Every finding on record at Oskaloosa Care Center

Based on clinical record review, policy review, and staff interview, the facility failed to carry out non-pharmacological interventions prior to the administration of as needed(prn) psychotropics(chemical substances that change how the brain works and alter a person's mood, thoughts, feelings, or behavior) for 1 of 5 residents reviewed for medications(Resident #11). The facility reported a census of 75 residents.Findings included: The Minimum Data Set(MDS) assessment tool, dated 6/20/26, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, hip fracture, and osteoporosis(brittle bones) and listed her Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. The July 2026 Medication Administration Record listed a 7/7/26 order for lorazepam(an anti-anxiety medication) 2 milligrams/per milliliter. Give 0.25 milliliters(ml) every 4 hours as needed for anxiety, restlessness, and agitation. The MAR documented the resident received the medication on the following dates/times:7/8/26 9:43 p.m.7/13/26 9:27 p.m.7/16/26 8:00 p.m.7/18/26 7:47 p.m.7/19/26 1:31 a.m. and 11:53 p.m.The resident's clinical record lacked documentation staff carried out non-pharmacological interventions prior to the above administrations.The facility policy Behavior Management, dated 5/2014, directed staff to develop non-pharmacologic interventions.On 7/29/26 at 4:22 p.m., the Director of Nursing(DON) stated staff documented non-pharmacological interventions in the nursing notes prior to the administration of a prn anti-anxiety medication.

Based on observation, policy review, and staff interview, the facility failed to post staffing data in a prominent place, readily accessible to residents, staff, and visitors. The facility reported a census of 75 residents.Findings included:On 7/27/26 at 4:00 p.m., the facility's staffing posting was not visible at the nursing station counters and was not posted in a prominent location.On 7/28/26 at 11:29 a.m. the staffing posting was on a clipboard located on a counter behind the front nursing station. The posting was not visible for those who were not behind the nursing station(residents/visitors).On 7/29/26 at approximately 10:00 a.m., Staff C Certified Medication Assistant/Social Services pointed out the posting which was on a clipboard, hung up on a bulletin board behind the front nursing station. The posting could not be easily read by those not behind the nursing station. On 7/29/26 at 4:22 p.m the Director of Nursing(DON) stated one would have to walk up to the clipboard(behind the nursing station) which hung on the bulletin board in order to read it. She stated she did not know that the facility needed to post the staffing in a prominent location. On 7/30/26 at 10:30 a.m. the staff posting was located in a plastic holder which stood up on the front nursing station. The posting was visible and clear for those outside the nursing station. The facility policy Staff Information Posting dated 9/2014, stated the facility would post staffing information in a visible place to include census, number of direct care hours provided, and the number of Registered Nurses(RNs), Licensed Practical Nurses(LPNs), and Certified Nursing Assistants(CNAs).

Based on observation, clinical record review, and staff interview, the facility failed to disinfect a glucometer(a machine used to obtain blood sugar readings) after use for 1 of 1 residents observed during a blood sugar check. The facility reported a census of 75 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 7/6/26, listed diagnoses for Resident #48 which included diabetes, high blood pressure, and anxiety disorder and listed the resident's Brief Interview for Mental Status(BIMS) score as 14 out of 15, The July 2026 Medication Administration Record(MAR) listed an order to check blood sugars three times daily. On 7/29/26 at 11:25 a.m., Staff A Certified Medication Aide(CMA) utilized a glucometer to obtain Resident #48's blood sugar using a drop of the resident's blood. After the procedure, she wiped the outside of the glucometer with an alcohol swab and put it back into the medication cart. Staff A did not use a disinfectant wipe and stated the facility used the same glucometer for multiple residents.The undated facility policy Blood Glucose Testing directed staff to disinfect the blood glucose monitor after each use. The policy did not specify how to disinfect the glucometer. On 7/29/26 at 3:24 p.m., the Infection Control nurse stated staff should wipe glucometers down with a disinfectant wipe and wait 2 minutes for it to dry. On 7/30/26 at 9:35 a.m., the Director of Nursing(DON) stated staff should use a disinfectant wipe to sanitize the glucometer in between residents.On 7/30/26 at approximately 2:00 p.m. during the facility's exit conference, the DON stated it would be ok for staff to utilize an alcohol wipe to sanitize the glucometer. The SA requested she provide the survey team with the glucometer's manufacturer's instructions for disinfecting.As of 8/3/26 at 12:30 p.m., the facility had not sent any instructions.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to administer an inhaler in accordance with professional standards for 1 of 2 residents observed for inhalers(Resident #32). The facility reported a census of 75 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 5/20/26, listed diagnoses for Resident #32 which included asthma, chronic obstructive pulmonary disease or chronic lung disease(diseases which caused difficulty breathing), heart failure, and Alzheimer's disease and listed her Brief Interview for Mental Status(BIMS) score as 3 out of 15, indicating severely impaired cognition. The July 2026 Medication Administration Record(MAR) listed a 6/12/25 order for budesonide-formoterol fumarate inhaler(used to treat breathing disorders, brand name Symbicort) 160-4.5 micrograms(mcg) 2 puffs twice daily.7/1/25 Care Plan entries stated the resident was at risk for altered respiratory status/difficulty breathing related to Alzheimer's disease. The entries stated the resident would have no complications related to shortness of breath and directed staff to administer her medications as ordered. On 7/28/26 at 8:10 a.m., Staff B Registered Nurse(RN) assisted the resident to take 2 puffs of her Symbicort inhaler and then gave her some water to drink. The resident took a drink and swallowed it. Staff B did not encourage/direct the resident to spit out the water. The Symbicort Highlights of Prescribing Information retrieved from https://www.mysymbicort.com on 7/30/26 directed to rinse one's mouth with water and spit the water out after each dose. It directed not to swallow the water as this would lessen the chance of getting a fungal infection(thrush) in the mouth and the throat.The facility policy Medication Administration, dated 1/2013, directed staff to instruct the resident to rinse their mouth(after administration) especially if the inhaler contained a steroid. On 7/30/26 at 8:03 a.m., Staff D Licensed Practical Nurse(LPN) stated after she administered an inhaler which contained a steroid, she directed residents to rinse their mouths with water and spit it out. On 7/30/26 at 9:35 a.m., the Director of Nursing(DON) stated staff should have residents swish and spit after the administration of an inhaler.

Based on staff interviews, resident interview and policy review, the facility failed to be respectful and provide care with dignity for 1 of 3 residents reviewed (Residents #2). The facility reported a census of 78 residents. Findings included:The Minimum Data Set (MDS) dated [DATE] identified Resident #2 (R2) with Brief Interview for Mental Status score of 15 of 15 indicating is intact cognition. Diagnosis included stroke affected one side. Resident #2 was coded for frequent pain and dependent, needed two or more to assist from chair to bed. The Care Plan revised on 6/9/25 for Resident #2 documented was completely dependent for transferring with the (redacted company name) stand lift and assistance of two staff. The Care Plan also directed to use caution during transfers and is at risk for pain, to anticipate needs. A Progress Note, titled, Incident Note dated 5/11/26 at 5:30PM (Late Entry 5/11/26 10:45AM) documented as follows; that Certified Nurse Aide CNA, Staff F filed a grievance on behalf of Resident #2 who reported was experiencing pain when transferred and CNA, Staff A said to R2 shut your mouth. Resident #2 was directly interviewed by the facility Social Worker. R2 reported to the Social Worker the following events; Staff A transferred R2 with the EZstand transfer device to the bed. R2 yelled out in pain when Staff A moved R2's arm. Staff A, responded You're all right R2 responded It is painful and if there is a noise that needs to get out, I'm going to let it out. Staff A responded Then just keep your mouth shut. R2 responded I can't. Staff A interview statements on 5/11/26 at 1:30PM included the following documentation, Resident A yelled in my ear so Staff A responded, The yelling please you are a bit loud and, can we try and hold it in. Staff A reported that he did not realize the comments hurt R2.An Incident Witness Statement dated 5/11/26 signed by Resident #2 relayed on 5/10/26 at approximately 7:00 PM, Staff A assisted with transfer via the lift alone, and moved Resident #2's injured arm so, he yelled out in pain. Staff A responded you are alright, and said, the noise. Resident #2 responded, it is painful and if there is a noise that needs to get out, he would let it out. Staff A responded, then just keep your mouth shut. An Incident Witness Statement dated 5/11/26 by Staff A relayed, assisted Resident #2 from recliner to bed, Resident #2 yelling out, groaning loudly in my ear and had responded, the yelling please, you are a bit loud, know you hurt but can we try and hold it in . Staff A relayed did not realize the comment hurt him.During an interview on 6/9/26 at 4:37 PM, the DON relayed expectation Is that residents are expected to be treated with respect and dignity and the report by Staff #2 was concerning.During an interview with Resident #2 on 6/9/26 at 2:30 PM, recalled when Staff A transferred from the chair to bed had yelled out and loud, it hurts. Staff A said noise/quiet caused him to be upset and said it can't be helped, it hurt. The CNA said keep your mouth shut it won't come out. During an Interview with Staff A on 6/10/ 26 at 12:55 PM relayed when transferred Resident #2, caused screaming, he was hurting and responded, was sorry and am almost done, felt no point he was mad or that I said anything wrong. A facility policy titled, Dignity, undated relayed residents to be cared for in a manner that promotes and enhances sense of well-being, level of satisfaction with life and feeling of self-worth and self-esteem, to be treated with dignity and respect at all times.

Based on clinical record review, staff interviews and policy review the facility failed to ensure 1 of 3 (Resident #1) residents reviewed for transfers was repositioned and kept clean and dry. Resident #1 sat for a prolonged time in a wheel chair without repositioning and with urine-soaked clothing. The facility reported a census of 78 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 4/1/26 listed diagnoses for Resident #1 included medically complex conditions, cancer, hip fracture, diabetes, anxiety and depression. The MDS coded urine incontinency, always incontinent of bowel and dependent on transfer to chair bed or toilet. The Brief Interview for Mental Status (BIMS) assessment scored 14 of 15, reflected cognition intact. The Care Plan for Resident #1 initiated 11/17/22 revealed assistance needed for all transfers, assistance of two with a mechanical lift, to use a purple sling. A Progress Note, titled, Incident Note dated 6/8/26 at 3:00 PM for Resident #1 revealed a report was received by Registered Nurse, Staff D at 7:35 AM that Resident #1 was still in her wheel chair, had been there all night, pants were visibly soaked and Resident #1 had slid down, feet were off the wheelchair pedals. Resident #1 relayed, could not recall if was laid down or changed overnight. Resident #1 quired again and relayed, was left in her wheelchair most of the previous day and all night, had not asked anyone to lay her down and could not recall if staff offered to lay her down and had not told staff she did not want to lay down. The Registered Nurse (RN), Staff E responsible for overnight cares relayed had last seen Res #1 in her wheel chair at 8:00 PM on 6/7/26 and did not receive any report that Resident. #1 refused help to bed during the third shift. A Certified Medication Aide (CMA), Staff G relayed had assisted Resident #1 to bed with Certified Nurses Aide (CNA), Staff C on the morning of 6/8/26 and Resident #1 responded, yes had been up in her wheel chair all night. Staff C also relayed saw a dried line on the resident's pants where Residents #1 had wet and was dried. Resident #1 had slid down in the wheel chair and back of pants were very wet, Resident #2 relayed could not recall how long was sitting up. CNA, Staff B, responsible for Resident #2 during the night was interviewed and relayed, saw Resident #1 at 10:30 pm, resident did not want to go to bed, saw resident again in the wheel chair at 1:30 AM and again at 2:20 AM said did let resident know would be back about 3:00 AM as she needed changed, at 3:30 AM assisted resident to bed with Staff H and asked resident if wanted back up to the chair after changing, sat resident back in the wheel chair because she refused offer to stay in bed and went back once more at the end of shift and resident still did not want to go to her bed, instead stayed in the wheelchair. A Licensed Practical Nurse (LPN) Staff I, relayed on 6/7/26, the evening shift saw Resident #1 up was not laid down for the night when most other residents went to bed which was not unusual. CNA, Staff H relayed at 3:30 AM helped Resident #1 into bed changed and asked numerous times if had wanted to be out of the wheelchair and go to bed, refused so changed Resident #1 and put her back in the wheel chair. An incident Witness Statement, dated 6/8/26 at 9:55 AM, CNA, Staff C relayed start of shift in the morning of 6/8/26, received report from Staff B, CNA that Resident #1 refused to lay down last night. Staff C documented that when she saw Resident #1 in her wheel chair she was slouched over, the front of the brief was wet, Staff C laid her down and saw that the brief was soaking the front of the pants. During an Interview on 6/9/26 at 10:40 PM with RN Staff E, confirmed worked the overnight shift 6/8/26 and it was not reported that Resident #1 refused to go to bed or would have intervened, felt resident is easy going and could have persuaded her to lay down. During an interview on 6/9/26 with CNA Staff B at 10:00 PM, relayed first saw Resident #1 at beginning of shift about 10:30 PM in the wheelchair and responded, no one put you to bed and then saw Resident #1 at least four times during the night and resident was good. Staff B relayed. at about 2:20 AM told Resident #1, would be back because, needed to be changed. At 3:30 AM used the lift from wheel chair to bed, changed resident and asked do you want to stay in bed or move back to the wheel chair. Reported Resident #1 wanted to go back to the chair so staff used the lift to get the resident back in the wheel chair. Staff B came back and saw resident one more time at the end of shift about 5:15 AM. Staff B relayed checked on residents about four times a shift and is aware repositioning should be every two hours. During an interview on 6/10/26 at 10:40 AM with CNA, Staff G, relayed on 6/ 8/26 about 8:00 AM saw Resident #1 slid down in the wheel chair, and could tell the resident had been wet and then dried, as there was an outline in the front of resident's pants, the back was very wet that was seen when resident was up in the lift. Resident #2 did not know how long she was left up and was not surprising due to resident progressive of cognitive decline. During an interview on 6/10/26 at 11:00 AM, CNA, Staff C relayed during the start of shift on 6/8/26 at 6:00 AM, Staff B reported to me that Resident #1 refused to get into bed during the night. Staff C relayed, normally we do rounds together and didn't that morning and regretted because did not see Resident until about 7:20 AM and Resident #1 was slouched down in the wheel chair. The front of her was soaked, was alarmed when realized how severe this was, felt terrible and emotional that hadn't seen resident sooner. Resident #1 responded she had been in the chair since dinner the night before and is not her norm to stay up, usually likes to lie down. Staff C stated Resident #1 was slanted over, slouched one foot dangling in the middle of the wheel chair, was soaked from front of pants and brief and even the transfer sling was drenched. During an interview on 6/9/26 at 5:15 PM RN, Staff D relayed when saw Resident #2 on 6/8/26 about 7:00 AM, had received report it was unknow how long resident was up in the wheelchair, resident was visibly soaked, assisted Staff C to lye Resident #1 in bed for head-to-toe assessment. Interview attempted with Resident #2 on 6/10/26 at 11:50 AM was not able to recall specifics of episodes over last few days, did not want to relay any further information. On 6/9/26 at 3:50 PM, The DON relayed, the Staff are expected to do walking rounds at shift change and should report resident refusals to nurse included refusals for positioning and or changing of clothes/incontinent cares. The DON relayed residents should be repositioned every couple of hours and change of briefs if neededThe facility provided policies included, Turning and Reposition, directives included to assist resident as needed into proper alignment. The facility document titled Rights and Responsibilities documented the facility to strive to assure that each resident has a dignified existence, self-determination with communication.

