Every finding on record at Ossian Care Center

Based on personnel file review, policy review and staff interview, the facility failed to complete a thorough background check before hire for 1 of 3 staff sampled (Staff A). The facility reported a census of 42 residents.Findings include:The personnel file for Staff A, Certified Nursing Assistant (CNA) documented a hire date of 3/02/26. The Personnel File 2/12/25 Single Contact License & Background Check documented further research was required, and to await Division of Criminal Investigation's (DCI's) final response for criminal history. The Personnel File contained a Record Check Evaluation Form signed by Staff A on 2/17/25 and a Criminal History Record Check Request Form from Staff A's prior employer which contained the Criminal History results as of 2/14/25. The Personnel File failed to document the DCI's Final Criminal History Response from the prior employer to ensure Staff A had been cleared to work.On 5/05/26 at 10:36 AM Staff B, Business Office/Human Resources explained the Record Check Evaluation Consent Form is attached to the facility application form and she addresses with the employee at that time. She completes and [redacted check], SING and [redacted check]. If there is a hit on a record, she faxes the records over to the Department of Human Services (DHS) and sends them an email to ensure they receive the paperwork. They email her back the results/charges that were on the background form. During an interview on 5/05/26 at 11:35 AM, the Administrator reported the facility had not conducted a complete background check for Staff A. The facility did not have any final Record Check documentation from the prior facility showing the Staff member may work in a health care facility. The Abuse Policy dated 2/2026 directed the facility would screen potential employees for a history of abuse in accordance with state and federal laws.

Based on observation, clinical record review and staff interview the facility failed to provide adequate supervision in the Chronic Confusion and Dementing Illness (CCDI) unit (a nursing facility unit designed to provide tailored care and a safe, home-like environment for individuals with advanced Alzheimer's disease or related dementias) to prevent a resident-to-resident altercation which resulted in two separate physical altercations and failed to provide adequate supervision to a resident that wandered into another residents room which placed a resident at risk of an altercation for 3 of 4 residents reviewed (Resident #2, #3, and #4). The facility identified a census of 42 residents.Findings include:1.An Electronic Healthcare Record (EHR) showed Resident #2 admitted to the facility on [DATE] and transferred into the CCDI unit on 1/13/26.Resident #2's Minimum Data Set (MDS) assessment dated [DATE] showed a short/long term memory impairment. Resident #2 remembered the location of her room only and had moderately impaired daily decision making. She exhibited inattention behavior continuously and disorganized thinking continuously. The MDS documented Resident #2 as independent with walking. The MDS listed diagnoses of Alzheimer's Disease with late onset and anxiety. Resident #2's Elopement Risk Assessment Checklist dated1/29/26 documented Resident #2 as up independent with walking, had a previous history of wandering, had a diagnosis of Alzheimer's Dementia, mental illness, disorientation/confusion, and resided in a locked dementia unit. Resident #2's Elopement Care Plan dated 2/7/25 documented Resident #2 wandered aimlessly looking for something to do. On 5/04/26 at 1:31 PM, Staff E, CNA voiced Resident #2 walks up right into other resident faces and usually they can redirect her. On 5/05/26 at 3:24 PM, Staff D, Licensed Practical Nurse (LPN) reported she has seen behaviors between Resident #2 and Resident #3. Resident #2 liked to pace/wander and get into other resident faces. Resident #3 didn't like other residents in his space. Staff had to constantly redirect Resident #2 and she could get pretty aggressive and hit/strike out at staff when trying to divert her from situations. Resident #2 couldn't comprehend why Resident #3 didn't want her in his personal space. They really had to keep a sharp eye on her. There was an incident where Resident #2 was coming out of her room with a family member and Resident #3 was coming out of room in his wheelchair. They had to get between the two residents or they probably would have had a resident get hit at that time. 2. An EHR Census Record documented Resident #3 admitted to the CCDI unit on 11/16/23.Resident #3's 2/12/26 MDS Assessment documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive loss. Resident #3 exhibited inattention which fluctuated in severity. Resident #3 also exhibited physical behaviors towards others 1-3 days per week. The MDS listed a diagnosis of Alzheimer's Disease, Non-Alzheimer's Disease Dementia, and adjustment disorder with mixed anxiety and depressed mood. Resident #3's Care Plan included a focus that Resident #3 had the potential to be physically aggressive, grabbing or trying to hit related to dementia and poor impulse control. The Care Plan intervention dated 4/10/24 directed if he became agitated, intervene before agitation escalates; guide away from source of distress; engage in calm conversation and ask the resident to go to his room. On 5/04/26 at 1:04 PM, Staff F, CNA reported she had worked at the facility since December 2025. Resident #3 didn't like people standing by him or talking to him. He has been that way ever since she had worked at the facility. She was told to keep residents out of his room. Some of the other residents that wander will pat others on the back or try to talk with them and he doesn't understand that. Resident #3 had yelled at other residents to get the hell away and get the f**k away from him. She had seen Resident #3 get mad at Resident #2 and point a finger at Resident #2 while yelling at her. On 5/04/26 at 2:56 PM Staff G, Registered Nurse (RN) reported Resident #2 liked to get up and get in Resident #3's face. Resident #2 seemed drawn to Resident #3. Resident #3 didn't want anyone touching him or his things. He had been that way for a long time. On 5/05/26 at 3:24 PM, Staff D reported she usually tried to get Resident #3 right back to his room when he got finished with his meal so that others were not getting into his personal space. 3. A Facility Self-Report Incident submitted on 3/17/26 at 9:22 AM for incident date 3/16/26 documented Resident #3 was agitated, yelling at Resident #2 to leave. The Incident Summary detailed Resident #2 had been walking around the (CCDI) unit and got too close to Resident #3 while he was eating a snack. When unit staff walked out of other resident rooms, Resident #3 had back-handed Resident #2. The Facility Self Report under Corrective Action Description documented staff were educated right away by the Director of Nursing (DON) when residents were up and moving in the unit, they needed to make sure there was always at least one person in the common area of the unit to keep an eye on the residents. A Facility Education for Dementia Care presented by the Director of Nursing (DON) documented the facility recently had a resident to resident contact within the unit and it was noted that there was an increased need for more visual monitoring. The Education directed if additional help was needed to call the (nursing home) floor staff and have someone go back to the unit while the CNAs/CMAs (Certified Medication Aide)/Nurse were in rooms with other residents. Observation on 5/05/26 at 1:15 PM revealed Staff M, CMA walked by Resident #2. Resident #2 reached out and grabbed Staff M's right arm as she walked by to go to Resident #3's room to check on him. On 5/05/26 at 2:33 PM, Staff H, CNA reported that day Resident #3 had been agitated before supper as other residents kept going in his room. Resident #3 came out for supper and was seated in his wheelchair at the far dining room table by the tub room. Supper usually ended around 6-6:15 PM. After supper, Resident #3 continued to sit in his wheelchair at the far dining room table watching television. She was in another resident's room assisting the resident into bed and Staff I, CMA was in another resident's room. As she was coming out of another resident's room, she saw Resident #3 strike Resident #2 in the right upper lip with the back of his left hand twice. She had a perfect frontal view of it. Staff H voiced she thought the incident could have been prevented as she should have taken Resident#3 back to his room after supper. Staff H reported she had not received any further guidance since the last incident other than to keep them two residents separate. On 5/05/26 at 2:52 PM, the DON reported the CCDI Unit Coordinator was going around ensuring all staff had read the updated resident's Kardex as she had asked staff earlier if they knew where to find the updated information (regarding Resident #2 and #3) and staff didn't know. The DON voiced she would ensure that Staff H received the updated information on what to do in the (dementia) unit. On 5/05/26 at 2:57 PM, Staff I reported staffing that night was just her and Staff H in the unit. Resident #3 liked his own space and they tried to keep other residents away from him. Resident #3 would strike out and hit staff during care. If it got too loud, he would yell at the ladies to shut up. Resident #3 would usually yell before he did anything. Staff H informed her Resident #3 had smacked Resident #2 in the upper lip when she came out of another resident's room. Resident #2 wandered. Prior to the incident, Resident #2 would walk up into Resident #3's personal space and they would have to redirect her back from him. They were instructed to ensure one staff member stayed out in the main area to supervise all residents but she couldn't remember when that direction was given, but they didn't want Resident #2 getting smacked or any resident getting smacked. She thought maybe the incident could have been prevented if they would have taken Resident #3 back to his room after supper. On 5/05/26 at 3:24 PM, Staff D reported she didn't not know if there had been any new interventions given regarding the two residents after the altercations. She just tried to keep the residents separated. They did have a Kardex and a report sheet they could review that may have that information. During an interview on 5/05/26 at 5:08 PM, Staff J, LPN reported she was called on the walkie talkie to come to the dementia unit the evening of the incident between Resident #2 and #3. Staff I informed her Resident #3 had hit Resident #2. When she entered the unit, Resident #2 was seated in a recliner by the nurse's desk and Resident #3 was in his room. Staff J verbalized there seemed to be an increase in resident to resident altercations in the unit. Resident #3 would sit in his wheelchair and intentionally try to trip other residents as they walked by. She had directed staff to take Resident #3 directly back to his room as soon as he was done eating his meals. Resident #3 did not like others in his personal space and Resident #2 didn't understand that, she would get right up into others personal space. When queried if the resident-to-resident altercation could have been prevented, Staff J responded, yes. The staff should have known Resident #3 needed to go back to his room right after meals. Resident #3 should not be left alone in the dining/common area. Some of the staff don't seem to understand that resident contact can happen very quick. It is common for Resident #2 to get up and wander. She gets more agitated and wanders more as the day goes along. They had a nursing meeting after the incident and one staff member should be in the dining/commons area supervising residents at all times. Observation on 5/06/26 at 8:19 AM revealed three staff in the CCDI Unit, the CCDI Unit Manager, Assistant Director of Nursing (ADON), and Staff M. Resident #2 got up from table [number redacted], pushed in the chair, and walked over to the dish cart and started to tidy items. Resident #3 sat at table [number redacted] in the dining room and watched television. At 8:26 AM, Resident #2 pushed the dirty dish cart out the front door of the CCDI Unit supervised by Staff M. Observation on 5/06/26 at 8:35 AM revealed the ADON and the CCDI Unit Manager assisted Resident #3 from the dining room table back to his room and shut the door, leaving six residents unsupervised in the common area. At 8:36 AM, Staff M returned to the unit with Resident #2 and then she stayed in the dining/common room area.Interview on 5/06/26 at 8:38 AM Staff M verified there were no staff in the common area when she entered back into the unit and there should be a staff member present in the main area supervising the residents at all times.On 5/06/26 1:58 PM, the CCDI Unit Coordinator reported she returned from vacation on 3/18/26 and was notified of the incident. On 3/18/26 the DON updated Resident #3's Care Plan to modify the environment, reduce noise, dim lights, take him to his room or provide 1 to 1 as needed, continue to encourage him not to lash out at other residents or staff. Resident #2's Care Plan was updated 3/18/26 by the ADON to ensure one staff member was monitoring the lobby (common area) during the late afternoon and into the evening as Resident #2 may become more persistent in looking for something to be doing. Resident #3 didn't like people in his personal space the entire time that she had worked at the facility. Resident #2 was a really friendly person. She liked to touch and tinker with things and didn't seem to recognize other resident boundaries which placed her at a higher risk. On 5/06/26 at 3:00 PM, the DON reported Resident #3 was eating pudding in the evening and Resident #2 went up to Resident #3 and attempted to assist him with his snack. When Resident #3 got upset he will swat out at others. Staff J informed her that night at 7:45 PM Resident #3 had backhanded Resident #2 in the check/neck area. At that time, they had a medication aide and a CNA on duty. It was pretty much known that Resident #3 did not like residents around him. There should have been staff supervising the residents at that time. During an interview on 5/06/26 at 3:23 PM the Administrator reported the facility didn't have a policy regarding supervision. The facility followed [State Regulation] for supervision regarding the unit. She became aware of the incident on 3/16/26 when she was in a board meeting that evening. Around 7:30 PM, Staff J came in to report the incident to the DON. The DON updated her after the board meeting. There was one CMA and one CNA staffed that evening in the unit. That was the normal staffing for the unit. Resident #3 had hit Resident #2. When queried if Resident #3 did not like residents around in his space, the Administrator responded, yes. It was in Resident #3's care plan. It was well known that Resident #2 wandered into others personal space even before Resident #2 was placed in the unit. The Administrator voiced she felt it should have been preventable. The staff should have been watching the residents. Resident #2 could be quick, helpful, and was always trying to clean or wipe something down. That did put her at more risk. 4. A Facility Investigation submitted on 4/13/26 for incident date 4/13/26 detailed on 4/13/26 at 11:51 AM, it was reported that Resident #3 back-handed Resident #2 in the common area of the CCDI unit where he was sitting as had just finished his noon meal. Resident #2 was walking around the unit and got very close to Resident #3. At the time of the incident Resident #3 was taken back to his room right away and Resident #2 was in the common area of the unit with staff supervision. The 4/13/26 Facility Self Report under Corrective Action Description documented care plans had been updated to have a CNA/CMA from the nursing home go to the unit during the noon meal to allow for extra staff in the unit while staff were cleaning up after the meal. A Written Account of the Incident by Staff L, CNA dated 4/13/26 at 11:51 AM documented Resident #3 was sitting at his spot at the dinner table. Resident #2 had already finished eating. Staff L cleaned up other resident's completed dinner trays. Her back was to Resident #3. In that time, Resident #2 invaded Resident #3's space. Staff L spun around and started to try to create space between the two residents. Before she could get there Resident #3 backhanded Resident #2 across the throat, not very hard, but contact happened. Resident #3 claimed that Resident #2 had hit him first. On 5/04/26 at 12:16 PM, Staff K, RN reported on that day, Resident #2 was seated at table [number redacted] and Resident #3 was seated at the last table in the dining area. Resident #2 finished eating and got up and walked down to Resident #3's table and was talking to him which irritated him. Staff K explained she was picking up dishes and dumping the dishes from table [number redacted] Staff L was wiping up the second table. Staff K further explained she was at table [number redacted] looking down picking up dishes and Staff L was looking down cleaning table [number redacted] and neither saw Resident #2 walk down by Resident #3. When she looked up, Resident #2 was standing to Resident #3's left side and it was too late. Resident #3 had swung out with the back of his left hand and hit Resident #2 in the right cheek/neck area. She went over to them as Resident #3 didn't like people near him. Resident #3 stated, go away! By that time, they separated the two residents. They had been instructed to watch Resident #2 when she was wandering to ensure she didn't get too close to Resident #3 or wander into his room. There was no special direction given as to who was to watch Resident #2, both of them should have been watching Resident #2 and #3. Resident #3 had yelled at Resident #2 to go away before there was ever physical contact. The second incident could have been prevented as they should have been watching Resident #2 as she was usually the first resident done with her meal and then gets up and starts walking around. On 5/06/26 at 9:54 AM, Staff L, stated Resident #2 was a wandering personality and liked to see what everyone was up to. The day of the incident she was at one of the dining room tables cleaning up other resident's dishes. Her back was to Resident #3 who was seated at the back dining room table. She didn't recall seeing Resident #2 walk by. By the time she spun around, it was too late. There was a table between her and the two residents that she had to try to get around to create space between the two residents. Before she could get there, Resident #3 backhanded Resident #2 in the throat. She thought that Resident #2 had touched Resident #3's shirt or something, but Resident #2 was very much in Resident #3's face. Resident #2 didn't seem to have much reaction, but Resident #3 knew that he had hit Resident #2. Staff L couldn't recall if there had been any altercations prior between the two residents, but they tried to maintain two people in the common room. It was hard to say if the incident could have been prevented as, unfortunately, there were other tasks that had to be done. On 5/06/26 at 1:11 PM, Staff G, RN reported they tried to send a staff person back to the unit during meals on the weekends if they had extra staff available, but it was hard. Sometimes they could and sometimes they couldn't and the two staff back in the unit had to do the best they could to supervise the residents. On 5/06/26 at 12:27 PM, Staff I reported they do the best they can. They don't always call nursing home staff back during the meals. They can if it is needed, but it is hit and miss if they can send someone back to the unit. On 5/06/26 at 12:34 PM, Staff M reported they did the best they can. One staff member tried to stay in the unit while the other staff member provided care to the residents. They can call up to the nursing home for staff to come back to the unit but they were not always able to get staff to come back to the unit to assist. They just had to do the best they can to supervise the residents. On 5/06/26 at 1:58 PM, the CCDI Unit Coordinator reported she was off on 4/13/26, but she did come in that night and found out about the incident. The DON directed to have an extra person during the noon meal to assist with increased monitoring of the residents. New interventions were placed in the care plans for Resident #2 and #3. The CCDI Unit Coordinator voiced there were two staff members in the dining room at the time of the incident. When queried how the resident made contact with each other, she stated that was a good question how they made contact with each other. She would hope the incident could have been prevented, but Resident #2 was very quick. She expected the unit to be supervised. On 5/06/26 at 3:00 PM, the DON reported she was notified of the 4/13/26 incident by Staff K. There were two staff in the dining room at the time of the incident. Staff L was on the opposite side of a different table with her back to the residents and she couldn't get around the table quick enough to get to the residents. Before Staff L could get to the residents, Resident #3 backhanded Resident #2 in the right cheek/neck area. When queried if could have been preventable, the DON stated, yes. Staff L should have been positioned where she could have observed Resident #3 as she cleaned the tables. That same day they directed for there to be another staff person back there during the noon meal. They have been able to sustain that 99.9% of the time. She had not done any follow up with staff to find out if that was working.On 5/06/26 at 3:23 PM, the Administrator reported on 4/13/26 Resident #3 backhanded Resident #2 in the neck because Resident #2 got into his personal bubble. The residents were immediately separated. The 4/13/26 incident should have been preventable. She expected the residents to be supervised in the unit. During an interview on 5/07/26 at 12:02 PM, the DON reported she did not do additional staff education after the 4/13/26 incident between Resident #2 and #3. She just tried to catch staff and update them as they worked as to what was needed in the unit. 5. Resident #4's MDS dated [DATE] showed a BIMS score of 1 out of 15 indicating a severe cognitive loss. Resident #4 exhibited inattention and disorganized thinking which was continuously present. The MDS documented Resident #4 wandered daily, was independent with walking, and had diagnoses of Non-Alzheimer's Dementia and anxiety. The Care Plan dated 2/10/26 documented Resident #4 as an elopement risk/wander related to wandering aimlessly. Observation on 5/05/26 at 1:47 PM Staff M assisted a resident with an activity at table [number redacted] in the dining room with her back to Resident #2, who was seated in a recliner behind her. Staff M's back was to Resident #3's room door. At this time, Resident #4 walked into Resident #3's room and tried to open his window. Resident #3 was positioned on his right side in bed and looked directly at Resident #4 as she walked by him and tried to open the window. Resident #3 reached out and gripped his side rail on the bed in the direction of Resident #4. Resident #4 was approximately 6-10 inches from Resident #3's reach. At this time, Staff M was alerted for safety that Resident #4 had entered into Resident #3's room. At 1:52 PM, Resident #4 tried to enter into Resident #3's room again and Staff M diverted Resident #4 back to her room.

