May 2023 lacked documentation of the process of what to do if a medication is not available.

Based on clinical record review, policy review, pharmacy and staff interviews, the facility failed to administer medications per physician orders for 2 of 3 residents reviewed (Resident #2 and Resident #5). The facility reported a census of 47 residents. Findings include:1. Resident #2's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 0, indicating severe cognitive impairment. The MDS included diagnoses of cancer, heart failure, and dementia. Resident #2's admission orders dated 11/20/25 documented an order for furosemide (diuretic medication to get rid of excess water and sodium from the body) 20 milligrams (mg) to be given daily. Resident #2's census tab in the Electronic Health Record (EHR) documented an admission date of 11/20/25 and discharge 12/1/25. Resident #2's November 2025 Medication Administration Record (MAR) lacked the order of furosemide or administration of it from November 21 through the end of the month. On 4/13/26 at 2:20 PM the Contracted Pharmacy reported when they delivered Resident #2's furosemide on admission, the facility sent it back. The facility never gave the medication. On 4/13/25 at 2:30 PM the Administrator reported the facility had an admission team in charge of putting orders in the computer for new admissions. After the admission team put in the orders, the night shift nurse would double check the orders. She reported she didn't know why Resident #2 didn't receive his furosemide and she will have to look into it. On 4/13/26 at 3:19 PM the Administrator reported she found the admission orders for the furosemide and couldn't find that it was discontinued, so the staff should have given it to Resident #2. The facility policy titled Medication Administration-Medication Pass revised May 2023 lacked documentation of the process to check a new admission medication to ensure the staff transcribed the medication list correctly. 2. Resident #5's MDS dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS included diagnoses of adult failure to thrive, diabetes and cancer. Resident #5's admission orders dated 10/3/25 documented an order for zinc sulfate 220 mg to be given daily starting on 10/4/26 Resident #5's October 2025 MAR listed the zinc order. Documentation directed to see progress notes from 10/4/26-10/9/26.The Orders-Administration Note 10/4/25 - 10/9/25 listed Zinc Sulfate as unavailable. On 4/14/26 at 10:45 AM the Administrator reported the previous staff member, who ordered stock medications, failed to obtain the zinc immediately because it remained on backorder. She noted her uncertainty regarding whether the pharmacy knew of the shortage, as the facility could not procure the medication from their regular supplier.On 4/14/26 at 11:50 AM the Administrator reported she still could not find documentation that the facility notified the pharmacy the zinc needed to be obtained from them because the company they ordered through held it on backorder.

Based on clinical record review, facility records, policy review and staff interviews, the facility failed to have competent staff explain the risks of not wearing a physician ordered knee immobilizer prior to transferring a resident from a chair to the bed for 1 of 3 residents (Resident # 3) reviewed resulting in bilateral closed fractures of the condyles of tibial plateau (the two rounded prominences at the top of the shin bone that form the weight-bearing surface, articulating with the thigh bone to create the knee joint ) and fibulae (smaller of the two bones between the knee and the ankle). The facility reported a census of 46 residents. Findings include:Resident #3's Minimum Date Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognition. The MDS documented Resident #3 had lower extremity impairment on one side. The MDS listed Resident #3 as dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed-to-chair transfers. The MDS listed active diagnoses of fractures, osteoporosis, diabetes mellitus, and morbid (severe) obesity. The MDS documented an open wound to the right knee. The MDS documented Resident #3 had received surgical wound care. The Care Plan included the following Focuses with target date of 3/14/26:Resident #3 required assistance with activities of daily living (ADL's). The Interventions directed the following:Right knee immobilizer on during transfers/ambulation. Transferring: dependent with assist of 2 staff member(s) to complete this ADL.Walking: dependent with assist of 2 staff member(s) to complete this ADL.Resident #3 had a risk for falls related to altered gate and balance complicated by osteoporosis, history of previous fracture, obesity, renal (kidney) failure requiring dialysis (external mechanical filtering of the wastes and toxins from the blood) and open wound with delayed healing to the knee. The Interventions directed: Assist resident with ambulation and transfers as needed.Call light within reach.Consult with therapy as needed.Nonskid footwear.Resident #3 had a history of noncompliance with therapy recommendations related to transfers, ambulation and use of assistive devices. The Interventions directed:Educate resident regarding potential risks and adverse effects refusing recommendations.Staff to maintain respect for resident rights to make own lifestyle choice.The Care Plan Report lacked direction of the specific staff competent to provide education regarding potential risks and adverse effects of refusing treatment.Review of the Durable Medical Equipment (DME) Miscellaneous (Free Text Entry) (Non-Medicare Covered): Rehab Facility Orders dated 12/16/25, noted by Staff A, Licensed Practical Nurse (LPN), reflected the Physician saw and evaluated Resident #3 at the clinic on 12/16/25. The orders indicated Resident #3 could start advancing with weight-bearing as tolerated on the right lower extremity with the assistance of Physical Therapy (PT) and should continue with the protective knee immobilizer at all times while ambulating.The Appointment Note dated 12/16/25 at 2:05 PM indicated Resident #3 arrived back to facility from an appointment. Resident #3 received an order to start advancing weight bearing status as tolerated but continue with immobilizer at all times when weigh bearing. Follow up visit on 1/6/25. The Communication - with Therapy Note dated 12/19/25 at 2:35 PM directed Resident #3 up with 2 assist with bariatric 2 wheeled walker for pivots and ambulation, must have knee immobilizer on.The Communication - with Therapy Note dated 12/25/25 at 12:21 PM indicated Resident #3 got up with 2 assist and a 2 wheeled walker, knee immobilizer must be on. She can walk to bathroom and in hallway short distances. The Incident Report Note dated 12/31/25 at 5:31 PM indicated a nurse heard a scream down hall 4 around suppertime. The aides called on the walkie talkie for a nurse to come to Resident #3's room immediately. When walking into the room the nurse saw Resident #3 fall backwards with her legs in a backwards W shape. Upon first sight Resident #3's wound appeared split open. The aides had the gait belt placed appropriately on her. Resident #3 wore proper footwear and used her walker. She had her room free of clutter with adequate lighting. After determining Resident #3 as stable, the nurse called 911 for an emergent transfer. The nurse informed both Resident #3's husband and son of the situation in which they agreed to send her out. The nurse went back and did a further assessment in which Resident #3 stated, I did not hit my head the girls caught me, they did nothing wrong. There was nothing they could've done to prevent this my legs just buckled. Resident #3 showed signs and symptoms of severe pain and couldn't move either of her legs. Resident #3's vitals remained within normal limits until taken by ambulance to hospital. The Assessment of Resident including range of motion and pain described Resident #3's leg as bent backwards, with the wound on her knee spread open and actively bleeding. Resident #3 had pain rated as 10/10 (0 no pain, 10 worst pain ever), nearly hyperventilating (breathing too fast taking in too much oxygen and not releasing enough carbon dioxide), she couldn't move either of her legs or wiggle her toes upon her assessment. Resident #3 couldn't move her legs upon assessment and had suspected bilateral broken legs. The nurse completed a head-to-toe assessment, stabilized her legs with pillows, and contacted emergency medical services (EMS). The nurse noted Resident #3 needed educated she needed the immobilizer for safe ambulation per PT recommendations and Care Plan if refused ambulating will be deferred due to safety risks.The Communication - with Physician Note dated 12/31/25 at 6:10 PM reflected the nurse called the Physician and received verbal orders to send Resident #3 to the emergency room (ER) for evaluation.The Communication - with Staff Note dated 1/2/26 at 10:17 AM documented Resident #3's spouse came and took her personal belongings the day before and didn't want to hold her bed.The Progress Notes lacked documentation of Resident #3's refusal to wear the right knee immobilizer or that the staff provided education of the potential risk and adverse effects of the refusal. Staff B, Certified Nurse Aide (CNA)'s, personnel file documented a hire date of 8/20/25. The CNA job description, signed 8/20/25 by Staff B, listed the following essential functions of the position:Provides quality nursing care to guests in an environment that promotes their rights, dignity and freedom of choice.Provides individualized attention, which encourages each guest's ability to maintain or attain the highest practical physical, mental and psychosocial well-being. Attends to individual needs of all guests in regard to incontinent care, transferring, ambulation, range of motion, communication and other needs.Must be knowledgeable of individual care plans and support the care planning process by providing supervisor with specific information and observations of the guests needs, preferences and report any behavioral changes.Follow established safety precautions when preforming tasks and using equipment and supplies.The Skills and Techniques Evaluation, signed by Staff A on 8/20/25 indicating she received orientation in each of the areas identified and she understood her role in the various topics), directed to complete during job specific orientation and re-evaluated annually with performance review and/or as needed. Each task included Staff A's initials with another person's initials for employee/facilitator. The Skills/Techniques included the following:Alerts to report to nurse: emergency care, fall, short of breath (SOB), bleeding, choking, skin alterations, fainting, seizure, abnormal vital signs, vomiting, diarrhea, constipation, pain, behaviors, changes in conditionAmbulation: assistive devices/walkers/cane, gait beltBehaviors: non-pharmacological approaches, reporting, documentationFalls: risks, interventions, prevention, reportingTransfers: body mechanics, bed to chair, with pivot turn, mechanical lift, 1- and 2-person lift, using gait beltPositioning/preventive devices, bed/chair cushions, hand rolls, splints, heel and elbow protectors, wedges, abductor pillows, reaching devicesSplints/braces: application, careTransfersThe form lacked a facilitator signature. The Skills and Techniques Evaluation lacked competency for alerting the nurse in regards to refusing immobilizers or appliances. In an interview on 1/6/26 at 10:40 AM, Staff B, CNA, reported she worked 12/31/25. Staff B stated she assisted Resident #3 to transfer from her chair to her bed when her legs gave out. Staff B verbalized they lowered Resident #3 to the floor. Staff B reported Resident #3 didn't have her right knee immobilizer on at the time of the transfer. Staff B acknowledged she knew Resident #3 needed to have the immobilizer on with transfers. Staff B reported Resident #3 refused to wear the immobilizer. Staff B verbalized she offered education to Resident #3 stating the immobilizer could be cleaned and would probably be better to have it on. Staff B acknowledged she didn't notify the nurse on duty of the refusal prior to the transfer. Staff B verbalized she didn't know when Resident #3 needed to have on the immobilizer. In an interview on 1/6/26 at 10:43 AM Staff C, Registered Nurse (RN), verbalized she worked 12/31/25. Staff C stated the staff used the walkie talkies to have her come to Resident #3's room. Staff C stated she ran down to the room and when she entered the room, she saw Resident #3's legs bent backwards. Staff C reported Resident #3 didn't wear her knee immobilizer. Staff C described Resident #3 as hyperventilating and in pain. Staff C reported the CNAs didn't call her down to Resident #3's room prior to the transfer.In an interview on 1/6/26 at 3:30 PM with Staff A and the DON, Staff A reported if a resident wore an immobilizer, the nurse should educate them if they refuse to wear the immobilizer. Staff A verbalized the staff used the walkie talkies to communicate with each other. Staff A acknowledged Resident #3 needed to have the immobilizer on with all transfers.In an interview on 1/6/26 at 3:34 PM the DON, acknowledged they expected the nurse to educate Resident #3 if she refused the immobilizer. If the Resident #3 continued to refuse to wear the immobilizer, the staff should have found an alternative instead of ambulating. The DON verbalized safety is priority over resident rights. The facility lacked a policy for training or competency of staff. The facility provided Transfer: Bed-Chair policy revised February 2024 defined the purpose as to move residents safely from bed to chair/wheelchair and from chair/wheelchair to bed. The policy directed to transfer according to the Care Plan unless using more assistance than Care Plan indicates due to weakness or change in condition. Follow procedures for notifying nurse and documentation of changes in condition. The Transfer: Bed-Chair policy lacked direction for immobilizers/appliances and who is responsible for education if immobilizers/appliances are refused.