Based on clinical record review, staff interviews, resident interview and policy/competency review, the facility failed to ensure safety precautions for 1 of 3 residents reviewed when used a mechanical lift was used to transferred from chair to bed (Resident #2), Two staff were required to assist the resident transfer when a mechanical lift is used for safety. The facility reported a census of 78 residents.Findings include:The Minimum Data Set, dated [DATE] identified Resident #2 with Brief Interview for Mental Status score of 15 of 15 indicated intact cognition. Diagnosis included stroke affected one side affected. The MDS coded Resident #2 had frequent pain and was dependent for two or more helpers for sit to stand, chair to bed or toilet transfers. The Care Plan focus initiated 6/9/25 for Resident #2 revealed completely dependent for transferring with use of (redacted company name) mechanical lift stand and assist of two staff. A Progress Noted, titled, Incident Report dated 5/11/26 5:30PM relayed grievance report on behalf of Resident #2 related to Certified Nurses Aide (CNA) Staff A who assisted resident #2 to bed, included the description of the pain caused with the transfer and how Staff A responded. The report revealed Resident #2 was put on the stand lift without assistance of a second staff person with transferring the resident#2 to bed.During an Interview with Resident # 2 on 6/9/26 at 2:30 PM relayed has had long term use of the stand lift device, arrived at the facility in 2025 and has had transfer of one person when only aide is available. Recalled when Staff A last used the stand lift alone and experienced a great deal of pain when Staff A moved the injured arm, it hurt bad, yelled out and loud, was upset. Resident#2 reported that he felt staff was not careful and reported the incident. During an interview with DON 6/9/26 4:37 PM The Director of Nurses, (DON) relayed Staff A should not of used the stand lift alone and all staff get checked off on the process when they start employment and periodically throughout, , and was confident all staff are aware of the proper way to use stand lifts. During an interview with Staff A on 6/10/ 26 at 1255 PM relayed was working his usual sixteen-hour shift and at about 7:30 PM Resident #2 wanted to go to bed. The resident was in the recliner and Staff A proceeded to transfer the resident with the stand lift to bed. Staff A relayed he did not have another staff along, was being inpatient, and just did the transfer alone. Staff A relayed, usually if the nurse is not available to help you can get another staff member. The nurse was not available and should have grabbed another person, and did not. The Competency Check off list dated 12/24/25 for Staff A documented lift and transfer training received. Facility policy titled Transfer Techniques directed to review any special precautions or approaches to take when transferring a resident.

Based on record review, staff interview, and facility policy review, the facility failed to provide services that met professional standards regarding following physician's treatment orders (Resident #4) and monitoring for adverse reactions to immunizations (Resident #1, #2, #3, #5, #6, #7, #9, #11, #13, #14) for 11 of 13 residents reviewed. The facility reported a census of 75 residents. Findings include:1. Review of Minimum Data Set (MDS) dated [DATE], revealed Resident #4's Brief interview for Mental Status (BIMS) of 14 indicating cognitively intact. Resident #4's diagnoses included, coronary artery disease, kidney failure, pneumonia, seizure disorder, malnutrition, anxiety, depression, chronic obstructive pulmonary disease (COPD), respiratory failure, and dysphagia (difficulty swallowing) requiring a feeding tube for nutrition. Review of Physicians Orders documented an order for Resident #4, percussion vest (wearable machine designed to break up and clear mucus from the lungs), apply everyday at bedtime, Resident must be sitting up in his recliner while he is wearing the vest. Vest to be worn for 15 minutes then removed for aspiration pneumonia. Do not run while tube feeding is running. Review of Nurses Progress Note dated 2/26/26 at 6:26 PM documented Resident #4's percussion vest was not done today due to a miscommunication between nurses and assignments.2. Review of Residents #1, #2, #3, #5, #6, #7, #9, #13, and #14's Electronic Health Record (EHR) documented receiving a vaccine on 2/13/26 during a facility held vaccine clinic administering physician recommended Shingrix (shingles), Pneumonia, COVID, Tdap (tetanus), and/or Flu vaccines. Review of Residents #1, #2, #3, #5, #6, #7, #9, #13, and #14's EHR failed to provide documented nursing notes indicating which vaccine the resident received, location of administration (left or right upper arm), and monitoring of residents for any adverse reactions. 3. Review of Resident #11's EHR- Immunizations indicated receiving pneumonia and COVID vaccine on 2/13/26. Review of Resident #11's Nursing Progress Notes revealed a new order on 2/17/26 at 5:29 PM, Triamcinolone cream, apply to left upper arm topically three times daily for rash and itching for 3 days. Review of Nurses Progress note dated 2/18/26 at 10:24 identified Resident #11's care plan meeting with Resident #11's daughters and facility staff. Resident #11's daughters had question related to nurses not assessing or documenting Resident #11's reaction to the vaccines. A Nurses Progress note for Resident #11, dated 2/18/26 at 10:25 PM documented continued monitoring of left upper arm rash with new order for Triamcinolone cream. Left upper arm continues with red raised rash. In an interview on 4/15/26 1:00 PM, DON stated the vaccines were provided by a contracted pharmacy. This pharmacy reviewed all resident's records to determine recommended immunizations. The facility physician then reviewed these recommendations and agreed with the pharmacy. Resident's and/or Resident's representative is notified of recommendations and consent or declinations was received. On 2/13/26 the pharmacy came to the facility and administered consented immunizations to designated residents. DON acknowledged the failure to document administered immunizations and monitoring for side effects for the residents that received immunizations. Further interview on 4/15/26 at 3:45 PM, DON stated it is expected for nursing staff to document and monitor for any adverse reactions, at least 72 hours after immunizations are administered.Review of facility provided Immunizations Administration Policy dated 3/2015 revealed the following:1. Document the date, time, and injection site on the Medication Administration Record (MAR) and the Immunization Record. 2. If a resident refuses, document refusal and physician notification in the medical record. 3. Monitor for any adverse reactions for 72 hours after giving the vaccine and obtain vital signs daily for 72 hours. 4. Notify the physician of signs and symptoms of adverse reactions and document in the medical record. 5. Administer medication to ease signs and symptoms of reaction as ordered by the physician.

Based on record review, staff interview, and facility policy the facility staff failed to administer medications correctly related to omission of medications, residents getting the wrong medications, and tube feeding not started timely, for five of five residents reviewed for physicians orders. (Residents #4, 12, 13,14, and 15). The facility reported a census of 75 residents. Findings include: 1. Review of Minimum Data Set (MDS) dated [DATE], revealed Resident #4's Brief interview for Mental Status (BIMS) of 14 indicating cognitively intact. Resident #4's diagnoses included, coronary artery disease, kidney failure, pneumonia, seizure disorder, malnutrition, anxiety, depression, chronic obstructive pulmonary disease (COPD), respiratory failure, and dysphagia (difficulty swallowing) requiring a feeding tube for nutrition. Review of Resident #4's January to March 2026 Medication Administration Records (MAR) failed to indicate the following scheduled medications had not been administered as ordered: 1. 1/14/26 at 5:00 PM, Keppra (seizure medication), water flush, Fluticasone nasal spray, Systane eye drops.2. 1/18/26 at 4:00 PM, Jevity 1.5 (nutrition feeding supplement), water flush, Albuterol nebulizer treatment with pre/post assessments.3. 1/18/26 at 5:00 PM, Fluticasone nasal spray and water flush.4. 2/28/26 at 2:00 PM, Carbidopa-Levodopa (parkinsonism and seizure medication).5. 2/28/26 at 4:00 PM, Jevity 1.5, Albuterol nebulizer treatment with pre/post assessments.6. 2/28/26 at 5:00 PM, Keppra, water flush, Fluticasone nasal spray, Systane eye drops.7. 3/14/26 at 5:00 PM, Keppra, Famotidine, Fluticasone nasal spray, Systane eye drops.8. 3/14/26 at 7:00 PM, Fluconazole. Review of Nursing Incident Note dated 2/26/26 at 5:30 PM, Staff G, Licensed Practical Nurse (LPN) documented, at around 5:00 PM nurse was made aware, Resident #4 had not received his 2:00 PM dose of Carbidop-Levidopa, Jevity feeding had not been started and did not receive his percussion vest treatment. 2. Review of MDS dated [DATE], revealed Resident #12 BIMS of 5, indicating severe cognitive impairment and diagnoses to include cancer, Non-Alzheimer's dementia, COPD, blepharitis of left lower eyelid (chronic inflammation and irritation of eyelid), and senile ectropion of left lower eyelid (outward turning of lower eyelid, causing dry eyes and irritation). Review of Resident #12's Physician Order Summary revealed the following orders:1. Erythromycin Ophthalmic Ointment, instill one application in left eye four times a daily for ectropion of left eye. 2. OcuSoft Lid Scrub Plus External Pad, apply to bilateral eyes topically one time a day for ectropion left eye and dry eyes. 3. Systane Ophthalmic Solution, instill one drop in both eyes two times a day for dry eyes. Review of Nursing Incident Note dated 1/2/26 at 11:10 AM, Staff G, LPN documented, when placing an eye drop in Resident #12's right eye, resident yelled out that it burned. After which this Staff G, LPN looked at the bottle and noted it was ear drops, not eye drops. Immediately flushed resident's eye as much as Resident #12 would allow. 3. Review of MDS dated [DATE], revealed the BIMS assessment was not completed indicating Resident #13's severe cognitive deficits. Resident #13's diagnoses included kidney failure, hypertension, Non-Alzheimer's dementia, and seasonal allergies. Review of Nursing Incident Note dated 12/8/25 at 9:14 AM, Staff G, LPN documented, Resident #13 received another resident's medications by error. Staff G, LPN had prepared medications for a resident and checked the picture on the eMAR, and table seating chart. Staff G then asked a resident if her name was [other resident], in which Resident #13 nodded her head in agreement. Staff G, LPN administered prepared medications for another resident to Resident #13. Review of medications administered to Resident #13 on 12/8/25 in error, included:1. 5 milligrams (mg) Lisinopril (hypertension)2. 50mg Metoprolol ER (hypertension)3. 20 milliequivalents (mEq) Potassium Chloride (low potassium)4. 10mg Buspirone (anxiety)5. 20mg Omeprazole (hearburn)4. Review of MDS dated [DATE] revealed Resident #14 BIMS of 15, indicating cognitively intact. Resident #14's diagnoses included A-fib, heart failure, arthritis, chronic pain, Non-Alzheimer's dementia, anxiety, and depression.Review of December 2025 MAR indicated Resident #14's pain medications, 50 mg Tramadol to be administered twice daily at 8:00 AM and 5:00 PM, extra strength Tylenol 500mg two tablets three times a day at 8:00 AM, 12:00 PM, 8:00 PM, and 200mg Ibuprofen three tablets every eight hours as needed for pain. Review of Nursing Incident Note dated 12/8/26 at 4:11 PM, Staff G, LPN documented failure to administer Resident #14's 8:00 AM Tramadol pain medication, realizing error at 2:25 PM. Staff G, LPN administered as needed ibuprofen to Resident #14 due to second Tramadol dose administration time at 5:00 PM and Resident #14 rating pain 8/10. In an interview on 4/8/26 at 3:15 PM, Staff G, LPN stated she had medication errors, including giving a resident's medications to the wrong person. During an interview on 4/15/26 at 3:30 PM, DON stated she expected nurses and medication aides to use the five rights before administering medications, right patient, right drug, right dose, right route, and right time. Review of facility provided Medication Administration Policy dated 1/2013 stated the following:1. Verify physician's orders for medication to be administered.2. Review any special precautions and perform needed evaluations prior to administering medication to the resident.3. Identify residents.4. Explain the procedure to the resident, including the type of medications ordered, the reason, frequency, and route. 5. Verify the following again, by comparing medication to MAR prior to administering:a. Correct residentb. Correct medicationc. expiration dated. Dose and dosage forme. Routef. time