Based on observations, staff interviews and facility cleaning checklists, the facility failed to maintain sanitary practices by improperly storing clean dishes and maintaining a clean kitchen. The facility reported a census of 37 residents. Findings include:During initial kitchen observation on 1/20/2026 at 9:10 AM, the following findings were identified: dried food and liquid splatter on the refrigerator in the main kitchen area, convection oven thick dust on top with dried food splatter, sugar and flour storage bins with dried food particle inside and outside of containers, open shelving where dishes are stored dusty and dried dark liquid noted, pans stored on open shelves not inverted, floors throughout kitchen, ceiling vents with thick grease and dust, fan in clean dish area blowing on dishes noted with thick dust, plastic covering for the metal cart which holds the cooking sheets with dried food particles on it, large mixer with dried food particles all over it, and counter top food weigh machine with dried food particles all over it. On 1/20/26 at 9:20 AM Staff E, [NAME] reported the bins on the outside get cleaned weekly and she could not remember the last time they were cleaned on the inside. She noted the container had the bags open but not dated. During follow up on 1/21/26 at 10:10 AM noted areas of concern noted on 1/20/26 remained the same. On 1/21/26 at 11:20 AM the Dietary manager showed the cleaning list for daily, weekly and monthly. She reported she did audits occasionally for cleaning. When showed the areas of concern, she acknowledged they needed to be cleaned. When looked at the cleaning list, staff documented the areas that were cleaned the day prior but when showed the areas and reported they remained the same areas of dirt and dust, she was unsure if they were properly cleaning. She reported the floor is cleaned daily but was unaware they had the same food particles and pieces of food from the day prior. She reported she would have to investigate why it remained the same. Review of the facilities cleaning checklists with a revised date of 12/8/25 documented the areas of concerns noted were to be cleaned daily.

