Every finding on record at Oelwein Health Care Center

Based on observation, clinical record review, policy review, Center for Disease Control and Prevention (CDC) Guidelines, resident and staff interviews, the facility failed to ensure proper hand hygiene and infection control practices were followed during the cleaning of a commode for 1 of 1 sampled residents (Resident #3). Specifically, staff failed to perform hand hygiene after glove removal, failed to properly sanitize a commode pan contaminated with fecal matter, and failed to wash hands for the required duration, creating a risk for the spread of infection.The facility reported a census of 51 residents. Findings include:Resident #3's Minimum Data Set (MDS) Assessment, dated 1/13/26, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS didn't list a diagnosis of dementia.The Care Plan Focus dated 2/2/26 identified Resident #3 had a risk of a chronic urinary disturbance. The Interventions directed the staff to encourage use of the commode and assist Resident #3 as needed.During an initial pool interview on 3/23/26 at 4:27 PM, Resident #3 reported only one Certified Nursing Assistant (CNA) washed their hands after emptying her commode bucket. She stated only 2 to 3 CNAs wore gloves to clean the bucket and she didn't see staff wash their hands or use hand sanitizer afterward. She noted staff sometimes refilled her water pitcher immediately after handling the commode, which she didn't like.Observation on 3/25/26 at 10:03 AM showed Staff D, CNA, assisted Resident #3 with the commode. After Resident #3 finished, Staff D removed the commode pan, which contained visible bowel movement (BM). Staff D placed the dirty pan half-tipped on the toilet seat used by Resident #3's roommate. Staff D removed her gloves and opened a drawer to retrieve a plastic bag without performing hand hygiene.Staff D applied new gloves, placed the dirty pan in the plastic bag, and returned it to the commode. She then changed her gloves again without performing hand hygiene and carried the commode over 60 feet down the hallway to the South dirty utility room. In the utility room, Staff D rinsed the pan, but visible BM remained in three different places on the rim. Staff D removed her gloves and without performing hand hygiene, left the room to get a cleaning chemical. Upon returning, she placed a glove on only her right hand without washing her hands. After spraying the pan, she washed her hands for approximately five seconds and left the area.During an interview on 3/25/26 at 10:25 AM, Staff M, Licensed Practical Nurse (LPN), verified that Staff D left the utility room without washing her hands and that visible BM remained on the commode pan. Staff M guessed the final hand wash didn't last the required 15 to 20 seconds and stated Staff D should've washed her hands after removing gloves.During an interview on 3/25/26 at 3:45 PM, Staff N, CNA, reported hand hygiene should be completed when entering and leaving resident rooms. She stated that if a commode bucket didn't rinse out, she'd sanitize it with bleach wipes and perform hand hygiene before leaving the room.During an interview on 3/25/26 at 3:54 PM, the Director of Nursing (DON) reported that best practice is for staff to perform hand hygiene after taking gloves off. She believed the facility policy required a 15 to 20 second hand wash. When asked if staff should wash hands between handling commode buckets and refilling water pitchers, she voiced, yes.The Hand Hygiene Policy, revised October 2023, documented the purpose as to prevent the spread of infection. It recommended hand hygiene before and after direct resident contact and after assisting with toileting.The Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, recommended washing hands after contact with body fluids, contaminated surfaces, and immediately after glove removal. The CDC directed that handwashing include rubbing hands vigorously for at least 20 seconds and noted that gloves aren't a substitute for hand hygiene.

Based on record review and staff interview, the facility failed to ensure that a resident with a high risk of aspiration and difficulty swallowing was fed only by licensed or certified staff for 1 of 2 residents reviewed (Resident #20). Specifically, the facility allowed Paid Nutritional Assistants (PNAs) to assist a resident who exhibited active coughing during meals. The facility reported a census of 51 residents.Findings include: Resident #20's Minimum Data Set (MDS) assessment dated [DATE] identified they had a mechanically altered diet while a resident at the facility. The Care Plan Focus revised 11/4/24 identified Resident #20 needed assistance with activities of daily living (ADLs) related to progressing Alzheimer's and the lack of awareness on how to initiate/complete cares. The Intervention related to eating revised 12/29/25 directed Resident #20 needed assistance from 1 staff member to eat.The Care Plan Focus revised 11/5/24 indicated Resident #20 had an actual risk for altered nutritional status due to dementia. The Interventions directed the following:a. 11/5/24: Provide diet as ordered: Pureed texture with nectar thick liquids in nosy cups.b. 12/29/25: Assess for signs and symptoms of aspiration (incorrectly swallowing food into the lungs instead of the stomach) or difficulty swallowing. A Video Swallow Study, dated 12/11/25, documented Resident #20 experienced coughing during meals and carried a diagnosis of dysphagia (the medical term for difficulty swallowing). The overall impression indicated Resident #20 had a risk for aspiration (when food or liquid enters the airway). Recommendations included a diet of pureed food with mildly thick liquids and strict safe swallow precautions, such as alternating solids and liquids, taking small bites and sips, and maintaining a slow rate of intake.The PNA-Resident Dining assessment dated [DATE] reflected the following:a. A Speech Therapist indicated Resident #20 had dysphagia.i. Recommendations of general diet, pureed texture, with nectar fluid consistency and nosy cups.ii. Resident #20 tolerated the current interventions without signs of aspiration.b. Resident #20 had a diagnosis of dysphagia.c. The Interdisciplinary Team determined Resident #20 could eat with the assistance of a PNA.In an email dated 3/25/26 at 5:00 PM, the Director of Nursing (DON) stated the facility didn't have residents that PNAs couldn't assist.During an interview on 3/26/26 at 9:10 AM, Staff P, PNA, verbalized she assisted Resident #20 with breakfast and lunch every other weekend.During an interview on 3/26/26 at 12:23 PM, the Speech Therapist verbalized she didn't make the decision regarding which residents a PNA could assist; she only provided clinical recommendations. She noted she hadn't seen Resident #20 since January and couldn't speak to their current swallowing status.During an interview on 3/26/26 at 12:25 PM, Staff Q, PNA, verbalized she assisted Resident #20 with meals every evening, except Wednesdays. Staff Q reported Resident #20 coughed after every drink. She stated the other staff told her to just let her cough it out, and she didn't report the coughing to the nurse.During an interview on 3/26/26 at 12:35 PM, the DON verbalized that a PNA may assist a resident if Speech Therapy approved. She stated she her expected the PNA must get a nurse if a resident started choking or coughing, so they could evaluate and assess the resident.The facility policy titled Paid Nutritional Assistant revised May 2025 directed the following:a. Residents who exhibit concerns with recurrent lung aspiration or difficulty swallowing will be fed only by nurses, nurse aides, or other licensed health professionals.b. If the Speech Therapist and facility team determined the resident didn't have evidence in the assessment of current symptoms of choking or aspiration (which would make that resident difficult to feed) the resident is appropriate to have a PNA help them eat.