Based on staff interview, facility investigation, and review of policy and procedures, the facility failed to report all alleged violations involving mistreatment, neglect, or abuse of a resident (Resident #1) to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours. The facility reported a census of 42 residents.Findings include:The Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 8/21/25, documented diagnoses which included heart failure, hypertension (high blood pressure), diabetes mellitus, weakness and need for assistance with personal hygiene. The MDS identified a Brief Interview for Mental Status (BIMS) score of 9 for which indicated moderate memory impairments, is usually understood and understand by others and substantial to maximal assistance with upper and lower body dressing, and supervision to set up with personal hygiene. The MDS documented no behaviors.The Plan of Care with an initiated date 8/19/25, revealed the resident has impaired cognitive function and needed time to respond and process tasks, to keep routine and environment consistent, offer cues, direction and redirection as needed, and orient resident to environment as needed.The Facility Investigation dated 9/6/25 at approximately 4:31 PM, documented, Staff A, Certified Nursing Assistant (CNA) worked a scheduled shift on 9/6/25 from 2:00 PM - 10:00 PM. Staff A was assigned to shower Resident #1 during that shift. The resident shower occurred from 4:31 PM-4:55 PM. At approximately 4:46 PM, another employee, Staff B, CNA, went to the shower room to obtain a wheelchair from storage behind the shower area. Staff B, stated that she knocked, cracked open the door to peek in and announce that Staff B was entering the room for equipment. Staff A appeared to be startled by the employee and was observed quickly changing position from kneeling down in front of the resident to standing beside resident's right side. During the announcement with the door cracked open, Staff B, stated that when she looked down, she saw that a cell phone was propped up against the wall and recording on Snapchat. Upon fully entering the shower room, Staff B, stated she could see her leg come into the view of the recording, and she could see Resident #1's leg within the phone screen. Staff B, then walked into the room to get equipment, passing Staff A, and the resident. When Staff B, turned back to leave the room, Staff A, was then observed standing in the doorway, no cell phone in sight.The resident was sitting in a shower chair during this time with a shirt and brief on, but pants were not fully on. Staff B, then left the shower room and immediately reported to the nurse on duty about the incident. After the incident, facility leadership was immediately notified and began a review of the situation. Resident #1 was interviewed on 9/9/25. Resident #1 stated that he had no concerns of improper treatment from facility staff, and he has not witnessed any cellphone use in care areas. Resident #1 had no recollection of the incident in question. Following a comprehensive investigation-including interviews with residents and staff, and a review of employment records-no evidence was found that Staff A was recording in the resident care area. The resident involved shows no signs of physical abuse or adverse effects and reports no emotional distress or mental anguish related to the incident. To reinforce expectations and safeguard resident privacy, the facility has implemented robust staff re-education, increased supervision, and ongoing monitoring to ensure strict adherence to all cell phone use and abuse prevention policies.Interview on 10/6/25 at 3:00 PM, the facility Administrator confirmed the facility failed to notify DIAL of the incident between Resident #1 and Staff A within the 2-hour time frame. The Patient Protection Guidelines with Abuse Prevention, Reporting, and Investigation Policy dated September 2025, documented, residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friend, or other individuals. All 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 Inspections and Appeals not later than 2 hours after the allegation is made.

Based on observation and staff interview, the facility failed to label and date food items when opened to reduce the risk of contamination and food-borne illness. The facility reported a census of 44 residents. Findings include: On 6/30/24 at 10:39 AM during the initial tour of the facility kitchen with Staff A, Dietary Aide, revealed the following: a. Two large bowls of broccoli salad not labeled or dated b. Opened bag of shredded lettuce not dated when opened c. Two opened bags of spaghetti noodles not dated when opened d. Opened bag of penne pasta not dated when opened e. Opened bag of egg noodles not dated when opened f. Opened bag of pudding pie filling not dated when opened g. Opened bag of plain gelatin not dated when opened In an interview on 7/2/24 at 6:01 PM, the Dietary Supervisor stated they expected the staff to mark and date food items when opened. The facility reported they didn't have a policy for labeling and dating food, as they follow the most recent food code, rules, and regulations.