Based on clinical record review, interviews, and policy review the facility failed to report a resident to resident altercations involving (R#1) and failed to report allegation of abuse involving (R#5) to the State Agency. The facility reported a census of 75 residents. Findings include:1. The Quarterly Minimum Data Set(MDS) assessment for Resident #1 dated 3/25/26 listed diagnoses included dementia. The Brief Interview for Mental Status (BIMS) assessment scored 3 of 15, indicating severe cognitive deficits. The MDS assessment for Resident #3 dated 3/18/26 listed diagnoses included Alzheimer's disease, anxiety disorder and depression. The BIMS assessment scored 00 of 15 indicating severe cognitive deficits. The MDS assessment for Resident #5 dated 1/7/26 listed diagnosis included cancer, non-Alzheimer's, unspecified dementia with other behavioral disturbances. The BIMS assessment was not completed indicating severe cognitive deficits. A Statement, handwritten dated 1/7/26 signed by Certified Nurse's Aide, (CNA) Staff A documented Resident #5 smacked Resident #3 on the left arm. After the altercation Staff A walked with Resident #5 throughout the unit, Resident #5, then smacked Resident #1 on the arm. Resident #1 raised his arm going towards Resident #5 who was then redirected by Staff A and by CNA, Staff B. In a Written Statement dated 1/7/26, Staff C, Social Services, documented her observations from across the room. Approximately five minutes after Resident #5 slapped Resident #3, Staff C observed Resident #5 tap Resident #1 on his upper body. Staff A and Staff B separated Resident #1 and Resident #5 and made sure Resident #1 wasn't too upset over the altercation. On 4/6/26 at 3:45 PM Staff C, Social Services, stated on 1/7/26 she saw Resident #5 slap Resident #3, then Resident #5 slapped Resident #1. The Director of Nurses (DON) directed Staff C to handle reporting. Staff C used the words slap and tap to describe the contact made by Resident #5, but these contacts were not different, both were with an open hand. On 4/8/26 at 11:45 AM Staff A, CNA relayed witnessing Resident #5 slap Resident #3, then reached over and smacked Resident #1. Both residents were separated. Resident #1 became upset and required redirection about five minutes after being smacked by Resident #5. Staff A reported this to the agency nurse on duty who summoned the Nurse Manager, Staff C. Staff A reported that Staff C gave instructions to write down the altercation between Resident #5 and Resident #3, and not to write about the altercation between Resident #5 and Resident #1, because it didn't happen. Staff A relayed it did happen and Staff B, CNA also saw it happen. On 4/8/26 at 12:25 PM Staff B, CNA reported writing a statement on 1/7/26. Staff B stated he had not written about the altercation between Resident #3 and Resident #5, because he didn't witness it. Staff B relayed, he did witness Staff #5 hit Resident #1 and did not document it because Staff D, RN said they were not going forward with reporting that altercation. Staff B stated he was directed not to write a statement involving Resident #5 and #1's altercation and did not. An interview on 4/8/26 at 2:30 PM Staff D, RN, revealed she was directed to the memory care unit by the DON on 1/7/26 at about 4:30 PM to address the altercations, including direction to submit the report to the state agency. Staff D was told by the DON, it is not necessary to address Resident #5 hitting Resident #1 because the video camera didn't show it happened. Staff D relayed she was instructed to submit to the state agency, and did not include the altercation with Resident #5 as was directed. On 4/8/26 at 3:50 PM the DON informed, the state reporting was completed by Staff D on 1/7/26 with DON guidance. The DON was able to recall an altercation between Resident #3 and Resident #5 but did not recall any altercation between Resident #5 and Resident #1. The DON acknowledge the written statements included Resident #5 and Resident #1's altercation and did not recall looking at the camera footage or reporting it had been automatically deleted. A review of the facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022, documented resident-to-resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm pain or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and or physical impairments which may result in resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. An example would be a resident slapping another resident who is physically or cognitively impaired even though the resident who was slapped showed no reaction, it is presumed the resident experience pain. Residents must not be subjected to abuse by anyone. All allegations of resident abuse, neglect, exploitation, mistreatment, should be reported immediately to the charge nurse, the charge nurse is responsible for immediately reporting the allegations to the Administrator or designated representative. Resident abuse allegations shall be reported to the State Agency. 2. The Care Plan dated 3/30/26 documented Resident #5's need for assistance of one with dressing and personal hygiene, allowing sufficient time for dressing and undressing due to Resident #5's dementia with behavioral disturbances and confusion. Due to Resident #5's communication problems and anxiety, the Care Plan documented for staff to allow adequate time for Resident #5 to respond and do not rush. During an interview on 4/7/26 at 10:17 AM Staff D, RN revealed on 1/17/26 she was made aware of an incident by the DON. Staff E, CNA had notified the DON she had observed Staff F, CNA, slap Resident #5. The DON informed Staff D, RN that Staff F, CNA would be suspended until the completion of the facility's investigation and Staff F, CNA had denied the incident had occurred. Staff D, RN also reported Staff E, CNA (reported the incident) had to retake her Mandatory Reporter/Dependent Adult Abuse training and was told by the DON she was being dramatic and didn't know what dependent abuse was. A few weeks after the incident Staff D, RN was informed the incident had not been reported to the Iowa Department of Inspections Appeals and Licensing. When Staff D, RN asked the DON about reporting to the state, the DON informed her she didn't feel it needed to be reported. An interview on 4/8/26 at 9:36 AM, Staff E, CNA stated Resident #5 is normally calm and wouldn't intentionally hurt anyone but does get scared with cares and brief changes. On 1/16/26 Staff E, CNA and Staff F, CNA were providing care for Resident #5, Resident #5 was scared while Staff F, CNA was being rough with her, telling her what to do, and rushing her. Resident #5 was swinging her arms in an attempt to push away Staff F, CNA and hit her on the back. Staff F, CNA then hit Resident #5 on the right thigh. Staff E, CNA told Staff F, CNA you can't do that, and Staff F, CNA responded it worked didn't it? Staff E, CNA then told Staff F, CNA to leave the room while Staff E, CNA finished Resident #5's cares. After exiting Resident #5's room Staff E, CNA asked that an activities staff stay on the memory care unit, Staff E, CNA then reported the incident to the DON and facility Administrator. Staff E, CNA reported she was yelled at by the DON and facility Administrator being told she was making the facility look bad, overreacting, causing problems, and sometimes we have to overlook things. Staff E, CNA was then sent to the staff breakroom and told by the DON and Administrator to stay there until they had heard back from the state. About thirty minutes later Staff E, CNA was informed by the DON, the State recommended to use this as a learning experience and both Staff E, CNA and Staff F, CNA would retake their Dependent Adult Abuse course online and Staff E, CNA was at fault as well for leaving the unit with Staff F, CNA. Threats of Staff E, CNA losing her certification and even prison time was possible due to her leaving the memory unit while Staff F, CNA would have access to Resident #5 by the DON. On 4/8/26 at 10:04 AM and 10:24 AM, requests for the facility's investigation for the abuse allegations against Resident #5 were requested by State Surveyor. Facility Administrator and DON were not able to recall this incident. During an interview on 4/8/26 at 10:38 AM, DON stated she was not aware of the abuse incident in January for Resident #5. After the DON was informed of the incident by State Surveyor, the DON stated she remembered the incident being referred to. DON stated she was in a meeting, another nurse pulled her out and informed her Staff E, CNA was upset. Staff E, CNA reported to DON that Resident #5 had hit Staff F, CNA and Staff F, CNA hit Resident #5 on the leg. DON recalled, she went to the memory unit and Resident #5 was calm sitting on a chair, instructed Staff F, CNA to leave the unit, then completed a full head to toe assessment of Resident #5 with no findings. The DON continued, after the assessment Staff E, CNA and the Administrator discussed the incident. Staff E, CNA informed them that Staff F, CNA was crouched down in front of Resident #5 as she was sitting, Resident #5 was swinging her arms in attempt to stop Staff F, CNA's assistance hitting Staff F, CNA on the back. Staff F, CNA then smacked Resident #5 on the leg. DON explained during this time, she sat on a chair and asked Staff E, CNA to reenact the incident, Staff E, CNA crouched down in front of DON (as Staff F, CNA had been with Resident #5) and patted DON's right thigh. DON instructed Staff E, CNA to show me how it happened, was there more force? DON was told by Staff E, CNA the slap was more of a pat. DON asked Staff E, CNA, when Staff F, CNA was patting on Resident #5's leg, was this to get her attention? Staff E, CNA then agreed, Staff F, CNA was trying to get Resident #5's attention. DON continued to explain, Staff F, CNA was interviewed about the incident and provided the same scenario as Staff E, CNA. DON acknowledged she did tell Staff E, CNA to use this incident as a learning experience and instructed both CNAs to retake their Dependent Adult Abuse training. The DON acknowledged this incident had not been reported to the state as she didn't feel it was abuse and was not aware of the reporting regulations. During an interview on 4/8/26 at 2:29 PM, Staff F, CNA stated on 1/17/26 she was provided cares for Resident #5, she had been combative, She had hit me like 800 fucking times on the back and the head. Staff F, CNA patted Resident #5's leg and said He Resident #5, can we get you dressed? in an attempt to distract her, which worked. Staff E, CNA then yelled at Staff F, CNA you just hit her, you abuse her, you can't do that! After Staff F, CNA was instructed to leave the unit while the DON assessed the situation. A short time later, Staff F, CNA, Staff E, CNA, DON and facility Administrator met to talk about the incident when Staff E, CNA told the DON and facility Administrator, I don't think it was abuse, she just patted her leg. Staff F, CNA was assigned to a different hall for the remainder of her shift and had to retake the Dependent Adult Abuse training. Review of Resident #5's Electronic Health Records (EHR) failed to provide documentation of the incident, head to toe assessment, continued monitoring of Resident #5, or notification to Physician and Resident #5's family. Review of facility provided self reports submitted to Iowa Department of Inspections Appeals and Licensing, failed to indicate incident had been reported. Review of facility provided Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 stated, Assault of a dependent adult means the commission of any act which is generally intended to cause pain or injury to a dependent adult, or which is generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act which is intended to place another in fear of immediate physical contact which will be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act. The risk for abuse may increase when a resident exhibits a behavior(s) that may provoke a reaction by staff, residents, or others, such as:a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating;b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects;c. resistive to care and services. 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 allegations of abuse to the Administrator, or designated representative. All allegations of Resident abuse shall be reported to Iowa Department of Inspections and Appeals no later than two (2) hours after the allegation is made.

Based on clinical record review, staff interviews and policy review, the facility failed to provide a thorough investigation into allegations of abuse for 1 of 1 residents (Resident #5) reviewed. The facility reported a census of 75 residents.Findings include:Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 indicated a Brief Interview for Mental Status (BIMS) was not completed, indicating severe cognitive deficiency. Listed diagnoses include, cancer, non-Alzheimer's dementia, and dementia with other behavioral disturbances. Review of Care Plan dated 3/30/26 documented Resident #5's need for assistance of one with dressing and personal hygiene, allowing sufficient time for dressing and undressing due to Resident #5's dementia with behavioral disturbances and confusion. Due to Resident #5's communication problems and anxiety, the Care Plan documented for staff to allow adequate time for Resident #5 to respond and do not rush. During an interview on 4/7/26 at 10:17 AM Staff D, RN revealed on 1/17/26 she was made aware of an incident by the DON. Staff E, CNA had notified the DON she had observed Staff F, CNA, slap Resident #5. The DON informed Staff D, RN that Staff F, CNA would be suspended until the completion of the facility's investigation and Staff F, CNA had denied the incident had occurred. Staff D, RN also reported Staff E, CNA (reported the incident) had to retake her Mandatory Reportor/Dependent Adult Abuse training and was told by the DON she was being dramatic and didn't know what dependent abuse was. A few weeks after the incident Staff D, RN was informed the incident had not been reported to the Iowa Department of Inspections Appeals and Licensing. When Staff D, RN asked the DON about reporting to the state, the DON informed her she didn't feel it needed to be reported. An interview on 4/8/26 at 9:36 AM, Staff E, CNA stated Resident #5 is normally calm and wouldn't intentionally hurt anyone but does get scared with cares and brief changes. On 1/17/26 Staff E, CNA and Staff F, CNA provided care for Resident #5, Resident #5 was scared while Staff F, CNA was rough with her, telling her what to do, and rushing her. Resident #5 swung her arms in an attempt to push away Staff F, CNA and hit her on the back. Staff F, CNA then hit Resident #5 on the right thigh. Staff E, CNA told Staff F, CNA you can't do that, and Staff F, CNA responded it worked didn't it? Staff E, CNA then told Staff F, CNA to leave the room while Staff E, CNA finished Resident #5's cares. After exiting Resident #5's room Staff E, CNA asked that an activities staff stay on the memory care unit, Staff E, CNA then reported the incident to the DON and facility Administrator. Staff E, CNA reported she was yelled at by the DON and facility Administrator being told she was making the facility look bad, overreacting, causing problems, and sometimes we have to overlook things. Staff E, CNA was then sent to the staff breakroom and told by the DON and Administrator to stay there until they had heard back from the state. About thirty minutes later Staff E, CNA was informed by the DON, the State recommended to use this as a learning experience and both Staff E, CNA and Staff F, CNA would retake their Dependent Adult Abuse course online and Staff E, CNA was at fault as well for leaving the unit with Staff F, CNA. Threats of Staff E, CNA losing her certification and even prison time was possible due to her leaving the memory unit while Staff F, CNA would have access to Resident #5 by the DON. On 4/8/26 at 10:04 AM and 10:24 AM, requests for the facility's investigation for the abuse allegations against Resident #5 were requested by State Surveyor. Facility Administrator and DON were not able to recall this incident. During an interview on 4/8/26 at 10:38 AM, DON stated she was not aware of the abuse incident in January for Resident #5. After the DON was informed of the incident by State Surveyor, the DON stated she remembered the incident being referred to. The DON stated she was in a meeting, another nurse pulled her out and informed her Staff E, CNA was upset. Staff E, CNA reported to DON that Resident #5 had hit Staff F, CNA and Staff F, CNA hit Resident #5 on the leg. DON recalled, she went to the memory unit and Resident #5 was calm sitting on a chair, instructed Staff F, CNA to leave the unit, then completed a full head to toe assessment of Resident #5 with no findings. The DON continued, after the assessment Staff E, CNA and the Administrator me to discuss the incident. Staff E, CNA informed them that Staff F, CNA was crouched down in front of Resident #5 as she was sitting, Resident #5 was swinging her arms in attempt to stop Staff F, CNA assistance hitting Staff F, CNA on the back. Staff F, CNA then smacked Resident #5 on the leg. DON explained during this time, she sat on a chair and asked Staff E, CNA to reenact the incident, Staff E, CNA crouched down in front of DON (as Staff F, CNA had been with Resident #5) and patted DON's right thigh. DON instructed Staff E, CNA to show me how it happened, was there more force? DON was told by Staff E, CNA the slap was more of a pat. DON asked Staff E, CNA, when Staff F, CNA was patting on Resident #5's leg, was this to get her attention? Staff E, CNA then agreed, Staff F, CNA was trying to get Resident #5's attention. DON continued to explain, Staff F, CNA was interviewed about the incident and provided the same scenario as Staff E, CNA. DON acknowledged she did tell Staff E, CNA to use this incident as a learning experience and instructed both CNAs to retake their Dependent Adult Abuse training. DON acknowledged this incident had not been reported to the state as she didn't feel it was abuse and was not aware of the reporting regulations. During an interview on 4/8/26 at 2:29 PM, Staff F, CNA stated on 1/17/26 she was provided cares for Resident #5. The Resident had been combative, She had hit me like 800 fucking times on the back and the head. Staff F, CNA patted Resident #5's leg and said He Resident #5, can we get you dressed? in an attempt to distract her, which worked. Staff E, CNA then yelled at Staff F, CNA you just hit her, you abuse her, you can't do that! After Staff F, CNA was instructed to leave the unit while the DON assessed the situation. A short time later, Staff F, CNA, Staff E, CNA, the DON, and the facility Administrator met to talk about the incident when Staff E, CNA told the DON and facility Administrator, I don't think it was abuse, she just patted her leg. Staff F, CNA was assigned to a different hall for the remainder of her shift and had to retake the Dependent Adult Abuse training. Further interview on 4/9/26 at 2:35 PM, DON confirmed no written/documented investigation had been completed and was not able to provide written witness statements, incident reports, or documented nursing assessments for Resident #5. Review of Resident #5's Electronic Health Records (EHR) failed to provide documentation of the incident, head to toe assessment, continued monitoring of Resident #5, or notification to Physician and Resident #5's family. Review of facility provided Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 stated, should an incident or suspected incident of Resident abuse be reported or observed the Administrator or his/her designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. 1. Review documentation in Resident record (including review of assessment of resident injury)2. Asses the resident for injury if the allegation involves physical or sexual abuse;3. Provide proper notifications to primary care provider, responsible party, etc. 4. Attempt to obtain witness statements (oral and/or written) from all known witnesses.5. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with.