Based on clinical record review, policy review, provider, family and staff interviews, the facility failed to notify the provider and family of a significant injury for 1 of 4 sampled residents (Resident #17). Staff identified an unexplained bruise to the resident's right eye on 3/15/26, but the facility didn't notify the medical provider or the family until 3/23/26, resulting in an 8-day delay. The facility identified a census of 51 residents.Findings include:Resident #17's Minimum Data Set (MDS) Assessment, dated 2/4/26, documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive loss. Resident #17 experienced memory problems, had moderately impaired decision-making, and was diagnosed with Alzheimer's Disease and Non-Alzheimer's Dementia. The MDS noted Resident #17 exhibited hallucinations, rejection of care, and physical and verbal behaviors toward others 1 to 3 days per week. The MDS documented no upper/lower extremity impairments in functional range of motion. The MDS listed Resident #17 as independent with sit to stand transfers and walking. The MDS included diagnoses of Alzheimer's disease and unspecified and non-Alzheimer's dementia.A General Progress Note, dated 3/15/26 at 6:00 PM, documented Staff A, Licensed Practical Nurse (LPN), arrived at Resident #17's room after a call from Staff B, Certified Nursing Assistant (CNA), and Staff C, CNA. Staff B and Staff C reported a 2 centimeter (CM) by 2 CM bruise above Resident #17's right eye.The clinical record lacked documentation from 3/15/26 to 3/22/26 indicating a provider or family member received notification of the bruise.A Physician Visit Note, dated 3/24/26 at 10:45 AM, documented Advanced Registered Nurse Practitioner (ARNP) K entered the facility to examine the bruising to Resident #17's right eye.During an interview on 3/24/26 at 2:49 PM, Resident #17's sister stated she noticed the bruise to the right eye on Saturday 3/21/26 during a visit. She stated the injury looked like someone punched Resident #17 in the eye and she took a picture. She noted the facility failed to notice the bruise until she brought it to the attention of the Director of Nursing (DON) on Monday 3/23/26.During an interview on 3/25/26 at 9:34 AM, ARNP L reported Resident #17 had a significant history of falls with head injury. ARNP L stated if staff find a resident with unexplained bruising on the face or head, they should notify her at the time of discovery, noting an eight-day wait remained inappropriate.During an interview on 3/25/26 at 11:20 AM, Staff J, LPN, reported nurses should document the area in the progress notes, complete an incident report, and notify the doctor and family.During an interview on 3/25/26 at 1:41 PM, Staff D, CNA, reported she noticed the bruising around Resident #17's right eye the previous weekend. She stated she informed Staff E, Certified Medication Aide (CMA), that day, and Staff E replied the nurses already knew about the bruise.During an interview on 3/25/26 at 2:11 PM, Staff F, Registered Nurse (RN), reported she saw the bruise above Resident #17's right eye during the previous week. She noted upon her return to work on Monday 3/23/26, the bruising had moved below Resident #17's right eye.During an interview on 3/25/26 at 2:39 PM, Staff G, CNA, reported she saw Resident #17's bruising to the right eye on 3/20/26 and 3/21/26 during her 10:00 PM to 6:00 AM shift.During an interview on 3/25/26 at 4:17 PM, Staff H, CNA, reported she saw Resident #17's bruising during the previous week and observed the bruise worsened by the end of the week.During an interview on 3/25/26 at 4:35 PM, Staff I, CNA, explained she first saw Resident #17's bruising around the right eye on 3/15/26 at suppertime. She described it as a small bruise around the right eye.During an interview on 3/25/26 at 4:45 PM, Staff B reported she and Staff C put Resident #17 to bed on 3/15/26 between 6:00 PM and 7:00 PM. She stated Resident #17's right eye appeared black at that time and they called Staff A to report it.During an interview on 3/26/26 at 8:02 AM, Staff A recalled recalled a call to Resident #17's room to observe a bruise above the right eyebrow. Staff A described the bruise as small measuring 2 CM x 2 CM on 3/15/26. Staff A reported she did not notify the provider or family because of the late hour. When inquired about the progress note written about the bruise at 6:00 PM, Staff A replied if it was documented at 6:00 PM, then that was when it happened. Staff A explained she worked Friday, Saturday, Sunday. Staff A confirmed the bruising darkened until Resident #17 had a black eye.During an interview on 3/26/26 at 9:52 AM, Staff M, LPN, reported if she found new bruising on a resident, she would notify the physician and family as soon as possible.During an interview on 3/26/26 at 11:22 AM, the DON reported she became aware of the situation on 3/23/26 when Resident #17's sister notified her. The DON stated while she felt unsure how timely the policy required family notification, the eight-day delay exceeded acceptable limits.The facility's Notification for Change of Condition Policy, revised June 2023, directed the facility must immediately inform Resident #17, consult with the physician, and notify Resident #17's legal representative or family member when an accident occurs resulting in injury with the potential for requiring physician intervention.

Based on record review and staff interview, the facility failed to ensure a complete medical record for 2 of 4 sampled residents (Resident #4 and Resident #8) by failing to maintain copies of hospital transfer documentation in the clinical records. The facility reported a census of 51 residents. Findings include:1. Resident #4's Minimum Data Set (MDS) Assessment, dated 12/3/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating she remained cognitively intact. The MDS indicated Resident #4 required staff dependence for transfers, did not walk, and carried diagnoses of malnutrition (a condition where the body does not get enough nutrients), pressure ulcer (a sore caused by prolonged pressure on the skin), and paraplegia (paralysis that affects the lower half of the body).Review of Resident #4's Progress Notes, dated 1/17/26 at 12:25 PM, documented an ambulance arrived to transport Resident #4 to the hospital.During an interview on 3/25/26 at 10:29 AM, Resident #4 stated she required a mechanical sling lift (a device used to help move people who have limited mobility) with two-person assistance for all transfers. She reported her last hospitalization resulted from an infection and emphasized multiple times the facility was not responsible for the illness.2. Resident #8's MDS Assessment, dated 12/17/25, documented a BIMS score of 15, indicating no cognitive impairment. Resident #8 carried diagnoses of paraplegia, diabetes (a disease that occurs when your blood glucose is too high), and anxiety (a feeling of fear, dread, and uneasiness).A Health Status Note in the Progress Notes, dated 2/5/26 at 4:22 AM, documented Resident #8 entered the local hospital for sepsis (a life-threatening medical emergency where the body has an extreme response to an infection) and a urinary tract infection (UTI) (an infection in any part of the urinary system).During an interview on 3/25/26 at 9:44 AM, Advanced Registered Nurse Practitioner (ARNP) L reported Resident #8 experienced a rapid onset of illness and stated they can become septic quickly, requiring an immediate transfer to the emergency room (ER), which staff cannot always prevent.In e-mail correspondence dated 3/25/26 at 9:39 AM, the Director of Nursing (DON), Licensed Practical Nurse (LPN), stated the nurse on shift failed to copy the transfer paperwork sent with Resident #4 and Resident #8 during their hospitalizations. She contacted the hospital's medical records department to obtain copies and confirmed nurses must send the Resident Transfer Sheet, advance directives (legal documents that specify what actions should be taken for a person's health if they are no longer able to make decisions for themselves), Medication Administration Record (MAR), Treatment Administration Record (TAR), and pertinent laboratory or x-ray results prior to transfer.During an interview on 3/26/26 at 9:38 AM, Staff R, LPN, stated staff must send the Resident Transfer Record, MAR, immunization records, and advance directives when transferring a resident to the hospital.During an interview on 3/26/26 at 12:34 PM, the DON reported she could not locate the hospital transfer paperwork for Resident #8's 2/5/26 hospitalization or Resident #4's 1/17/26 hospitalization. She noted the local hospital provided documentation they retained from Resident #4's 1/17/26 transfer, including an admission Record and an Order Summary Report.

Based on record review, document review, the Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Resident Assessment Instrument (RAI) Manual and staff interview, the facility failed to ensure the timely transmission of the Discharge Return Not Anticipated (DRNA) assessment for 1 of 2 sampled residents (Resident #34). The facility transmitted the assessment 118 days after the required completion date. The facility identified a census of 51 residents:Findings include:An Electronic Healthcare Record (EHR) Census Record showed Resident #34 discharged from the facility on 11/21/25.The Minimum Data Set (MDS) Summary Page documented the DRNA Assessment completion on 11/26/25 and locking on 3/24/26.An MDS Assessment History showed the iQIES (Internet Quality Improvement and Evaluation System) (the system used to transmit resident assessments) accepted the DRNA Record with an accepted date of 3/24/26.A Batch Report (a document tracking group submissions), dated 3/25/26 at 7:28 AM, documented the acceptance of Resident #34's DRNA Assessment on 3/24/26.During an interview on 3/25/26 at 8:05 AM, Staff J, Licensed Practical Nurse (LPN), reported Resident #34 used a Medicare Advantage plan (a type of health insurance plan). She stated she believed the discharge record remained marked not to submit for that reason. Staff J reported she normally waited for the Director of Nursing (DON), to sign off the MDS records, and then she transmitted the records each week. She voiced she did not think the facility maintained a policy on transmitting MDS records and noted the facility followed the Resident Assessment Instrument (RAI) Manual requirements.The CMS LTC RAI October 2025 Manual directed in Chapter 2, page 19, that the facility required the transmission of the DRNA 14 days from the completion date.