Based on staff interviews, family interview, and review of facility policy, the facility failed to provide care for 1 of 14 residents reviewed in a manner to promote dignity and respect (Resident #21). The facility reported a census of 45 residents. Findings include: Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS included diagnoses of Parkinson's, depression, and adjustment disorder with anxiety. During an interview on 5/18/23 at 9:08 a.m., Resident #21's daughter reported she witnessed Staff D, Registered Nurse (RN) during medication administration state to Resident #21 you need to stop acting like a bitch. On 5/18/23 at 10:31 a.m., the Administrator reported that she expected staff to interact with residents in a dignified manner and by using appropriate language. On 5/18/23 at 10:49 a.m., Staff D, RN reported she was sorry for her actions. Staff D, RN stated she was out of line. Staff D, RN stated she had tried to give Resident #21 her pills and she clamped her mouth shut. Staff D, RN stated she asked Resident #21 twice to open her mouth and take her pills. Staff D, RN stated Resident #21 told her to stop being a bitch. Staff D, RN stated she was taken back by it and without thinking, she stated you are the one being a bitch. Staff D, RN stated she should not have said it, it was unprofessional, and she was so sorry. An undated facility policy titled Enhancing and Maintaining Quality of Life documented the facility will care for its resident in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. The policy directed staff to treat each resident with dignity and respect in full recognition of his or her individuality as they carry out activities that assist the resident to maintain or enhance his/her self-esteem and self-worth.

Based on clinical record review, staff interview, and policy review, the facility failed to develop care plans related to diuretic medication and possible adverse effects for 2 out of 14 residents reviewed for comprehensive care plans (Resident #2 and #16). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #16 received diuretic medication the last 7 out of 7 days. The Physician's Order dated 3/22/23 showed Resident #16 was ordered to receive diuretic medication, Lasix 40 Milligram (MG) daily, for heart failure. The Medication Administration for March 2023 showed Resident #16 received Lasix 40 mg daily for heart failure. The Care Plan dated 4/20/22 for Resident #16 lacked documentation pertaining to the usage of a diuretic medication and failed to inform the staff of the possible adverse effects the diuretic could cause. The Care Plan also failed to address the heart failure diagnosis related to the Lasix order. 46875 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #2 was independent with bed mobility, walking, and transfers using a walker . The MDS included diagnoses of congestive heart failure, atrial fibrillation and coronary artery disease. The MDS identified Resident #2 received diuretic medications for 7 days during the MDS 7 day look back period. A hospital discharge summary dated 4/5/23 revealed Resident #2 was hospitalized from 3/31/23 to 4/5/23 for acute on chronic combined systolic and diastolic heart failure (heart can not pump or fill adequately). A Physician order dated 4/5/2023 directed staff to administer Torsemide (diuretic) 20 mg (milligrams) two tablets by mouth twice a day for acute on chronic combined systolic and diastolic heart failure. A Physician order dated 4/5/23 directed staff to administer Spironolactone (diuretic) 25 mg one tablet by mouth one time a day for acute on chronic combined systolic and diastolic heart failure. A Physician order dated 4/5/23 directed staff to obtain a daily weight and update the Physician if weight gain of 2-3 pounds overnight or 4-5 pounds in 5 days. The current Care Plan with a target date of 7/13/2023 lacked documentation of the use of diuretic medications, potential side effects and what to monitor for while taking the medications. The care plan did not address obtaining a daily weight and when to report to the Physician. The care plan did not address Resident #2's risk for congestive heart failure and signs and symptoms to monitor for. On 5/17/23 at 9:07 a.m. the Administrator reported the facility does not have a care plan policy. The Administrator reported the facility references the RAI (Resident Assessment Instrument) Manual regarding care plan revisions. On 5/17/23 at 8:05 a.m., Staff C, Licensed Practical Nurse (LPN)/MDS Coordinator acknowledged and verified diuretic medications were not addressed on the care plan. On 5/17/23 at 12:45 p.m., Staff C, LPN/MDS Coordinator reported she would expect diuretic medications and weight monitoring to be addressed in the nutrition care plan. Staff C, LPN/MDS Coordinator stated she had not addressed the risk for fluid imbalances on a care plan before. Staff C, LPN/MDS Coordinator stated weight parameters and reporting are addressed through the physician orders and she does not address the parameters on the care plan as they can fluctuate.

Based on staff interviews, clinical record review, and facility policy review, the facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications (Resident #29). The facility reported a census of 45. Findings include: Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07, indicating moderately impaired cognition. The MDS identified Resident #2 was independent with bed mobility, walking, transfers and toilet use. The MDS included diagnoses of dementia, anxiety, depression, and mild intellectual disabilities. The MDS identified Resident #2 received antipsychotic medication, antianxiety medication, and antidepressant medication for 7 of 7 days during the MDS look back period. A Physician order dated 12/13/2021 directed staff to administer Abilify (antipsychotic) 10 mg (milligrams) one tablet by mouth once a day for major depressive disorder. A Physician order dated 1/26/2022 directed staff to administer Buspirone HCL (antianxiety) 15 mg one tablet by mouth two times a day for anxiety disorder. A Physician order dated 9/12/2022 directed staff to administer Fluoxetine HCL (antidepressant) 10 mg two capsules by mouth once a day for major depressive disorder and anxiety disorder. A facility form titled Pharmacy Review-GDR Request Psychotropic Medications dated 11/30/22 documented the Psychiatrist response for a GDR request for Resident #29's Abilify medication was contraindicated due to a diagnosis of paranoid schizophrenia. The facility GDR form lacked a clinical rationale. A facility form titled Pharmacy Review-GDR Request Psychotropic Medications dated 11/30/22 documented the Psychiatrist response for a GDR request for Resident #29's Buspirone medication was contraindicated due to a diagnosis of paranoid schizophrenia. The facility GDR form lacked a clinical rationale. A facility form titled Pharmacy Review-GDR Request Psychotropic Medications dated 11/30/22 documented the Psychiatrist response for a GDR request for Resident #29's Fluoxetine medication was contraindicated due to a diagnosis of paranoid schizophrenia. The facility GDR form lacked a clinical rationale. Review of Resident #29's clinical record lacked supporting documentation for the diagnosis of paranoid schizophrenia that was listed on the facility GDR forms dated 11/30/22. On 5/16/23 at 10:00 a.m. the Director of Nursing (DON) reported she could not locate supporting documentation in Resident #29 's medical records for the paranoid schizophrenia diagnosis. The DON reported the facility had reached out to the Psychiatrist for further information. The DON stated the paranoid schizophrenia diagnosis was added to Resident 29's medical record. On 5/16/23 at 4:00 p.m. the DON reported the Psychiatrist reviewed his progress notes before and after the GDR request on 11/30/22 and believed the diagnosis of paranoid schizophrenia was an error. Review of a Psychiatry letter dated 5/16/23 clarified Resident #29 does not have a diagnosis of paranoid schizophrenia. A facility policy titled Antipsychotic Drug Use revised 7/07 documented residents who use antipsychotic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these medications. The policy documented if a request for a reduction is denied, the physician must provide a risk benefit analysis, which should include a clinical rationale for why any reduction would be likely to impair the resident's function or increase distressed behavior.

Based on observation, staff interview, and facility policy review, the facility failed to ensure staff used proper food handling procedures to prevent possible contamination of food. The facility reported a census of 45 residents. Findings include: On 5/16/23 at 11:25 AM, Staff A, cook, was observed to be wearing food service gloves to serve the lunch meal, touching plates, ladle/tong handles, and paper menus filled out by residents. One of the residents required meat to be pulled off of the chicken leg and cut up. Staff A, while wearing the gloves she had been serving with, used the tongs to place two chicken legs on a plate, hold them with her left hand and pull meat off the bone with a fork, using her right hand. Staff A then threw the bones in the garbage, came back to the steam table, placed her left hand on the chicken pieces to hold them in place while she used a knife to cut the meat into smaller pieces. She then removed the gloves, threw them in the garbage, washed her hands and returned to serving. Review of document titled General Food Preparation and Handling, dated 9/1/09 revealed that food would be prepared and served with clean utensils or other suitable implements so as to avoid manual contact of prepared or ready to eat foods. In an interview on 5/17/22 at 10:00 AM with Staff B, Dietary Manager, it was revealed that her expectation is that staff wear food service gloves only when actually handling food, and not when serving with ladles and tongs due to this reason.