Based on Electronic Record Review (EHR), staff interviews and facility policy review, the facility failed to assess, intervene, and monitor interventions per the facility's Bowel Regulatory Program for four of four residents (Resident #1, #2, #3, and #4) reviewed for increased risk of constipation. The facility reported a census of 82 residents. Findings include Review of facility provided Bowel Regulatory Program Policy stated the following:1. Constipation- individuals are considered constipated if bowel movement (BM) frequency is less than three times per week and/or if straining is experienced with more than 25% of bowel movements.2. A daily Bowel Movement Record must be kept for all dependent residents in order to track regularity and assess need for interventions. All CNAs should document whether or not the residents they provided care for had a BM during their shift by indicating the size (e.g. 0, sm, med, lg.) on the record in the space for the appropriate day. 3. It is the charge nurse's responsibility to look at the BM record each shift and initiate interventions as appropriate. 4. If a resident has not had a significant BM for 3 days, laxative treatment is necessary, per physician order. A stepwise progression of laxative treatment is recommended, Constipation is resolved, management should be moved back to the top of the laxative pyramid. following steps are recommended: a. exercise, fluid and fiberb. Stool softeners (e.g. Milk of Magnesium) once dailyc. Suppository, instill rectally as needed 5. The resident's physician should be notified of any new patterns of constipation in which a previously regular resident has a BM less than three times per week and/or is straining with more than 25% of BMS or a resident with chronic constipation is uncontrolled to the extent of fecal impaction removal. Review of facility provided, Night Shift BM Monitor document, stated Please record all residents who have not had a BM in 2 days. (small don't count unless it is 3 [NAME] a day) and day shift will give MOM (Milk of Magnesia). If resident has not had a BM in 3 days ([NAME] don't count unless it is 3 [NAME] a day), resident will get a suppository. 1. Review of Minimum Data Set (MDS) dated [DATE], revealed Resident #1's Brief Interview for Mental Status score of 4, indicating severely impaired cognition. Resident #1's diagnoses included breast cancer, hypertension, hyperlipidemia, and Non-Alzheimer's Dementia. The MDS documented that the resident required staff assistance with toileting hygiene, and was frequently (2 or more episodes of bowel incontinence, but at least one continent bowel movement) incontinent of bowel and bladder.Review of Bowel Elimination report dated 10/1/25-10/30/25 indicated Resident #1 had ten consecutive days (10/16/25-10/25/25) of no documented BM or 3 small BM in one day. Indicating criteria had been met for regulatory tracking and assessment of need for interventions for Resident #1.Review of Night Shift BM (Bowel Movement) Monitor documents for October 2025, documented Resident #1 on the following days, date of last BM, and interventions provided:10/11/25- last BM 10/7/25, no intervention or nurse signature documented10/12/25- documented no residents to be monitored for not having BM in 2 days. 10/14/25- last BM 10/12/25, BM documented by Resident #1's name. No interventions or nurse signature documented. 10/17/25- last BM 10/14/25, nurse noted, had large BM 10/16/25.10/18/25- last BM 10/14/25, noted large on 10/19, no nurse's signature documented.10/19/25- last BM 10/14/25, no intervention or nurse signature documented.10/21/25- last BM 10/15/25, noted had BM yesterday10/25/25- last BM 10/20/25, suppository administered, effective with large BM.Review of Resident #1's October 2025 Medication Administration Record (MAR) indicated the following medications and administration:a. Milk of Magnesia Suspension 1200mg/15mL. Give 30mL by mouth once daily as needed for constipation, to promote bowel movement. No administration documented. b. Bisacodyl Laxative Suppository 10mg, insert 1 suppository rectally as needed for constipation. Administered on 10/26/25 at 4:46 AM with unknown effectiveness documented. 2. Review of MDS dated [DATE], revealed Resident #2's Brief Interview for Mental Status score of 3, indicating severely impaired cognition. Resident #2's diagnoses included hypertension, Non-Alzheimer's Dementia and history of stroke. The MDS documented that the resident required staff assistance with toileting hygiene, and was occasionally incontinent of bowel.Review of Bowel Elimination report dated 10/1/25-10/30/25 indicated Resident #2 had four consecutive days (10/19/25-10/22/25) of no documented BM or 3 small BM in one day. Indicating criteria had been met for regulatory tracking and assessment of need for interventions for Resident #2 for the following days:Review of Night Shift BM Monitor documents for October 2025, documented Resident #2 on the following days, date of last BM, and interventions provided:10/20/25- last BM 10/18/25, nurse signed and noted MOM administered as intervention.10/23/25- last BM 10/18/25, no intervention or nurse signature documented.Review of Resident #2's October 2025 MAR indicated the following medications and administration:1. Milk of Magnesia Suspension 1200mg/15mL. Give 30mL by mouth once daily as needed for constipation, to promote bowel movement. Administered 10/26/25 at 8:02 AM, effective with large BM. 2. Bisacodyl Laxative Suppository 10mg, insert 1 suppository rectally as needed for constipation. No administration documented. Review of Resident #2's Nursing Progress notes, indicated the following:1. Staff A, Licensed Practical Nurse (LPN) documented on 10/26/25 at 2:51 PM, Staff reported to this nurse that resident vomited two times the shift. upon assessment, resident afebrile, denies any nausea. 10/29/25 at 7:39 AM, progress note stricken out by Staff A, LPN, due to incomplete documentation.2. Staff A, LPN documented on 10/26/25 at 5:25 PM, Resident noted to have multiple emesis throughout the shift which were water like, with one emesis showing food. Resident did have MOM today for constipation, and produced positive results. abdomen non-distended, slightly firm, bowel sounds present x4. Notification left for physician. lemon lime soda and crackers offered, will continue to monitor. 10/29/25 at 7:40 AM, progress note stricken out by Staff A, LPN, due to incomplete documentation.3. Staff B, LPN documented on 10/26/25 at 5:30 PM, This nurse was called into the unit to assess resident, CNAs reported that Resident was throwing up all morning and had been having bowel issues. Resident was given MOM and had good results, but then started to get sick. vitals stable. Phone call placed to provider, received telephone order for Zofran 4 mg every 4 hours. medication was given to resident, resident did vomit up medication several more times. Phone call place to provider again, telephone order received to send resident out to the hospital. phone call was placed to Resident's wife and call to nurse manager on duty. Resident left via ambulance around 6:30 p.m. 4. Staff A, LPN created a Late Entry Nursing Progress Note on 10/29/25 at 7:45 AM, with effective date of 10/26/25 at 8:10 AM, Stated, CNA reported to this nurse that Resident appeared to have stool that he was unable to pass. Upon assessment, abdomen non-distended and slightly firm. Upon palpation, resident does not complain of pain or discomfort. skin warm and dry and normal in color. MOM administered at 8:02 AM will continue to monitor.5. Staff A, LPN created a Late Entry Nursing progress note on 10/29/25 at 8:01 AM, with effective date 10/26/25 at 9:10 AM, at approximately 9:00, this nurse called back unit due to resident produced an emesis. Resident observed sitting upright and common area upon arrival. resident awake and alert with no signs or symptoms of distress noted and emesis appeared to be color and consistency of undigested food of this morning meal. Skin warm and dry and normal color. Abdomen non-distended and continues to be slightly firm, respirations un-labored at 16. Upon assisting resident and CNA to Resident's room for cares, Resident was noted to have a large brown and firm BM possibly as a result of the MOM. resident shows no signs or symptoms of pain or discomfort at this time. This nurse notified staff that she would continue to monitor resident. 6. Staff A, LPN created a Late Entry Nursing progress note on 10/29/25 at 8:12 AM, with effective date 10/26/25 at 1:00 PM, Nurse was notified that Resident produced another emesis. Upon arrival to resident, he was observed sitting upright in his room and holding an emesis basin. amount appears to be less than a cup, liquid and yellow and color with no odor. resident awake and alert, with no signs or symptoms of distress. respirations un-labored at 16. abdomen non-distended and continues to be slightly firm with no signs and symptoms of pain or discomfort upon palpitation. 7. Staff A, LPN created a Late Entry Nursing progress note on 10/29/25 at 8:20 AM, with effective date 10/26/25 at 5:30 PM, Nurse was informed that Resident had an emesis. Upon arrival to Resident's room this nurse observed the resident using restroom. Resident awake and alert and shows no signs of distress, pain or discomfort. Emesis light yellow in color, liquid, no odor and about less than a cup. Abdomen non-distended and soft, upon palpitation no signs or symptoms of pain or discomfort. This nurse encouraged staff to offer saltine crackers and clear liquids. vital signs: temp 97.7, pulse 78, respirations 16, blood pressure 145/80. On interview on 10/29/25 at 4:50 PM, Staff C, Director of Nursing (DON) and Staff D, Registered Nurse revealed Resident #2 had been admitted to the hospital for a bowel obstruction. Review of Emergency Department Progress notes dated 10/26/25, Resident #2's diagnosis includes; massive hiatal hernia with associated large bowel obstruction.3. Review of MDS dated [DATE], revealed Resident #3's Brief Interview for Mental Status score of 4, indicating severely impaired cognition. Resident #3's diagnoses included depression and Alzheimer's disease. The MDS documented that the resident required staff assistance with toileting hygiene, and was always continent of bowel.Review of Bowel Elimination report dated 10/1/25-10/30/25 indicated Resident #3 had six consecutive days (10/25/25-10/30/25) of no documented BM or 3 small BM in one day. Indicating criteria had been met for regulatory tracking and assessment of need for interventions for Resident #3.During an interview on 10/30/25 at 11:48 AM, Staff C, DON, stated the provided Night Shift BM Monitor documents for Resident #3 are the only ones she can locate.Review of facility provided Night Shift BM Monitor documents for Resident #3, both dated 10/28/25. One document identified Resident #3's last BM 10/24/25, nurse signed and noted suppository administered as intervention. Second document identified Resident #3's last BM 10/24/25, nurse noted no intervention, medium BM on 10/28/25Review of Resident #3's October 2025 MAR indicated the following medications and administration:a. Milk of Magnesia Suspension 1200mg/15mL. Give 30mL by mouth once daily as needed for constipation, to promote bowel movement. Administered 10/27/25 at 8:00 AM, ineffective results. b. Bisacodyl Laxative Suppository 10mg, insert 1 suppository rectally as needed for constipation. No administration documented. 4. Review of MDS dated [DATE]/25, revealed Resident #4's Brief Interview for Mental Status score of 00, indicating severely impaired cognition. Resident #4's diagnoses included Alzheimer's disease, non-Alzheimer's dementia, seizure disorder, anxiety disorder, depression, psychotic disorder, and hypothyroidism. The MDS documented that the resident required assistance with toileting hygiene.Review of Bowel Elimination report dated 10/1/25-10/30/25 indicated Resident #4 had 5 consecutive days (10/7/25-10/11/25), four consecutive days (10/15/25-10/18/25), four consecutive days (10/22/5-10/28/25) of no documented BM or 3 small BM in one day. Indicating criteria had been met for regulatory tracking and assessment of need for interventions for Resident #4.During an interview on 10/30/25 at 11:48 AM, Staff C, DON, stated the provided Night Shift BM Monitor documents for Resident #4 are the only ones she can locate.Review of Night Shift BM Monitor documents for October 2025, documented Resident #4 on the following days, date of last BM, and interventions provided:10/11/25- last BM 10/6/25, nurse signed and noted MOM administered as intervention.10/12/25- last BM 10/6/25, nurse noted suppository administered as intervention. 10/17/25- last BM 10/15/25, nurse signed and noted MOM administered as intervention.10/18/25- last BM 10/14/25, nurse noted MOM administered with effective results. Review of Resident #4's October 2025 MAR indicated the following medications and administration:a. Milk of Magnesia Suspension 1200mg/15mL. Give 30mL by mouth once daily as needed for constipation, to promote bowel movement. Administered 10/11/25 at 8:06 AM, unknown effectiveness documented. 10/17/25 at 8:40 AM, effective results. b. Bisacodyl Laxative Suppository 10mg, insert 1 suppository rectally as needed for constipation. No administration documented. In an interview with Staff C, DON on 10/30/25 at 3:55 PM, Staff C, DON acknowledged the Night Shift BM Monitoring is not being done daily and lack of nursing documentation. Staff C, DON stated she would expect nurses to document a nursing note for every resident that is placed on BM Monitoring and complete a GI assessment. These residents will remain on the Hot Charting until the resident has had results or the Physician is notified for further instructions. Staff C, DON stated the facility BM protocol is two days with no BM, MOM is to be given. Three days with no BM a suppository is to be administered. If a resident does not have results from these interventions the Physician must be contacted for direction. Staff C, DON also stated she expected nurses to complete a full head to toe assessment on all residents with changes in symptoms, illnesses to include vomiting. If the resident vomits two times the Physician is to be called immediately to notify and receive further recommendations.