Based on record review, document review, family, staff, and physician interviews, and policy review the facility failed to ensure clinical monitoring and physician notification for critical lab values and significant injuries for 3 of 10 sampled residents (Resident #5, Resident #25, and Resident #17). Specifically, the facility failed to notify providers of dangerously high and low blood sugar readings and failed to perform neurological assessments for a resident with an unexplained head injury. The facility reported a census of 51 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) Assessment, dated 12/10/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating she remained cognitively intact. The MDS documented she received daily insulin and carried diagnoses of fracture, diabetes (a disease that occurs when your blood glucose is too high), and long-term insulin use. Review of Resident #5's Blood Sugar Summary from 1/30/26 to 3/26/26 documented blood glucose levels less than 60 milligrams per deciliter (mg/dL) or greater than 450 mg/dL. Readings below 65 mg/dL indicate hypoglycemia (low blood sugar), while readings over 450 mg/dL indicate severe hyperglycemia (high blood sugar); both conditions require prompt action and medical consultation: a. 1/30/26 at 7:56 AM: 58 mg/dLb. 1/14/26 at 8:26 PM: 461 mg/dLc. 1/20/26 at 8:34 PM: 483 mg/dLd. 2/7/26 at 8:39 AM: 55 mg/dLe. 2/14/26 at 8:13 AM: 43 mg/dLf. 3/2/26 at 7:21 PM: 457 mg/dLg. 3/21/26 at 8:41 PM: 515 mg/dL A review of Resident #5's Progress Notes on 3/26/26 revealed a lack of notification to the provider regarding the blood sugars listed. During an interview on 3/26/26 at 9:38 AM, Staff R, Licensed Practical Nurse (LPN), stated Resident #5's provider, Advanced Registered Nurse Practitioner (ARNP) K, required notification for blood sugar readings less than 70 mg/dL or greater than 450 mg/dL. Staff R further stated that nurses are expected to document the physician communication in the resident's Progress Notes. Review of Resident #5's current Care Plan on 3/26/26 documented that she remained at risk for complications related to diabetes. The established goal was for the resident to remain free of complications related to hyperglycemia and hypoglycemia. The facility implemented interventions to monitor blood glucose levels as ordered and to report findings outside of specified parameters to the provider. 2. Resident #25's MDS, dated [DATE], documented a diagnosis of type 2 diabetes mellitus with diabetic neuropathy (a condition causing high or low blood sugar), schizoaffective disorder, bipolar type (a chronic mental health condition), chronic kidney disease (a condition where kidneys cannot filter blood properly), heart failure (a condition where the heart cannot pump blood efficiently), and obesity. The Progress Notes in the Electronic Healthcare Record (EHR) lacked documentation the facility notified the physician of blood sugars above 450 mg/dL on the following dates: a. 3/5/25 at H.S. (bedtime): 480 mg/dLb. 3/6/26 at H.S.: 483 mg/dLc. 3/7/26 at H.S.: 510 mg/dLd. 3/8/26 at supper time: 539 mg/dLe. 3/15/26 at lunch: 522 mg/dLf. 3/22/26 at H.S.: 533 mg/dL During an interview on 3/26/26 at 12:35 PM, the Director of Nursing (DON) verbalized the facility had the parameters posted in the medication room. Each provider has its own set of blood sugar parameters, if not specific parameters for each diabetic resident. She stated she expected staff to notify the physician for orders if blood sugar was below or above parameters. If the DON saw they had high blood sugars for a few days in a row, she'd send them to the physician for review. In an email dated 3/26/26 at 1:30 PM, the DON confirmed Resident #25's chart lacked documentation of physician notification. The facility policy titled Diabetes Management (hyperglycemia/hypoglycemia) directed staff to notify the physician of clinical condition, including vital signs and blood glucose levels, during hyperglycemia. 3. Resident #17's MDS Assessment, dated 2/4/26, documented a BIMS score of 99, indicating severe cognitive loss. Resident #17 exhibited memory problems. The MDS noted Resident #17 exhibited hallucinations (perceptual experiences in the absence of real external sensory stimuli), physical and verbal behaviors toward others, and rejection of care 1 to 3 days per week. The MDS included diagnoses of Alzheimer's disease and non-Alzheimer's dementia. The Care Plan Focus dated 12/23/24 indicated Resident #17 had a risk of elopement. The Interventions directed staff to redirect Resident #17 from entering other resident rooms and to common areas as needed. The Care Plan Focus dated 1/6/25 indicated Resident #17 had a risk for falls. The Intervention directed the staff to redirect Resident #17 if observed walking toward a resident in a wheelchair to prevent further falls. The Care Plan Focus dated 4/1/25 indicated Resident #17 required assistance with her activities of daily living. The Interventions instructed the following:a. Attempt to redirect Resident #17 if they walk too close to wheelchairs to prevent injury to her feet.b. Resident walked and transferred independently. A Progress Note, dated 3/15/25 at 6:00 PM, documented Staff B, Certified Nurse Aide (CNA) and Staff C, CNA, summoned Staff A, LPN, to Resident #17's room to report a 2 centimeter (CM) by 2 CM bruise to her right eyebrow. The Progress Notes from 3/15/26 to 3/22/26 lacked documentation of further assessment or neurological assessment (an evaluation of sensory and motor responses to determine if the nervous system is impaired). An Incident Report, dated 3/23/26 at 12:28 PM (8 days later), documented Resident #17 had a bruise under her right eye. The report detailed the bruise over the eye moved underneath the eye. The Incident Report under List Any Treatment Provided documented Assessment. The Incident Report identified new interventions for Physical/Occupational Therapy to evaluate and treat and to attempt the use of a soft helmet. A Secure Conversation Note, dated 3/23/26 at 12:51 PM, documented the DON notified ARNP L of the bruise under Resident #17's right eye, of unknown origin. A General Progress Note dated 3/23/26 at 1:36 PM documented the DON placed a soft helmet on Resident #17. A Physician Visit Note dated 3/24/26 at 10:45 AM documented ARNP K examined Resident #17's bruising to her right eye while in the facility. During an interview on 3/25/26 at 9:34 AM, ARNP L reported Resident #17 has a significant fall with head injury history. She explained that with unexplained bruising to the head/face, neurological changes would be of concern. She'd expect a neurological assessment at the time the bruising was discovered, noting an 8-day wait remained inappropriate. If there were changes, she'd want the resident sent out for a potential bleed or neurological changes right away. A 3/25/26 review of Resident #17's EHR Assessments showed Skin Evaluation Non-Pressure Wound monitoring dated 3/3/26, 3/17/26 and 3/17/26 for facial bruising to the left side of the face from a fall sustained on 3/2/26. The EHR Assessment showed a Skin Evaluation for bruising to the right eye wasn't started until 3/24/26. During an interview on 3/25/26 at 11:20 AM, Staff J, LPN, reported she started a skin sheet weekly during rounds, on Tuesdays. She stated nurses should document the area in the progress notes. Staff J then picks up the skin sheet during the week when she did her wound care documentation. Staff J added the facility just implemented a soft helmet that week for Resident #17. During an interview on 3/25/26 at 1:05 PM, Staff O, CNA, reported they noticed Resident #17 had bruising around her right eye on 3/22/26. She stated it had a green undertone, looking like an older bruise. She thought she'd seen it on 3/19/26 but didn't report it because she thought the nurses already knew. During an interview on 3/25/26 at 1:41 PM, Staff D, CNA, voiced she noticed bruising around Resident #17's right eye the previous weekend. She stated Staff E, Certified Medication Aide (CMA), told her the nurses already knew about it. During an interview on 3/25/26 at 2:11 PM, Staff F, RN, reported she saw the bruising above Resident #17's right eye the previous week. When she returned to work on 3/23/26, she saw the bruising moved below the right eye. During an interview on 3/25/26 at 4:17 PM, Staff H, CNA, reported she saw the bruise to Resident #17's right eye the previous week and it got worse by the end of the week. During an interview on 3/25/26 at 4:35 PM, Staff I, CNA, voiced she first saw a small circle of bruising to the right eye on 3/15/26 at suppertime. During an interview on 3/25/26 at 4:45 PM, Staff B reported she and Staff C put Resident #17 to bed on 3/15/26 and her right eye appeared black at that time. They called Staff A to the room to report the bruise. During an interview on 3/26/26 at 8:02 AM, Staff A recalled the call to Resident #17's room to observe the bruise. She didn't notice bruising to Resident #17's right eyebrow earlier in the shift. She added didn't know of any recent falls, altercations, incidents or anything significant that happened leading up to the bruise. Staff A explained she documented the area in the Progress Notes and then printed off the Progress Note and put it in the Director of Nursing's (DONs) box to notify the DON of the bruise. The DON usually does a small investigation into the cause of what may have happened. She explained she'd documented the area but didn't perform vital signs or a neurological assessment due to Resident #17 sleeping. The nurses pass resident concerns through a verbal report and sometimes put the concerns on the Alert Charting to follow up. She couldn't recall if she put it on the Alert Charting Log but she passed it through report. Staff A voiced she knew the facility had a policy for assessing injuries but she probably didn't follow it. During an interview on 3/26/26 at 9:52 AM, Staff M, LPN, reported if she found a new bruise on the head of a resident, she'd perform a neurological exam as soon as possible and stated 8 days later wasn't timely. She would put resident concerns on the Alert Charting Log to have the nurses get vital signs and assess for pain for 72-hours. Staff M didn't recall anything coming through shift-to-shift report to monitor Resident #17's bruise on the right eye. Unknown bruising should be assessed and monitored. She personally talked to the DON if she finds any resident injuries. She noted unknown bruising should be monitored. The Alert Charting Logs provided by the facility on 3/26/26 from 3/9/26 – 3/25/26, lacked documentation on 3/15/26 to assess or monitor Resident #17's bruising to the right eye. During an interview on 3/26/26 at 11:18 AM, the DON explained she would address using the Alert Change Log and following the facility's processes with Staff A. She didn't personally look at the Alert Charting for Resident #17's bruising. The DON explained the normal process is for the nurse to measure the area when found, document an incident report, and place the resident on the Alert Charting Log for 72 hours of observation and vital signs. The DON reported she couldn't honestly say if Resident #17 needed neurological checks as she didn't know the cause of her bruising of her right eye. The DON stated she didn't believe Staff A left any notification in her box regarding the bruise.

