Every finding on record at Perry Lutheran Homes Eden Acres Campus

Based on facility document review, staff interview and policy review, the facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours, 7 days a week. The facility reported a census of 48 residents. Findings include:Review of the facility staffing sheets and schedule for the month of July 2026, revealed three days in which the facility did not have 8 hours of consecutive Registered Nurse (RN) coverage during the required 24 hour time period. On July 4, 2026 the facility had only 4 hours of consecutive RN coverage. On July 23rd and July 24th, 2026, the facility did not have any hours of RN coverage, for either day. During an interview 7/30/26 at 9:34 AM, the Administrator acknowledged the facility did not have RN coverage for 8 consecutive hours for July 4, July 23rd and July 24th, 2026. The RN scheduled for these days had a call in and the scheduler did not fill the position with an RN. The Administrator stated an expectation the facility has 8 consecutive hours of RN coverage daily. Review of the facility policy Staffing, dated 2026, documented the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The facility is expected to maintain a minimum of eight (8) consecutive hours of onsite Registered Nurse (RN) coverage each day in accordance with applicable federal and state regulations.

Based on clinical record review, staff interviews and policy review, the facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Form 10123 Notice of Medicare Non-Coverage (NOMNC) at least two calendar days prior to the final day of covered services for 1 of 3 residents (Resident #5) reviewed. The facility reported a census of 48 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] indicated that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition (normal thinking and memory).The Electronic Health Record (EHR) contained Resident #5's NOMNC indicating covered services would end on 5/6/26. The document was signed by Resident #5 on 5/5/26.In an interview on 7/29/26 at 2:45 PM Staff A, Social Services stated that the NOMNC needs to be signed two days before services end. She was not sure why Resident #5's episode ending 5/6/26 was signed on 5/5/26. She stated that Resident #5 has a replacement plan that emails them the NOMNC already filled out except for the signature. She stated it was either they didn't get the email until after 4:00 PM on 5/4/26 which they would not have gotten until 5/5/26, they just missed it or they did not get it until 5/5/26. Either way she stated it should be done 2 days in advance.In an interview on 7/29/26 at 3:09 PM the Administrator stated that the NOMNC should be signed two days in advance of discharge from Medicare services.In an interview on 7/30/26 at 9:45 AM Staff B, Occupational Therapy (OT) stated that Resident #5 was on services from 4/24/26 through 5/6/26. She was getting Physical Therapy (PT) and OT 5 times weekly and Speech Therapy (ST) 8 visits in 4 weeks. Therapy received an email on 5/4/26 from Resident #5's Medicare Health Maintenance Organization (HMO) containing the NOMNC stating services to end on 5/6/26.In a policy titled Beneficiary SNF Liability Notices dated 2026 it indicated that a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

Based on clinical record review, staff interviews and policy review, the facility failed to notify the Long Term Care (LTC) Ombudsman of discharge/transfer of residents as required for 1 of 2 residents reviewed who were discharged /transferred from the facility (Resident #5). The facility reported a census of 48 residents. Findings include:Review of the MDS (Minimum Data Set) assessment dated [DATE] and the facility's Electronic Health Record (EHR) revealed Resident #5 had discharged from the facility on 4/16/26, and was hospitalized until reentered the facility on 4/23/26. In addition, the MDS assessment dated [DATE] and the EHR revealed Resident #5 discharged from the facility on 6/25/26, and was hospitalized until reentered the facility on 7/1/26. The clinical record lacked documentation of notification to the LTC Ombudsman that Resident #5 had discharged to the hospital in April, and again in June, as required by federal regulation.During an interview 7/28/26 at 1:30 PM, the facility Social Worker (SW), stated she is the staff person responsible for sending the monthly LTC Ombudsman reports for discharges and transfers. She acknowledged the report for April and the report for June did not have the notice for Resident #5's transfer to the hospital. She stated the transfer to the hospital for both of these months should have been on the report to the LTC Ombudsman. During an interview 7/28/26 at 1:42 PM, the Administrator stated an expectation the LTC Ombudsman is notified of transfers and discharges timely and accurately. Review of the facility policy Transfer or Discharge Notice, dated 2026, documented a copy of the transfer or discharge notice is sent to the office of the State Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Residents and/or representatives are notified in writing at least thirty (30) days prior to a transfer or discharge, or as soon as practicable, but before the transfer or discharge.