Based on clinical record review, policy review, and staff interview, the facility failed to carry out cardiopulmonary resuscitation(CPR) in accordance with the resident's wishes, and follow the physician's orders for 1 of 1 residents reviewed for cardiopulmonary resuscitation status(Resident #1). The facility failed to correctly identify that Resident #1 desired CPR related to discrepancies in code status listed in multiple locations and a staff member incorrectly reading the resident's chart. Approximately 7 minutes after Resident #1 was last seen alive, the Advanced Registered Nursing Practitioner(ARNP) issued an order to withhold CPR due to the facility staff's delays. The facility staff also lacked knowledge of how to locate the facility's crash cart. This failure resulted in Immediate Jeopardy(IJ) to the health, safety, and security of the resident. The facility reported a census of 76 residents.The State Agency informed the facility of the IJ on [DATE] at 3:35 p.m.The IJ began on [DATE], the day Resident #1 expired. Facility staff removed the Immediate Jeopardy on [DATE] through the following actions:Reeducation of staff regarding the location of resident code statuses and emergency equipment.Placement of a code status book at each nursing station.An audit of resident code statuses.The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure.Findings included:The Minimum Data Set(MDS) assessment tool, dated [DATE], listed diagnoses for Resident #1 which included heart failure, hemiplegia(one-sided paralysis), and anxiety disorder. The MDSlisted his Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. Care Plan entries, dated [DATE], directed staff to carry out advance directives per the request of the resident and the family and stated the resident wished to have Staff carry out CPR. The CPR Policy, dated [DATE], stated the resident wished for CPR to be initiated if his heart stopped beating and stated the facility employees would provide basic life support until paramedics arrived. The Physician Order type labeled as advanced directives dated [DATE] directed staff to provide CPR.The [DATE] Medication Administration Record(MAR) listed CPR for the resident's advance directives. The heading on the resident's Electronic Health Record(EHR) listed CPR for the resident's advance directives. A [DATE] Nurses Note stated on [DATE] at approximately 7:45 a.m., Staff A Certified Nursing Assistant(CNA) entered the resident's room followed by Staff C Registered Nurse(RN) and the resident was slumped in his recliner. It appeared the resident was in distress when Staff A and Staff C repositioned him. The resident had an incontinent bowel movement and was diaphoretic(sweating profusely) and unresponsive. Staff C exited the room to obtain assessment tools, summoned the Director of Nursing(DON) to the room, and directed Staff B Licensed Practical Nurse(LPN) to call an ambulance and verify the resident's code status. When the DON arrived, she noted that the resident appeared ashen and diaphoretic and had agonal respirations(abnormal, involuntary gasping for air that indicated a serious medical emergency). The DON checked for a carotid pulse(pulse felt over arteries in the neck) and did not locate one. (Facility Staff) transferred the resident to the floor and the DON opened the resident's airway. Staff C left the room to confirm the resident's code status. Two way radio communication indicated the resident was a No Code per Staff B. Staff were directed to clean and clothe the resident for family viewing. The DON called Staff F ARNP to report the death and Staff F confirmed with the nursing staff(based on Staff B's report) that the resident was a No Code and advised release of the body to the funeral home. During this time, Staff C notified the resident's spouse. While she reviewed the chart, Staff C noted that the resident was listed as a Full Code. She then reviewed the paper chart and confirmed the code status as a Full Code. The DON contacted Staff F to report the discrepancy. Based on assessment findings which included an undetermined time of unresponsiveness, ashen color, mottling(,a pattern of irregular, blotchy discoloration of the skin) and absence of pulse, staff did not initiate resuscitative efforts. On [DATE] at 9:53 a.m., Staff F stated she received a call from the DON (on [DATE]) at 7:51 a.m. The DON reported that Resident #1 was deceased as of 7:49 a.m. Staff F inquired as to the resident's code status and the DON reported he was a Do Not Resuscitate (DNR) and Staff F gave an order to release the body. The DON then called Staff F back at 7:57 a.m. and said that she(the DON) was upset and they were incorrect, the resident was a Full Code. Staff F stated at that time, the resident had been gone for almost 10 minutes so she did not advise them to start CPR from that point. Staff F stated she did not expect to receive a phone call that the resident expired and stated he was not healthy but there was nothing leading up to his death. Staff F stated if a resident was unresponsive, the first thing staff should do was call 911. She stated with regard to Resident #1, staff should have initiated CPR. On [DATE] at 10:35 a.m., via phone, Staff E CNA stated (on the day of the incident) she worked down another hall but saw Staff G Certified Medication Assistant(CMA) running down the hall toward the resident's room. Shortly after that, she saw Staff B run down the hall and asked her how she could help. Staff E stated Staff G and Staff B looked for the crash cart but could not locate it. Staff E stated she located it and that all new employees received education regarding the location of the crash cart and it was marked with an automated external defibrillator(AED) sign. Staff B then told Staff E the situation was under control so Staff E continued her daily tasks. Later, after the resident was deceased , she assisted with post-mortem cares. She stated there was some confusion related to the resident's code status. She stated if a resident was a Full Code, there was a green sticker on the outside of the door. She stated there was a green sticker but it was located on the resident's roommate's side so they presumed the resident was a DNR. Staff E stated each resident had a binder which contained their code status and it was easy to locate. On [DATE] at 10:31 a.m., via phone, Staff D CNA stated she entered the room to assist Staff A and Staff C in lifting Resident #1. She stated he was warm to the touch and was profusely sweating. They tried to stand him up and he stated he needed to sit. Staff C left the room to retrieve her vitals equipment and all of the sudden the resident's eyes rolled back in his head like he had a seizure. When Staff C returned, he was still shaking. The DON arrived and said they needed to call an ambulance, obtain the code status, and get the crash cart. They lowered the resident to the floor and she believed Staff B told Staff C that the resident was a DNR. Staff D stated the stickers outside the door were incorrect also due to the fact that the resident recently changed rooms. She stated the label on the chart was correct though and indicated the resident was a Full Code. She stated no one called the ambulance and Staff B stated she forgot to call. She stated although Staff B stated that the resident was a DNR, the resident's paper chart stated he was a Full Code as well as his Medication Administration Record. She stated his chart had a green sticker affixed to it(to indicate Full Code). On [DATE] at 10:59 a.m., Staff C Registered Nurse(RN) stated she and Staff A CNA entered the resident's room and he was slumped over in his recliner, almost sliding out. She stated he was very diaphoretic and had had a bowel movement. She stated he was warm but not so warm he was feverish. She stated they were not able to get him up and he was not responsive. She called over the two-way radio for the DON and told Staff B to call 911. She stated they placed him on the ground and stated outside the resident's room, there was not a sticker present so that meant the resident was a DNR. Staff B stood at the doorway and Staff C directed her to double check the Code Status. The DON opened the resident's airway and they were ready to start compressions but Staff B took a long time and had not returned with the verification of the Code Status. Staff C left the room and at the nursing station, Staff B was fumbling and could not find the resident's code status in the paper chart. Staff C told Staff B it was under Advanced Directives and Staff B stated the resident was a DNR. It was at this time that they called the time of death. Staff C stated the aides got him cleaned up and when she opened the resident's EHR to obtain the phone number for the resident's wife, she saw that the resident was a Full Code. Staff C asked Staff B why the EHR stated Full Code when the paper chart said DNR. Staff C stated if she had known he was a Full Code, she would have started CPR. She stated after she spoke with the wife, she thought she should call and cancel the ambulance and she looked at Staff B and stated you called the ambulance, right? Staff B stated oh, I forgot because she tried to find the crash cart. On [DATE] at 11:18 a.m., Staff B stated she and the DON were summoned to the resident's room and he sat in the chair and was purple. She stated she was asked to call 911 and the DON asked her to check the resident's Code Status. She stated she looked for the crash cart and she did not know where it was at first. She stated she and Staff C looked at the resident's code status and stated the resident was a No Code but this was incorrect and they both misread it. She stated they were all flustered. She stated she was working on calling 911 when she retrieved the crash cart. She stated she was flustered and should have called 911. She stated she probably would have initiated CPR(if she had known he was a Full Code). On [DATE] at 12:24 a.m., the DON stated Staff C asked her to meet her in the resident's room. She stated when she arrived, the resident displayed agonal breathing and was diaphoretic and ashen in color. Staff C asked Staff B to check the resident's code status and to call an ambulance. Staff C left the room because they did not have his Code Status and when she found out he was a No Code, she called the time of death. She stated she called Staff F and informed her the resident was a No Code and she gave an order to release the body to the funeral home. She stated Staff C called the family and stated the resident's EHR stated he was a Full Code. She stated she called Staff F back to tell her and it was 7:57 a.m. The DON stated she did not believe if they had initiated CPR it would have changed things but stated they owed it to the family to do so. She stated Staff B stated she forgot to call the ambulance and had gone to look for the crash cart which was not her assignment. She stated Staff B did not know where the crash cart was but they educated her on this during orientation. The DON stated she would have started CPR if she had that information but thought she could trust a fellow nurse. She stated during the incident, the resident's door did not contain the correct sticker to indicate he was a full code due to room changes. On [DATE] at 3:22 p.m., the Administrator stated the Full Code sticker was on the chart but on the wrong side of the resident's door. She stated after the incident they checked all the door stickers and added another book at each nursing station which contained code statuses. On [DATE] at 9:16 a.m Staff G stated she was at the medication cart and someone directed Staff B on the two-way radio to call 911. She stated Staff B was closer to the radio than she was and that she(Staff B) could hear the request. She stated Staff B asked her to locate the crash cart. After she retrieved the crash cart, Staff B told her that the resident was a DNR.