Based on clinical record review, document review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Resident Assessment Instrument (RAI) Manual, provider and staff interviews, the facility failed to ensure an accurate picture of a resident's health status by coding a diagnosis that lacked a direct relationship to the resident's current status for 1 of 2 residents reviewed (Resident #7). The facility coded schizophrenia on the Minimum Data Set (MDS) (a resident assessment tool) based on 1990 medical records, despite a lack of supporting documentation from current providers. The facility identified a census of 51 residents.Findings include:The Electronic Healthcare Record (EHR) documented Resident #7 admitted to the facility on [DATE].Resident #7's admission MDS, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. The MDS documented active diagnoses of generalized anxiety disorder (GAD) (a condition of excessive worry), depression, and agoraphobia with panic disorder (a severe anxiety condition characterized by fear of places where escape might be difficult). The MDS documented Resident #7 received antianxiety and antidepressant medications.A Mental Health Institute Hospital Discharge Summary, with a facsimile date of 6/24/25, documented Resident #7 had been hospitalized and discharged on 11/28/1990 with a final diagnosis of schizophrenia, residual type, and schizoid personality disorder. The discharge lacked documentation indicating the resident received quetiapine (antipsychotic medication) (a medication used to treat certain mental or mood conditions) at that time.Behavioral Health, Psychiatric Progress Notes, dated 9/10/25 and 2/25/26, documented Resident #7 prescribed quetiapine for diagnoses of major depressive disorder, post-traumatic stress disorder (PTSD), and GAD.A 10/22/25 Behavioral Health Therapist Visit Note, documented by a Licensed Social Worker (LISW), listed visit diagnoses including GAD, schizoid personality disorder, and agoraphobia with panic disorder. The note documented a 30-minute consultation performed over the telephone and included an order for quetiapine with no diagnosis listed.Facility Visit Notes, documented by Resident #7's primary provider on 11/19/25, 1/14/26, and 3/4/26, included an active problem list but lacked a current diagnosis of schizophrenia or schizoid personality disorder. The notes listed an active physician order for quetiapine without an actual diagnosis on the order.The 2/11/26 quarterly MDS lacked documentation of active delirium, behaviors, hallucinations, or delusions. The MDS listed a new diagnosis of schizophrenia and documented Resident #7 received antipsychotic medication.A Medication Order Entry Audit Detail Report detailed the Director of Nursing (DON) (the person in charge of nursing services) entered an order for quetiapine in the EHR on 2/25/26 at 12:48 PM with a diagnosis of residual schizophrenia.During an interview on 3/25/26 at 11:50 AM, the Psychiatric Nurse Practitioner (PMHNP), an Advanced Registered Nurse Practitioner (ARNP) specializing in mental healthcare, stated that in June 2025, Resident #7 exhibited behaviors including not sleeping, anxiety, agitation, rudeness, and pacing. She reported starting the resident on quetiapine for off-label use (prescribing a medication for a condition other than what it is officially approved for) to treat panic-type anxiety, agoraphobia, and PTSD. The PMHNP noted she saw old documentation from 1990 where Resident #7 had a diagnosis of schizophrenia and schizoid personality disorder. She stated she had not diagnosed the resident with those conditions herself, nor had she seen other providers do so. She confirmed she had not treated Resident #7 for schizophrenia or schizoid personality disorder and did not feel those diagnoses were relevant to the resident's current condition.During an interview on 3/25/26 at 3:10 PM, Staff J, Licensed Practical Nurse (LPN), explained she coded active diagnoses treated within the last seven days on the MDS. She stated she coded schizophrenia on the 2/11/26 MDS after the facility received 1990 records and admitted she never verified with providers if the diagnosis remained current, as the DON did that.During an interview on 3/25/26 at 3:23 PM, the DON reported the psychiatric ARNP only examined Resident #7 at the facility. The DON stated she did not know the criteria for coding diagnoses on the MDS. She explained she retrieved the schizophrenia diagnosis from 1990 mental health records when she entered the quetiapine order into the EHR.The DON reported she spoke with the psychiatric ARNP, who expressed uncertainty regarding the accuracy of the original diagnosis but did not clarify if it remained current. After reviewing the psychiatric ARNP's visit notes, the DON confirmed she found no documentation to support a schizophrenia diagnosis. She stated the inclusion of schizophrenia on the MDS was a coding error.During an interview on 3/25/26 at 5:03 PM, the Primary ARNP for Resident #7 reported she would defer psychiatric diagnosis and medication regulation to the psychiatric provider.During an interview on 3/26/26 at 11:58 AM, the Mental Health Licensed Social Worker reported she pulled the diagnosis of schizoid personality disorder from the facility diagnosis sheet for the Therapist Visit Note on 10/22/25. As it didn't have a resolved date, she thought it was a current diagnosis. She stated she did not provide diagnoses as part of her treatment sessions.The Centers for Medicare & Medicaid Services (CMS) Long-Term Care (LTC) Resident Assessment Instrument (RAI) Manual, Chapter 3, directed the facility to code diseases having a direct relationship to the resident's current status. The manual stated the MDS assessment should generate an accurate picture of the resident's health status based on active diagnoses in the last seven days.A 3/26/26 review of the manufacturer's Highlights of Prescribing Information for quetiapine documented the initial United States approval for the medication occurred in 1997.