Based on clinical record review, policy review, resident and staff interviews, the facility failed to protect residents from abuse for which caused psychosocial harm for 3 of 4 resident reviewed (Resident #3, #4 and #2). On 12/19/25 during the night shift a nurse reported that multiple residents residing on B hall reported concerns regarding the conduct of Staff A, Certified Nursing Assistant (CNA). The staff's actions resulted in residents being scared of Staff A. The facility identified a census of 49 residents. Finding include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating no impaired cognition. Resident #3 can hear adequately and could understand and be understood by others with no behavior or mood issues. Resident #3 required substantial to maximum assistance with sit to lying and lying to sitting on side of bed and rolling from left to right, functional limitation in range of motion to upper and lower extremity on one side, walker and wheelchair used for mobility device, and frequently incontinent of bladder. The MDS included diagnoses of heart failure, cerebrovascular accident (a medical condition where blood flow to part of the brain is suddenly interrupted, causing blood cells to die from lack of oxygen leading to weakness to a side of the body) hemiplegia (paralysis affecting one side of the body) history of pressure ulcer of the sacral region (the triangular area at the base of your spine) and a diuretic ( a medications used to increase urine production, helping the kidneys flush out excess salt and water) used in the last 7 days.The Care Plan with an initiated date of 3/17/25, indicated Resident #3 required assistance of 1 with getting out of bed, may have bladder accidents, anticipate needs and provide prompt assistance as indicated.The Plan of Care Response History dated 12/19/25 at 2:51 AM, documented Resident #3 incontinent of urine.The facility's untitled page of resident interviews dated 12/20/25, documented Resident #3 stated that Staff A, Certified Nursing Assistant (CNA) told the resident to put the residents head down because Staff A, is not going to hurt her back (Staff A's) for the resident by assisting with turning. Resident #3 is scared of Staff A.The Social Service Note dated 12/22/25 at 11:10 AM, documented, met with resident this AM and resident states is having a good day so far.The Social Service Note dated 12/22/25 at 3:08 PM, documented, notified that resident had some concerns that needed addressed, Met with resident, Director of Nursing (DON) and social services. Concerns and questions were answered and went over. Resident stated that she feels better now and not worried anymore.The Social Service Note dated 1/5/26 at 1:55 PM, documented, met with resident twice last week both times resident was not scared or worried about anything at that time. Resident appeared to be pleasant and cheerful.The Social Service Note dated 1/6/26 at 2:21 PM, documented, met with resident today, she is doing fine. States she knows the staff member will not be back and is happy that with that.On 1/6/26 at 2:00 PM, Resident #3 stated that Staff A, was yelling and screaming in the hallway during the night shift on 12/19/25. Resident #3 explained that Staff A came into her room around 3:00 AM, and demanded that resident put her head down while lying in bed because Staff A was not going to hurt her back for the resident. Resident #3 explained that she had an urinary accident in the pad and refused to put on the call light due to being scared of Staff A, and laid in a urine soaked brief until the next shift came on at 6:00 AM. Resident #3 did not report this until the Social Worker did an interview with the resident in the afternoon of 12/20/25, due to Resident #3 was fearful of retaliation.On 1/8/26 at 11:30 AM, Staff B, Social Worker, stated that Resident #3 was upset that Staff A, did not treat her with dignity and respect during cares on 12/19/25 and was scared of Staff A. 2. Resident #4's MDS assessment dated [DATE], documented a BIMS score of 14, indicating no impaired cognition. Resident #4 can hear adequately and could understand and be understood by others with no behavior or mood issues. Resident #4 was independent with activities of daily living but required supervision for shower/bathing. The MDS included diagnoses of hypertension (high blood pressure) diabetes mellitus, anxiety, depression, insomnia, and benign prostatic hyperplasia (enlargement of the prostate gland that puts pressure on the urethra, causing incomplete bladder emptying, urgency, frequency and weak urine stream). The MDS documented the resident received a depression medication and a diuretic medication in the last 7 days of the look back period.The Care Plan with an initiated date 3/10/24, indicated Resident #4 as independent with personal hygiene and toilet use, staff to converse while providing cares.The facility's untitled page of resident interviews dated 12/20/25, documented Resident #4 stated that around 4:00 AM, Staff A, came into his room without knocking and was bossy to him and told him to get up you are wet, threw his pad towards him and treated him like he was nothing. Resident #4 is scared of Staff A.The Social Service Note dated 12/22/25 at 11:08 AM, documented, checked in on resident this AM. Resident states he is having an okay day so far. The Social Service Note dated 1/5/26 at 1:59 PM, documented, met with resident twice last week. Resident felt safe and comfortable here at the facility. The Social Service Note dated 1/6/26 at 2:17 PM, documented met with resident today, states he is doing great.On 1/5/26 at 1:30 PM, Resident #4 stated that on 12/19/25, Staff A, came into his room without knocking, told him he was wet and threw a pad at him and told him to get up and change his soiled pad. Resident #4 stated that he felt he was not treated with dignity and respect and was scared of Staff A. Resident #4 stated that Staff A was yelling and raising her voice out in the common area by his room.On 1/5/26 at 3:30 PM, Staff A, verified that she was upset and her voice was loud and raised due to not having any staff help with answering call lights and taking care of the residents on B-hallway. Staff A reported that she was terminated on 12/20/25 by the Director of Nursing. On 1/8/26 at 11:30 AM, Staff B, Social Worker, stated that Resident #4 was upset that Staff A, did not treat him with dignity and respect on 12/19/25 and was scared of Staff A.3. The MDS for Resident #2 dated 11/22/25 documented a BIMS score of 6 indicating cognitive impairment. The MDS documented a mood severity score of 1 indicating minimal depression. The MDS documented she required substantial/maximal assistance with her activities of daily living and was frequently incontinent of urine. The diagnosis list documented Parkinson's disease.The facility's QA Investigation: Allegation of Abuse dated 12/20/25, documented the following:Summary of Situation: On 12/20/25 a nurse reported that multiple residents residing on B hall reported concerns regarding the conduct of Staff A. Residents described Staff A as not being kind and was rough during care and impatient.Actions Taken: Staff A was removed from the schedule and terminated on 12/20/25. Two residents were transferred to the emergency room (ER) for medical evaluation. Conclusion: Based on the information from the ER there was a determination to be consistent with abuse.The Progress Notes for Resident #2 documented the following:On 12/20/25 at 2:14 PM resident noted to be very anxious and tearful this morning till after lunch. When asked what is wrong states My husband is leaving me, nobody cares or loves me. Resident complaining of chest discomfort.On 12/20/25 at 6:03 PM resident noted to have bruising to right medial thigh, left medial thigh and right lateral thigh. Resident stating that she is having discomfort to bilateral lower legs, noted to be very anxious and tearful. Physician notified and orders to send out for evaluation.On 12/21/25 at 1:57 AM resident returned from the hospital via family vehicle. Diagnosis per emergency room (ER) documented adult abuse confirmed, and acute cystitis.The Emergency Medical Services (EMS) report dated 12/20/25 at 5:55 PM documented they were called out for a patient with discomfort. Staff and family on scene. Staff advised the patient having discomfort from some bruising on her right leg and right side of her chest. Staff also advise that this is due to possible abuse from a staff member. The resident had a fall the previous night that was not reported, otherwise there is no trauma to account for the bruises. Patient complains of pain all over and whimpers when moved.The Hospital Emergency Department records dated 12/20/25 at 6:19 PM documented an injury that was unknown. Full body check with left lower and right lower pinpoint bruising noted. Small areas of bruising to the inner thighs. Old bruising to the right knee. Family reports their parent has been outwardly upset. Their mother told them that staff at the nursing home had told her that her husband does not want to talk to her anymore and he is with another woman. This patient's daughter works at the nursing home where the patient resides. This daughter reported she had to console her several times due to her becoming upset. The daughter reports her mother not wanting to eat. They report their mother stated that the staff at the nursing home were mean to her. The patient reported that she was put on the floor by lots of people. Her entire body is in pain. She told the provider it was a surprise attack. She stated the incident happened last night. Impression included: Adult physical abuse, confirmed, initial encounter. Acute cystitis, multiple contusions, assault by nursing home staff, chest wall pain and right hip pain.The Abuse Policy dated 2/2025, All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation and any physical or chemical restraint not required to treat the residents medical symptoms.

Based on electronic health record review, staff interviews, and policy review the facility failed to ensure safe transfer techniques used by not using a gait for assisted transfers and the resident fell and received a fractured hip for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1, dated 9/13/25, included diagnoses of stroke, hemiplegia (paralysis of 1 side of the body), and repeated falls. The MDS identified the resident required partial/moderate assistance of staff for toileting and transfers and weighed 97 pounds. The MDS identified the resident had a fall in the past 3 months and a Brief Interview for Metal Status score of 8, indicated moderate cognitive impairment for decision-making. Resident #1's Car Plan, initiated 10/10/24 revealed: a. Focus: Self-care deficit with interventions for ambulation assist of 1 staff with 4 wheeled walker and transfer with assist of 1 staff with four wheeled walker.b. Focus: Potential for falls related to impaired balance with interventions of use call light for all transfers, staff education to not leave resident alone on the toilet, and anticipate needs and provide prompt assistance as needed.Resident's Fall Risk Screening Tool dated 9/10/25, revealed the resident is at risk to have falls, 1-3 falls in 3 months, and the resident is to have assist of 1 staff with a gait belt and walker for ambulation in and out of her room. Facility Fall-witnessed Report for Resident #1 dated 9/30/25 at 10:40 AM, revealed nurse was called to the resident's room where the resident was noted to be lying on her right side with legs flexed in shower, resident reported she lost balance when she went to turn around to sit on the toilet and fell into shower, hit right side of her head on her walker. The report further revealed the resident was ambulating with assist, using a walker, and sent to the emergency room (ER) for evaluation. Corrective action provided for Certified Nurse Aide (CNA) related to gait belt use. Resident #1's Physician Note dated 9/30/25, revealed physical exam findings of: Elderly woman lying on the floor in the shower. She appears acutely uncomfortable, has a great deal of swelling to the upper eyelid, she is uncomfortable with movement of the right hip, is going to be transported to the ER, as she has an apparent hip fracture. Resident #1's Hospital History and Physical dated 9/30/25 revealed a right hip fracture with a plan to send the resident to a higher level of care hospital the next day for surgery to the right hip.Interview on 10/28/25 at 11AM, Staff A, Certified Nurse Aide (CNA) stated she had been employed with the facility for about 4 years. Staff A stated Resident #1 was an assist of 1 staff with a walker and