Based on observation, Ecolabs document review and staff interview, the facility failed to ensure dietary staff utilized proper sanitizing recommendations for cleansing countertops in the food preparation areas. The facility census was 46 residents. Findings include: 1. Observation on initial tour of the main kitchen on 9/25/17 at 9:40 a.m., revealed a dietary staff person wiping down the preparation countertop next to the steam table. Dietary staff placed the dishcloth into a red bucket when completed. The Dietary Manager tested the red bucket, used for sanitizing, for the effectiveness of the solution. The dipstick (Hydrion strips) showed an orange color, indicating no sanitizer solution present. The Dietary Manager stated she would change out the bucket, by putting fresh sanitizer solution into the bucket. During interview on 9/26/17 at 10:30 a.m., Staff A, Cook, reported filling the sanitizer bucket at 5:00 a.m., yesterday morning (9/25/17) and had not changed it out before the kitchen tour. Staff A reported she does not change out the red bucket on a routine basis, but changes it when it looks dirty. During observation on 9/26/17 at 10:30 a.m., the Dietary Manager checked the red bucket for sanitization. The dipstick turned green, indicating sanitization at 400 pmm (parts per million). The Dietary Manager reported the dipstick color indication was to be at 150 pmm or above to show sanitization. She said the red bucket was used for cleansing the countertops in the kitchen. The Dietary Manager noted the red bucket was to be changed out twice during each shift. During interview on 9/27/17 at 1:50 p.m., the Dietary Manager reported the facility did not have a policy or procedure for sanitizing the red bucket. The facility follows Ecolab's information/instructions. Review of information for Ecolab's Oasis 146 Multi-Quat Sanitizer instructions showed it was effective against foodborne bacteria. The solution's range of 150-400 ppm stays within proper range longer. This solution prevents cross-contamination on food-contact surfaces and ware. Hard water, food bites, and leftover detergent can reduce the solution's effectiveness. The information recommended to change the solution when it looks dirty or its concentration is too low and to check the concentration often.

Based on observation and staff interview, the facility failed to follow appropriate infection control technique while performing blood sugar checks for two of three residents observed (Residents #13 & #14). The facility census was 46 residents. Findings include: 1. Observation on 9/26/17 at 8:10 a.m., revealed Staff B, licensed practical nurse, LPN placed all blood sugar testing supplies on a small tray and took the tray into the room of Resident #13. Staff B placed the tray of supplies on the residents bedside table without placing a clean barrier to prevent transfer of any possible infectious material to the bottom of the tray. Staff B performed the blood sugar test and removed the tray from the resident room and placed it on the counter top at the nurses station without sanitizing the bottom of the tray. Staff B placed the tray on top of the medication cart before taking it into the medication room and placing it on the counter top without sanitizing the bottom of the tray. On 9/26/17 at 9:05 a.m., Staff B placed all blood sugar testing supplies on a small tray and took the tray into the room of Resident #14. Staff B placed the tray of supplies on the residents bedside table without placing a clean barrier to prevent transfer of any possible infectious material to the bottom of the tray. Staff B performed the blood sugar test and took the tray out of the residents room and placed it on the counter top at the nurses station without sanitizing the bottom of the tray, Staff B moved the tray to the counter top in the medication room without sanitizing the bottom of the tray. During interview at the time, the Director of Nursing, DON agreed some form of barrier should have been used under the tray of supplies to prevent any possible infectious materials from being carried out of resident rooms on the bottom of the tray and possibly spread to anyone else.

Based on observation and staff interview, the facility failed to keep foods dated and labeled in the walk in freezer. The facility census was 40 residents. Findings include: 1. During initial dietary tour of the kitchen on 8/22/16 at 8:24 a.m., revealed the following: a. An undated bag of 3 frozen pizzas with ice crystals on the bottom of the bag. The Dietary Supervisor stated she had no idea when the pizzas were used last, took them out of the freezer and threw them away. b. One 1/2 empty bag with round brown items, identified as donuts by the Dietary Supervisor. She stated the donuts should be dated and labeled and threw these away also. During an interview with the Dietary Supervisor at the time of the observations, she stated that staff need to date and label any food that goes into the cooler or the freezer.

Based on clinical record review, observation and staff interview, the facility failed to ensure staff maintained acceptable hand hygiene following incontinence care for 1 of 9 current residents reviewed (Resident #2). The facility identified a census of 40 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 with [DIAGNOSES REDACTED]. The MDS documented the resident with a Brief Interview for Mental Status a score of 8, which indicated moderate cognitive impairment. Resident #2 required the assistance of 2 with toilet use, the assistance of one with personal hygiene activities and as always incontinent of bladder. The care plan, with a target date of 9/24/16, documented the resident always experienced incontinence and instructed to check and change the resident routinely upon rising, before/after meals, at the hour of sleep and during night rounds approximately every two hours. During observation on 8/22/16 at 1:30 p.m., Staff A (certified nursing assistant) and Staff B (certified nursing assistant) performed incontinent cares for Resident #2. Staff A and Staff B assisted the resident to a standing position with the EZ stand. With gloved hands, Staff A pulled down the resident's sweat pants and removed the soiled brief between their legs. Staff A cleansed the resident with wet wipes handed to them by Staff B. Staff A cleansed all the areas where the soiled brief with urine touched the resident's skin. Staff A then took a clean white brief and placed it in between the resident's groin area, pull up the residents slacks, then removed her gloves. Staff A failed to perform hand hygiene or change her gloves after providing incontinence care and before helping the resident to dress. During an interview on 8/22/16 at 1:44 p.m., Staff C (licensed practical nurse), confirmed and verified that Staff A needed to change her gloves prior to placing the clean brief on the resident.

Based on record review and staff interview, the facility failed to assure staff followed physician's orders for 1 of 12 residents reviewed (Resident #3). The facility reported a census of 48 residents. Findings included: 1. The Minimum Data Set (MDS) with an assessment reference dated 8/6/15, documented Resident #3 with [DIAGNOSES REDACTED]. A facsimile dated 2/18/15, documented resident returned from hospital and has a Stage 2 pressure ulcer over coccyx, scan amount of yellow slough, and tender to touch. A physician order dated and signed 8/26/15, instructed staff to place a geo matt in the chair when the resident was in it. Observation on 9/28/15 at 2:42 p.m., revealed the resident sat in their recliner in their room with no geo matt in the recliner. Observation on 9/29/15 at 8:54 a.m., revealed resident sat in their recliner with no geo matt as a cushion. The resident requested the surveyor to get a staff member to place something in their recliner for them to sit on because their bottom was hurting. Observation on 9/30/15 at 9:50 a.m., revealed resident sitting in their recliner in their room with no geo matt underneath them. During an interview on 9/30/15 at 2:33 p.m., Staff B (Quality Assurance Nurse) confirmed and verified the geo matt needed to be in the recliner and the wheelchair of the resident. A physician order dated and signed 8/26/15, instructed staff to administer [MEDICATION NAME] 25 milligrams (mg), 0.5 mg tablet by mouth every 12 hours, hold if heart rate <60 or systolic blood pressure <100. The April 2015 MAR, staff documented the resident pulse as 58 on the evening shift 4/2/15. Staff documented the medication administered. The May 2015 MAR, staff documented the resident pulse as 59 on the evening shift 5/20/15. Staff documented the medication administered. The July 2015 MAR, staff documented the resident's blood pressure as 96/52 and pulse of 54 on the day shift 7/22/15. Staff documented the medication administered. The July 2015 MAR, staff documented the residents blood pressure as 96/60 on the day shift of 7/25/15, and 98/64 on the day shift of 7/26/15. Staff documented the medication administered. The August 2015 MAR, staff documented the resident's blood pressure as 96/60 on the day shift 8/31/15. Staff documented the medication administered. The September Medication Administration Record for 2015 (MAR), staff documented the residents pulse as 59 on the day shift 9/26/15. Staff documented the medication administered. During an interview on 5/20/14 at 11:16 a.m. the Director of Nursing (DON) examined the MAR and confirmed the [MEDICATION NAME] had been administered when the resident's blood pressure measured less than 140/80. She stated a medication error report had been completed and the physician notified.