Based on clinical record review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) Assessment timely upon hospice election for 1 of 2 residents reviewed on hospice services (Resident #2). The facility reported a census of 45 residents. Findings include: An Electronic Healthcare Record (EHR) Progress Note dated 3/3/25 at 12:18 PM revealed a referral had been made for hospice care services. The hospice care provider scheduled an onsite visit for 3/4/25. An EHR Progress Note dated 3/3/25 at 2:00 PM documented family agreeable to hospice consultation. The EHR census detail page failed to document hospice as the primary payer for Resident #2 effective 3/4/25. An EHR Progress Note on 3/10/25 at 9:03 AM documented Resident #2 had been admitted to hospice care services. The MDS 3.0 Summary page in Resident #2 EHR revealed the facility failed to complete the SCSA MDS when hospice services had been elected within the required timeframe. A review of the hospice clinical record revealed the following: * The Hospice Election Packet signed by Resident #2's family member documented the start of service date as 3/4/25. * The hospice Interdisciplinary Group Meeting dated 3/19/25 at 1:00 PM documented a current admission status for Resident #2 admitted on [DATE]. * The physician Progress Note dated 03/17/25 at 11:57 AM documented the certification of terminal illness for hospice admission. The Progress Note had been electronically signed by the physician on 3/17/25 at 12:13 PM. During an interview on 3/26/25 at 11:09 AM with Staff A, Licensed Practical Nurse (LPN) acknowledged Resident #2 had been on hospice care services. During an interview on 03/26/25 at 11:12 AM, the MDS Coordinator, acknowledged she is responsible for completing all required MDS assessments. The MDS Coordinator revealed Resident #2 elected hospice services on 3/12/25. The MDS Coordinator revealed SCSA MDS had been in process and would be completed on 3/26/25. The MDS Coordinator revealed she follows the RAI manual when completing required assessments. During an interview on 03/26/25 11:20 AM the Director of Nursing (DON) acknowledged Resident #2 had been admitted to hospices services on 3/4/25. The DON revealed she did not know when the SCSA MDS had to be completed and would need to check with the MDS Coordinator. During an interview on 3/26/25 at 11:24 AM with the DON and MDS Coordinator, the MDS Coordinator acknowledged hospice care services had been elected on 3/4/25. The MDS Coordinator acknowledged she failed to complete the SCSA MDS within the required timeframe. The MDS Coordinator revealed the SCSA MDS should have been completed by 3/17/25. The LTC RAI 3.0 User's manual Version 1.19.1 October 2024 documented the RAI states an SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The RAI Manual specified the SCSA MDS completion date is 14 days from the determination that a significant change in resident status occurred (determination date plus 14 calendar days). The Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(2)(ii) states the facility must conduct a comprehensive assessment of a resident in accordance with the time frames specified.

Based on observation, record review, and staff interview the facility failed to utilize proper food handling to prevent potential cross contamination of food to prevent risk of food borne illness for 3 out of 3 meals observed. The facility reported of census 45 residents. Findings include: A review of the Diet Type Report dated 3/24/25 revealed three residents with a diet texture of pureed. During observation of preparation of pureed meals on 3/25/25 at 9:00 AM, Staff B, Dietary [NAME] placed a single glove on her left hand. Staff B removed a green lid from a clear plastic container with her left gloved hand. The container held buttered bread slices. Staff B reached into the container with her left gloved hand and removed 4 slices of buttered bread and placed the bread slices into the food processor and blended them with green beans. Staff B failed to utilize proper food handling to prevent cross contamination to prevent food borne illness. When blended, Staff B placed the blended bread slices and green beans into a steam table pan. During an interview on 3/25/25 at 9:43 AM with Staff B and Staff C, Dietary Manager, Staff C acknowledge she observed Staff B remove the green lid from the clear container containing buttered bread slices with her left gloved hand, reach in and remove 4 slices of buttered bread, placing them into the food processor. Staff C revealed Staff B should have used tongs to remove the bread from the container. Staff B acknowledged she had been instructed to use tongs when handling bread. During an interview on 3/25/25 at 5:13 PM, Staff C, Dietary Manager revealed the facility failed to have a policy for food handling and follows the current Iowa Food Code. A review of the Iowa Administrative Code website (https://www.legis.iowa.gov/law/administrativeRules/rules?agency=481&chapter=34&pubDate=03-19-2025) revealed rule 481-34.6(137D) food preparation and protection. * 34.6(1) Food protection. Foods shall be processed, stored, and distributed in a manner that protects food from contamination, including cross contamination from the environment, and allergen cross contact.

Based on clinical record review and staff interview the facility failed to revise and implement interventions on the comprehensive Care Plan to include hospice services for 1 of 2 residents reviewed on hospice services (Resident #2). The facility reported a census of 45 residents. Findings include: Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating moderate cognitive impairment. The MDS documented non-traumatic brain dysfunction (damage to the brain that does not result from a blow or external force to the head, but rather from internal factors like illness, stroke, or lack of oxygen), heart failure, diabetes mellitus, and non-Alzheimer's dementia. A Hospice Election Packet signed by Resident #2's family member documented the start of service date as 3/4/25. The Care Plan initiated on 4/5/24 for Resident #2 failed to include a focus area for a terminal prognosis with election of hospice care services to include interventions directing staff on cares provided. During an interview on 3/26/2025 at 11:12 AM, the MDS Coordinator acknowledged the Care Plan should have been updated on election of hospice care services. The MDS Coordinator revealed she updates the Care Plan. During an interview on 3/26/25 at 11:20 AM, the DON revealed the MDS Coordinator is responsible for updating/revising the Care Plan.

Based on observation, clinical record review, Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the health status of 1 of 4 residents reviewed for MDS accuracy (Resident #6). The facility identified a census of 45 residents. Findings include: Resident #6's MDS dated [DATE] documented the resident did not use a feeding tube. The MDS documented no calories or fluid intake through a feeding tube. Resident #6's MDS dated [DATE] documented the resident did use a feeding tube. The MDS documented no calories or fluid intake through a feeding tube. During an observation on 3/24/25 at 12:00 PM, Resident #6 did not have a visible feeding tube. During an observation of the Resident's room at the same time, the room lacked feeding tube equipment present. During an interview on 3/26/25 at 10:39 AM, the Director of Nursing (DON) explained Resident #6 does not have and has not had a feeding tube present. During an interview on 3/26/25 at 10:41 AM, the MDS coordinator acknowledged the MDS was coded in error. The resident should not have been coded as having a feeding tube. During an interview on 3/26/25 at 11:12 AM, the MDS coordinator explained the facility does not have a policy for completing the MDS's, they follow the RAI.

Based on clinical record review, family and staff interview, and document review, the facility failed to complete a Minimum Data Set (MDS) significant change assessment for a resident discharged from hospice care for 1 of 1 residents reviewed for a significant change (Resident #2). The facility reported a census of 49 residents. Findings include: The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses including hip fracture, non-Alzheimer's dementia, and encounter for palliative care. The MDS documented a Brief Interview for Mental Status (BIMS) of 5 indicating severely impaired memory and cognition. The MDS revealed the resident required total dependence of 2 staff for bed mobility and personal hygiene and total dependence of 1 staff member with eating. The MDS further documented the resident received hospice care in the past 14 days. The quarterly MDS assessment dated [DATE] revealed Resident #2 required extensive assistance of 2 staff with bed mobility, extensive assistance of 1 staff member with personal hygiene and required set-up help only with eating. The MDS did not document the resident received hospice care in the past 14 days. Review of Progress Notes dated 4/21/22 revealed Resident #2 was on the floor and could not move her right leg without pain and had a possible fracture of the right hip. The Progress Notes further documented an order was received to transfer the resident to the hospital where the resident was noted to have a broken right hip. Review of the clinical record for Resident #2 revealed she received an order for Hospice referral 4/23/22. A Hospice form dated 5/9/22 at 9:42 PM discharged Resident #2 from Hospice documenting the patient to revoke service due to level of care (LOC) change and signed by the licensed practitioner 5/10/22. The physician orders in the Electronic Health Record (EHR) documented Hospice was discontinued 5/12/22. Review of the MDS schedule for Resident #2 documented the following: 4/21/2022- Discharge Return Anticipated 4/23/2022- Entry 4/28/2022- Significant Change 7/27/2022- Quarterly Review of The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019 stated in Chapter 2, pages 23-24, directed the following: A Significant Change in Status Assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The Assessment Reference Date (ARD) must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill. During an interview 3/15/23 at 1:11 PM the Director of Nursing (DON) acknowledged a significant change had not been completed after Resident #2 was discharged from hospice level of care. The DON further revealed the facility does not have a policy for MDS significant changes as they follow the Resident Assessment Instrument (RAI) manual.

Based on observation, clinical record review and staff interview, the facility failed to follow Occupational Therapy recommendations as planned for one of 15 residents reviewed. (Resident #11) The facility census was 59 residents. Findings include: 1. The The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #11 required assistance of two staff for bed mobility, transfers and did not ambulate and had functional limitations in range of motion affecting 1 upper extremity. The Home Therapy Program recommended by Occupational Therapy on 11/26/18, directed staff to apply a splint to the resident's right elbow 4 hours daily on the 6:00 a.m. to 2:00 p.m. shift. During observation on 10/22/19 at 8:57 a.m., Staff A, Certified Nurse Aide, CNA and Staff B CNA transferred the resident from the Broda chair to the bed. The resident had a palm protector on her right hand but no splint on the right elbow as recommended. During observation on 10/22/19 at 1:57 p.m., the resident was in bed with the elbow splint on a chair next to the bed. The resident had not had the splint on any time that day. During observation on 10/23/19 at 6:49 a.m., the resident was in bed and the elbow splint remained in the chair at the bedside. During observation on 10/23/19 at 7:50 a.m., the resident sat in the Broda chair. The resident had the palm protector in place but the elbow splint was not applied. During observation on 10/23/19 at 9:19 a.m., the resident sat in the Broda chair with no splint in place on the right elbow. During observation on 10/23/19 at 2:43 p.m., Staff C, CNA stated she did not apply the splint on resident's elbow today.