Based on record review, staff interviews, and policy review the facility failed to obtain informed consent prior to starting psychotropic medications that have black box warnings (the most serious safety warning used by the Food and Drug Administration (FDA) and requires the healthcare provider to have a comprehensive discussion with the resident about the risks, benefits, and alternatives for use) for 5 of 5 residents reviewed for psychotropic medications (Resident #33, #2, #14, #4, and #3). The facility reported a census of 37 residents. Findings include: 1.Resident #33's 10/23/25 Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating a moderate cognitive loss. The MDS documented Resident #33 did not exhibit any behaviors, hallucinations or delirium and had diagnoses of depression. Resident #33 utilized antidepressant medication. A Medication Review Report signed by the Provide on 11/18/25 listed the following physician ordered medications:a. Bupropion Hydrochloride (HCL) (antidepressant medication) extended release, give 150 Milligrams (MG) by mouth every morning. Order date 1/24/23. b. Paroxetine HCL (antidepressant medication) 40 Milligrams (MG) give 1 tablet by mouth one time a day. Order date 1/24/23.c. Mirtazapine (antidepressant medication) give 30 MG by mouth every day at bedtime. Order date 10/2/24. d. Lorazepam oral concentrate (antianxiety medication) 2 MG/Milliliter (ML), give 0.25 ML by mouth every 4 hours as needed for 6 months; give 0.5 MG by mouth sublingual every 4 hours as needed. Order date 8/1/25. A review of the November, December 2025 and January 2026 Electronic Medication Administration Records (EMAR) revealed Resident #33 consistently received the medications as ordered. During an interview on 1/22/26 at approximately 8:45 AM the Assistant Director of Nursing (ADON) reported she would check with the Director of Nursing (DON) on the medication consent as she was working on getting the medication consents completed yesterday (1/21/26). A review of Resident #33's Miscellaneous Clinical Record showed a Consent for Psychotropic Medication Use reviewed with the family on 1/22/26. During an interview on 1/22/26 at 11:19 AM the ADON explained the facility had been doing psychotropic consent forms for the use of antipsychotic medications only. They had not realized they needed to provide the education for antidepressant/antianxiety medications as well. They completed the education with the family this morning and will be addressing all psychotropic medication use/education with resident/family going forward. 2. Resident #2's MDS assessment dated [DATE] documented a BIMS score of 5 out of 15, indicating severe cognitive impairment. The MDS included diagnoses of dementia, anxiety, and depression. Resident #2's Medication Administration Record (MAR) revealed the following orders: Lorazepam 0.5 mg every 8 hours as needed for agitation, anxiety, restlessness started on 7/29/25, as well additional orders after 7/29/25 for the medication. Resident #2's MARs documented he received lorazepam in July 2025, August 2025, September 2025, October 2025, November 2025, and December 2025. On 1/22/26 at 11:14 AM, the ADON reported the Lorazepam risks and benefits were not done for Resident #2. 3. The MDS assessment dated [DATE] for Resident #14 documented a BIMS of 00 indicating severe cognitive impairment. Review of Resident #14 Clinic Note dated 1/16/26 documented continued orders of psychotropic antidepressant medications sertraline and mirtazapine, but lacked start date. Review of Resident #14 MAR on 1/22/26 documented she received the following psychotropic antidepressant medication sertraline since 9/27/23 and mirtazapine since 12/20/23. Resident #14 Consent for Psychotropic Medication Use consent form, revealed the facility received consent from her resident representative to give her psychotropic antidepressant medication during the survey on 1/21/26 at 12:05 PM 4. The MDS assessment dated [DATE] for Resident #4 documented a BIMS of 12 out of 15, indicating moderate cognitive impairment. Review of Resident #4 Office Visit dated 12/22/25 documented continued order for use of psychotropic antidepressant sertraline, but lacked start date. Review of Resident #4 MAR on 1/22/26 documented he received the following psychotropic antidepressant medication sertraline since 7/18/2025. Resident #4 Consent for Psychotropic Medication Use consent form, revealed the facility received consent from his resident representative to give his psychotropic antidepressant medication during the survey on 1/21/26 at 12:09 PM 5. The MDS assessment dated [DATE] for Resident #3 documented a BIMS of 3 out of 15, indicating severe cognitive impairment. Review of Resident #3 Medication Review Report dated 11/18/25 documented he started on psychotropic antidepressant medication sertraline on 4/10/24 and continued to receive the medication. Resident #3 Consent for Psychotropic Medication Use consent form, revealed the facility received consent from his resident representative to give his psychotropic antidepressant medication during the survey on 1/21/26 at 12:15 PM. Review of the facilities undated policy, Use of Psychotropics Drugs, instructed the following: The Facility will obtain signed consents for psychotropic medications that are prescribed at admission or added during residents stay at the facility, and reviewed quarterly.a. Informed consent must be obtained from the resident or the resident's authorized representative before initiating or continuing the use of psychoactive drugs.b. The information about responsible prescribing of the medication should provide the resident or authorized representative with information about the potential benefits, risks, and alternatives to the medication.c. The resident or authorized representative will have the opportunity to ask questions and make an informed decision regarding the use of psychoactive drugs.

Based on observation, clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to accurately code the use of restraints for 2 of 4 resident reviewed on the Minimum Data Set (MDS) Assessment (Resident #24 and #27). The facility identified a census of 37 residents. Finding include:1.Resident #24's 11/6/25 Minimum Data Set (MDS) Assessment showed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating a severe cognitive loss. Resident #24 did not exhibit upper/lower extremity impairments and was dependent upon staff for chair/bed to chair transfers. The MDS included diagnoses of Alzheimer's Disease with late onset and anxiety. The MDS documented bed rails were utilized daily as a restraint.A Medication Review Report (MRR) signed by the Provider on 12/12/25 listed a physician order for side rails at the head of the bed to aide in bed mobility and repositioning. Original order date 1/12/23. The MRR lacked documentation of restraint orders. Observation on 1/20/26 at 9:51 AM Resident #24 lay in a low bed with an upper half side rail on the right side of the bed and a lower half side rail on the right side of the bed. Resident #24 lay resting with his eyes closed making no attempts to pull at the side rails or get out of bed unassisted. A 1/21/26 review of Resident #24's Risk of Falls related to Dementia and Overestimates Abilities Care Plan revised 8/2025 by the Assistant Director of Nursing (ADON) directed as of 5/14/25 side rails applied both head of bed and foot of the bed as a safety measure. The Activities of Daily Living Self-Care Performance Deficit Care Plan revised 1/12/26 by the ADON directed under Bed Mobility the resident needed 1-2 staff assistance and the resident could use the side rails to help with positioning. A Side Rails assessment dated [DATE] documented Resident #24 with the following:a. Diagnosis of dementia, cognitive impairment or impaired judgement that would affect side rail usage.b. Medical Necessity - resident needs a boundary marker; resident did not need the side rail to assist in positioning, and the legal representative requested the side rail despite the lack of medical necessity. During an interview completed on 1/21/26 at 10:55 AM Staff A, Certified Nursing Assistant (CNA) reported Resident #24 uses the upper and lower rails. The rails are half rails and he can still get out through the center of the bed. He will use the rails to try to stand up in the middle part of the bed. He also uses the upper half rail to assist with turning in bed. He can still get out of bed. The side rails are more of a boundary for him. The rails do not really keep him from doing anything. During an interview on 1/21/26 at 11:00 AM Staff B, CNA explained the resident uses the upper and lower rails on the outer bed. He will use the upper rails to hold onto when they do a check and change for him. Resident #24 can still get through the rails and uses them to stand up which is why he has a fall mat outside of the bed. He hasn't tried to get out of bed for a long time. On 1/21/26 at 12:17 PM, the ADON explained it was the family that signed the side rail consent form stating they wanted the side rails. Resident #24 needed some boundaries and she thought they needed to re-evaluate him. He could still move his feet out of the bed and he could stand up holding onto the rails, but he hadn't tried to do it for a long time. His dementia was advancing and she felt he needed to be reassessed. The ADON voiced it was an MDS coding error, not a restraint issue. She stated she had reviewed the RAI but was still confused on how to code the MDS. She didn't believe the facility had a MDS policy for coding the MDS. She used the RAI to code the MDS. The CMS LTC RAI User's Manual, October 2025, Version 1.20.1, Page 1-4 documented the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require the assessment accurately reflects the resident's status.Chapter 3 directed if a device is a restraint to code if it is not used, used less than daily or used daily. 2. Resident #27's MDS assessment dated [DATE] showed a BIMS score of 9/15 indicating a moderate cognitive impairment. Resident #27 did not exhibit upper/lower extremity impairments and required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with chair to bed to chair transfers. The MDS included diagnosis of normal pressure hydrocephalus (a condition where cerebrospinal fluid buildup in the brain which causes difficulty walking, impaired bladder control and cognitive decline). The MDS documented Resident #27 utilized bed rails daily as a restraint. Resident #27's Care Plan revealed family and resident request for repositioning grab bar at the head of the bed, created date 10/23/25. The Care Plan lacked documentation of any restraint use. A 1/12/26 Side Rail Assessment documented Resident #27 utilized a U shaped repositioning bar and lacked documentation the U bar was restraining. Interview on 1/20/2026 at 11:01 AM Resident #27 stated he has the U bar on his bed to assist him with turning and getting in and out of bed. A 1/20/26 review of Resident #27's Medication Review Report signed by the provider on 12/10/25 lacked documentation of a physician order for restraining bed rails. During an interview on 1/21/26 at 12:17 PM the ADON voiced she had also coded Resident #27's MDS incorrectly for restraints. His U bar is to assist him with turning and getting in and out of bed. It did not restrain him.

Based on observation, clinical record review, policy review and staff interview the facility failed to notify the physician/provider when holding cardiac medication according to physician ordered vital sign parameters for 1 of 1 residents reviewed for a change in condition (Resident #12). The facility identified a census of 37 residents.Findings include:Resident #12's 12/18/25 Minimum Data Set (MDS) Assessment showed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating a moderate cognitive loss. The MDS listed diagnoses of heart failure, high blood pressure, end stage renal disease, Alzheimer's Disease, Non-Alzheimer's Dementia, and unspecified atrial fibrillation (an irregular heartbeat that makes the heart less efficient at pumping blood and raises the risk of blood clots, stroke and heart failure). A 10/31/25 Clinic Note documented Resident #12 admitted [DATE] to hospital after presenting in the emergency room with heart rates in the 160's. She was hospitalized with atrial fibrillation and received medication adjustment. Resident #12 presented with a heart rate of 40 beats per minute at the clinic appointment. Parameters were added to the Cardizem (heart medication) to notify the provider/hold if the blood pressures were less than 90 systolic or heart rate less than 60. The adult average pulse rate is 60 beats per minute (BMP) to 100 BMP. A Medication Review Report signed by the Provider on 12/12/25 listed to administer Cardizem Extended Release 24 hour 240 Milligrams (MG) tablets, give 480 MG (2 tablets) by mouth one time a day. Hold the medication and notify the healthcare provider if the blood pressure is less than 90 systolic or if the pulse if less than 60 BPM. Medication Task Observation on 1/21/26 at 7:23 AM revealed Staff D, Certified Medication Aide (CMA) completed a blood pressure and pulse check prior to preparing Resident #12's morning medication. Staff D stated Resident #12 had clear parameters set by the physician for the Cardizem medication. Staff D documented Resident #12's blood pressure of 115/94 and pulse 67 in the medication record. Staff D stated Resident #12 tends to run low so they have to watch her closely and hold the heart medication, but it was okay to give today.A 1/21/26 review of Resident #12's Electronic Medication Administration Records (EMARs) revealed the following pulses were outside the physician ordered parameters for the Cardizem medication:a. November (2025) 1, 3, 5, 16, 17, 21, 22, 29.b. December (2025) 3, 9 (pulse 44), 10 (pulse 52), 11, 13 (pulse 50), 20 (pulse 40), 23 (pulse 36), 27, 31 (pulse 53).c. January (2026) 5 (pulse 46), 7 (pulse 48), 11 (pulse 49), 13 (pulse 53), 15, 17 (pulse 43), 18, 19, 20. A 1/21/26 review of the Progress Notes revealed the nurses documented Resident #12's Provider was notified of the Cardizem medication being held on 11/22/25 and 1/20/26. During an interview on 1/22/26 at 7:50 AM the Director of Nursing (DON) reported she and another nurse had reviewed the Resident #12's medical record and did not find that the provider had been notified each time Resident #12's blood pressure or pulse was outside the parameters. The DON stated, We don't have them.Interview completed on 1/22/26 at 8:08 AM the Assistant Director of Nursing (ADON) explained they recently found out management were the only ones that could access the [specific] notification system. The nurses have to notify the provider by facsimile (fax). She would expect if Resident #12's pulse was below the parameters, the nurse would re-assess as sometimes it is the Certified Medication Aides (CMA's) that take the pulse and blood pressure, then the nurse would fax the provider with the information. During an interview on 1/22/26 at approximately 8:59 AM the Provider/Medical Director explained he would expect the nurses to follow the physician order for the parameters on the Cardizem. He further explained most of the time a fax is appropriate, but if the heart rate is falling to 36 or in the 40's he would appreciate a phone call notification. The Change in Condition Policy, undated, provided by the facility directed the facility would promptly notify the physician of vital signs that fall outside of the clinical reference ranges in accordance with physician-specified parameters.