Based on clinical record review, and staff interview the facility failed to adequately monitor 2 of 11 current residents reviewed receiving a [MEDICAL CONDITION] medication to ensure staff attempted alternative interventions and administered the medication only when needed (Residents #4), and the facility failed to ensure Resident #1's drug regimen remained free from unnecessary drugs through adequate assessment, indications for use and monitoring. The facility identified a census of 48 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had [DIAGNOSES REDACTED]. The MDS documented the resident received no antianxiety and antipsychotic medications daily during the last 7 days of the assessment period. a. A physicians order sheet signed and dated 9/8/15, documented an order for [REDACTED]. The PRN Medication Administration Record [REDACTED]. The PRN flow sheet for August 2015, documented the resident received [MEDICATION NAME] 2 times during the month for comfort and agitation and [MEDICATION NAME] 1 time during the month for agitation. The PRN flow sheet for July 2015, documented the resident received [MEDICATION NAME] 2 times during the month for comfort and [MEDICATION NAME] 1 time during the month for comfort. The Interdisciplinary Nurses Notes lacked documentation of any alternative interventions attempted prior to the use of the PRN antianxiety and antipsychotic medication. The Care Plan with a problem with no date, documented My mood varies from day to day. Sadness, anxiety, agitation. Interventions/tasks included: *Due to not being able to talk, anticipate my feelings/mood by my reactions and expressions and ask if I am feeling anxious or sad. Offer support and encouragement. *Monitor/record/report to Medical Doctor for acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep pattern diminished ability to concentrate, change in psychomotor skill. *Offer assistance with my oil/crystals, these help with my concerns. *Please help me to get my medications as ordered. Monitor/document for side effects and effectiveness. *Provide the following interventions 1-1, repositioning, snack, essential oils, etc. prior to prn anti anxiety medication use. During an interview on 9/29/15 at 2:01 p.m., the facility director of nursing stated the facility expected staff to attempt non pharmalogical interventions prior to the administration of the PRN medication. During an interview on 9/29/15 at 2:22 p.m., the Quality Assurance Nurse verified the Interdisciplinary notes and the PRN flow sheet did not contain documentation of any non-pharmalogical interventions attempted prior to the use of the medications administered. 2. The MDS dated [DATE] documented Resident #1 had a [DIAGNOSES REDACTED]. Resident #1's Care Plan dated 11/12/15 documented the resident used [MEDICAL CONDITION] medications related to depression, anxiety and [MEDICAL CONDITION]. The care plan included intervention to discuss with the Doctor, the resident and the residents family regarding ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness. The care plan lacked any non-pharmalogical interventions related to anxiety. physician's orders [REDACTED]. Resident #1's August 2015 Medication Administration Record [REDACTED]. The September 2015 Medication Administration Record [REDACTED]. The PRN Record listed anxiety as the reason for administering the medication. The PRN Record had documentation staff offered 1:1, reassurance and snack for type of non-pharmalogical interventions to promote relaxation along with use of [MEDICATION NAME]. The form included documentation of results of use of prn medication, staff documented relief. Resident #1's clinical record lacked any documentation staff assessed the resident for possible causes of anxiety, behaviors the resident exhibited and any notification to the physician of the residents almost daily use of the medication. During interview 9/30/15 at 9:40 a.m. the Director of Nursing stated they did not have any assessment of Resident #1's frequent use of prn [MEDICATION NAME], behaviors for use of the medication or notification to the physician related to the amount of medication used.