Based on interviews, clinical record review, and facility policy review, the facility failed to carry out timely assessments and interventions after a resident complained of chest pain for 1 of 3 residents reviewed for a change in condition(Resident #9). The facility reported a census of 76 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 6/8/25 listed diagnoses for Resident #9 which included hypertension(high blood pressure), nonrhematic aortic stenosis(a condition where the aortic valve, which controls blood flow from the heart to the body, becomes narrowed or obstructed), and weakness and listed her Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. The facility policy Clinical Change in Condition, dated 6/2015, directed staff to assess the resident's status when there was a change in condition and to contact the provider. Care Plan entries, dated 6/23/25, stated the resident had altered cardiovascular status related to high blood pressure, a history of cerebrovascular accidents(strokes), and aortic stenosis and stated the resident would be free from complications of cardiac problems through the review date. The Care Plan directed staff to assess for chest pain with every interaction and to enforce the need to call for assistance when the pain started. An 8/5/25 10:13 a.m. Nurses Note, written by Staff B Licensed Practical Nurse(LPN), stated the resident did not appear to have shortness of breath or wheezing, her appetite was good, and (staff) would continue to monitor.An 8/5/25 12:31 p.m. Orders-Administration Note, written by Staff B, stated the resident received 2 puffs of an albuterol(a medication which helped with breathing)inhaler for shortness of breath after dinner and after ambulation. An 8/5/25 1:51 p.m. Nurses Note, written by Staff B, stated the resident slept since dinner time but stated she was short of breath after ambulation. The resident received her albuterol inhaler and her vitals were: temperature 98.1, pulse 93, respiration 16, blood pressure 106/63, oxygen saturation 96%. The resident rested in a recliner and (staff) would continue to monitor. The resident had a good appetite at meals today. The August 2025 Documentation Survey Report v2 report documented on 8/5/25 the resident ate 10% of her breakfast and lunch. A 2:02 p.m. Orders-Administration Note, written by Staff B, stated the resident's albuterol inhaler was effective. The August 2025 Medication Administration Record(MAR) lacked documentation that staff administered acetaminophen(a non-narcotic pain reliever) to the resident on 8/5/25. The facility lacked further assessments of the resident on 8/5/25 between 2:02 p.m. and 6:56 p.m. and lacked documentation of an update given to the provider. An 8/5/25 6:56 p.m. Nurses Note, written by Staff H LPN, stated staff reported the resident was not acting like herself. The Certified Nursing Assistants(CNA's) reported the resident had marked lethargy(a state of feeling tired, sluggish, and lacking energy) for the majority of the day and this increased as the day progressed. The resident did not eat, drink, or void today and did not wake up to take medications this afternoon/evening. The CNAs stated the resident complained of chest pain. The resident was difficult to arouse and responded only to a sternal rub but then immediately closed her eyes again with no further response. Her blood pressure was 168/82. The facility received on order to send the resident to the emergency room for evaluation and treatment. An 8/6/25 2:20 p.m. Nurses Note stated ER Staff reported the resident admitted for abnormal labs which included high troponin(a protein found in the heart muscle which is elevated when there was heart damage). A hospital Emergency Department Provider Note, dated 8/5/25, stated the resident complained of left-sided chest pain and her left chest wall was tender.A Hospital Discharge summary, dated [DATE], stated the resident admitted on [DATE] with chest discomfort and staff felt the resident suffered a myocardial infarction (heart attack). The resident received medications including aspirin and Clopidogrel(a medication used to prevent blood clots) to treat the condition. On 9/10/25 at 9:53 a.m. Staff F Advanced Registered Nurse Practitioner (ARNP) stated there was a situation with Resident #9 when Staff B worked when she needed sent out and more assessment was needed. During a follow-up interview on 9/11/25 at 8:47 a.m., Staff F, ARNP stated Resident #9 had a significant cardiac history but after she moved back to the dementia unit she was fairly stable. She stated she was in the facility (the day the resident subsequently went to the hospital) and Staff B was the resident's nurse. Staff F stated while she was at the facility, she received no updates from Staff B regarding Resident #9. She stated she left the facility for the day and Staff H from the night shift called her and said she wasn't herself. She advised Staff H to send the resident to the emergency room and she had an elevated troponin. Staff F stated after her hospitalization, she was sent to a Hospice house. Staff F found out later that the resident had expressed chest pain throughout the afternoon but Staff B dismissed this. On 9/16/25 at 12:28 p.m., Staff I CNA stated on the day the resident went to the hospital she just sat there and did not eat normally. She stated the resident complained of chest pain and pointed to her chest and said it felt heavy. Staff I stated she told Staff B this between 2:00 p.m. and 3:00 p.m. Staff I stated Staff B came back to the unit and told the resident she just needed to sit down and that she was fine. Staff I stated she told Staff B that the resident was not normally like this. She stated Staff B left the facility at 6:00 p.m. and Staff H LPN took over. Staff I stated as soon as Staff H arrived in the resident's unit, she called 911 and an ambulance subsequently arrived. Staff I stated the resident had a heart attack. On 9/16/25 at 1:00 p.m., Staff K CNA stated the day the resident went to the hospital, she was pale, lethargic, and coughed. She reported this to Staff B between 7:30 a.m. and 8:00 a.m. and Staff B stated the resident was fine and gave her an inhaler about an hour later. Staff K stated Staff B did not complete vitals until almost 2:00 p.m. She did come back and administer the resident's medications and inhalers and stated the resident was fine but did not complete vitals until around 2:00 p.m. She stated the resident was very different from her baseline and was lethargic and not herself. On 9/16/25 at 2:17 p.m., Staff B stated she remembered the resident had chest pain and she took her vitals and they were normal. She stated she monitored the resident but couldn't remember if she called the provider. She stated she gave her Tylenol and told the staff to keep an eye on her while she passed medications in the other hallways. Staff B stated the resident seemed the same to her as other days. Staff B then stated that she didn't think the resident had chest pain but had chest discomfort. Staff B stated she gave her acetaminophen and she was better. When queried as to whether she thought she should have notified the provider, Staff B did not answer. On 9/16/25 at 3:22 p.m., via phone, Staff J CNA stated she transferred to the resident's unit at 2:00 p.m. on the day in question. She stated the resident seemed really off, wasn't very active, and was not responding. She stated she and other staff told Staff B multiple times that she wasn't answering questions. She stated around 6:00 p.m., she and Staff I tried to get the resident up but could not. She then went to the nursing station where Staff B was giving Staff H report and told them that the resident was not getting up and had not moved or said anything and this was uncharacteristic. Staff J stated when she said this to Staff B and Staff H, Staff B snapped at her and said she had not gotten to that in report yet. Staff J stated after Staff B's shift was over and she left, Staff H came and assessed the resident. At that time, the resident did not respond until after staff gave her a sternal rub. Staff H called the ambulance and the resident admitted to the hospital. On 9/16/25 at 4:18 p.m. via phone, Staff H LPN stated she worked nights on the day in question. When she received report from Staff B, one of the aides stated that Resident #9 wasn't doing great and Staff B snapped at the aide and told her she hadn't gotten to that yet. When Staff B did get to Resident #9, she reported that the aides said she was super tired but that she was fine and was just playing possum. Staff H stated that Staff B acted like it was no big deal and did not report to her that the resident had chest pain. After Staff B left, staff reported to her that she needed to come and look at the resident. Staff H stated normally the resident was talkative, busy and pacing but at this point she was not herself and extremely lethargic. She stated the resident was slumped over and did not respond much. She had to carry out a sternal rub and the resident opened her eyes but closed them again. She stated she called Staff F and they sent her to the hospital for evaluation. On 9/17/25 at 10:03 a.m., the Director of Nursing (DON) stated if a resident complained of chest pain, staff should carry out an assessment and notify the provider. She stated if a resident had chest pain, they could not rule out that it was a cardiac event. She stated when she heard about the situation with Staff B and Resident #9, she was upset. She stated Staff L was the DON at the time of the incident.On 9/17/25 at 4:00 p.m., via phone, Staff L stated she was not in the building at the time of the situation with Resident #9 but stated staff came to her the next day. Staff reported to her that they told Staff B the resident had chest pain but she just told the resident to sit down. Staff L stated the aides should have reported this to her if the nurse did not listen. Staff L stated Staff B should have notified the provider and had her sent out for evaluation.

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in compliance and ethics for 6 of 6 staff reviewed(Staff B, M, N, O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q and non-new hires Staff M and Staff N completed training in compliance and ethics upon hire/annually. An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar did not list compliance and ethics as a training topic.On 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to implement training for multiple topics for 6 of 6 staff reviewed (Staff B, M, N, O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q completed training in Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and infection control upon hire and lacked documentation that non-new hires Staff M CNA and Staff N CNA completed training in QAPI and compliance and ethics on an annual basis.An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar listed infection control as a topic but did not include QAPI or compliance and ethicsOn 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in Quality Assurance and Performance Improvement(QAPI) for 6 of 6 staff reviewed(Staff B,M, N, O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q and non-new hires Staff M and Staff N completed training in Quality Assurance and Performance Improvement(QAPI) upon hire/annually. An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar did not list QAPI as a training topic.On 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Based on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in infection control for 4 of 6 staff reviewed (Staff B,O, P, Q). The facility reported a census of 76 residents.Findings included: An Employee Face Sheet listed the hire date for Staff B Licensed Practical Nurse(LPN) as 1/8/25. The facility's Hired List By Date listed the following hire dates:Staff O Certified Nursing Assistant(CNA) 4/16/25Staff P CNA 7/16/25Staff Q CNA 8/28/25The facility lacked documentation that new hires Staff B, Staff O, Staff P and Staff Q completed training in infection control.An undated, untitled facility document stated the facility training program was for all departments including new hires and existing staff. The facility Inservice Attendance calendar listed infection control as a training topic.On 9/17/25 at 12:41 p.m., the DON stated she did not see any additional education in the staff's files and stated they would work to building their training program.

Based on observation, staff interviews, record review and policy review, the facility failed to ensure open items were dated, covered and labeled and food was stored under sanitary conditions to prevent cross contamination. The facility further failed to test twice daily the dishwasher to ensure the low temperature dishwasher was getting to the correct temperatures and chemical solution to appropriately sanitize dishes. The facility reported a census of 81 residents. Findings include: During a continuous observation 6/16/25 beginning at 10:45 AM of the pantry and refrigerator with the Dietary Manager (DM) present revealed the following: 1. Open, undated bag of graham cracker crumbs. 2. Open, undated bag of powered sugar. 3. Open, undated bag of quick rise soft roll mix. 4. Open bag of muffin mix, with an opened date of February 2025. 5. A full pan of frozen shredded pork thawing in the refrigerator on a shelf above a shelf of eggs. A record review of the dishwasher temperature and sanitization chemical strip test log maintained by the facility revealed several dates missing in the previous three months. In the month of March 2025, there were 18 days that did not have documentation for the temperature and chemical test strip test of the dishwasher. In the month of April, 2025, there were 8 days and in the month of May there were 18 days. An observed test of the low chemical dishwasher completed on 6/16/25 at 11:00 AM revealed appropriate temperatures and chemical solution. During an interview 6/16/25 at 10:55 AM, the DM stated an expectation thawing meat should not be placed above other food items in the refrigerator and acknowledged the pan of thawing meat was placed above a shelf of eggs. The DM stated an expectation food should be dated when opened and used within a short time of the open date. The DM stated an expectation the dishwasher temperature and chemical sanitizer test strip should be conducted and documented daily, both on the AM shift and the PM shift and acknowledged this had not taken place for several days in the past three months. The DM stated she had provided education to staff. During an interview 6/18/25 at 1:38 PM, the Administrator stated an expectation thawing meat should be on the bottom shelf with no other food below it and an expectation food that has been opened have an open date and thrown away if not consumed within a short time. The dishwasher temperature and chemical checks should be completed twice daily and documented. A review of the facility Sanitation and Food Production policy, dated 6/15, documented foods are thawed properly to prevent food borne illness and frozen meats placed on the lowest shelves in the refrigerator to prevent juices from dripping onto other foods and causing cross contamination. A review of the facility Food Labeling Reference Guide policy, dated 6/2015, documented when food item is opened and not completely used, write the open date on the food container and a use by date on the food container. Mixes should be used within 7 days of the open date. A review of the facility Dish Machine/Sanitizer Log policy, dated 6/2015, documented to monitor and record once a shift the sanitizing concentration for low temperature dish machine.

Based on clinical record review, staff interview and policy review, the facility failed to limit a PRN (as needed) psychotropic drug (drugs that affect a person's mental state) to 14 days and failed to ensure the resident had an appropriate diagnosis for the psychotropic drug for 1 of 6 residents reviewed (Resident #28). The facility reported a census of 81 residents. Findings include: According to the Minimum Date Set (MDS) assessment dated [DATE] Resident #28 scored 13 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The resident did not have a diagnosis of anxiety and did not have physical, verbal or other behavioral symptoms directed towards others and scored a 0 on the resident mood interview (PHQ-2, Patient Health Questionnaire) which indicated no depression or minimal depression symptoms. The resident received an antianxiety medication during the 7 day look back period. The Electronic Health Record (EHR) lacked a diagnosis of anxiety or other mood disorders for Resident #28. The EHR (Feburary 2025 Medication Administration Record) for Resident #28 included an order for Lorazepam (medication to treat anxiety disorders) oral tablet 0.5 mg (milligrams), give 1 tablet by mouth every 4 hours as needed for anxiety, not to exceed 3 doses per 24 hour period, with a start date of 2/19/25 and a discontinue date of 3/15/25. The Medication Administration Record (MAR) for the month of February and March revealed Lorazepam was administered to the resident 7 of the 10 days in February and 11 of the 15 days in March. The EHR for Resident #28 included an order for Lorazepam oral tablet 0.5 mg, given 1 tablet by mouth every 4 hours as needed for anxiety, not to exceed 5 doses per 24 hour period, with a start date of 3/15/25 and a discontinue date of 5/15/25. The MAR for the months of March, April and May revealed Lorazepam was administered to the resident 17 of the 17 days in March, 30 of the 30 days in April and 15 of the 15 days in May. The EHR for Resident #28 included an order for Lorazepam oral tablet 0.5 mg, give 1 tablet by mouth every 4 hours as needed for anxiety, with a start date of 5/15/25 and no end date. The MAR for the months of May and June revealed Lorazepam was administered to the resident 17 of the 17 days in May and 19 of the 19 days so far in June. The EHR for Resident #28 included a Pharmacist Medication Regimen Review (MRR) dated 2/19/25, recommending the facility review this resident's PRN Lorazepam under the 14 day rule for PRN psychotropic's, be sure that it is discontinued, or evaluated and given a stop date. The EHR lacked a response by the facility to the MRR. The EHR for Resident #28 included a Pharmacist MRR dated 5/16/25, referencing the MRR dated 2/19/25 for the PRN Lorazepam 14 day rule, with a recommendation status from the facility as no response. During an interview 6/19/25 at 1:00 PM the Director of Nursing (DON) acknowledged the facility did not respond to the pharmacy recommendations regarding the PRN Lorazepam for Resident #28 and acknowledged the resident did not have an appropriate diagnosis for the anti-anxiety medication. The DON stated the resident became anxious when she had difficulty breathing and would request the Lorazepam. During an interview 6/19/25 at 1:44 PM the Administrator stated an expectation PRN psychotropic medications not exceed the initial 14 days without a rationale to extend the medication by the physician. The Administrator further stated an expectation the resident should have an appropriate diagnosis for the psychotropic medication. Review of the facility Medication Regimen Review policy, undated, documented the MRR will be completed by a consultant pharmacist and the DON will forward to the physician the MRR findings that require their response.