gait belt for short distance walking and transfers and was a wheelchair (W/C) for distant mobility. Staff A stated Resident #1 would self-transfer at times and would remind her to use the call light. Staff A stated she provided care for the resident frequently and knew the resident was an assist of 1 with a gait belt. Staff A stated if she didn't know a resident's transfer status she would look at the resident's Care Plan or ask another staff member. Staff A stated she was working 9/30/25, not sure of the time but during the morning, she was assisting the resident with getting up for the day, was walking the resident from her bed to the bathroom, was standing right next to the resident, Staff A turned her head for a split moment, and the resident lost her balance, thinks was trying to turn to get onto the toilet, and the resident fell into the shower with the walker in her hands. Staff A stated the resident hit her head on the shower bar, walker landed on the resident, the resident's eye swelled up, could have been worse, but the result ended up being bad with the fractured hip. Staff A stated she sat with the resident, called for help on the radio, and Staff B, Registered Nurse and the physician came to the resident's room. The physician did range of motion on the resident's legs and the resident said it hurt really bad. The resident was sent out to the ER by ambulance. Staff A stated she did not have a gait belt on the resident, that there was no gait belt in the room that day, but normally would go get a gait belt, but she did not go get a gait belt that time. Staff A stated she doesn't know why she didn't go get a gait belt. Staff A further stated staff are now required to wear a gait belt on themselves and she knew at the time of the fall that any resident that required assist of staff needed to have a gait belt on the resident. Staff A stated she was provided re-education on always using a gait belt for residents that require assistance, to wear a gait belt on self at all times, follow the care plan/Kardex (form that provides resident's care needs), and also received a verbal warning. Interview on 10/28/25 at 11:25 AM, Staff B stated on 9/30/25 she responded to a call for help over the radio for Resident #1's room. Staff B stated the resident was on the floor, Staff A was with the resident, and the resident did not have a gait belt on. Staff B stated she got the physician as he was in the building, assessed the resident, and sent her out of the facility via ambulance. Staff B further stated the resident had swelling on the side of her face and a lot of pain in the right hip area. Staff B stated the resident was assist of 1 with gait belt for transfers. Staff B stated staff usually wear gait belts on themselves, the facility have extra gait belts on the counters, some residents have gait belts on their walkers, and gait belts are readily available. Interview on 10/28/25 at 11:54 AM, Staff C, CNA stated she has been employed with the facility over 2 years and worked with Resident #1 frequently. Staff C stated the resident used a 4 wheeled walker, gait belt, and required assist of 1 staff for transfers and ambulation. Staff C stated the resident's care plan provided the information needed to care for a resident, their transfer/ambulation status, and she always uses the resident's care plan. Staff C stated she always uses a gait belt for any resident that is hands on assist with transfers or walking and gait belts are readily available, in the residents' rooms and staff carry on themselves, along with staff are issued a gait belt when hired. Interview on 10/28/25 at 12:05 PM, Staff D, CNA stated she has been employed at the facility for 4 years and did work with Resident #1 some. Staff D thinks the resident was 1 assist with walker and gait belt for transfer/ambulation. Staff D further stated a resident's transfer status was on their care plan, would ask another staff, and also have report sheet that list the resident's transfer status. Staff D stated use a gait belt on any resident that is a hands-on assist, gait belts are readily available as have extra in the supply room and are issued to staff when hired. Interview on 10/28/25 at 3PM, Staff E, Certified Medication Aide, stated she has been employed for 10 years, but usually works at the other facility campus. Staff E stated transfer sheet/report sheets are at each nurses' station to know residents' status for transfers and care. Staff E stated all residents with hands on assistance requires a gait belt and extra gait belts are available in the linen closet and at the nurse's station, and staff are required to wear a gait belt. Interview on 10/28/25 at 3:15 PM, Staff F, CNA, stated he has been employed for 6 years, cared for Resident #1, and the resident was an assist of 1 with gait belt for transfers. Staff F stated the resident had no problem with wearing the gait belt and gait belts used with any residents that are assist of 1 or 2, fall risk, or any hands on need to have a gait belt on the resident. Staff F further stated the gait belt is part of the uniform and it is in the employee handbook that they are required to be worn. Staff F stated extra gait belts are in the supply room and the report sheet provided information on the residents' care and assistance needed. Facility Gait Belts Policy dated 2/2025, directed that all employees providing direct resident care are required to utilize a gait belt whenever hands on assistance is needed for resident transfer and/or ambulation unless otherwise indicated with the rationale to ensure that the residents and employees' safety is protected during transfers and ambulation. The gait belt is to be considered a part of the uniform. All direct care staff are required to wear the gait belt while on duty and things to remember include: the gait belt can be used to assist with walking, it can serve as a handle if the resident begins to fall, and this can help to prevent the fall or control the resident's descent. Facility form with Topics: Basic AM and hour of sleep cares, Gait Belts, Empathy, and Care of Skin dated 9/16/25 revealed Staff A signed as completing the training. Interview on 10/28/25 at 3:45 PM, the Administrator stated her expectation for staff to always use the gait belt for transfers/ambulation with residents that require assistance.