Based on record review, and staff interviews the facility failed to provide residents and family with adequate notification of financial responsibility when Medicare Part A services were scheduled to be discontinued for 1 of 3 residents reviewed (Resident #42.) The facility reported a census of 37 residents. Findings include:Record review for Resident #42 indicated he received skilled services from 12/17/25 to 1/6/26. Resident #42's Electronic Health Record lacked documentation of the notices being given. On 1/22/26 at 10:49 AM, the Administrator reported Resident #42 did not get a notice of skilled care ending. The Administrator reported she was unaware that the notices were for part A.

Based on observation, clinical record review, staff interviews, and Manufacturer's Patient Information review, the facility failed to follow the Manufacturer's Patient Information for proper administration of an insulin pen for 1 of 1 resident sampled (Resident #9). The facility identified a census of 37 residents. Findings include:During Medication Administration Task observation on [DATE] at 7:57 AM Staff C, Licensed Practical Nurse (LPN) reviewed Resident #9's [DATE] Electronic Medication Administration Record (EMAR) which contained a physician order to administer Novolog (insulin aspart) inject 5 units under the skin (subcutaneously) one time a day for diabetes mellitus. Staff C removed Resident #9's insulin pen from the medication cart, placed a needle on the pen without cleaning the rubber stopper with alcohol, dialed the dose knob to 5 units without priming the pen per the Patient Instructions and stated she planned to administer Resident #9's insulin as she walked approximately 10 feet away from the medication cart toward where Resident #9 sat.Staff C was stopped from administering the insulin due to unsafe practice of not priming the pen. Staff C returned to the medication cart. Set the insulin pen to 2 units and primed the insulin pen, then set the dial knob to 5 units. Staff C stated she was ready to give the insulin and walked to within a few feet of Resident #9, when Staff C was stopped a second time from administering the insulin. Staff C failed to check the insulin expiration date. Resident #9's insulin pen's date open label was blank. Staff C check the medication cart for the insulin box but there was no box or bag for the insulin pen. Staff C then pointed to the label on the insulin pen stating the insulin expired in 2027. Staff C was unaware the insulin was only good for 28 days after the pen was opened. Staff C asked the Director of Nursing (DON) what she should do and she was directed to get a new Novolog insulin pen. Staff C obtained a new Novolog insulin pen, failed to clean the hub with alcohol prior to attaching the needle, primed the pen with 2 units, then set the dial knob to 5 units. Staff C administered the 5 units of insulin in Resident #9's upper right arm and failed to complete a 6 second hold during the administration. A [DATE] review of Resident #9's Clinical Record showed a Physician Order to increase the morning dose of Novolog insulin to 5 units signed by the Provider on [DATE].A [DATE] review of Resident #9's Diabetes Mellitus Care Plan directed to administer hypoglycemic (blood sugar lowering) medications as ordered by the physician. Interview completed on [DATE] at 9:36 AM the Assistant Director of Nursing (ADON) reported the nurses would follow the manufacturer directions that come in the box with the insulin pen. The nurse should prime the pen with, she believed 1-2 units of insulin per the manufacturer's directions, then follow the physician order and set the pen to the amount of ordered insulin and give the insulin to the resident. On [DATE] at 9:40 AM the ADON provided the manufacturers Patient Information for the Novolog Injection Pen. She explained the insulin pen did require the pen be set to 2 units to properly prime the pen. The ADON further explained the nurses have a cheat sheet on the medication room fridge that guides them on how long the insulins are good for. Observation on [DATE] at 9:42 AM revealed a small sign labeled Insulin Expiration after Opening hung on the front of the medication room refrigerator. Under (insulin) pens the sign failed to list Novolog (insulin aspart) on the guide. Further observation revealed another small sign hanging on the front of the refrigerator that stated all insulins need an open date and expiration date on both bottle and box when opened. During an interview on [DATE] at 11:15 AM the Director of Nursing (DON) explained she expects the nurses to prime the insulin pen with two units of insulin prior to administering the insulin. The insulin pen is to be dated when opened and if an insulin pen is undated, then the insulin pen should not be used. When queried on insulin pen administration, the DON failed to identify the insulin pen should be held for six seconds to ensure full administration.During an interview completed on [DATE] at 8:30 AM, the DON reported the facility did not have an insulin pen administration procedure until yesterday ([DATE]) evening when she wrote a new procedure to educate the nurses on. The Manufacturer Patient Information Novolog (insulin aspart) Injection under preparing the Novolog Flex Pen directed to pull off the pen cap and wipe the rubber stopper with an alcohol swab. Under Giving the Air shot before each injection the following was directed:a. Turn the dose selector to 2 units.b. Hold the insulin pen with the needle pointing up. Tap the cartridge gently with a finger a few times to make any air bubbles collect at the top of the cartridge.c. Keep the needle pointing upward, press the push-button all the way in until the dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. Under Giving the Injection, the Patient Instructions directed to keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out of the skin to ensure the full dose has been given.

Based on record review, staff, Pharmacist, and Physician interview the facility failed to provide timely interventions and notification to the resident's Physician after a resident presented with a low blood pressure. was lethargic, drowsy, and had blood pressure of 63/36 millimeters of mercury (mmHg) (normal blood pressure is considered to be less than 120/80 millimeters of mercury (mmHg) for one of three residents reviewed for assessment and intervention (Resident #1). The facility reported a census of 40 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderate cognitive impairment. The MDS also identified the resident was dependent (staff did all the effort) for assistance with transfers and partial to moderate assistance (staff did less than half the effort) with bed mobility. The MDS include diagnoses of hypertension, heart failure, anemia, and fracture.Review of Resident #3's Skilled Charting assessment dated [DATE] at 11:02 PM, locked on 9/17/25 at 12:06 AM, documented vital signs of temperature 97.6 degrees Fahrenheit (F) (normal temperature 97-99 F), pulse 89 beats per minute (bpm) (normal 60-100 bpm) respiration of 16 (normal respirations 16-20), blood pressure of 63/36 mmHg (normal blood pressure, top number less than 120 and bottom number less than 80) lying down, and with a recheck blood pressure of 61/50. The document reported the resident presented as very drowsy and did answer but slept through assessment and denied pain.Review of Resident #1 Medication Administration Record (MAR) for September 2025 documented the following opioid (a type of drug that acts on the body's opioid receptors to reduce the intensity of pain signals) medication orders effective on 9/17/2025: Fentanyl patch 12 micrograms (mcg) change every three (3) days and Hydromorphone 1 milligram (mg) every six (6) hours.Review of Resident #1's ED Provider Notes from the Hospital, dated 9/17/25 at 8:11 AM, documented a chief complaint of altered mental status with low blood pressure. Review of Physical Exam section revealed Resident #1's temperature 97.9, pulse 98, respirations 29, blood pressure 89/54, and oxygen 93% (normal above 90%). The ED Provider Notes further revealed the resident had a recent thoracic spine fracture that was not operable and had been having trouble with pain management. [Resident #1] was having delusions when he was on Dilaudid (Hydromorphone), medication was decreased, [Resident #1 received Fentanyl patches, and was recently started on Risperdal 1 milligram (an antipsychotic medication, it is believed to work by balancing levels of dopamine and serotonin in the brain) twice a day. Per the primary care team the Risperdal did help the delusions as well as decreasing his Dilaudid dose. However, since last night [Resident #1] has had decreased blood pressure and altered mental status. Review of the Care Plan for pain medication therapy (Hydromorphone) included the following inventions, both dated 9/20/25: Hold medication if [Resident #1] was lethargic and/or had decreased responsiveness. Per Provider, if [Resident #1's] systolic (top number) of the blood pressure is less than 90 and/or diastolic (bottom number) is less than 60, update the provider or on call provider.An interview on 10/16/25 at 9:06 AM with Resident #1's Physician revealed he would expect to be notified of blood pressures lower than 90/50 mm/Hg. An interview on 10/16/25 at 9:24 AM with Staff D, Licensed Practical Nurse (LPN) explained the Physician increased risperidal from 0.5 mg to 1 mg, and thought low blood pressure was related to the increased dose. The resident did not sleep well the night prior and he was responsive when given his scheduled dilaudid. Staff D explained a blood pressure lower than 90/50 would require a physician notification. Staff D also explained she tried different blood pressure cuffs as she thought it was an error blood pressure reading. An interview on 10/16/25 at 11:01 AM with the facility's Pharmacist informed she would have thought a nurse would call the Physician if there was a concern related to a low blood pressure. An interview on 10/16/25 at 2:56 PM with Staff E, Certified Nursing Assistant (CNA) informed she observed Resident #1 on 9/17/25 around 12:30 AM and had no concerns with him at the time. She then revealed she observed Resident #1 more than 20 times throughout the night, and he was the same. She also revealed the nurse checked on him frequently. She then informed at about 5:30 AM his eyes were glazed and he appeared different. An interview on 10/20/25 at 2:48 PM with the Assistant Director of Nursing (ADON) revealed on 9/17/25 at approximately 6:20 AM she assessed Resident #1 with Staff D and noticed he did not present as he normally did, she assessed his blood pressure and it read 84/62. She then informed she would have expected Staff D to reassess Resident #1 blood pressure when it was 60/36 with a manual blood pressure cuff to ensure accuracy and to notify the ADON, the Director of Nursing (DON), or the on-call physician of the low blood pressure. An interview on 10/20/25 at 3:58 PM with the DON and Administrator explained she would have expected the Staff D to reassess resident #1 blood pressure on 9/16/25 to ensure accuracy using a manual blood pressure cuff and to notify the ADON, the Director of Nursing (DON), or the on-call physician of low blood pressure.