Based on observation, record review, ambulance crew, First Responder and staff interviews the facility failed to provide adequate assessments and timely intervention for Resident #3 who have an onset of adverse symptoms which represent a change in a physical condition following a fall and the facility failed to assess and provide adequate supervision and interventions to prevent accidents. Although the staff assessed the resident ' s vitals and neurological signs, the resident had bleeding present which was not assessed nor pressure applied. The facility had implemented a negotiated risk agreement with the resident ' s family which allowed the resident to ambulate independently without staff assistance. The resident had experienced falls and did not have the safety awareness to prevent falls, so continued supervision and assistance with ambulation was warranted. The facility failed to apply wheelchair pedals to Resident #5's wheelchair which resulted in falls. The sample consisted of 6 residents and the facility identified a census of 43 residents. Findings include: 1. Resident #3 had a Minimum Data Set (MDS) assessment with a reference date of 2/27/13, identified [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, required extensive assistance of 2 staff members with transfers and required limited assistance of 2 staff members for ambulation in his/her room. The MDS reflected the resident experienced 2 or more falls (without injury) since admission or the prior assessment. According to a Resident Care Plan, the Resident had been at risk for falls related to a history of falls and syncopal (dizzy) spells. The approaches directed the staff to perform the following: ? Increase visual checks to check for my wants and/or needs. (3/4/13). ? I made poor/unsafe decisions placing me at risk for falls. My family had signed a negotiated risk for me to be up independently in my room as I chose. (2/7/13) ? My family requested a bed/recliner alarm. (3/6/13) ? I had syncopal episodes with falls noted. ? Try to keep my room clean and pathways clear. (3/1/13) ? Room had been carpeted and bathroom nonskid. (3/1/13) ? Utilized a bedside commode. (2/21/13) ? My spouse frequently disconnected my seat alarm, my family requested staff to re-apply as able. (3/9/13) Please provide more assistance when I am tired or weak, utilized a wheel chair as needed (2/7/13) I received anti-anxiety medication that could have increased my risk for falls. (1/29/13) A Negotiated Risk Agreement dated 2/7/13 indicated the following: Cause For Concern: Physical Therapy recommended assist of one for transfer/ambulation at all times. The resident wanted to have been able to transfer/ambulate in his/her room as he/she chose. What Family and/or Resident Wanted: Wanted the resident to have been able to transfer/ambulate independently in his/her room as he/she chose. Probable Consequences of the Resident/Family's Choices: The resident may fall and injure himself/herself when transferring/ambulating independently. Final Agreement: The resident would transfer/ambulate in the room at his/her choosing. Who Will Follow-Up and When: MDS/Care Plan nurse with each assessment (quarterly, annual and change in condition) An Admission/Readmission Fall Risk Assessment form dated 2/4/13 identified the resident as a fall risk. According to the Incident Report Forms the resident had fallen on the following dates: a. 3/4/13 at 5:30 a.m. - head laceration. b. 2/21/13 at 4:35 a.m. - no injuries c. 1/27/13 at 8:45 a.m. - no injuries. Resident #1 required supervision due to at risk for falls and a history of falls. The negotiated risk agreement does not prevent the facility from providing supervision and assistance with ambulation to prevent falls. The Medication Administration Record (MAR) dated 3/2013 indicated the resident did not receive any medications with blood thinning agents. The Interdisciplinary Progress Notes dated 3/4/13 at 5:30 indicated the following: The resident ' s spouse requested assistance as the resident laid on the floor. The staff member documented a pillow had been placed under the resident's head and the resident had been in a supine position on the left side of the recliner in his/her room. The staff member documented that range of motion (ROM) had been performed and within normal limits (WNL) and the resident denied pain with movement. The staff member documented neuro checks had been initiated and WNL, pupils equal and reactive, the resident as oriented per usual to self and the blood pressure had been 144/77, pulse 89 and respirations 22. The staff member documented a walker had been standing in front of the recliner, the floor as dry and gripper socks had been on the resident's feet. The staff member documented the resident had been last observed at approximately 4:30 a.m. after having put on his/her call light and that staff responded and repositioned the resident and applied oxygen but the resident denied needing to use the restroom and resting quietly on exit. When the staff member went to obtain a 2nd set of vitals she noticed the resident had 8 centimeters of bleeding from an unknown source located on the pillow under his/her head. The staff member paged the physician on call and informed him of the bleeding on the pillow from the back of the head/neck area, that the resident identified pain and the neuro checks were WNL and orders were received to transport the resident to the emergency room via ambulance. The staff member documented she telephoned the ambulance service for an emergency transit, the first call responders and hospice were also notified. The Interdisciplinary Progress Notes dated 3/4/13 at 5:45 a.m. indicated the following: Blood pressure 142/86, pulse 95 and respirations 20. The pupils were 4 millimeters (mm), brisk, equal and reactive. The resident remained alert and denied pain. The Interdisciplinary Progress Notes dated 3/4/13 at 5:55 indicated the following: The First Responders and ambulance crew arrived with a condition report given and the resident had been a Hospice patient. According to a Nora Springs Care Center Neuro Check form dated 3/4/13 at 5:30 a.m., the resident's assessment had been as follows: On 3/4/13 at 5:30 a.m. - blood pressure 144/77, pulse 89, respirations 22, pupils equal, 3 mm in size, the upper/lower extremities were bilaterally equal, the resident had been orientated to own functional level, the resident denied pain and there had been a small amount of blood noted on the pillow under the resident's head. On 3/4/13 at 5:45 a.m. - blood pressure 142/86, pulse 95, respirations 20, pupils 4 mm in size and there had been blood noted on the pillow under the resident's head. On 3/4/13 at 5:50 a.m. - blood pressure 158/67, pulse 100, respirations 20, pupils were 4 mm in size and sluggish. On 3/4/13 at 5:55 a.m. - the ambulance crew had arrived. According to a First Responder Report form dated 3/4/13, the responders were dispatched to assist with an elderly female who had fallen at the Nora Springs Care Center and the ambulance crew had been in route. Once inside the facility they were guided to the patient's room where care center staff had been present but no care had been provided other than a pillow placed under the patient's head. The patient had been lying on his/her back with a pillow propped under his/her head. The patient's head had been near the base of a small wooded end table with a considerably large pool of blood under and on the pillow which measured approximately 2 1/2 feet in diameter. The blood pool appeared thick and clotting as if it had been pooled for some time. The patient had been alert and conscious but the staff advised them the patient had dementia. The staff members present were asked if anyone had witnessed the fall. They advised they had not and that they were not the ones who found the resident. The responder then asked to speak to the person who had found the resident. The patient had been alert and conscious and responded to questions appropriately without any obvious signs of dementia. The Nora Springs Care Center staff member that had found the resident had sent another person to speak with the responders to inform them the resident had been found but not moved at approximately 5:30 a.m. The responder then cut away the patient's shirt on his/her left side to access and locate the point of bleeding. The responder had been able to determine the bleeding had been from a general area located at the base of the patient's head and neck. The responder stated he did not have to move the patient to have been able to thoroughly investigate the wound. The responder then placed a trauma dressing with slight pressure making sure not to move the patient. The patient had been unable to tell him how he/she had fallen but had been requesting to sit up. The responder asked the patient if he/she had been in pain and he/she replied that his/her head and legs hurt. The resident again requested to sit up and that her legs hurt. The responder noticed the patient had tried to hold his/her knees elevated. The responder then requested the Nora Springs Care Center Staff to place a folded pillow under the patient's knees at which time the patient said that felt better. The responder continued to maintain direct pressure to the area of the wound until the paramedics arrived. The responder documented the patient's answers and responses seemed to come slower and longer and he/she had appeared to have been tiring while they were on the scene. The responder then documented the ambulance crew also struggled to locate the staff member that found the patient and that the responder assisted the ambulance crew to apply a cervical collar with addressing, a backboard placement and loading the patient. The ambulance crew then transported the patient to the hospital. According to an Iowa Emergency Medical Service (EMS) Report dated 3/4/13 the ambulance service had been dispatched at 5:40 a.m. via a direct call from the Nora Springs Care Center that a resident had fallen and had a severe laceration to the posterior head. The facility staff indicated the resident had fallen sometime between 5:15 a.m. and 5:30 a.m. and that the nursing staff had stated that at 5:15 a.m. the patient had been sitting in his/her chair but they next observed him/her on the floor at 5:30 a.m. The staff members thought he/she had hit his/her head on a table next to his/her chair. The Nora Springs Rescue was on the scene first and stated no one had been holding direct pressure on the patient's head before they arrived. When the responder arrived he held direct pressure and maintained a manual cervical spine. The first responder thought the laceration was at the posterior base of the skull and had cut the patient's shirt off on the left arm to locate the laceration due to the amount of blood on the floor. The patient had dementia and had been on Hospice care for congestive heart failure. The patient had been only been alert to self with no change in the patient ' s status. The form indicated the resident complained of neck and pain all over his/her body while in route to the hospital. The form indicated when the ambulance crew arrived the patient had been lying supine on the floor with a pillow under his/her head with a first responder holding direct pressure and cervical spine. The resident had regular breathing, skin pale cool and dry, bilateral pupils were not reactive to light, wound had not been observed due to hair and the location of the dressing applied to the area. There had been a