Based on observation, clinical record review and staff interview, the facility failed to ensure physician orders [REDACTED]. (Resident #54) The facility census was 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #54 had [DIAGNOSES REDACTED]. A Medication Review Report included an order for [REDACTED]. The care plan dated 6/26/18, included a problem of infection/impaired skin integrity: peripheral artery disease/[MEDICAL CONDITION] related to narrowed blood vessels from [MEDICAL CONDITION] manifested by swelling, weeping and repeated infections in my lower legs. Resident being treated for [REDACTED]. At risk for bruising due to aspirin and a blood thinner. The problem included the following interventions: -administer intravenous antibiotic as ordered per peripherally inserted central catheter (PICC). -monitor for blue or purple areas developing on feet and notify the nurse right away-it may mean resident completely lost circulation to an area. -notify provider right away if resident shows evidence of acute ischemia to lower legs. -help with wound clinic appointments as ordered. -encourage resident to elevate legs whenever possible as long as can tolerate it. -needs assistance with knee high [MEDICATION NAME]. Apply as recommended by physical therapy, most recent restorative program related to [MEDICAL CONDITION] management. -heels are at risk for skin breakdown, examine them when applying or removing [MEDICATION NAME] for areas of increased redness and notify the nurse. -complete skin treatments as ordered per medication administration record. -administer vitamin with minerals as ordered to aid in healing. -help resident avoid injuries to lower legs by watching for items that could bump them on such as foot pedals, such poor circulation healing is difficult. -resident likes staff to apply lotion to skin to help with dryness, do not apply to lower legs other than feet. -encourage resident to wear pants and long sleeves to help protect skin from injury. The Medication Administration Record [REDACTED]. The treatment was initialed as applied on the morning of 7/31/18. On 7/31/18 at 9:00 a.m., the resident sat in a recliner in the room with no [MEDICATION NAME] on their legs. At 12:00 p.m., the resident sat in a wheel chair in the dining room with no [MEDICATION NAME] on their legs. At 1:32 p.m., the resident sat in the room in a recliner with no [MEDICATION NAME] on their legs. At 2:20 p.m., the resident sat in the room in a recliner with no [MEDICATION NAME] on their legs. Staff A, Registered nurse stated the resident should have the [MEDICATION NAME] on and whoever completed the treatment that morning should have put them on. Staff A noted the [MEDICATION NAME] sat on a table in the residents room. Staff A asked the resident why the [MEDICATION NAME] was not on and the resident stated they had asked someone earlier but they did not put them on. On 8/1/18 at 2:10 p.m., the Director of Nursing, DON stated there was no excuse for the [MEDICATION NAME] not to be in place as directed. At 2:21 p.m., Staff B, Licensed Practical Nurse, LPN stated they had completed the treatment the morning of 7/31/18 and did not apply the [MEDICATION NAME] because they thought the Certified Nurse Aide was responsible for that. At 2:30 p.m., Staff C, LPN verified they had initialed the MAR for the [MEDICATION NAME] as being on because they thought the nurse that did treatments in the morning was responsible for putting them on.

Based on record review and staff interviews, the facility did not always provide pharmaceutical services ( including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents reviewed (Resident #4). The facility reported a census of 51 residents. Findings include: According to documentation in the medical record, Resident #4 had [DIAGNOSES REDACTED]. According to the Medication Administration Record [REDACTED]. During an interview on 09-15-2016 at 11:07 a.m. the director of nursing stated when the nurse prepared to apply a new patch on the evening of 08-28-2016, there were no patches left in the box. The director of nursing indicated the staff nurse left the patch on however, a family member indicated the patch was not on Resident #4 on 08-29-2016. The director of nursing stated the staff nurse reordered the Scopolamine via the electronic record. She indicated the facility does not have a policy on reordering, but rather it is included in the education of the electronic medication administration system which all nurses have completed prior to administering medications. The director of nursing also reported the staff nurse did not check the emergency medication box for the Scopolamine.

Based on observation and staff interview, the facility failed to ensure foods in the dry storage area and refrigerated areas were covered, dated and labeled. The facility census was 50 residents. Findings include: During the initial tour of the kitchen on 4/11/16 at 8:50 a.m., observation in the dry storage area revealed a package of chocolate pieces and a large package of dry cereal both open with no opened date marked. During the same tour observation in the walk-in freezer revealed a clear plastic bag with what appeared to be meat which sat opened and not re-sealed, with the contents exposed. The bag was dated 4/6 but had no label. Observation in the same freezer revealed a clear plastic bag of french toast sticks not re-sealed, with the contents exposed. The bag had no label or date opened. Several pieces of meat sat on a shelf not in a package. During the tour the Dietary Manager discarded the items from the dry storage and cooler and stated the items should have been re-sealed with dates and labels.

Based on observation, clinical record review and staff interview, the facility failed to ensure one of nine residents reviewed had a call light in reach at all times. (Resident #4) The facility census was 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two for bed mobility. The undated care plan included a problem of potential for falls due to having a history of falls while at home and need for assistance with transfers/ambulation. The problem included an intervention the resident could no longer manipulate call light, would call out for help when needed it. Once in a while, may use my call light but not very often. During observation on 4/11/16 at 11:45 a.m., the resident laid in bed. The call light had been tied to the left side rail and hung off the bed near the floor. At 11:50 a.m., the call light remained near the floor. At that time the surveyor notified Staff A, Licensed Practical Nurse (LPN) who verified the resident could not reach the call light. Staff A stated the resident yelled when wanted something but the call light should have been placed in reach. Staff A placed the call light in the residents reach. At 2:30 p.m., the resident lay in bed facing the right side. The call light was tied to the left side rail and hung down from the bed to the floor. When informed, Staff B, Certified Nurse Aide (CNA), verified the resident should have the call light in reach. Staff B went to the room and placed the call light in the resident's reach. On 4/12/16 at 7:50 a.m., Staff C, CNA and Staff D, CNA, completed the resident's morning cares. The resident had been able to ask for water and hold the glass, drink and wipe their mouth. Staff C and Staff D finished cares and exited the resident room. The resident lay in bed on the right side, with the call light hanging off the left side of the bed toward the floor. When notified, Staff C returned to the room and placed the call light in the resident's hand. Staff C verified the resident should have had the call light in reach. During interview on 4/13/16 at 3:00 p.m., the Director of Nursing stated the resident should have had the call light in reach.

Based on observation, clinical record review and staff interview the facility failed to follow medication recommendations for one of two residents observed that received eye drops. (Resident # 10). The facility reported a census of 56. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented [DIAGNOSES REDACTED]. The MDS documented the resident required no assistance for bed mobility or transfer. The MDS documented the resident could understand others with clear comprehension. The plan of care initiated 1/10/12, contained no information relating to [MEDICAL CONDITION] or special directives for the use of eye drops. Clinical record review revealed the resident underwent [REDACTED]. A [MEDICAL CONDITION] medication instruction sheet dated 4/2/15, included the following medications: [REDACTED] a. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) one drop both eyes every evening b. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) one drop both eyes three times a day c. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) one drop both eyes three times a day The sheet included a guidelines for medications section which included a directive to gently close the eyes after each drop for three to five minutes, which allowed more medicine to get into the eye and less into the bloodstream. The sheet also included a directive to wait at least ten minutes between different drops. During observation of medication pass on 6/23/15 at 7:25 a.m., Staff A (Licensed Practical Nurse, LPN) administered [MEDICATION NAME] one drop to both eyes. Staff A did not assist or instruct the resident to keep the eyes closed. Staff A waited five minutes then administered [MEDICATION NAME] one drop to both eyes. Staff A did not assist or instruct the resident to keep the eyes closed. During an interview on 6/24/15 at 9:42 a.m., an eye care technician from the facility that completed the procedure stated after the drops are given, the eye should be kept closed for three to five minutes, then wait at least ten minutes between different drops, the longer the better. The eye care technician stated this would give the drop time to work and prevent the next drop from washing the first one out. During an interview with Staff A on 6/24/15 at 11:00 a.m., they stated neither of the drops they had administered to the resident could have a systemic reaction. They also stated they only needed to wait five minutes between drops. During an interview with the facility Consultant Pharmacist on 6/24/15 at 12:34 p.m., they stated the facility should follow the University of Iowa [MEDICAL CONDITION] Clinic recommendations. At 12:45 p.m., Staff B (Licensed Practical Nurse, LPN) verified the instruction sheet in the resident's clinical record included a directive to wait at least ten minutes between eye drops.