Based on observation, document review, manufacturer information, and staff interview the facility failed to have a proper system in place to ensure proper sanitation of all dishware. The facility identified a census of 37 residents. Findings include: Upon entrance to the facility on [DATE] at 10:00 AM the Administrator reported the facility had a COVID 19 outbreak with 9 residents positive for COVID 19. Observation on 11/18/24 at 10:26 AM revealed the dishwasher running with a wash temperature of 150 degrees and a rinse temperature of 151 degrees. Further observation revealed a Lo Temp Sanitizer chemical system in place running to the dishwasher. Staff K, Dietary reported they had changed the system over to a chemical sanitation system. Staff K tested the dishwasher for proper sanitation by utilizing a Hydrion test strip. After running the dishwasher through two different wash/rinse cycles, Staff K dipped the test strip into the hot water. She laid the test strip next to the test chart and stated the dishwasher was sanitizing. The test strip remained a light gray color when compared to the color chart registered at 10 parts per million (PPM). Staff K repeated the above testing again with no change noted in the test strip. Both test strips failed to change to a dark purple color to indicate a disinfection level of 50 -100 PPM. Inspection of the dish washer revealed a container of low-temperature sanitizer sitting on the floor and a chemical dispense system on the wall to the right of the dishwasher. Manufacturer Directions for Hot water Sanitizing and Chemical Sanitizing noted posted on the front panel of the dishwasher directed the following: 1. Hot Water Sanitizing a. Wash Temperature 150 degrees Fahrenheit minimum b. Rinse Temperature 180 degrees Fahrenheit minimum 2. Chemical Sanitizing a. Wash Temperature 120 degrees Fahrenheit minimum b. Rinse Temperature 120 degrees Fahrenheit minimum. A 11/18/24 11:39 untitled document provided by the facility contained a service note for the dishwasher noting the dishwasher tested too low for chemical disinfection. The product line was disconnected from the injection port and the port was plugged. The line was hooked up to a different port and the dishwasher tested fine. On 11/20/24 at 11:45 PM the Certified Dietary Manager (CDM) reported they had the dishwasher inspected on 11/18/24 and found a crack in one of the dispensing lines and another dispensing line for the sanitizer had blown off the back of the dishwasher. Their vendor had fixed the issue on 11/18/24 after the surveyor identified the dishwasher had not been sanitizing the dishes. Interview on 11/20/24 at 1:30 PM the CDM voiced the sanitation strips on the dishwasher are run three days a week by the 8:00 AM dishwasher. If they do not do the test strip, then she does it. She didn't keep the strips prior to 11/09/24 because all the testing strips turn back to a light tan color. A review of the November 2024 Dish Machine Temperature Chart revealed no documented test strips prior to 11/09/24. The Chart revealed the only testing completed on 11/09/24 and 11/13/24 were a tan color so documentation could not support if the dish machine was properly sanitizing. The November 2024 Dish Machine Temperature Chart documented a wash temperature ranging from 151 to 155 degrees and a rinse temperature ranging from 109 to 122 degrees. On 12:54 PM the CDM reported she could not find the Dish Machine Temperature Chart Documentation for October 2024. The CDM could not verify the last time the dishwasher had actually been sanitizing based on the documentation. The CDM reported Staff L, Dietary staff, signed she completed the sanitation strip test on 11/09/24. On 11/20/24 at 1:25 PM Staff L, Dietary, verbalized she runs the dish washer in the kitchen, but she only works in the kitchen about every three weeks. She doesn't recall running the test strip check on the dishwasher on 11/09/24. Normally they ask the CDM for a test strip. They place the test strip on a fork and put it on a rack. They run a load of dishes through the machine. The test strip will turn yellow. She hasn't done a test strip on the dishwasher for around a year. If the dish machine is not correctly sanitizing, she would notify the CDM. Interview on 11/20/24 at 1:32 PM Staff G, Certified Nursing Assistant (CNA) and Dietary voiced she works in the kitchen every once in a while. She reported she checks to be sure the dishwasher temperatures are within the parameters on the Dish Machine Temperature Chart. She usually never documents the dishwasher temperatures. She just gives the temperature ranges to the [NAME] and the [NAME] records the information. The [NAME] will direct them when to start using the three-compartment sink to wash, rinse, and sanitize the dishes. She has never mixed the sanitizer for the three-compartment sink. She reported the last time they used the three-compartment sink was about a month ago when the system was put in. On 11/20/24 at 1:36 PM Staff M, Dietary runs the dishwasher frequently. She does test the dishwasher, but she looks to Staff K and the CDM for guidance. She sticks the test strips in the water then compares to the box to ensure the dishwasher is sanitizing. She disposes of the test strip after she tests the machine. She does not write anything down on the documentation sheet. She would report to the CDM right away, then call maintenance if she had issues with the dishwasher. They use the three-compartment sink when the dishwasher is down. She has only had to do it once and she didn't know how to do it, so she had to have the CDM walk her through mixing the sanitizer. That was about a month ago when maintenance was working on the dishwasher. During an interview on 11/20/24 at 1:45 PM the Maintenance Director reported about a month ago they were converting the dishwasher over to a cold-water disinfection system. He relied heavily on the guy setting up the system. He reported a vendor came out to service the machine on 11/18/24. They serviced the pump as the sanitizer level was too low. They found a line in the back of the machine had blown off and no one noticed it. They bypassed that and upped the level of the sanitizer to where it should be. He couldn't say how long the line had been off of the dishwasher. The machine is computerized so he is surprised there isn't some sort of warning that comes up on the machine. It had to have been in the past week or weekend that the hose popped off. A few weeks ago, staff were complaining there was water leaking on the floor under the dishwasher. He had to come in and change a fitting on the dishwasher and everything was okay at that time. In the past week, maybe last Wednesday, the clear goblet glasses were more cloudy. So that may have indicated a change, but he wasn't putting two and two together at that time. Observation on 11/20/24 at 2:08 PM the CDM ran a test strip through the dishwasher and revealed the test strip at 100 PPM appropriately sanitizing. The CDM reported no one had come to her with any reports the dishwasher was not running correctly so she felt the issue with the line had to have been in the past week or two. Going forward she plans to have the staff document the PPM strip test on the Dish Machine Temperature Chart. She expects if the dishwasher is not sanitizing, the staff will immediately stop use of the dishwasher, report to her and the Maintenance Director and move to using the three-compartment sink system for wash, rinse, and sanitation. The facility lacked a documentation system to ensure prior dishware sanitation in the dishwasher.