large amount of blood pooling under and around the patient's head that had clotted prior to their arrival. The amount of blood had been described at approximately 500 to 1000 ML. The first responder informed the crew that he thought the laceration had been at the base of the posterior skull which was confirmed by the nursing staff and doctor in the emergency room . According to an Emergency Department Physician Notes form dated 3/4/13 at 7:04 a.m. the resident presented to the emergency room with a 2 centimeter linear occipital scalp laceration which had been subcutaneous in depth with moderate pain and minimal bleeding which the emergency department personnel cleansed and applied 6 staples. The form indicated that at 7:15 a.m. the resident's hemoglobin had been 5.6. (normal = 11.7 - 16.1) The Preliminary History and Physical form dated 3/4/13 the resident arrived at the hospital status [REDACTED]. The Discharge Summary form dated 3/5/13 indicated the resident received 3 units of blood during the hospitalization . The resident had complained of pain in the left knee area with x-rays that showed a possible stress fracture. An x-ray form dated 3/4/13 at 5:13 p.m. indicated the resident had a questionable stress fracture involving the medial tibial plateau. A flow sheet Print Request form indicated the resident had the following hemoglobin test results: a. 3/4/13 at 5:51 p.m. - 8.5 b. 3/5/13 at 5:43 a.m. - 7.2 c. 3/6/13 at 9:05 a.m. - 8.7 d. 3/13/13 at 11:15 a.m. - 9.1 The Clinical Laboratory form dated 1/16/13 indicated the resident had hemoglobin of 8.7. During an interview 3/21/13 at 6:04 p.m., Staff A, (Certified Nursing Assistant (CNA)) confirmed she had been notified by the resident's family member that he/she required assistance. The staff member responded and found the resident lying on his/her back on the floor beside a recliner chair with head positioned beside a broken base of a bedside table. The CNA asked the resident if he/she had been OK at which time the resident confirmed he/she had been OK however he/she wanted to get up off the floor. The CNA encouraged the resident to remain on the floor until the nurse arrived, placed a pillow partially under the resident's head, denied having noticed any blood and went into the hallway and requested assistance from the nurse. The nurse immediately responded and assessed the resident while Staff B, CNA entered the resident's room. Staff A indicated that she had been in and out of the resident's room following the initial entry post fall but had recalled having observed a baseball sized bloody area on the floor in a diagonal area between the resident's shoulder and his/her head could not recall the exact time. On 3/19/13 at 4:15 p.m., Staff C (Licensed Practical Nurse (LPN)) was interviewed and stated at approximately 5:30 a.m. a family member stepped into the hallway and informed Staff A the resident had fallen. Staff A informed her of the fall at which time she responded immediately. When she arrived in the resident's room, the resident had been laying on his/her back on the floor beside his/her recliner chair with a pillow under his/her head. Staff C confirmed she performed vitals, initiated neuro (neurological) checks, assessed the resident's arms and legs, stated the resident denied any pain but there had been blood on the resident's right and left hands. The staff member cleansed the resident's hands but had not been able to locate an injury. The staff member stated when she performed range of motion on the resident she noticed approximately 2-3 centimeters of thick dark blood visible on the pillowcase on both sides of the resident's head and at that point she realized the resident had a head injury. Staff C requested Staff B stay with the resident as she went to the nurses ' station and telephoned the physician, family, ambulance crew and prepared the paperwork. The staff member confirmed she had not attempted to find the site of the bleed and/or laceration, had not applied and/or attempted to apply pressure to the head laceration but felt the resident hit his/her head on the base of the bed side table as it had been broken. The staff member confirmed when the first responders arrived on the scene, the resident complained of leg pain for the first time so the responders placed a pillow under the resident's legs without moving the extremities. The staff member confirmed when the ambulance crew arrived she went to the resident's room, updated them as to the resident's condition and [DIAGNOSES REDACTED]. Staff C confirmed the facility ' s policy had been not to move a resident with a suspected head injury. On 3/19/13 at 4:35 p.m., Staff B (CNA) was interviewed and stated she had not been present when the resident fell however she had been called via a " Walkie Talkie " to assist with the resident. When she arrived in the room, the resident had been lying on his/her back beside the recliner and the nurse had been assessing the resident's vital signs while Staff A had been present as well. Staff C requested the CNA'S assist the resident off of the floor but before they moved the resident they noticed there had been blood on the pillow under the resident's head. The nurse then gave the directive not to move the resident and requested Staff B stay with the resident while she prepared the paperwork and Staff A checked on the other residents. Staff B confirmed that initially there had been very little blood but as time went along the blood had spread which she described as very thick. The staff member confirmed she stayed with the resident holding his/her hand until 2 first responders arrived. While they waited the resident complained of leg pain and wanted to sit up however the staff member had been able to keep the resident calm and relaxed. Upon the arrival of the 2 first responders the staff member stepped back to allow them to treat the resident and noted them to place a pillow under the resident's knees. After the ambulance crew arrived the CNA confirmed she observed the ambulance crew transfer the resident to the gurney but she had not been able to visualize the resident's head. Staff B stated she did observe a large amount of blood on the floor. The staff member described the amount of blood as so much that it no longer soaked into the carpet. The staff member confirmed no pressure had been applied and/or attempted to have been applied to the laceration and that she had been aware that a portion of the base of the bedside stand had been broken. On 3/21/13 at 11:52 a.m., Staff D (LPN) was interviewed and confirmed she had received a call from Staff C who requested she come to the facility as soon as she could. When Staff D arrived at the facility she had been informed the resident had fallen. Staff D went to the resident's room and observed the resident positioned on his/her back, legs extended with his/her entire head positioned on a pillow which had been 1/2 covered in dark red blood with Staff B sitting beside the resident holding his/her hands. Staff D performed a set a vital signs and neurological checks on the resident and gave the assessment to Staff C. Staff D confirmed that when the first responders arrived, Staff C escorted them to the resident's room and when the ambulance crew arrived she escorted them to the resident's room. Staff D stated staffs were not to move a resident with a suspected head injury which would have included a pillow placement. The staff member confirmed she would have applied pressure to a head laceration but that she would not have attempted to try to find the source of a bleed if it had been on the back of a resident's head. A Happy Trail Daily Report Sheet dated 3/4/13, reflected the resident had been transferred to the hospital and admitted for a 24 hour observation due to a fall at which time he/she hit the back of his/her head and lost a large amount of blood. On 3/21/13 at 8:15 a.m., the Director of Nursing (DON) was interviewed and stated she would have expected staff not to move a resident in the event of a suspected head injury On 3/2/13 at 9:47 a.m., a Physician Assistant was interviewed and confirmed it would have been appropriate to apply pressure to the resident's laceration without moving the resident's head. A written statement the facility obtained from the facility ' s Medical Director/resident's Physician on 3/22/13 indicated the physician felt although the resident suffered a scalp laceration; the nursing staff were unable to safely move the resident to apply consistent compression to the posterior scalp area where the wound had been located. The facilities Guidelines for Charting After A Fall form included the following: a. Range of motion to all extremities with or without discomfort (if severe discomfort noted or shortening of the extremity or external rotations, do not move the resident until the emergency medical technician (EMT) arrived for transportation to the hospital). b. If the resident hit his/her head, or it would have been likely the resident hit or bumped his/her head, but unable to communicate due to diminished cognition, initiate neuro (neurological) checks and documented on the neuro (neurological) flow sheet. 2. Resident #5 had a Minimum Data Set (MDS) Assessment, with a reference date of 3/14/13, which identified [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, required extensive assistance of two with transfers, ambulation, locomotion on and off the unit and toileting. The Resident Care Plan dated 3/21/13 indicated the resident as at risk for falls. The interventions included the following: a. Needed reminders to keep feet on foot pedals, frequently wiggles and takes off, watch. (dated 2/22/13) b. Please assure non-skid footwear. c. I needed assist of 1 to 2 people to transfer and utilized a front wheeled walker for ambulation. d. My transfer and ambulation abilities fluctuated daily. Please provide more assistance as needed. e. Please assist me to toilet on each round during the night. According to Incident Report Forms the resident had fallen on the following dates/times in the past 6 months: a. 3/7/13 at 1:40 p.m. b. 2/22/13 at 4:55 a.m. c. 1/14/13 at 6:30 a.m. d. 12/27/12 10:15 p.m. e. 12/10/12 at 7:05 p.m. f. 11/26/12 at 1 p.m. g. 11/23/12 at 7:20 a.m. An Interdisciplinary Progress Notes entry dated 2/22/13 at 4:55 a.m. indicated staff propelled the resident, via a wheel chair, from the shower room after having been toileted when the resident placed his/her feet onto the floor. The resident then fell forward from the wheel chair onto his/her knees on the floor without injury. The notes failed to indicate if the footrests had been placed on the wheel chair. During an interview 3/21/13 at 12 p.m., the Director of Nursing (DON) confirmed the facility staff failed to apply the foot pedals to the resident's wheelchair as expected prior to propelling the resident. During an interview 3/21/13 at 2:20 p.m., the DON, Staff D, Nurse Manager and Staff E, Nurse Manager, confirmed the facility arranged a skills fair in January of 2013 at which time the facility staff who participated were educated on proper placement of foot pedals on the residents' wheel chairs' prior to propelling them. According to the participation records Staff A, certified nursing assistant (CNA) and Staff F, CNA participated in the event. Review of the Meeting Notes for the Employee Meeting form dated 7/16/12 indicated the facility staff were directed that residents were not to have been propelled in their wheel chairs without proper placement of the foot pedals.