Based on record review, staff interview, and policy review the facility failed to have staff currently certified in Dependent Adult Abuse Mandatory Reporter Training for 1 of 1 staff reviewed. Facility reported a census of 47.Findings include:Review of Staff A's, Certified Nurse Aide, education file lacked an Iowa Department of Health and Human Services certificate for Dependent Adult Mandatory Reporter Training. On 10/29/25 at 7:20 PM, the Administrator (ADM) sent via email a certificate for Dependent Adult Abuse Mandatory Reporter Training dated 10/29/25 for Staff A. Facility Abuse Policy dated 2/2025, revealed upon initial employment, each employee shall be provided with a copy of the facility's policies and procedures relating to abuse identification and reporting requirements. Each employee shall be required to complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment. Each employee shall complete at least two hours of additional dependent adult abuse identification and reporting training every five years. Interview on 10/30/25 at 9:45 AM, the ADM stated she was unable to provide no other Dependent Adult Abuse Mandatory Reporter Training certification prior to the certificate she provided on 10/29/25 at 7:15 PM for Staff A. The ADM stated she had a spread sheet that documented Staff A was due in October for the training but was unable to find the certificate that shows the staff was due. The ADM stated her expectation for staff to be current with training.

Based on the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1 - March 31, 2025) review and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 47 residents. Findings include: The PBJ Staffing Report for Fiscal Year 2025, Quarter 2, reflected the facility failed to have licensed nursing coverage 24 hours day on seven days of the quarter. The Administrator was notified of this on 6/25/25. She stated she was aware there had been an issue with the time clocks and some of the employee hours were not getting included in the time cards. She stated the facility used a consultant group to submit the PBJ hours to submit the required staffing information to CMS. She stated the consultant group sends an email when issues are noted and she believed the issue was fixed. On 6/25/25 at 1:42 pm, after reviewing the seven days in question, the Administrator stated the facility has a sister facility nearby and Staff A, Registered Nurse (RN) worked at both locations. Staff A had worked all seven of those days. Staff A was present and worked all seven days as scheduled at this facility. However, she accidentally clocked in under the incorrect facility code, which caused the error. Although she was scheduled for and physically worked at this facility, the time clock entry reflected the other facility, due to the code mistake.

Based on observations, staff interviews, and facility policy review, the facility failed to store frozen food in a clean freezer. The facility reported a census of 47 residents. Findings include: On 6/23/25 at 9:58 AM, a dual-door, upright freezer had condensation in the location where both doors met. A black substance was noted on the top of the bottom freezer door. The freezer contained a bag of frozen cookie dough. On 6/24/25 at 8:20 AM, the condensation and black substance were still noted in the same location on the upright freezer. At 8:24 AM, the Certified Dietary Manager (CDM) stated the freezer should not look like that and needed to be cleaned. A policy titled Infection Prevention & Control Protocol dated 6/2024 included a protocol to reduce the risk of spread of infection by managing food safety.

2. The MDS of Resident #35 dated 4/1/25 indicated that the resident used corrective lenses and hearing aides. The MDS identified a BIMS score of 10 indicating moderate cognitive impairment. Diagnoses listed on the MDS included cataracts, glaucoma or macular degeneration. The assessment triggered Care Areas for both visual function and communication, with documentation dated 4/8/25 that these would be addressed in the resident's care plan. On 6/23/25 at 3:03 pm, Resident #35 was observed wearing glasses and bilateral hearing aides. She was overheard telling an activity staff member that she was unable to read the activity calendar and requested a larger-print version. A review of Resident #35's Care Plan on 6/23/25 showed that neither vision nor communication concerns were addressed in the Care Plan. On 6/26/25 at 9:34 am, the MDS Coordinator confirmed both vision and communication should have been included in the Care Plan and stated she normally addresses those areas under the Activities of Daily Living (ADLs) Focus Area. She acknowledged their absence and stated she would add both areas. On 6/26/25 at 10:56 am, Resident #35 was observed in her wheelchair approximately three feet from her closet door, where the activity calendar was posted. She stated she could not read it at all due to the small print. She noted in previous months, the calendars were printed in a larger format. The October 2024 RAI 3.0 User's Manual documented the following: For each triggered care area, Column B Care Planning Decision is checked to indicate that a new care plan, care plan revision, or continuation of the current care plan is necessary to address the issue(s) identified in the assessment of that care area. The Care Planning Decision column must be completed within 7 days of completing the RAI, as indicated by the date in V0200C2, which is the date that the care planning decision(s) were completed and that the resident's care plan was completed. For each triggered care area, indicate the date and location of the CAA documentation in the Location and Date of CAA Documentation column. Chapter 4 of this manual provides detailed instructions on the CAA process, care planning, and documentation. The facility policy Care Plans, Comprehensive Person-Centered dated 2024 documented the following: Point 2: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Based on observation, clinical record review, resident and staff interview, the October 2024 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and facility policy review, the facility failed to care plan a high risk medication for 1 of 5 residents reviewed (Res #19). The facility additionally failed to fully develop and personalize a care plan for vision and communication for Resident #35. The facility reported a census of 47 residents. Findings include: 1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS identified Resident #19's MDS documented diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia, Parkinson's disease, depression, insomnia and restlessness and agitation. Resident #19's Clinical Physician Orders revealed an order for Lorazepam (antianxiety) 1 mg tablet by mouth every 8 hours as needed for agitation related to restlessness and agitation. The facility received the order on 3/31/25 and the end date for 9/27/25. The Care Plan with an initiated date of 4/9/21 failed to mention the high risk medication, non pharmacological interventions or side effects. The Medication Administration Record for the month of April 2025 revealed Resident #19 received the Lorazepam 13 times. The month of May 2025, Resident #19 received it 2 times and for June 2025 Resident #19 received it 2 times. On 6/26/25 at 11:50 am the MDS Coordinator stated that she was working on the MDS and was going to update the care plan today. She stated that Resident #19 had only taken the medication a couple of times this month. The MDS Coordinator stated that she pulls a report weekly to see when there are new medications to add to the care plan, the MDS Coordinator acknowledged that she missed this medication. On 6/26/25 at 12:11 pm in an interview, the Director of Nursing stated the expectation is to have high risk medications addressed on the care plan when the medication is implemented.