Based on observation, clinical record review, Center for Disease Control and Prevention (CDC) Infection Control Guidance: Sudden Acute Respiratory Syndrome (SARS) COVID 2 Guidelines, COVID 19 Clinical Guidance Summary Review and staff interviews, the facility failed to follow CDC COVID 19 guidance and utilize personal protective equipment (PPE) to prevent the potential spread of COVID 19 affecting 7 of 10 resident in the CCDI (chronic confusion or dementing illness) unit (Resident #4, #10, #13, #25, #21, #36 and #38). The facility reported a census of 37 residents. Findings include: Upon entrance to the facility on [DATE] at 10:00 AM the Administrator reported the facility had 9 residents on isolation for COVID 19. The facility provided a Resident Roster which listed Residents #4, #10, #21 and #36 as positive for COVID 19 in the CCDI unit. Resident #13 tested positive for COVID 19 on 11/19/24. Observation on 11/18/24 at 11:29 AM revealed Resident#21 with an isolation bin outside of her room that contained N95 masks (National Institute for Occupational Safety and Health (NIOSH); an N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. Note that the edges of the respirator are designed to form a seal around the nose and mouth) masks, gloves, isolation gowns and a face shield. Resident #21 room contained no signage to indicate any type of isolation precautions or special use of PPE. Further Observation revealed isolation bins outside of Resident #4, #10 and #36 rooms. Resident #4 and #10 lacked signage indicating any type of special precautions or what type of PPE was required for care. Resident #36 had a CDC sign for Enhanced Barrier Precautions (EBP) due to use of a catheter on the top of the isolation bin. No additional signage noted to direct precautions for COVID 19 or any CDC signage on how to properly apply and take off Personal Protective Equipment (PPE). Observation on 11/18/24 at 11:24 AM Staff F, Licensed Practical Nurse (LPN) wearing a medical mask responded to Resident #10 fall alarm. Staff F checked Resident #10 from the open doorway. Resident #10 sat in her recliner not attempting to get up. Staff F applied an isolation gown and gloves to enter into Resident #10 room. Staff F failed to apply an N95 mask and eye protection. Staff F shut off the fall alarm and approached resident within 4 foot of the resident to offer a drink of water. Resident #10 did not wear a mask. At 11:26 AM Staff F removed the isolation gown and gloves to exit Resident #10 room. Staff F failed to change the medical mask when exiting the COVID 19 isolation room. On 11/18/24 at 11:34 AM Resident#4 got out of bed and was up walking in his room. Staff F followed up with resident asking if he had pain. Staff F told Resident #4 she would get his pain cream and be back. At 11:35 AM Staff F performed hand hygiene, donned an isolation gown, gloves, goggles and wore her existing medical mask into Resident #4 room to administer his medication and pain cream. Resident #4 observed not wearing a mask as Staff A stood within a few feet of him administering his medications. Staff F exited Resident #4 room still wearing the same medical mask. Staff F walked to the medication cart and prepared medications for medication pass. At 11:41 AM Staff F approached Resident #38 (COVID negative resident) still wearing the medical mask from the COVID isolation room) sitting within 2 feet of Resident #38. She handed him a glass of water and his medication cup. Staff F touched Resident #38 left wrist to adjust his watch for him. At 11:46 Staff F assisted Resident #38 back to his room to administer his eye drops. She then walked with him out of the room talking to him within 4 feet of the resident still wearing the same medical mask worn into a COVID isolation room. Resident #38 leaned toward Staff F within 2 feet prior to walking along-side the resident. At 11:49 AM Staff F walked along-side Resident #38 around the unit within 2 feet of the resident. At 11:53 AM Staff F assisted Resident #38 to sit down at the dining room table. On 11/18/24 at 11:37 AM Resident #10 set off her chair alarm. Staff F immediately went to the doorway to check on the Resident #10. Resident #10 sat in the room recliner, but did not attempt to get up. Staff F applied an isolation gown, gloves, N95 mask and goggles to enter into Resident #10 room to assist to the bathroom. Resident #10 did not wear a mask. On 11/18/24 11:54 AM Staff G, Certified Nursing Assistant (CNA) assisted Resident #21 (COVID positive; not wearing a mask) from her room approximately 50 feet through the main dining area to the tub room passing within four feet of Resident #38 (negative for COVID 19) who sat at the dining room table. Staff G wore an N95 mask, isolation gown, gloves and eye goggles. The Hospice CNA followed Staff G out of Resident #21 room wearing only a medical mask and gloves following to the tub room. At 11:58 AM Staff G came out of the tub room wearing her full PPE and went past Resident #38 within 4 feet of him sitting at the table and went into Resident #21 room. At 11:59 AM Staff G exited Resident #21 room with her PPE off. Staff G failed to disinfect the goggles when she exited Resident #21 room. At 12:16 PM the Hospice Aide opened the tub room door to ask Staff A, Infection Preventionist for help. The Hospice Aide stood within 6 feet of Resident #21. Resident #21 observed not wearing a mask and the Hospice Aide observed not wearing an isolation gown. At 12:17 PM Staff F applied an isolation gown, gloves, N95 mask and goggles to enter the tub room to assist the Hospice Aide with Resident #21. At 12:19 PM the Hospice Aide assisted Resident #21 out of the shower room in the wheelchair. Resident #21 had not been provided with a mask. The Hospice Aide wore only gloves, a medical mask and goggles at this time. The Hospice Aide wheeled Resident #21 through the dining room within 4 feet of Resident #38 and Resident #25 (COVID negative resident). At 12:21 PM Hospice Aide walked out of Resident #21 room still wearing her gloves, medical mask and goggles. The Hospice Aide removed her gloves right before punching in the code to leave the dementia unit. The Hospice Aide continued to wear the same medical mask out into the main part of the nursing home. On 11/18/24 12:22 PM Staff A was alerted the Hospice Aide left the unit to enter the nursing home area wearing the same medical mask from the COVID isolation room. Staff A reported all the resident up at the main nursing home had already had COVID. When specifically asked by the Surveyor if every resident had COVID 19, Staff A replied, twelve resident had COVID on the other end. Staff A verbalized the Hospice Aide only sees one resident and indicated it wasn't a problem. On 11/18/24 at 2:36 PM Staff H, CNA donned an isolation gown, gloves, goggles, and wore her existing medical mask, then entered Resident #10 room without donning an N95 mask. Staff H directed Resident #10 let's go to the bathroom. At 2:47 PM Staff H came out of Resident #10 room and placed the goggles on top of the isolation bin without sanitizing the goggles. On 11/18/24 at 2:44 PM Staff G verbalized she uses alcohol wipes to sanitize the goggles after use in a COVID 19 isolation room. On 11/19/24 at 7:51 AM the Surveyor entered the unit to see Staff I, Registered Nurse (RN) performing a nasal swab test for COVID 19 for Resident #13 in the lounge area next to the nurses desk wearing a medical mask, gloves and her prescription eye glasses. Resident #38 sat at the dining room table in the lounge. Resident #13 exhibited nasal congestion and a congested cough. Resident #13 sneezed twice after the nasal swabbing with Staff I standing approximately two foot from the resident. The DON stood within four to six feet of Resident #13 wearing only a medical mask and gloves as she instructed Staff I how to complete the COVID test. The DON verbalized due to Resident #13 symptoms they were testing her again today for COVID 19. Staff J stood within 6 foot of Resident #13 wearing only a medical mask. At 7:59 AM the DON instructed Staff J, CNA that Resident #13 likely had COVID 19 and to take her to her room and make her comfortable. Staff J assisted Resident #19 via wheelchair back to her room and assisted to put her call light in reach without performing hand hygiene, donning an N95 mask, isolation gown, gloves or eye protection. Observation at 8:00 AM revealed Staff I entered into Resident #25 room wearing the same medical mask that she used when she tested Resident #13 for COVID 19. Staff I then came out of Resident #25 room and started to put on an isolation gown. The DON informed Staff I Resident #25 was not COVID positive, but she could still wear PPE in the room if she wanted to. Observation on 11/19/24 at 8:09 AM revealed Staff I performed hand hygiene, donned an isolation gown, applied an N95 mask with a medical mask over top and wore her regular prescription eye glasses into Resident #10 room to administer her morning medications. Observation at 8:11 AM revealed plastic goggles with side shields lay on top of the isolation cart outside of Resident #10 room. Resident #10 coughed twice with Staff I within two foot of her during medication administration. At 8:12 AM Staff I exited Resident #10 room after removing her gown and gloves in the room. Staff I came out of the room and removed her dirty mask and donned a new medical mask without performing hand hygiene between the mask change. On 11/19/24 at approximately 8:13 AM the Director of Nursing (DON) asked Staff I about Resident #13 COVID test. Staff I checked the test and reported Resident #13 was positive for COVID 19. During an interview on 11/19/24 at 8:15 AM the Director of Nursing (DON) reported she expected staff to wear an N95 mask, isolation gown, gloves, and protective eyewear into a COVID positive isolation room. She reported staff are to use the goggles with side shields which are in the isolation bins. The goggles should be sanitized with the Sani wipes when the staff exit the rooms as they do not have disposable face shields. At 8:18 AM she voiced if a resident is symptomatic, she imagined they should wear full PPE (N95, isolation gown, gloves and eye protection) when testing for COVID 19. She acknowledged that they did not have any signage on Resident #4, #10, #36 room doors to communicate need for PPE and type of precautions. She verbalized they have a communication sheet they use to communicate resident positive for COVID 19 through report, but acknowledged this does not communicate to outside vendors and visitors if precautions are needed. She voiced the vendors or visitors would see the isolation bins and probably know resident were on precautions. She reported she didn't see any of the sanitizing wipes available in the unit to sanitize goggles. Interview on 11/19/24 at 9:36 AM Staff I reported she received in report which residents were positive for COVID 19 without much more direction. She was just told she could wear her (prescription) glasses, a medical mask and gloves for PPE to care for COVID 19 residents. They were not given any direction on sanitizing goggles. She works as needed and was just being honest with her answers. Interview on 11/19/24 9:52 AM Staff J revealed he was taught to wear an N95 mask, isolation gown, gloves and eye protection into a COVID 19 room. Surveyor shared observation that he did not have goggles on early this morning when he came out of Resident #10 room. He stated his goggles had fallen off in the resident's room. He didn't want her to fall so he just kept going and went back to get the goggles later. Observation on 11/19/24 at 8:23 AM the DON instructed Staff I on proper PPE to wear into the COVID isolation rooms, changing masks when exiting a COVID 19 room, performing hand hygiene and sanitizing goggles after use in the COVID 19 isolation rooms. During an interview on 11/20/24 at 1:19 PM the DON reported the facility started the COVID 19 outbreak on 10/29/24. Interview on 11/21/24 at 9:28 AM with the Infection Preventionist revealed she expects staff to follow the posted (CDC) signs to apply and take off PPE. They follow the CDC procedures for applying and removing PPE for COVID 19 isolation. She voiced residents suspected of COVID 19 symptoms should be tested in their rooms and the nurses should wear an N95 mask, isolation gown, gloves and eye protection during the test procedure. The facility has some disposable goggles, but the plastic goggles should be sanitized with the Clorox bleach wipes to disinfect the goggles for three minutes. On 11/21/24 at 9:34 AM Staff H reported she is required to disinfect the goggles after being in a COVID 19 isolation room with alcohol wipes. During an interview on 11/21/24 at 9:45 AM the MDS Coordinator reported she had previously been the Infection Control Preventionist and she is still assisting Staff A with infection control as she is new to the position. She reported she expect staff to apply a N95 mask, gown, gloves and eye protection to enter into a COVID 19 isolation room. Staff should remove their PPE as close to the exit door as possible. Once out of the room, staff should perform hand hygiene and apply a new mask. The goggles should be disinfected after use. She reported she likes to use the small disinfectant packets, but couldn't recall the name of the disinfectant. She then said the Sani wipes. She wasn't sure on the length of time the Sani wipes needed to stay wet on the goggles for disinfection, but thought 3-5 minutes. Staff should test residents suspected of COVID 19 in their rooms wearing an N95, isolation gown, gloves and eye protection. On 11/21 24 the Infection Preventionist provided the Iowa Health Care Association Member COVID 19 Clinical Guidance Summary dated August 7, 2023 for review as part of their facility policies/procedures. The Guidance included the intent of the document to provide clinical guidance and best practices for implementing recent CMS changes. CMS recommends the application of Core Principles of COVID 19 Infection Prevention as noted below: a. Hand hygiene with use of alcohol-based hand rub is preferred. b. Face covering or mask (covering mouth and nose) in accordance with CDC guidance. c. Appropriate staff use of PPE. The Guidance further outlined Transmission-Based Precautions: Transmission-based precautions (TBP) should be applied when caring for a resident who has suspected or confirmed COVID 19 infection. Health Care Personnel (HCP) who enter the room of a resident on TBP should adhere to standard precautions, as well as wear a NIOSH-approved respirator (N95), gown, gloves and eye protection (i.e., goggles or face shield that covers the front and sides of the face. Respirators should be used for care provided to a COVID 19 positive resident, as indicated in transmission-based precautions. The Guidance further directed while (COVID) tests are pending, residents with signs and symptoms should be placed into TBP. The Guidance defined close contact as being within six feet of a COVID positive individual for 15 minutes or more within a 24 hours period. Higher-risk exposure is defined as an HCP who had prolonged (15 minutes or more in a 24 hour period) with a person who confirmed positive for COVID 19 and one of the following: a. HCP were not wearing a respirator (or if wearing a face mask, the person with COVID infection was not wearing a cloth mask or facemask). b. HCP was not wearing eye protection if the person with COVID infection was not wearing a cloth mask or facemask. The Testing Safety Considerations specified during specimen collection, facilities must maintain proper infection control and use recommended PPE, which includes a NIOSH-approved N95 or equivalent or higher-level respirator, eye protection, gloves and a gown when collecting specimens. The 6/24/24 CDC COVID 19 Infection Control Guidance: SARS-CoV-2 under recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection directs the following: 1. Personal Protective Equipment a. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 2. Visitation a. Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. 3. Environmental Infection Control a. Dedicated medical equipment should be used when caring for a patient with suspected or confirmed SARS-CoV-2 infection. All non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to the manufacturer's instructions and facility policies before use on another patient.

Based on record review, staff interviews, and policy review the facility failed to ensure 1 of 16 residents Advance Directive forms was signed by the resident and their Doctor in a reasonable amount of time upon admission to the facility (Resident #9). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #9 documented an admitted into the facility of 10/17/24. The MDS also documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Record review on 11/18/24 at 2:40 PM revealed Resident #9 Advance Directives form documented Resident #9 requested an order for Do Not Resuscitate (DNR) on 10/17/24, however, the form lacked documentation of her Physicians signature giving an order for her wishes Record review of Resident #9 Medication Review Report dated 10/18/24 gave an order for DNR Code signed by her Doctor, but lacked Resident #9 request. Follow up record review of Resident #9 Advance Directive form on 11/19/24 revealed her physicians signature was obtained for her DNR order on 11/19/24. During an interview on 11/21/24 at 11:03 AM with the facilities Administrator and Director of Nursing revealed they would expect every resident Advance Directives form be signed as soon as possible upon admission to the facility or within a reasonable amount of time. Review of the facilities undated policy, Advance Directive Policy and Procedure on 11/21/24 lacked a procedure to obtain physicians signature on Advance Directive forms.

Based on record review, staff interviews, and policy review the facility failed to ensure antipsychotic medication (a class of drugs used to treat severe mental health disorders and psychotic symptoms) had appropriate diagnoses for use and create resident specific interventions and medication side effects for 1 of 1 residents reviewed (Resident #36). The facility also failed to obtain informed consent for use of psychotropic medications for 1 of 1 residents reviewed (Resident #36). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #36 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS also documented diagnoses of dementia and anxiety, and was taking antipsychotic and antidepressant medications. Record review of Resident #36 orders in his Electronic Health Record (EHR) on 11/21/24 revealed his first order for antipsychotic medications started on 10/4/24 and had frequently changed. Record review of Resident #36 current orders in his EHR on 11/21/24 revealed the following antipsychotic medications were ordered on 11/19/2024 and currently in use: 1. Quetiapine (Seroquel) 12.5 mg bedtime for behaviors 2. Quetiapine (Seroquel) 12.5 mg daily as needed for agitation until 11/29/2024 Record review of Resident #36 Progress Note dated 11/19/2024 at 8:34 AM documented his as needed Quetiapine 12.5 mg daily as needed until 11/29/2024 was for behaviors. Record review of Resident #36 current Care Plan on 11/19/24 lacked resident specific intervention for use of as needed Quetiapine. The Care Plan also lacked instruction to staff he was on antipsychotic medications and side effects to monitor for. During an interview on 11/21/24 at 8:13 AM with the facilities MDS Coordinator revealed the facility does not have a process to obtain consent or refusal for psychotropic medications. She informed the facility will educate families but unsure what each nurse will say, and there is not a formal document with side effects and risks for usage of psychotropic medications. During an interview on 11/21/24 at 10:26 AM with the facilities Social Worker revealed she would expect Resident #36 Care Plan to have resident specific interventions for as needed antipsychotic medications During an interview on 11/21/24 at 11:03 AM with the facilities Administrator and Director of Nursing revealed they would expect resident Care Plans to address usage of psychotropic medications, side effects to monitor for, and resident specific interventions.