Based on clinical record review, staff interviews and policy review, the facility failed to assess and provide a timely intervention for 3 of 3 residents reviewed for catheter care (Resident #1, #4, #5). Resident #1 had little to no urinary output for 3 days without intervention. Residents #4 & #5 clinical records for urinary output lacked documentation. The facility failed to notify the attending physician of blood glucose levels greater than 400 for 1 of 1 resident reviewed (Resident #1). This failure resulted in possible distress for the resident, therefore causing an immediate Jeopardy (IJ) to the health, safety, and security of the resident. The facility reported a census of 76. On April 27, 2023 at 1:45 PM, the State Agency informed the facility the staffs failure to identify, and intervene and intervene for Resident#1 without urinary output for three days. Resident#1 created an immediate Jeopardy situation, which began on 4/23/23. The facility staff removed the immediacy on 4/27/23, when the facility staff implemented the following Corrective Actions: a. All contracted nurses who will be working on an extended contract will be required to complete an orientation checklist. b. Staff education for all staff on change of condition reporting, to nurses and physician on call, with significant changes also reported to nurse manager on call. c. Nurses will now be required to document output on the medication administration record (MAR). Nurse will empty catheters three times a day (TID) as of 4/27/23. d. All nursing staff will have a review and education provided specific to catheter care, the complications that are possible and how to assess for these complications. e. Nurse manager On Call will either make a phone call or make a facility visit for a verbal report on residents and staffing during the weekend to ask questions and offer guidance with any resident concerns. f. All professional nurses will receive additional education on complications related to indwelling catheters including but not limited to signs and symptoms of infection, obstruction, leakage, bladder spasms, and drainage. All nurses will receive education and review for blood sugars and following parameters. Medication aides will also be educated with instructions to follow up again with the nurse to ensure the physician was called if outside the parameters. g. Education on the importance and the completion of daily documentation for the aides to be audited on a weekly basis with follow up and disciplinary actions as needed for noncompliance. The facility staff's actions lowered the scope and severity from a J to a D at the time of the survey, after the State Survey Agency staff verified the facility staff had implemented the education and additional corrective actions. Findings include: 1. The Admission Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnosis of diabetes mellitus, dementia, and urinary retention (difficulty urinating and completely emptying the bladder), requiring staff to provide extensive assistance with hygiene and urinary catheter care. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated poor cognitive ability. The Care Plan with initiated date 3/13/23 for Resident #1 identified the focus of a urinary catheter, and directed staff as follows; provide catheter care with the assistance of 1 person and identified dementia, monitor for physical and nonverbal indicators of discomfort, stress, and follow up as needed. monitor for too much fluid (fluid overload) and to document food taken in (intake) and urination (output) as per the facility policy and to notify the physician if there was a decrease or no urinary output. During an interview on 4/27/23 at 11:10 AM, Staff A, Certified Nursing Assistant (CNA) stated On the skilled care unit, the catheter cares are completed at the end of the shift, that is cleaning the catheter, emptying the catheter and documenting the output. Staff A stated the end of the shift is every 8 hours. During an interview on 4/27/23 at 11:18 PM, Staff B, CNA stated that the day shift CNA's clean the entire urinary catheter every morning and then at 2 PM drain the catheter bag. Staff B stated if there was little to no urine, they are directed to check for a kink in the tubing and then alert the nurse. The facility provided a written statement dated 4/26/23 by Staff G, Certified Medication Aide (CMA) that revealed on 4/22/23 at 5:30 AM it was reported to the nurse that Resident #1 had 100 milliliters (ml) output, and at 10 PM, no urinary output. Staff G documented on 4/23/23 at 5:30 AM, she reported to the nurse that there was no urinary output and at 4:30 PM reported to Staff E a blood sugar result of 557 and no urinary output for Resident #1. Staff G documented that Staff E stated I know about it therefore Staff G reported the findings to Staff C whom immediately responded to Resident #1's room. During an interview on 4/27/23 at 3:19 PM Staff C, Licensed Practical Nurse (LPN), stated on 4/23/23 about 4 PM the medication aide reported that Resident #1 did not have a urine output for 2 days. Staff C stated that Resident #1 was lying in bed, eyes closed, fists clinched, his teeth clinched, felt warm, and his temperature was 97.8, but his skin was clammy. Staff C stated Resident #1's wife stated he did not have a urine output and his blood sugars were high. Staff C stated, I touched his distended abdomen and he flinched back; he was visibly in pain. Staff C stated she did not know the location of Staff E, Registered Nurse (RN), Resident #1's nurse, so she flushed the urinary catheter with 20 ml's of normal saline and nothing returned. Staff C stated, I deflated the balloon and the force of blood came out, pushed the catheter out. Staff C stated she called Staff D, Advanced Registered Nurse Practitioner (ARNP) and received an order to replace the urinary catheter and flush if able, if not, transfer to the emergency department. Staff C stated she was unable to place the new urinary catheter and Staff E entered the room. Staff C stated the need to transfer Resident #1 to the hospital. Staff C stated Staff E left the room to copy Resident #1's records and did not see Staff E assess Resident #1's vital signs before the ambulance arrived 15 minutes later. During an interview on 4/27/23 at 2:43 PM Staff D, ARNP stated she was at the facility on Friday 4/21/23 and Staff E worked without a complaint for Resident #1. Staff D stated on 4/23/23 at 16:44 PM staff E called and stated Resident #1 did not have a urinary output for 3 days and his blood sugar was over 500 all day. Staff D stated, I should have received multiple calls about that. Staff D stated Staff C called immediately after that and stated she had intervened, attempted to flush the catheter and orders were given that if she could not flush the catheter, send Resident #1 to the emergency room (ER). Staff D stated, I gave nurse (Staff E) the same order and she told me that her intervention was to pass the orders onto the next shift. Staff D stated that Staff C was not able to advance the new urinary catheter so she was given the order to transfer to the ER. Staff D stated, I have never had this happen before in this facility and the nurse (Staff E) did not do what should have done. During an interview on 5/1/23 at 10:55 AM, Staff F, RN, stated she had worked on 4/21/23 on the night shift and Resident #1 did not have any issues, but on 4/22/23 she was made aware, after 4 AM by the CNA, that Resident #1 did not have a urinary output. Staff F stated she attempted to flush his catheter and nothing returned. Staff F stated she reported this to Staff E. During an interview on 5/1/23 at 11:24 AM, Staff E, RN, stated she took care of Resident #1 on Friday, 4/21/23 and he did not have any issues and she did not see Staff D that day. Staff E stated on 4/22/23, Resident #1 had a low blood sugar and she gave him orange juice. Staff E stated on 4/23/23, the night nurse told her that Resident #1 did not have a urinary output and she checked him immediately, stated he did not have discomfort at that time, checked him again at noon when his blood sugar was 510 and gave him his insulin. Staff E stated she called Staff D to report the blocked urinary catheter and high blood sugars. Staff E stated she had received orders and that Staff C assisted. The Nurses Progress notes for Resident #1 reveals: a. 4/21/23 at 11:30 AM Staff E documented urine doesn't look out the normal. b. 4/23/23 at 3:15 PM Staff E documented Resident has urine retention, not urinated in 3 days, both legs have pitting 4 edema (swelling), fluid oozing from right lower extremity, nurse did a doctor notification form. c. 4/23/23 at 4:30 PM Staff E documented BS (Blood Sugar) is running 402-501. d. 4/23/23 at 5:30 PM Staff E documented Resident sent out, unable to urinate, Foley irrigated and changed, still no urine, (Staff D) and family notified, Vital signs temperature 97.8, respirations (R) 20, pulse (P) 80, blood pressure (BP) 142/78. e. 4/23/23 5:40 PM Staff E documented Sent to hospital by ambulance. A document titled Mahaska Health Emergency Department dated 4/23/23 revealed Resident #1 arrived at 6:18 PM, BP 87/48, P 90, R 23, he was difficult to arouse, the staff administered Narcan (a medicine given to people who are overdosing on Opioids). Resident #1's abdomen was significantly distended and grunted with palpitation (pressing fingers to the abdomen). The staff started intravenous fluids and inserted a Foley urinary catheter with the immediate return of three liters of purulent (thick) bloody drainage, similar appearance to a strawberry smoothie. The electrocardiogram (EKG) revealed Atrial Fibrillation (irregular heart beat), new rhythm for him, with a heart rate of 90, the possible cause was sepsis (a life-threatening complication of an infection). Resident #1's blood cultures were gram positive cocci (Staphylococcus infection in the blood), and a urine culture revealed a high glucose (sugar content) in urine. Impression: acute (a sudden onset) kidney injury, obstructive uropathy (obstructed urinary flow), UTI (urinary tract infection), Urosepsis, A-fib due to sepsis, acute cystitis (inflammation of the bladder). Dictated by physician, Staff H. The document titled Output for April 2023 for Resident #1 revealed: a. On 4/16/23 at 5:43 AM 1400 ml, at 1:35 PM 250 ml. b. On 4/17/23 at 1:30 PM 500 ml. c. On 4/18/23 at 5:43 AM 2500 ml, at 1:59 PM 500 ml. d. On 4/19/23 at 4:03 AM 300 ml, at 1:59 PM 650 ml, at 9:14 PM 1000 ml. e. On 4/20/23 at 1:24 PM 500 ml. f. On 4/21/23 at 1:50 PM 600 ml, at 9:59 PM 550 ml. g. On 4/22/23 at 5:23 AM 100 ml, at 9:59 PM 0 ml. h. On 4/23/23 at 5:23 AM 0 ml, at 1:57 PM 100 ml. Policy Catheter Care Indwelling dated 1/13 revealed: #24 Catheter Care check catheter system and empty drainage bag every shift #25. Complete catheter care at least daily #27 monitor for obstruction, hematuria, leaking around catheter #28. Notify physician of any changes or concerns The Medication Administration Record (MAR) for Resident #1 listed the time and glucose levels for the date of 4/23/23: a. 8 AM Blood Sugar (BS) level 507. b. 12 PM BS level 510. c. 5 PM BS level 557. The MAR directed staff to notify the physician if the blood sugar level was greater than 400. The Policy titled Blood Sugar Monitoring: General documentation guidelines: a. If blood glucose level is outside physician given parameters, document the time the physician was notified. b.Blood glucose levels for residents with diabetes vary depending on food intake, insulin dose, and exercise. Target glucose levels should be established by the residents attending physician. During an interview on 5/1/23 at 11:47 AM, the Director of Nursing (DON) stated, When there was no urinary output in a shift, I expect the nurse to call the physician and receive an order to flush the catheter. The DON stated that the physicians are at the facility every Monday through Friday, 4-5 hours a day. The DON stated, Nurses are trained to take action, I would expect them to call the physician or me. 47336 2. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderate cognitive impairment. The MDS revealed the medical diagnosis of retention of urine, unspecified. The MDS coded the presence of an urinary catheter. The MDS revealed Resident #4 needed extensive assistance with toilet use of 2+ person physical assistance. The MDS documented Resident#4 had the diaganoses including the following; a. retention of urine, unspecified b. unspecified urinary incontinence c. acute cystitis with hematuria The Point of Care (POC) Task B&B (Bowel and Bladder)- Catheter Care look back for the last 14 days revealed the following: a. urine output completed twice on 4/17/23 at 1:44 PM and 8:29 PM b. urine output completed once on 4/18/23 at 8:32 PM c. urine output completed once on 4/22/23 at 1:59 PM d. urine output completed twice on 4/23/23 at 5:01 AM and 3:15 PM e. urine output completed once on 4/25/23 at 8:32 PM The Care Plan revealed a focus problem dated 3/16/23 of a suprapubic catheter related to urinary retention. The intervention dated 1/19/23 directed staff to document and monitor intake and outputs as per facility policy. During an observation on 4/27/23 at 8:59 AM, Resident #4 sat in his recliner with his feet propped up. Clear yellow urine observed in catheter tubing with privacy bag covered the foley bag attached to the trash can. The Physician Orders dated 4/27/23 at 9:23 AM: a. nurse documentation of catheter output every 8 hours- every 8 hours for monitoring get the output from the CNA (Certified Nurse Aide) and input for documentation and close monitoring of urinary output 3. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the medical diagnosis of benign prostatic hyperplasia (BPH) and urinary tract infection (UTI) within the last 30 days. The MDS coded the presence of an urinary catheter. The MDS revealed Resident #5 total dependent assistance with toilet use of 2+ person physical assistance. The MDS documented Resident#5 had the diagnoses including the following; a. unspecified urinary incontinence b. benign prostatic hyperplasia with lower urinary tract symptoms c. urge incontinence d. retention of urine, unspecified The Care Plan revealed a focus problem dated 4/10/23 of an indwelling catheter related to urinary retention. The intervention dated 4/10/23 identified to document and monitor intake and outputs as per facility policy. The Task B&B (Bowel and Bladder)- Catheter Care look back for the last 14 days revealed the following: a. urine output completed twice on 4/14/23 at 5:43 AM and 1:59 PM b. urine output completed twice on 4/16/23 at 5:44 AM and 9:59 PM c. urine output completed twice on 4/18/23 at 4:32 AM and 9:59 PM d. urine output completed twice on 4/19/23 at 1:59 PM and 09:46 PM e. urine output completed twice on 4/20/23 at 1:56 PM and 9:38 PM f. urine output completed twice on 4/21/23 at 5:21 AM and 9:59 PM g. urine output completed twice on 4/24/23 at 1:59 PM and 9:59 PM The Physician Orders dated 4/27/23 at 9:21 AM: a. nurse documentation of catheter output every 8 hours- every 8 hours for monitoring get the output from the CNA and input for documentation and close monitoring of urinary output During an observation on 4/27/23 at 10:22 AM, Resident #5 wore a polo shirt and tan khaki pants and non-slid socks. The catheter bag strap observed at the bottom of the resident's pant's leg. The State Agency informed the facility of the Immediate Jeopardy (IJ) on April 27, 2023 at 1:45 P.M. Facility staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. All contracted nurses who will be working on an extended contract will be required to complete an orientation checklist. b. Staff education for all staff on change of condition reporting, to nurses and physician on call, with significant changes also reported to nurse manager on call. c. Nurses will now be required to document output on the medication administration record (MAR). Nurse will empty catheters three times a day (TID) as of 4/27/23. d. All nursing staff will have a review and education provided specific to catheter care, the complications that are possible and how to assess for these complications. e. Nurse manager On Call will either make a phone call or make a facility visit for a verbal report on residents and staffing during the weekend to ask questions and offer guidance with any resident concerns. f. All professional nurses will receive additional education on complications related to indwelling catheters including but not limited to signs and symptoms of infection, obstruction, leakage, bladder spasms, and drainage. All nurses will receive education and review for blood sugars and following parameters. Medication aides will also be educated with instructions to follow up again with the nurse to ensure the physician was called if outside the parameters. g. Education on the importance and the completion of daily documentation for the aides to be audited on a weekly basis with follow up and disciplinary actions as needed for noncompliance. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures.