Based on facility record review, staff interviews, and facility policy review the facility failed to perform and document findings of root cause analysis after a resident had a fall to help determine the reasons for a resident's fall and in order to prevent further falls for one of four residents reviewed for falls (Resident #1). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of hip fracture, non-Alzheimer's dementia, orthostatic hypotension (a condition in which the blood pressure suddenly drops after a person stood up). The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS indicated the resident required limited assistance of one staff for transfers, ambulation, and toileting. The MDS documented the resident had two falls without injury and one fall with injury since the prior MDS assessment. Resident #1's care plan revised 3/27/22 revealed the resident had a self-care deficit related to a left hip fracture and dementia, and required assistance with ADL's (activities of daily living). The resident required limited assistance of one staff and a walker for ambulation and transfers as the resident allowed. The resident also had a history of falls related to impaired balance, poor safety awareness, functional impairment, incontinence, and use of medication that increased her risk for falls. The care plan directives included the following interventions added: o On 3/26/21, anticipate needs and provide prompt assistance as indicated. o On 1/2/22, Use your Call light sign hung from Walker. o On 2/28/22, hospice provided a recliner for the resident. Black gripper strips placed between the bed and chair. o On 3/6/22, room rearranged to make it easier to maneuver around the room. o On 3/11/22, old gripper socks removed and replaced with new gripper socks. o On 3/22/22, check on the resident frequently and offer repositioning. o On 3/26/22, non-skid strips placed on the floor on the window side of the room. o On 3/27/22, resident to wear cotton pajamas versus satin pajamas due to satin is slick and could cause the resident to fall. The progress notes revealed the following: a. On 1/2/22 at 9:13 PM, resident found lying on the floor on her left side. No injury or bruising found. Resident indicated I was trying to go to the other side of the bed. Bedspread hung off the foot of the bed and onto the floor. Oxygen (O2) saturation 80% on room air. Nasal cannula (NC) placed back in the resident's nose and O2 saturation increased to 89% on O2 at 2 L (liters) per minute. Resident not aware of possible safety concerns. Resident educated to use the call light and staff would gladly assist her. Intervention included a sign placed on the resident's walker to remind resident to use the call light. b. On 2/28/22 at 4:55 AM, resident found sitting on the floor at the foot of the bed at 1:55 AM. Resident indicated she was trying to get a book. Resident pointed toward non-existent overhead bookshelf above the bed and chair. Resident had two bruises and a skin tear near her left wrist and a laceration on the back of her head on the left side. Laceration cleansed and bacitracin (antibiotic) and steri-strips applied. An intervention added for hospice to provide recliner for the resident, and black gripper strips placed between the bed and the chair. c. On 3/6/22 at 2:35 PM, resident found sitting on the floor with her back against the divider wall. ROM (range of motion) within normal limits (WNL). No hip rotation, foot drop, or injuries noted. Resident denied pain. Resident assisted off the floor and into the chair. Room rearranged so room would be easier to maneuver around. Resident had taken oxygen off. No respiratory difficulty noted. Blood pressure (B/P) 94/50, temperature (T) 97.7, pulse (P) 108, respirations (R) 20, pulse oximeter (PO) 85% on RA (room air). Physician and power of attorney updated. d. On 3/11/22 at 10:26 AM, resident lying on back next to the wall in her room. [NAME] tipped over and resident had oxygen on. Resident stated she hit her head. Neurological checks WNL. ROM WNL. No hip rotation or foot drop noted. Resident assisted off the floor and into the bathroom. Resident had non-skid slippers on and incontinent. Gait slightly unsteady using FWW (front wheeled walker). Resident complained of floor being too slick. e. On 3/22/22 at 4:33 PM, resident found sitting on the floor on her buttocks at the foot of her bed with legs stretched out toward the dresser. No injury noted. Resident assisted back to the recliner by two staff and use of a gait belt. Neuro checks initiated for an unwitnessed fall. f. On 3/26/22 at 7:00 PM, resident observed on the floor with her back toward the bed and legs stretched out in front of her. Resident stated she slipped out of bed fast. Resident had satin pajamas which contributed to sliding from the side of the bed. FWW in room away from the bed. Resident denied pain. Assisted back to bed by three staff. Resident complained of right great toe discomfort but moved toe without acute pain. Pajamas changed to cotton ones. g. On 3/31/22 at 8:03 PM, phone call received from the charge nurse the resident had a fall and concerned the resident had a fracture. Called 911 and the physician. Resident sent to the hospital. h. On 4/1/22 at 4:36 AM, Staff A, Registered Nurse (RN) documented a late entry. At 7:10 PM (on 3/31/22), called to the resident's room. Resident observed lying flat on the floor and complained of severe pain in her right leg. Unable to transfer resident to bed or use a hoyer lift due to resident's severe pain. Pillows placed under the resident's head and under her knees. Right thigh swollen. Resident unable to verbalize how she fell , but asked to be helped. Physician notified of the incident. Order obtained to send the resident to the hospital. Ambulance, DON (director of nursing), family, and hospice notified. Morphine