Based on record review, staff interview, and policy review the facility failed to ensure 1 of 1 residents reviewed for falls with major injury fall interventions were in place at the time of a fall when a clip alarm to alert staff a resident was moving failed to be attached to a residents clothing (Resident #36). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #36 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS also documented diagnoses of dementia and anxiety. The MDS revealed he is dependant on staff for walking and needs substantial to moderate assist with transfers. Record review of the facilities Root Cause Analysis for Resident #36 fall dated 9/28/24 documented his fall occurred in the facilities dementia unit lobby at 5:30 AM. Prior to the fall he was sleeping in a recliner with the foot rest up. Resident #36 used two (2) alarms, a clip alarm to his clothing and a motion sensor and they were not in use during the fall. Record review of Resident #36 Fall Root Cause Analysis Worksheet for his fall on 9/28/24 documented a list of contributing factors to be: a. Alarm not utilized b. Recent decrease/discontinue of medications c. Staff knowledge regarding his Care Plan and Alarm usage Record review of State for Resident #36 Fall Resulting in Fracture signed by the Director of Nursing (DON) on 9/30/24 revealed the following: On 9/28/24 Staff B, Certified Nurse Aide (CNA) was working in the dementia unit of the facility and during the time of Resident #36 fall reported she had been doing a lot of one on one with Resident #36 throughout the night as well as sitting next to him in the lobby. She then informed Resident #36 was resting in the recliner and both CNA's on the unit went to provide care for another resident on rounds during the time of the fall. Staff B informed she was unsure if Resident #36 was to have an alarm on while in the lobby and did not know where the Care Plan was to check it. She informed she would keep other residents doors slightly open so she could periodically monitor Resident #36 when assisting the other resident in the room. Record review of a Major Injury Determination Form for Resident #36 fall on 9/28/24 revealed his fall was determined to be a major injury by his provider on 10/2/24. Record review of Resident #36 current Care Plan on 11/19/24 instructed on 5/28/24 and intervention to have a clip alarm at all times was implemented and revised on 10/1/24. During an interview on 11/21/24 at 8:13 AM with the facilities MDS Coordinator revealed she revised Resident #36 Care Plan after his fall on 9/28/24 to clearly state his clip alarm is to be in place at all times. During an interview on 11/21/24 at 11:03 AM with the facilities Administrator and Director of Nursing revealed they would expect staff to follow all interventions on residents Care Plans. Record review of the facilities undated Fall policy instructed the following: Determine potential causes for the fall and add teaching and/or interventions to the plan of care to prevent another fall from occurring.

Based on record review and staff interviews the facility failed to ensure 1 of 1 residents Preadmission Screening and Resident Review (PASRR) reflected all current diagnoses related to mental health (Resident #3). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS also documented diagnoses of Major Depressive Disorder, Adjustment Disorder, Post Traumatic Stress Disorder (PTSD). The MDS dated [DATE] for Resident #3 documented diagnoses of Major Depressive Disorder, Adjustment Disorder, Post Traumatic Stress Disorder (PTSD). Record review on 11/20/24 of Resident #9 current PASRR completed on 11/21/2023 lacked diagnoses of Adjustment Disorder, PTSD. During an interview on 11/21/24 at 10:26 AM with the facilities Social Worker revealed she would expect Resident #3 diagnoses of PTSD be listed on her PASRR within a reasonable amount of time once diagnosed . She revealed she did not have a process to ensure all diagnoses are routinely reviewed but plans to review quarterly going forward. During an interview on 11/21/24 at 11:03 AM with the facilities Administrator and Director of Nursing revealed they would expect every resident PASRR to reflect current mental health diagnoses.

Based on record review, staff interview, and policy review the facility failed to complete comprehensive Minimum Data Set (MDS) assessments resulting in failure to implement a comprehensive Care Plan for 2 of 4 residents reviewed (Resident #3 and #36). The facility reported a census of 37 residents. Findings include: 1. The comprehensive Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS also documented diagnoses of Major Depressive Disorder, Adjustment Disorder, and Post Traumatic Stress Disorder (PTSD). During an interview on 11/21/24 at 10:26 AM with the facilities Social Worker revealed she would expect Resident #3 diagnosis of PTSD be on her Care Plan and include goals and interventions relevant to her PTSD. She revealed she did not have a process to ensure all diagnoses are routinely reviewed and implemented into the Care Plan but plans to review quarterly going forward. 2. The comprehensive Minimum Data Set (MDS) dated [DATE] for Resident #36 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS also documented diagnoses of dementia and anxiety and was taking antipsychotic medications. The Care Area Assessment (CAA) of the MDS lacked staff review and documentation of his antipsychotic medications and what would be implemented into the Care Plan. Record review of Resident #36 current Care Plan on 11/19/24 Care Plan lacked instruction to staff he was on antipsychotic medications and side effects to monitor for. During an interview on 11/21/24 at 8:13 AM with the facilities MDS Coordinator revealed she would expect antipsychotic medications be on the Care Plan. During an interview on 11/21/24 at 11:03 AM with the facilities Administrator and Director of Nursing revealed they would expect resident Care Plans to address resident diagnoses of mental health and usage of psychotropic medications, side effects to monitor for, and resident specific interventions. The facility policy, MDS 3.0 Completion with a copyright date of 2023, instructed the following: a. Based on the CAA review, key findings regarding a resident's status are documented, including the nature of the condition, complications and risk factors that affect the care planning decision, factors that must be considered in developing care plan interventions, and the need for referrals or evaluation by appropriate health professionals.

Based on observation, policy review, and staff interview the facility failed to properly label and date opened food prior to storage. The facility identified a census of 38 residents. Findings include: During an initial tour of the kitchen on 10/09/23 at 2:45 PM the following food items were observed not labeled and dated in the food storage areas: a. 1 package of hamburger buns with 3 1/2 buns left in the package b. 1 bag gluten free bread with 5 slices of bread in the bag c. 1/2 package of open coconut flakes d. 1 package 1/4 full of butterscotch baking chips e. 1/2 bag of mixed nuts f. 1/2 loaf of raisin bread g. 3/4 package of raspberry gelatin h. One 12 pack of Cream of Wheat with 7 packages left in the box i. One 12 pack of Cream of Wheat with 11 packages left in the box j. 1/2 bag of open frozen raspberries k. 1 container Hormel Thick and Easy nectar consistency water with hint of lemon 3/4 full l. 1 shaker cup of an unknown liquid substance, unlabeled and dated m. 1 container 3/4 full of Liqua Cel Orange Sugar Free drink n. 1 package of frozen pancakes with 7 pancakes inside o. 1/2 package of wonton strips During a follow-up visit to the kitchen the following observations of unlabeled and undated food were found: a. 1 bag gluten free bread with 5 slices of bread in bag b. 1/2 package of open coconut flakes c. 1 package 1/4 full of butterscotch baking chips d. 1/2 bag of mixed nuts e. 1/2 loaf of raisin bread f. One 12 pack of Cream of Wheat with 7 packages left in the box g. One 12 pack of Cream of Wheat with 11 packages left in the box h. Open package of [NAME] gluten free table crackers, undated i. 1/2 bag of cheese puffs j. 1 box of opened strawberry toaster pastries k. 1 package 1/2 full of Great Value gluten free cream cookies l. 1 box opened gluten free oatmeal m. 1 package of frozen hot dog buns with 3 hot dog buns left in the package n. 1/2 package of wonton strips On 10/11/23 at 11:34 AM Staff B, Dietary Aide, reported all food that is opened should be labeled and dated before being stored. She voiced the morning cook is to go through and clean out the fridges and remove any food items that are not labeled and dated. On 10/11/23 at 12:10 PM Staff C, Cook, reported all opened food is to be labeled and dated prior to being stored. During an interview on 10/11/23 at 12:15 PM Staff A, Dietary Manager, reported she expects all open food to be labeled and dated prior to storage. She voiced the morning and afternoon cooks are to go through and throw away any food that is not properly labeled and dated. She expected all staff to be responsible for properly labeling and dating food for storage and expected all staff to throw out food items that were not appropriately labeled, dated, or stored. The Food Handling Policy undated provided by the facility under Prevention of Contamination Guidelines specified the following: a. Cover, label, date and refrigerate al leftovers as soon as serving is completed. b. Store all pre-poured beverages and pre-portioned foods in refrigerator, covered and labeled until ready to serve. The Food Handling Policy did not address food labeling and dating of dry food pantry items.

Based on clinical record review, facility document review, policy review, and staff interview the facility failed to complete a thorough investigation after an allegation of abuse. The facility reported a census of 38 residents. Findings include: Resident #27's Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE]. The MDS listed diagnosis including Alzheimer's Disease. The MDS documented the resident required extensive assistance of 2 people for transfers, toilet use and personal hygiene. She required extensive assistance of 1 person for eating and dressing. She required physical assistance for bathing. The Progress Note written on 4/20/23 at 11:43 AM by Staff D, Registered Nurse (RN), documented Staff E, Certified Medication Aid (CMA), reported red marks on the resident's neck that were not there prior to the resident's shower. Facility document titled Incident Audit Report documented the red marks were noted at 7:15 AM. A summary of the situation typed by Staff F, Licensed Practical Nurse (LPN), documented Staff D informed her of the red marks at 9:00 AM. The same document records Staff F informed the Administrator at 11:10 AM. The Progress Notes, Incident Audit Report, and the summary lacked documentation of a head to toe assessment looking for additional injuries. The documents lacked physical assessments of other residents that had received showers by the same staff person that same morning. Facility Policy titled Abuse Prevention, Identification, Investigation and Reporting last revised on 11/28/16 directs the Director of Nursing (DON) or charge nurse to conduct a physical assessment immediately if an injury has occurred. The policy further directs staff to document the physical assessment in the resident's chart. During an interview on 10/11/23 at 3:57 PM Staff F stated she didn't know what to do with the alleged staff member so she separated him from the resident and waited for direction from the Administrator She acknowledged there was not an assessment documented for Resident #27. She acknowledged that no other residents were assessed for injury or abuse.

Based on clinical record review, facility document review, and staff interview the facility failed to report an allegation of abuse in the required 2-hour time frame to the Iowa Department of Inspections, Appeals, and Licensing (DIAL). The facility reported a census of 38 residents. Findings include: Resident #27's Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE]. The MDS listed diagnosis including Alzheimer's Disease. The MDS documented the resident required extensive assistance of 2 people for transfers, toilet use, and personal hygiene. She required extensive assistance of 1 person for eating and dressing. She required physical assistance for bathing. The Progress Note written on 4/20/23 at 11:43 AM by Staff D, Registered Nurse (RN), documented Staff E, Certified Medication Aid (CMA), reported red marks on the resident's neck that were not there prior to the resident's shower. Facility document titled Incident Audit Report documented the red marks were noted at 7:15 AM. A summary of the situation typed by Staff F documented Staff D informed her of the red marks at 9:00 AM. The same document records Staff F informed the Administrator at 11:10 AM. The Facility Self Report print out from the DIAL website documented a submission date and time of 4/20/23 at 3:02 PM. On 10/11/23 at 11:43 AM the Administrator acknowledged the allegations should have been reported to DIAL within 2 hours.