Based on record review and staff interviews, the facility failed to provide adequate supervision and implement Resident #1' s care plan intervention to prevent accidents. Record review identified a facility staff failed to use a gait belt when transferring Resident #1 on 3/20/14. Resident #1 fell backwards and sustained a collarbone fracture and scapular fracture.Prior to Resident #1's injury on 3/20/14, the same staff had been transferring him/her for approximately one week without a gait belt. The facility identified a census of 56 residents, with four (4) additional residents reviewed. Findings include: The Minimum Data Set (MDS) assessment for Resident #1 dated 1/29/14, documented [DIAGNOSES REDACTED]. Resident #1 scored 7 on the Brief Interview for Mental Status (BIMS) cognitive test. A score of 7 established Resident #1 with severe cognitive impairments. The MDS assessment determined Resident #1 required two staff to assist with transfers, bed mobility and toilet use; and he/she required one staff to assist with walking in his/her room. The test for balance identified Resident #1 was not steady and only able to stabilize his/her balance with staff assistance when moving from seated to standing position. The care plan initiated on 8/23/13, included a problem of risk of falls related to weakness and shortness of breath. The problem included an intervention on 8/28/13 which directed staff to transfer the resident with the assist of one staff and gait belt with wheeled walker and portable oxygen. The same care plan included a problem of needs assistance with activities of daily living related to weakness, shortness of breath and limited motivation. The problem included an intervention dated 3/13/14 which documented occupational therapy had placed two cushions in the resident ' s wheelchair so the resident could push themselves up without staff assistance. A Home Therapy Program form dated 3/13/14, included the following directives for wheelchair positioning for the resident: a. 22 inch wide wheelchair. b. Bilateral standard leg rests. c. Black 4 inch cushion in seat. d. Blue 3 inch foam cushion on top of black cushion (to increase resident's ease for sit to stand and decrease pain. e. Remind resident to push up from the arm rests to help come up to stand. The form identified for staff to use facility wheelchair to follow the resident while walking according to PT/ (FM) program as tolerated. The form had been signed by Staff A (Licensed Practical Nurse, LPN) and Staff B (Certified Occupational Therapy Assistant, COTA). An entry in the progress notes dated 3/20/14 at 9:00 a.m., documented the nurse had been summoned to the resident ' s room by the housekeeper. The Certified Nursing Assistant (CNA) was walking resident into the bathroom using a wheeled walker. Nurse aide turned to adjust oxygen tubing, resident lost balance and fell backward onto floor, striking head. Vital signs: Temperature 97.6/0, blood pressure lying 153/80-67-20; sitting 147/78-75, standing 158/79-69. Alert to person and place. Skin pink, warm and dry-good turgor. Hematoma 8 centimeters (cm) by 7.5 cm by 1.0 cm height. Note abrasion 3.5 cm by 0.8 cm by 0.1 cm present in hematoma. Bleeding profusely. Pupils equal and reactive to light. Ice pack applied. Lungs clear-oxygen saturation 95% with oxygen at liters per cannula. Grips firm and equal. Abdomen soft-active bowel sounds. No edema. Assessment of resident including range of motion and pain: Range of motion good to lower extremities, left shoulder good range of motion-complains of pain with right should range of motion-but states "it's my arthritis, it always hurts". No swelling, bruising or redness right shoulder noted. The note included a section which listed relevant interventions that were in place at the time of the incident: wearing gripper socks, using wheeled walker. The note also included a section for preliminary recommendation, if any, for consideration as further preventative measures: Be sure oxygen tubing is in order before standing resident up to go anywhere. An late entry in the progress notes at 1:15 p.m., documented the follow-up to the incident when the resident fell backwards onto floor striking head. The note documented the resident now reported increased right shoulder pain with noted decreased range of motion. Rated pain as a "5". No redness, bruising or swelling is noted. The note documented the physician assistant had been notified with request of x-ray of right shoulder. A progress note at 1:45 p.m., documented the resident left via facility van for x-ray of right shoulder. An entry in the progress notes at 5:00 p.m., documented the resident returned to the facility. Diagnoses: [REDACTED]. Non-displaced mid scapular fracture. To wear immobilizer. May have Ibuprofen 600 milligrams every 6 hours as needed for pain. A Major Injury Determination Form signed 3/20/14, documented that after reviewing the circumstances, injury and prognosis of the patient, the physician believed the injury sustained had not been a major injury and, to the best of their knowledge, barring any complications, they believed the patient would return to their previous functional status. An entry in the progress notes on 3/22/14 at 11:00 a.m., documented a page had been placed to the Advanced Registered Nurse Practitioner and an order received to transport to the local emergency room for evaluation. An entry in the progress notes at 11:15 a.m., documented the resident left the facility for the local emergency room . An change in condition progress notes dated 3/22/14 at 2:10 p.m., documented the resident ' s mental status worsening-increased confusion, lethargy, level of consciousness. Change in muscle tone/strength noted- more assistance needed for ADLs. No verbal or physical aggression noted. No behaviors noted. Resident appears groggy, much more difficult to rouse. Unable to respond to requests to open eyes for pupil check; pupils dilated and sluggish. Denies any pain, including head. Denies nausea. A hospital neurosurgery discharge summary documented the resident had been admitted [DATE], and discharged [DATE]. The summary documented the resident had been evaluated in the emergency department then transferred to the floor for close neurologic monitoring and workup for syncope. The form documented the resident had a computerized tomography scan of the brain on admission which showed a left occipital bone fracture and a right subdural hemorrhage. During an interview with the facility Director of Nursing on 3/31/14 at 9:42 a.m., they stated they had been at the nurse's station and Staff C (housekeeping/CNA) said they needed a nurse in the resident's room. The resident had been lying on their back, and head bleeding. The DON stated the first thing they noticed had been the resident had no gait belt on. The DON stated the resident's head had been iced and an assessment had been done which revealed no pain and range of motion and neurological assessments had been started after getting the resident settled in. The DON stated they had gotten Staff D (CNA) and told them they needed to go to the Administrator's office in ten minutes. The DON stated they had been upset because staff D had not used a gait belt, and they needed 10 minutes before talking to the aide. The DON stated when they visited with them after the incident, Staff D stated they understood therapy to say the resident could get up on their own. The DON stated that what therapy really said had been that they put a cushion on the resident's chair so the resident could push up. The DON stated Staff D had been shaking and very upset because Staff D knew they had hurt the resident. The DON stated Staff D had been suspended for three days. The DON stated that at about 12:30 p.m. the same day, the resident had complained of arm pain and had been sent for an x-ray. The resident had a fractured scapula and had been put in an immobilizer. The resident returned to the facility the same day. The following day the resident had been doing O.K. and assessments were O.K.. The DON stated the next day (two days after the incident) the resident had been groggier and they called the physician and sent the resident to the local emergency room . The DON stated the resident had then been sent to a larger hospital and had been found to have a hairline skull fracture. The DON stated Staff D usually used a gait belt, and they thought Staff D had misunderstood. During interview with the facility Administrator on 3/31/14 at 1:30 p.m., they stated they had been notified there had been a concern regarding the resident's fall and they brought Staff D in immediately after. The DON had stated the resident had no gait belt on. Staff D had been disciplined. Staff D stated that at in-service the 13th of the month Staff B Certified Occupational Therapy Assistant, COTA) had told them they put a new cushion in the resident's wheelchair and it had helped the resident push themselves up more. Staff D took this to mean the resident could ambulate independently. The Administrator stated they had now changed the way therapy communicated to staff so that CNA's had to repeat any changes made back to the therapist. At that time the Administrator provided the surveyor with a follow-up incident summary which included the following: a. as an added corrective action, all certified staff in the building were instructed to wear gait belts even if working in different departments. Communicated via communication books and by mouth to employees. Supervisory staff responsible for monitoring. b. have staff repeat back to therapy what they were educated on to assure the message had been communicated thoroughly and accurately. Communicated via huddle 3/27/14 and staff weekly newsletter 3/26/14. Therapy aware of intervention and therapists have been instructed on directive. c. Staff D had been given a written warning d. Staff D would be required to complete additional Siverchair educational training regarding resident safety and transfers, and would be required to review resident care plans with the DON to ensure they understood and followed care plans before returning to work. e. intervention had been added to the resident ' s care plan to assure proper placement of oxygen tubing before standing to ambulate/transfer. During an interview with Staff E (CNA) at 2:00 p.m., they stated if therapy made a change with a resident they would have direct communication from the therapist. They stated if the therapist put a cushion in a resident ' s wheel chair to help the resident stand that would mean the resident had problems with transfers and you would use a gait belt. During an interview with Staff C (CNA) at 2:17 p.m., they stated they had been in the room at the time of the incident and cleaning the mirror. They looked over and Staff D had brought the resident in the room in a wheelchair. As Staff F bent down to change a garbage bag, they heard a noise and looked over and saw the resident on the floor with Staff D beside them, and Staff D stated to go and get the nurse. Staff F stated they had not noticed anything unusual prior to the fall. Staff D stated that they had worked with the resident and had been aware they had a cushion in their chair. Staff C stated they always used a gait belt with the resident, and if a therapist said a resident had a cushion to help push up it did not mean do not use a gait belt. During an interview with Staff G (LPN) at 2:25 p.m., they stated they had a CNA come down and stated the resident had been on the floor. The DON and Staff G responded and maybe another nurse. The resident had been by the bathroom with head toward window. The resident had been bleeding from the back of the head. The resident said they had been O.K. and had not been moved initially. They got ice for the resident ' s head and an assessment had been done at the same time with vitals, neuro and range of motion all normal. The resident had no pain except to the back of the head, cognitive level had been the same. The resident had been able to sit up. Staff G stated that had been the extent of their involvement. Staff G stated the resident had not been wearing a gait belt and from what they understood Staff D though the resident had been a stand by assist. Staff G stated that if a change had been made a therapist would tell the staff or it got passed on in report. Staff G stated the resident should have had a gait belt on. During interview with Staff B on 4/1/14 at 9:15 a.m., they verified they had been the one to add the cushion to the resident ' s wheel chair, and stated their goal had been to get the resident higher in the wheelchair so they could push-up. Staff B stated the procedure for a therapy change is they write a program and had the DON sign, then go to the CNA's and review it verbally with them. Staff B stated they had told Staff D and Staff C about the cushions in the resident ' s wheelchair and how to cue the resident to stand up. Staff B stated it had been their intention to continue to have the CNA's use the gait belt with the resident. Staff B stated they had never said that specifically. During interview with Staff D at 1:40 p.m., they stated since the incident they had been working in housekeeping and not working with any residents for personal cares. Staff D stated they had been coming back from breakfast the day of the incident and got to the resident ' s room. They parked the resident ' s wheelchair inside the doorway. The resident stood up and Staff D stated they had been undoing oxygen tubing because they had not realized it had been tangled until the resident had been standing up. Staff D stated as they had been doing that the resident took three to four steps, did a 180 and fell . Staff D stated they had understood occupational therapy to say the resident had been a stand by assist. Staff D stated the week prior to the incident Staff B had come to them and said they had added a four riser and the resident had been a stand by assist and they understood that meant the resident could ambulate with one assist and no gait belt. Staff D stated they had worked with the resident frequently after Staff B had told them that, and had been ambulating the resident for a week prior to the fall without a gait belt. During a second interview with the facility DON on 4/2/14 at 9:45 a.m., they verified the communication between the therapist and CNA had been strictly verbal with no demonstration. The DON stated the facility had not considered doing demonstration as part of the therapy to nursing communication and stated they thought that would be a good idea. At that time the surveyor pointed out the care plan interventions for the resident and the DON stated they could see how a CNA might be confused. They stated Staff A had been the only person to sign the home therapy form and that had been the standard, only one staff person signed it. A Home Program/FMP (functional maintenance program) policy revised 8/30/01, provided information on how to provide written documentation of all recommendations/education/exercises to patient/family/nursing staff/doctors. The form documented all recommendations were to be documented in detail such as walking to meals, activity of daily living routine, upper extremity strength. The form documented the therapist should complete hands-on 1:1 training regarding home program with patient/family/nursing/rehab aide/DON as applicable. If nursing home patient is cognitive, still educate nursing staff. The form also documented after education completed to appropriate people, have them sign home program at bottom left corner vs writing in their name, multiple signatures of trained staff are required. A facility policy for Transfer/Gait Belts/Ambulation/ and Use of Safety Straps/Belts revised 11/08, documented that staff would use gait belts on residents who require assistance with transfers and/or ambulation when mechanical lifting devices are not used. During interview on 4/3/14 at 8:30 a.m., the Administrator stated the policy which stated the therapist would demonstrate changes to staff and all staff would sign when educated, had been the policy for the therapy company and not the facility. During an interview with Staff F (Occupational Therapist) at 10:48 a.m., they stated occupation therapy should be doing a demonstration as part of their communication with nursing staff and all staff educated should sign a form. During interview with Staff A at 10:52 a.m., they stated occupational therapy verbally reviewed the change when the cushions had been added with no demonstration. They stated they did not take the information provided to mean the resident did not need a gait belt.