dose administered at 7:35 PM. Ambulance arrived at 7:35 PM. Phone call to hospital and inquired about resident status. Informed the resident had a spiral fracture of the femur and surgery scheduled in the morning. i. On 4/5/22 at 11:19 AM, Staff B, RN, documented phone call placed to resident's sister to discuss room change to have resident moved closer to the nursing office for safety as she could be noncompliant in using a call light. Approval received for room change to be closer to location in the event the resident returned to the facility. Fall scene investigation reports revealed the following: a. On 1/2/22 at 7:10 PM, resident found at the foot of bed lying on her left side, bedspread at the foot of the bed and lying on the floor. The resident tried to walk around to the other side of the bed and fell . Last seen by staff on 1/2/22 at 6:10 PM when the resident used the bathroom and got into bed. Safety devices in place included gripper socks, black velcro strips on the floor next to her bed on the side toward the bathroom. Resident has history of dementia, anxiety, and depression. Resident occasionally forgets to use her call light. Resident likes to be independent and unaware of her own safety. Resident also has a history of COPD and forgot to place nasal cannula back in her nose. b. On 2/28/22 at 1:55 PM, resident found sitting on floor at the foot of the bed. The resident reported she was trying to get a book, then pointed to a non-existent overhead bookshelf above the bed and chair. Safety devices in place included gripper socks, call light, and a walker. [NAME] was not used at the time of the fall. Resident last seen resting in bed on 2/28/22 at 12:30 AM. Morphine administered to the resident four hours prior to the incident. Resident had a history of falls, a cognitive deficit, history of hip fracture and COPD. Resident on hospice care. Incident Reports revealed the following: a. On 1/2/22 at 7:10 PM, called to resident's room by CNA (certified nursing assistant) about the resident on the floor at the foot of the bed. Resident tried to walk to the other side of the bed. Assessed for injury but no injury found. Resident assisted to stand with two CNA's. Resident oriented to person and situation but confused. Resident had impaired memory and ambulated without assistance. Sign use your call light hung on the walker and added to the care plan b. On 2/28/22 at 1:55 AM, found resident sitting on the floor at the foot of the bed. Resident reported she was getting a book and pointed to a non-existent overhead shelf above the bed and chair. Injuries included two bruises and a skin tear to her left wrist, and a laceration to the back of her head on the left side. Predisposing factors included poor lighting, resident confusion, and the resident ambulated without assistance. Additional notes included plan for hospice to provide a recliner for the resident, and black gripper strips placed between the bed and chair. A facility investigation file revealed on 3/31/22 at 7:10 PM, Staff A called to the resident's room. Resident observed lying flat on the floor and complained of severe pain in her right leg. Resident unable to report why she fell . Vital signs obtained. Physician notified. Order received to send the resident to the emergency department. Resident diagnosed with a spiral fracture to the right femur. Scheduled for surgical repair on 4/1/22. During an interview 4/20/23 at 2:40 PM, Staff C, certified medication assistant (CMA) reported she had worked at the facility for 2 years but didn't know Resident #1 until after the resident fell and fractured her leg. She was not working during the time when the resident had a fall. During an interview 4/24/23 at 11:30 AM, Staff B, RN/former DON, reported she worked at the facility for 2 1/2 years, then left in 2/2023. Staff B reported whenever a resident fell , staff called the on-call manager, awaited results from radiology, alerted the administrator, submitted an initial report on-line, and then did an investigation of the incident. Staff B reported she kept a file in her office with investigations she did, including interviews with staff. The investigation file included a detailed summary. Staff B reported she briefly remembered the incident on Resident #1. Staff B reported the resident was forgetful and would not use her call light for assistance. The resident was on hospice, and had started on anxiety medication just prior to her fall. Since injury was a major injury, she initiated a report to the State DIA on-line. During an interview 4/24/23 at 1:00 PM, Staff D, CNA, reported Resident #1 liked to lay in bed a lot. The resident was independent at times but had a decline and needed more help. The resident walked from the bed to the bathroom. She came out of her room very confused and agitated at times, and staff took her to the day room for her safety so she wouldn't fall. Staff D reported she worked on the day the resident had a fall. She found the resident on the floor in her room by her bed, and complained of hip pain. Resident #1 had gotten up on her own and fell . The resident had attempted to get up on her own before, and took the O2 off often, then her O2 saturations dropped fast. The resident sometimes used her call light, and sometimes she didn't. Staff D couldn't recall what interventions were in place for the resident. During an interview 4/24/23 at 2:30 PM, Staff A, agency RN, worked a month at the facility on the night shift. Staff A stated a CNA called her to the resident's room on the day the resident had a fall. She observed the resident lying on the floor and her leg was rotated outward. She called an ambulance and the physician, and sent her to the hospital. The resident tried to get up on her own. She wanted to move the resident next to the nurse's station to keep an eye on her. Strips