Based on observations, manufacturers recommendations, and staff interview the facility failed to ensure the automatic dishwasher sanitized dishes/utensils as required. The facility census was 31 residents. Findings include: During observations on the initial kitchen tour on 6/26/22 at 10:10 a.m. the surveyor noted the automatic dishwasher used by the facility dietary staff utilizes high water temperature to sanitize the dishes that are washed, observation of the digital temperature readout showed the wash cycle reached temperatures of 150 degrees and then the rinse cycle also reached temperatures of 150 degrees. Review of the manufacturers recommendation printed on the side of the automatic dishwasher on 6/26/22 at 10:10 a.m., revealed that for hot water sanitizing machines, they are to reach a temperature of at least 150 degrees in the wash cycle then are to reach a temperature of at least 180 degrees during the rinse cycle. During an interview at that time Staff A (cook), the day shift cook, stated they were not aware the automatic dishwasher was not reaching high enough temperature to sanitize the dishes and was not aware of any routine testing log for the dishwasher to monitor regularly for proper function. During an interview on 6/26/22 at 11:20 a.m. Staff A (cook) came to the surveyor and stated maintenance had been called to check why the automatic dishwasher did not reach the required high water temperature to sanitize dishes. Staff A stated they had not turned on the booster (used to increase the water temperature from 150 degrees to 180 degrees for the rinse cycle) but the booster has been turned on and the dishwasher is reaching the required temperatures. During a follow up observation in the kitchen on 6/27/22 at 9:55 a.m. found that the automatic dishwasher again was not reaching the required rinse water temperature of 180 degrees only reaching temperatures of 173 to 177 degrees with multiple cycles repeated by the Dietary Manager, so she called Maintenance again to check their booster for high water temperature. During an interview on 6/27/22 at 12:12 p.m. the facility Dietician stated she had been informed about the automatic dishwasher not reaching the required rinse water temperature of 180 degrees, maintenance had checked the booster but couldn't find the problem so a technician from their supplier was coming to find the problem and until then they will be using their 3 compartment sink and hand washing, rinsing, and sanitizing the dishes. During an interview on 6/28/22 at 7:53 a.m. the Dietary Manager stated the technician from their supplier did come and check the booster for high water temperature and found a heating element had burned out and that is why the water temperature did not reach the required temperature of 180 degrees, it was replaced and it does now reach the required temperaure to sanitize dishes.

Based on observation, record review and physician and staff interviews, the facility failed to serve Resident #1 a therapeutic diet as ordered by the physician. The sample consisted of 4 residents and the facility reported a census of 45 residents. Resident #1 was not served the ordered mechanical soft diet, choked and died . During the investigation, observation of a meal served revealed mechanical soft/ground meat diets were not served. The facility identified 8 residents were to receive ground meat/mechanical soft diets. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 5/23/14. The MDS identified the resident had [DIAGNOSES REDACTED]. Resident #1 had a moderately impaired cognitive ability, could understand others and could make self- understood. The resident required oversight of 1 staff person for transfers, walking and ate independently. The MDS reflected Resident #1 required a mechanically altered diet. Review of the Care Plan dated 6/2/14 identified Resident #1 feed self independently in the main dining room. Review of Resident #1's Medication Review Report (physician's orders [REDACTED]. Review of a form titled Diet Type Report dated 6/25/14 reflected Resident #1 had a diet order for regular, small servings, mechanical soft, and ground meat regular diet and to avoid known intolerances. The diet report identified 6 additional residents to receive ground meat diets. Review of the Daily Nurses Notes dated 4/27/14, reflected Resident #1 was eating breakfast and began to cough during the meal. The note reflected the resident spoke and reported the food "went down wrong". The staff notified the resident ' s physician. On 4/28/14 a telephone order reflected the physician ordered speech therapy to evaluate and treat as indicated and determine an appropriate diet. The Speech Therapist evaluation and plan of treatment dated 4/29/14, the Speech Therapist recommended a swallow evaluation for the resident and ordered a diet of nectar thick liquids and regular solids with ground meat. Review of the Video Swallow report dated 4/30/14, the Speech Therapist ordered the following: thin liquids with mechanical soft solids, utilize a chin tuck strategy, encourage the resident to take small sips/bites and take 1 sip/bite at a time (The resident ' s care plan did not direct staff to serve this diet, thin liquids or encourage the resident to do chin tucks during eating. The care plan did not direct the resident to take sips between bites). During an interview with Staff G, Speech Therapist on 6/26/14 at 11:15 a.m., Staff G stated they worked with Resident #1 on 3 occasions to teach her/him proper eating technique and correct diet due to choking tendencies. Staff G stated a mechanical soft diet included ground meat with extra gravy on the meat. Staff G stated a mechanical soft diet would not include a regular consistency turkey sandwich, but should have been ground meat. Review of the Daily Notes dated 6/22/14 at 5:45 p.m. reflected a dietary staff person alerted (called) a nurse over to the resident's table (in dining room). When the staff approached the resident's table, the resident could not talk. The resident had cyanosis around his/her lips and became unresponsive. The resident did not cough or gasp for air. The nurse raised the resident ' s arms and had no response. Another nurse was called to assist and that nurse performed the [MEDICATION NAME] maneuver without success. The resident became unresponsive and was lowered to the floor. The dentures were removed and oxygen applied via a face mask. A pulse oximetry tested no readying (oxygen saturation and normal is 96-100). When the EMS (Emergency Medical Service) system arrived a 3 lead cardiac monitor was place on the resident which identified no cardiac activity. The time of death was identified as 6:10 p.m. Review of the Ossian Ambulance Service Patient Care Report dated 6/22/14 revealed the request for an ambulance was received at 5:56 p.m., due to a resident choking. The note reflected upon arrival to the facility, the resident laid on the mat on the floor and in a supine position. A staff person was seated at the resident ' s head. The note reflected the registered nurse in charge stated the resident had placed her/his hands at the neck area, as though appeared to be choking. The registered nurse stated he had performed the [MEDICATION NAME] without success and had performed a blind finger sweep. The registered nurse had obtained a small amount of food from the resident ' s mouth. A 3 lead cardiac monitor revealed no cardiac activity and the ambulance personnel identified the resident had neither carotid nor radial arterial pulse present. According to the Menu for Week 1-Sunday (6/22/14), the menu directed the Cook to serve those residents who required a mechanical soft diet the following: 1 serving of chicken vegetable soup, 1 serving of ham salad sandwich, 1 serving of crackers, 1 serving of peaches and 6 ounces of milk. On 6/25/14 at 5:10 p.m., Staff A (cook), was interviewed and stated she prepared and served the Sunday evening meal on 6/22/14. Staff A stated she served chicken soup, a turkey sandwich with butter on a piece of bread, crackers and peaches. Staff A stated she served everyone a turkey sandwich on bread even when the resident had an order for [REDACTED]. The facility identified 8 residents who required a ground meat diet on the evening of 6/22/14. Staff A stated they failed to serve all 8 residents a ground meat diet according to their physician's orders [REDACTED]. On 6/26/14 at 8:00 a.m., Staff J (certified nursing assistant) was interviewed and stated she sat in the dining room at the table next to Resident #1's table (could only see the resident ' s back) on 6/22/14 during the evening meal. Staff B approached them and reported "I think they are choking"(referring to Resident #1) Staff J attempted to get up to assist but her foot got caught in a wheelchair, Staff J stated another staff member got to Resident #1. On 6/25/14 at 6:35 p.m., Staff B (dietary aide) was interviewed and stated Resident #1's table mate told her she thought Resident #1 was choking. Staff B asked Resident #1 if he/she was choking and the resident shook his/her head yes. The resident did not cough or gag. Resident #1 had his/her hands pointing to the upper chest area. Staff B called another staff to the area. Staff B stated the evening of 6/22/14 the dietary served Resident #1 chicken soup, crackers, and a turkey sandwich. Staff B stated Resident #1 received a regular consistency turkey sandwich, the same type of sandwich they served to all of the other residents. On 6/26/24 at 8:30 a.m. Staff H (dietary aide) was interviewed and stated he worked the evening meal of 6/22/14. Staff H stated he was working with drinks (water, apple juice), when the tablemate to Resident #1 informed him of the resident choking. Staff H stated he did not know what the resident drank or ate. Staff H stated no one recorded what Resident #1 ate or drank. On 6/25/14 at 4:00 p.m. Staff C (licensed practical nurse) was interviewed and stated she started the medication administration pass around 5:30 p.m. on 6/22/14. Staff B approached her and stated she thought Resident #1 was choking. Staff C stated she asked Resident #1 if he/she were choking but the resident made no response. Staff C stated the resident ' s eyes were fixed and looking forward. Staff D, registered nurse, entered the building to report to work and Staff C called out for help. Staff C stated Staff D performed the [MEDICATION NAME] and performed a finger sweep. Staff C stated Staff D pulled out chewed food. On 6/25/14 at 4:00 p.m. Staff D (registered nurse) was interviewed and stated he came on duty at the facility on 6/22/14 at 5:45 p. m. Staff D stated at 5:50 p.m. he heard a nurse in the dining room asking a resident if he/she could speak. Staff D stated he approached Resident #1's table and noted the resident sitting in the chair with a "look of terror" on her/his face. The resident had her right hand on the chest area and the left arm on the chair. Staff D did the [MEDICATION NAME] maneuvered on Resident #1 three times without success. Staff D stated the staff placed the resident on the floor and he performed a finger sweep. Staff D stated he thought he removed chewed up chicken soup and crackers. Review of the evening menu for 6/25/14 directed the cook to prepare and serve to the residents who required ground meat a 1 serving of ground chipped beef over a biscuit. During observation of the evening meal on 6/25/14 at 5:38 p.m. Staff F (Cook) placed regular consistency creamed chipped beef on a biscuit for a resident who required a ground meat diet (Resident #5). The Food Service Supervisor-Staff E stopped the cook and directed her to ground up the meat before they serve it to Resident #5. Staff F stated they didn't ground up the meat because they felt the chipped beef had small enough pieces. During the serving of this meal, Staff E had to direct Staff F-Cook to ground up the meat for the resident who required ground meat. During an interview with Staff E-Food Service Supervisor on 6/25/14 at 6:30 p.m., Staff E stated that Staff A prepared the evening meal on 6/22/14. Staff E stated they were aware that the evening meal of 6/22/14, the cook, Staff A, served Resident #1 and all other residents who required a ground meat sandwich a regular consistency (not ground) sandwich. Staff E stated they started re-education regarding serving proper diets on 6/24/14. Review of the Dietary In-service of 6/24/14 indicated both Staff A and Staff F (cooks) completed the re-education for serving proper diets on 6/24/14. Review of a Dietary Staff written in-service sheet dated 6/24/14 directed the dietary staff they need to follow diet menus. The cooks need to make sure they are preparing ground meat for residents that have a diet order for ground meat, and that other staff that serve the resident meals are checking to make sure they are following or serving it to the correct person that it is intended for. Staff A and F signed the in-service on 6/24/14. On 6/26/14 at 9:40 a.m. the facility medical director was interviewed in the activity room with the administrator present. The medical director (Resident #1 ' s physician) stated this to be an acute heart episode. The physician stated he would put this as a cause of death and the resident had [MEDICAL CONDITION] in April. The resident had [MEDICAL CONDITION] at dinner time and died . When the medical director was informed the resident had been served the incorrect diet, the medical director challenged to prove the resident choked. The medical director stated " What do you want me to do, call for an autopsy? " The physician continued to say this facility is one of the best places around and he has been in practice for [AGE] years. On 6/26/14 at 8:20 a.m. Staff I (dietician) as interviewed and stated Resident #1 should have received a ground turkey meat sandwich the evening of 6/22/14. Staff I stated on 6/25/14 the food service supervisor called her to request an in-service for serving proper diets. The facility dietary cook staff did not serve ground meats to residents as ordered to receive ground meat diets even after the re-education on 6/24/14. Note: At the time of the complaint investigation, the complaint was coded at a "K", immediate and serious jeopardy. By 6/27/14, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "E" level. The facility dietician, presented an education on 6/27/14 about altered consistencies of food, location of therapeutic spread sheets, equipment use and blending/grinding food. As of the 7/10/14 exit conference, the facility continued to need to: . Finish in-servicing all employees regarding the altered consistencies of foods, location of therapeutic spread sheets, equipment use and blend/grinding of food. . Continue to monitor all meals to ensure the physician ordered therapeutic diets are served appropriately.