Based on review of clinical records and facility policy, physician, family and staff interviews, the facility failed to complete an ongoing assessment for one of seven residents reviewed and inform the attending physician of the continued decline (Resident #3). The facility identified a census of 50 residents Staff B stated Resident #3 was normally cooperative but on 1/4/2012 the resident began " swinging " at her and would not get out of bed. A fax was sent to the physician on 1/4/2012 and the morning insulin was discontinued so the resident could sleep and the morning oral medications held until awakened. The record revealed no assessment for the change of behaviors. The resident continued to have elevated blood sugars and the record lacked assessments. On 1/10/2012 the resident was sent to the hospital Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 11/23/2012 identified Resident #3 had [DIAGNOSES REDACTED]. Resident #3 had an admission date of [DATE]. The MDS identified the resident as severely cognitive impaired and required extensive assistance with activities of daily living and limited assistance with eating and walking in the room. The MDS reflected the resident did not display behaviors. The resident's plan of care dated 3/9/11 identified a problem with self care deficit due to required assistance to complete activities of daily living needs. An approach dated 11/23/11 reflected "I get combative at times with my cares especially in the morning. Leave me to rest in bed and approach later." The care plan identified a problem with altered health maintenance/comfort regard to requires medications to manage. The approach indicated "I'm a Diabetic on insulin therapy; please observe/report any signs of high or low blood sugar." The physician orders [REDACTED]. The orders included to check the resident ' s blood sugars every week and as needed. The physician progress notes [REDACTED]. The plan was to continue current treatment regimen. The December 2011 and January 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. On 12/4/2011 - 248 b. On 12/11/2011 - 150 c. On 12/18/2011- the resident refused a blood sugar check d. On 12/25/2011- 270 e. On 1/1/2012- 351 f. On 1/8/2012- 389 and 558 On 1/4/2012, a nurse sent a fax to the resident ' s physician. The nurse informed the physician of the resident getting up later and later in the morning and the resident cross swinging and wanting to sleep. The physician returned the fax on 1/4/2012 and ordered the oral morning medications may be given when the resident awakens and to discontinue the morning insulin. The record revealed no assessment. A Physician Notification facsimile dated 1/9/12 documented the resident's family requested staff check the resident's blood sugar. The blood sugar tested 389. The morning insulin was discontinued on 1/4/12. "Do you want the insulin started again?" The record revealed no assessment after the blood sugar test identified a high blood sugar. The IPN dated 1/10/12 at 9:30 a.m., documented the resident as very lethargic this morning, took only bites of breakfast. Blood sugar checks result of 558. Resident diaphoretic. Call out to the clinic and awaiting a response. The record revealed no assessment following identification of a high blood sugar. The IPN dated 1/10/12 at 10:00 a.m. indicated the physician gave a new order for the resident to receive 15 units of [MEDICATION NAME]now. Insulin given at 10:05 a.m. as ordered. The IPN dated 1/10/12 at 11:20 a.m., documented recheck of blood sugar prior to lunch read "Hi" on meter! The record revealed no assessment of the resident. Call to clinic with update. New order received to transfer the resident to the emergency room by ambulance due to [MEDICAL CONDITION]. An assessment had not been performed. A hospital History and Physical dated 1/10/12, documented the resident became combative (at the facility) and it was believed to be due to [DIAGNOSES REDACTED]. On 1/4/2012, the resident's insulin was stopped. On Sunday the resident's glucose (blood sugar) approached 300. Today the resident's glucose measured in the 500's. The resident was pleasant and cooperative and appears to have reasonable cognition. The diagnostic data documented the resident's blood glucose to be 464. The history and physical document, signed by the physician on 1/11/2011, identified the resident as hyperglycemic secondary to insulin being stopped. The resident received 15 units of [MEDICATION NAME] stat and was placed on [MEDICATION NAME] 10 units daily and [MEDICATION NAME] 3 units per carbohydrate choice at meals, as well as low dose correction factor. The physician progress notes [REDACTED]. The resident was currently on [MEDICATION NAME]10 units every 12 hours at 8:00 a.m. and 8:00 p.m. The resident was also on [MEDICATION NAME]and [MEDICATION NAME] rapid acting per sliding scale with meals and at bedtime. The resident has blood sugar checks four times a day. On 2/13/12 at 1:25 p.m., the resident's physician was interviewed and stated on 1/4/12, he received a facsimile from the facility informing them of the resident's refusal of morning medications and morning insulin. Due to the fact the insulin was normally given twice a day, the physician did not want to order staff to give the resident the morning insulin at a later time due to they assumed the resident also received an afternoon dose of insulin. The physician stated the facility failed to provide them with complete/thorough information regarding the resident's insulin use. The physician stated had the facility informed him the resident only received insulin once a day, they would not have discontinued the insulin; they would have changed the time of the insulin administration. The physician stated they were not informed of the resident's elevated 7:00 a.m. blood sugar check on 1/1/12 and had he had known the results of the blood sugar check, then would not have discontinued the resident's morning insulin. The physician stated on 1/9/12, when the resident's family requested the nurse check the resident's blood sugar they would have expected the nurse to document and report a thorough assessment of the resident's condition. The physician stated since the family was concerned about the resident, the resident's only insulin had been discontinued and the resident's blood sugar tested 389, the physician would have expected the nurse to pick up the telephone and either call him or the physician on call and not send a facsimile. On 2/14/12 at 8:30 a.m., the resident's power of attorney was interviewed and stated the facility failed to inform him/her of the discontinuation of the resident's insulin. He/she stated they would have wanted to be informed of the sudden/unexpected change due to the resident's long history of insulin dependence. On 2/14/12 at 2:15 p.m., Staff A, Licensed Practical Nurse was interviewed and stated on 1/4/12 she received a return facsimile from the physician to discontinue the resident's insulin. Staff A stated she did not think anything about the order. Staff A stated on 1/8/12, the resident's family voiced concern due to the resident not eating and had a decreased appetite. Staff A stated she did not assess the resident's appetite, did not notice if the resident was eating his/her meals and did not assess the resident's weight or the resident's blood sugar. Staff A stated on 1/9/12, the resident's family came to her and stated they were concerned due to the resident was not acting right and asked Staff A to check the resident's blood sugar. Staff A checked the resident's blood sugar that registered 389. Staff A stated it was too high, even for a diabetic and she did not know why she did not call the physician. Staff A did not assess the resident for additional signs or symptoms of [MEDICAL CONDITION] and did not document the family's concern or the resident's condition in the progress notes. Staff A stated she sent a facsimile to the resident's physician the evening of the resident's elevated blood sugar. On 2/14/12 at 9:24 a.m., Staff B, Registered Nurse, stated the resident was normally cooperative for her. Staff B stated on 1/3/12 at 8:00 a.m., the resident was swinging and hitting because of not wanting to get out of bed. Staff B offered the resident breakfast in his/her room and the resident did get up out of bed later that morning. Staff B did not offer to give the resident insulin after the resident was up and cooperative. Staff B did not call the resident's physician to see if she could give the insulin after the resident got up out of bed and did not assess the resident's blood sugar after holding the insulin on 1/3/12. Staff B stated on 1/4/12 at 8:30 a.m., the resident was "cross", swinging and did not want to get up. Staff B did not assess the resident to see why he/she did not want to get up and did not offer the resident breakfast in bed. Staff B held the resident's morning insulin and did not offer the resident insulin after the resident got up. Staff B did not call the resident's physician to see if the insulin could be given after the resident got up out of bed. Staff B did not check the resident ' s blood sugar. Staff B stated they sent a facsimile to the resident's physician to see if they could change the timing of the resident's medications, including insulin to noon, due to the resident wanted to sleep in. Staff B stated she did not ask the physician if she could change the resident's insulin time to noon. Staff B stated when she returned to work on 1/8/12, she did not wonder why the physician had discontinued the resident's insulin. Staff B verified the resident's routine weekly blood sugar test was scheduled on 1/8/12; however Staff B did not test the resident ' s blood sugar on 1/8/12. Staff B stated she could not say how the resident ate that day, nor could she say how the resident was doing that day. Staff B stated she worked on 1/7/12 and on 1/8/12. Staff B stated it never occurred to her to check the resident's blood sugar even though it was listed on the MAR (Medication Administration Record) to complete and even though the resident ' s insulin had been discontinued on 1/4/12. On 2/14/12 at 10:35 a.m., the Director of Nursing was interviewed and stated she were unaware the resident's insulin had been discontinued and had she had known of the new order, she would have questioned the physician order [REDACTED]. The facility policy/procedure titled Minimal Standards for Documentation & Assessment (not dated) identified the purpose was to assure that all residents have accurate documentation, follow up assessment and appropriate notification to the physician and family. The procedure directed staff to obtain a full body assessment and vital signs. Documentation of the significant change in condition in the resident's medical record would include: the date, time of change in condition, a description of the change noted in the resident's condition, full assessment of the resident including vital signs and the resident's physical and mental status.