Based on observation, clinical record review, resident and staff interviews, the facility failed to talk to residents with respect and provide care in a respectful manner in an environment that enhanced his or her self-esteem and self-worth for 3 of 5 residents reviewed (Resident # 2, #3, and #6). The facility staff and temporary agency staff failed to incorporate the resident's goals, preferences and choices. The facility reported a resident census of 76. Findings include: 1. The facility provided a document titled Facility Investigation, not dated, which revealed: Resident #2 claimed she was not sleeping at night for fear of Staff I, Certified Nursing Assistant (CNA), who balled up her fists when Resident #2 asked to go to the bathroom and was not assisted to bed when requested and was made to wait until Staff I was ready to assist her. Resident #6 claimed Staff I, CNA, did not assist her to bed until Staff I decided it was time and Staff I yelled at Resident #6 when she asked to go to the bathroom. Resident #6 reported she had a Urinary Tract Infection (UTI). The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the diagnosis of urinary tract infection, urinary stent placement (a tube placed into the ureter to help urine drain from the kidney to the bladder), dementia, arthritis (inflammation of the joints), muscle weakness and required assistance of 1 person for transfers and toileting. Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 which indicated an intact cognition. The Care Plan with initiated date of 12/20/2021 for Resident #2 directed staff to assist with transfer, provide prompt response for all requests for assistance and encouraged Resident #2 to void at first urge, not to hold urine for an extended amount of time. During an observation on 5/15/23 at 11:30 AM, Resident #2 was alert, oriented, and relaxed in her recliner in her room. During an interview on 5/15/23 at 11:30 AM Resident #2 stated Staff I, CNA shook her fist at her when she asked to go to the bathroom and to go to bed. Resident #2 stated she had to wait to go to the bathroom and it made her feel like she was not important. 2. The Quarterly MDS dated [DATE] for Resident #6 revealed the diagnosis of heart failure, diabetes mellitus, obesity and required assistance of 1 person for transfers and extensive assist of 1 person for toileting. Resident #6 had a Brief Interview for Mental Status (BIMS) of 15 suggesting an intact cognition. The Care Plan with initiated date of 12/27/2 2 for Resident #6 directed staff to assist with transfers and toileting. During an interview on 5/16/23 at 1:14 PM, Resident #6 stated she needed assistance to the bathroom and Staff I, CNA, told her to wait. Resident #6 stated she waited for 2 hours. Resident #6 stated it made her feel Real bad, so she told the agency nurse who said to wait for the CNA and if she wet herself, they will clean her up. Resident #6 stated she was interviewed after the incident by the Director of Nursing (DON). Resident #6 stated the problem was taken care of. During an interview on 5/15/23 at 1:07 PM Staff I, CNA stated she gets to each resident as soon as she can, the residents are forgetful and resentful to their families. Staff I stated Resident #2 was a story teller. Staff I denied the incidents occurred. Staff I's employee record included a Certificate for the Dependent Adult Abuse Mandatory Reporter training on 4/17/21 and participated in the following Staff training: a. In 2021 proper nursing etiquette, end of life care, and intellectual disability training, and participated in 7 out of 12 hours of CNA training that was offered by the facility. b. In 2022 which included Chronic Confusion or a Dementing Illness (CCDI), and resident rights, and Staff I participated in 12 out of 12 hours offered. c. In 2023 Staff I did not participate in the staff training that was offered. During an interview on 5/15/23 at 9:56 AM, the Director of Nursing (DON) stated she had conversations with Staff I, CNA, who believed the residents needed to go to bed in a specific order and was not willing to adjust how she did her care but felt she was doing what was in the best interest of the resident. The DON stated, She did not honor their wishes. During an interview on 5/16/23 at 9:40 AM, Staff L, CNA stated she had worked at the facility for [AGE] years and had not heard of a complaint from residents that involved physical or verbal abuse. Staff L stated, All of us try our hardest. 3. The Quarterly MDS dated [DATE] for Resident #3 revealed the diagnosis of Alzheimer's disease, kidney failure, weakness and required the extensive assistance of 1 for dressing and toileting. Resident #3 had a Brief Interview for Mental Status (BIMS) of 5 suggesting a severe cognitive impairment. The Care Plan with initiated date of 6/25/20 for Resident #3 directed staff to keep the Chronic Confusion or a Dementing Illness (CCDI) unit calm, and allow Resident #3 plenty of time to respond to questions and aid with dressing and toileting. A written statement dated March 25 revealed Staff M, CNA, entered the CCDI unit and could hear Staff J, CNA, telling Resident #3, You're the one who pissed yourself and If you were my mom I would spank you. Staff M documented that she intervened and Staff J left the room and stated to leave her naked. A document provided by the Administrator dated 3/25/23 revealed an interview with Staff J, CNA regarding an allegation of abuse to resident #3. Staff J stated she tried to clean Resident #3, who was combative. Review of the employee record for Staff J, CNA, revealed the following; hired on 7/13/20, completed the Dependent Adult Abuse Mandatory Reporter training on 4/14/21 and participated in the following Staff training: a. In 2022 which included Chronic Confusion or a Dementing Illness (CCDI), and resident rights, and Staff J participated in 12 out of 12 hours of staff training that was offered. b. In 2023 Staff J participated in 3 out of the 3 staff training that was offered. During an interview on 5/16/23 at 2:12 PM, Staff N, Certified Medication Assistant (CMA) stated on 3/25/23 Staff M, CNA asked for assistance in the CCDI unit, and when she entered the unit, found Resident #3 in her room naked and visibly upset. Staff N stated she assisted Staff M to dress Resident #3 and another resident who was also naked in their room. Staff N stated she told Staff J that she could not leave residents naked and Staff J responded that she did not have help and Resident #3 was combative. During an interview on 5/16/23 at 2:30 PM Staff O, CNA stated she worked on the morning of 3/25/23 in the CCDI unit and found Staff M and Staff N dressing Resident #3. Staff O stated, I was pretty sure that all the residents were not touched, the residents were soaked with urine or had no brief on at all. Staff O stated she reported her findings to Staff C, Licensed Practical Nurse (LPN). During an interview on 5/16/23 at 9:40 AM, Staff K, CNA stated she had been employed since 2016, attended all monthly staff training to include (CCDI), abuse and dignity training, which are available to view in the conference room if unable to attend the in-person training. Staff K stated the Administrator was present for all meetings. Staff K stated if she saw abuse, she knew how to report and who to report to. During an interview on 5/17/23 at 8:08 AM Staff P, CNA stated she was called into the CCDI unit on 3/25/23 to assist, the unit was in chaos, I could see the residents were rattled. Staff P stated she heard Resident #3 crying in her room. Staff P stated that she has reported to the nurses that Staff J does not participate in rounds at the end of shift. Staff P stated I struggle holding another CNA accountable so I suck it up and clean it up, every time. Staff P stated she had reported to the charge nurse. During an interview on 5/16/23 at 9:06 AM, Staff C, Licensed Practical Nurse (LPN) stated, As a whole I feel there could be more education offered to increase respectful interactions to provide dignity. On 5/17/23 at 9:20 AM, attempt to call and text Staff J, who was unavailable for comment. During an interview on 5/17/23 at 9:31 AM, the DON stated her expectation was for the CNA to tell the nurse if another CNA refused to do end of shift rounds, the nurse would see the rounds were done, and if that was not effective, the nurse would inform the Administrator or herself and they would perform rounds with the CNA. During an interview on 5/17/23 at 12:40 PM the Administrator stated she had been made aware of a concern in the CCDI unit and had conducted unannounced audits during the night shift to find 4 of 9 residents to be wet with urine and provided an education to the night staff on the importance of rounding throughout the night. The Administrator stated on 1/16/23 during a Quality Assurance meeting, she addressed a grievance from Resident #2 in regards to waiting to go to the bathroom and to be assisted to bed, and responded with The Guardian Angel Visits, management visits with residents to address these issues, and will continue this intervention every month. The Administrator stated I don't like abuse at all. The Administrator stated she had created power point slides for an all staff training on 5/23/23.

The following deficiency relates to incident -I: Based on observation, record review, and interviews with resident and staff, the facility failed to protect and ensure Resident #1 received adequate supervision and provision against hazards in the environment for (1) of four (4) residents. A staff person pushing a laundry cart down a hallway did not see Resident #1 walking with his/her walker and knocked the resident to the floor. Resident #1 sustained pain and a fractured pelvis from the fall. Resident #1's care plan directed staff to provide supervision in the hallways. The facility reported a census of 66. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 3/13/13, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating minimal short and long term memory deficits and minimal impairment of cognitive skills for daily decision making. The resident transferred and ambulated independently with the assistance of a wheeled walker. Resident #1's [DIAGNOSES REDACTED]. The assessment identified the resident had no falls since admission or since the prior assessment. The assessment revealed Resident #1 had no balance concerns during transition and walking (steady at all times). Resident #1's care plan dated 1/14/10 indicated a problem with vision loss related to glaucoma and risk for falls. The care plan approaches include keeping environment free of clutter and keeping personal items within reach. The care plan approaches also directed all staff of Resident #1's independent transfers using a walker with supervision in halls. The facility incident report dated 5/18/13 at 3:00 p.m. indicated nurses were summoned to the hallway to find Resident #1 sitting on the floor. Staff A indicated she ran into Resident #1 and he/she fell (to the floor). The form indicated to prevent recurrence, the laundry cart should be pulled, not pushed. The nursing staff assessed Resident #1 who complained of left hip pain. The resident continued to complain of pain and had been taken by ambulance to the emergency room for pain control. The laundry staff reported the incident on the CNA Fall investigation form dated 5/18/13. She (Staff A) reported when the laundry cart hit Resident #1 the cart knocked the resident and he/she fell to the floor. The laundry staff reported feeling very bad and will pull the cart from now on. Another fall investigation form dated 5/18/13 identified the laundry aide had not observed the resident walking in the hall which contributed to the fall. The Radiology records dated 5/18/13 indicated Resident #1 had hip and knee pain. The left hip radiology report identified acute fractures involving the superior and inferior pubic rami (pelvis). In an interview 6/19/13 at 9:55 a.m. Staff A, Laundry staff, indicated on 5/18/13 at around 3:00 p.m. she was pushing the laundry cart from behind down the 300 hall along the left side of the hall. Staff A noticed a resident along the left side of the hall and maneuvered the laundry cart to the right side and continued down the hall. Staff A failed to notice Resident #1 walking independently up the right side of 300 hall. Staff A bumped her cart into Resident #1 causing him/her to fall. Staff A indicated she had worked at the facility 2 years and had been trained on the proper management of the laundry cart, which includes to always pull the cart. On 6/26/13 at 10:05 a.m., Resident #1 reported he/she had been walking down the hall and the (laundry) cart had been moving very fast and ran into him/her. Resident #1 reported he/she had been unable to move out of the way (in time). In an interview 6/19/13 at 10:24 a.m. Staff B, Housekeeping/Laundry supervisor, indicated all laundry personnel, including Staff A, are trained on using equipment safely in the facility. Staff are trained to always pull the laundry cart because of the height of the cart. Staff B indicated she had never witnessed anyone pulling a laundry cart in an unsafe manner and knows of no other instances in which a cart had ran into a resident. In an interview 6/24/13 at 10:50 a.m. Staff C, Administrator, indicated there is no specific policy related to maneuvering laundry carts safely, but it is addressed in orientation training. Staff C indicated there had been no similar incidents involving carts running into residents. Staff C indicated Staff A had no previous disciplinary action in her personnel file and no history of being reckless or careless towards resident safety. In an interview 6/19/13 at 10:14 a.m. Staff D, Housekeeping/Laundry staff, indicated she was trained to pull the tall laundry cart with staff in front of the cart to ensure viability of residents. In an interview 6/24/13 at 10:32 a.m. Staff E, Housekeeping/Laundry staff, indicated she had been trained to always pull the laundry cart while standing beside it. Staff E indicated she had never witnessed anyone pushing the laundry cart. Observation of the laundry cart involved in the incident 5/18/13 noted the cart to be in excess of six feet high with solid cloth covering the exterior shell. The covering obstructs the view of anyone pushing the cart from behind. An observation on 6/24/13 at 1:50 p.m. noted Staff A delivering laundry and utilizing the laundry cart. Staff A properly maneuvered the laundry cart by pulling the cart down the hallway.