Based on observation, clinical record review and staff interview, the facility failed to ensure Advanced Directives reflected the resident's choices for resuscitation for three of thirteen residents reviewed. The facility census was 57 residents. Findings include: 1. Record review for Resident #1 noted a red/orange dot beside the resident's name on the outside of the clinical record that indicated the resident was DNR (do not resuscitate). Further review of the resident's clinical record revealed at the back of the chart an Advanced Directive Acknowledgement form dated [DATE], documented the resident's choice was to request resuscitation efforts to be initiated at the time of cardiopulmonary or respiratory arrest. At the time the Director of Nursing removed the red dot from the resident's chart. 2. Record review for Resident #2 noted a red/orange dot beside the resident's name on the outside of the clinical record that indicated the resident was DNR (do not resuscitate). Further review of the resident's clinical record revealed at the back of the chart an Advanced Directive Acknowledgement form dated [DATE], documented the resident's choice was to request resuscitation efforts to be initiated at the time of cardiopulmonary or respiratory arrest. At the time the Director of Nursing removed the red dot from the resident's chart. 3. Record review for Resident #11 noted no red/orange dot beside the resident's name on the outside of the clinical record indicating the resident was a Full Code (to be resuscitated). Further review of the resident's clinical revealed at the back of the chart, the first paper form (under the resuscitate tab) noted an Advanced Directive Acknowledgement dated [DATE], that designated the resident's choice stating of NOT wanting resuscitation efforts to be initiated at the time of cardiopulmonary or respiratory arrest. However the next paper in the record, titled Do Not Resuscitate Request, documented on the bottom stating a revocation provision signed [DATE]. The documentation stated the resident/DPOA (durable power of attorney) revoked the above stated declaration that the resident wanted a do not resuscitate order, in other words the resident's request was to be resuscitated. Observation revealed you would not know if you did not turn to the next paper. At the time the Director of Nursing agreed it was confusing. During interview on [DATE] at 2:20 p.m., the Director of Nursing stated a red dot by a resident's name on the outside of the clinical record indicated Do Not Resuscitate and remarked if there was any question regarding that concern or choice, staff would look under the resuscitate tab for the facility forms, in the back of the records. If the paper form for Advanced Directive Acknowledgement was present, staff would not resuscitate, if there was not documentation and the only other paper was a living health will, then the resident would be resuscitated. During interview on [DATE] at 2:20 p.m., the Director of Nursing remarked there seemed to be a hole in the Advanced Directive's procedure pattern and to do CPR or not to do CPR was an important issue.