placed next to her recliner and bed to keep her from sliding. Staff A stated they tried different things to keep her from falling. One time the resident wore satin pajama's and she requested to change to a different material so the resident couldn't slip so easily. The resident used her walker to walk around and stood up on her own. The resident was confused but didn't want to do things that would make her upset. Staff A reported whenever a resident had a fall, she assessed the resident, checked ROM, asked about pain level, if the resident hit their head, checked VS's, and then got assistance to move the resident. If no apparent injury, neuro checks done, and an assessment entered into computer. Staff A stated she also tried to determine an interventions for falls. During an interview 4/24/23 at 3:30 PM, Staff E, RN/Interim DON, reported she had worked at the facility for 2 years. Staff E reported Resident #1 became really confused, restless, and didn't understand. Her O2 levels dropped frequently even when she had O2 on. The resident had some falls toward the end of her stay, took morphine, and was on hospice. Staff E stated whenever a resident had a fall, neuro checks performed, an assessment performed, and risk management report completed. A UDA (user defined assessment) filled out in the electronic health record, then staff determined a reason for falls and interventions to put into place. Interventions put in place for Resident #1 included placement of a sign on the resident's walker, anticipation of needs, gripper strips placed between the bed and the chair, rearranged her room to be less of a fall risk, ensure gripper socks on, and use of cotton pajamas instead of silk pajamas. She tried to check in on the resident frequently. The resident was really confused and anxious toward the end, so they tried to keep an eye on her, but not able to do 1:1 with her. During an interview 4/25/23 at 12:00 PM, the Administrator reported falls reviewed during weekly QA (quality assurance) meetings. The administrator reported resident falls had been trending downward so not doing as much with this project other than trying to maintain level of less falls. After a resident had a fall, she looked at the staff who worked, what the situation was, and how the fall happened. She also looked at the care plan interventions, added an intervention if needed, or evaluated the need for other interventions. The administrator reported falls reviewed at weekly QA meeting, and had a list of residents discussed but nothing written down about the details of what was discussed for root cause analysis. It was more of a verbal discussion. A Fall Risk Assessment policy revised 3/2018 revealed the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The policy included the following steps to determine a resident's risk for falls: 1. Upon admission, the nursing staff and the physician shall review a resident's record for a history of falls, and ask the resident and/or family about any history of the resident falling. 2. Medications reviewed that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. 3. Staff looked for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. 4. The attending physician and nursing staff evaluate the resident's vital signs, assessed the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose the resident to falls. 5. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. 6. The staff and the attending physician evaluated functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. 7. The staff sought to identify environmental factors that may contribute to falling, such as lighting and room layout. 8. The staff and attending physician collaborated to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.

Based on records review, and interviews, the facility failed ensure development of care plan for the use of an antianxiety medication for 1 of 4 residents (Resident #11) reviewed for unnecessary medications. The facility reported a census of 31 residents at the time of the survey. Findings include: Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] listed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS recorded antianxiety medications used for 3 out of seven days in the lookback period and the use of an antidepressant for seven of seven days in the lookback period. The facsimile (fax) signed by the provider on 12/1/20, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 12/17/21 revealed that Resident #11 had a risk for falls related to the use of medications that increase fall risk. The Assessment tab showed the Fall Risk Screening Tool documented Resident #11's history of falls on the following dates: 1/5/21, 2/7/21, and 7/4/21. Resident # 11's care plans also showed multiple updates on the following dates: 5/21/21, 6/22/21, 7/23/21, 10/15/21, and on 12/17/21. However, the care plans did not include a focus area regarding the use of the antianxiety medication, even though Resident # 11 has been on [MEDICATION(S)] 0.5 mg by mouth on Monday, Wednesday, and Friday since 12/1/20. On 2/23/22 at 8:37 AM, when asked about antianxiety medication use, Resident #11 replied there was a time before when I was feeling, not really anxious, but just the thought of going to be on [CONDITION(S)] for the rest of my life. On 2/23/22 at 8:52 AM, Staff B, Certified Medication Aide (CMA), reported that she administers an antianxiety medication to Resident #11 on [CONDITION(S)] days. Staff B verified Resident #11 used anti-anxiety medication since initially ordered on 12/1/20. Staff B further reported that Resident #11 already took the antianxiety medication and that he was in his room waiting to go to [CONDITION(S)]. On 2/28/22 at 2:05 PM, the Director of Nursing (DON) verified that the care plans did not address the use of the antianxiety medication. The DON also stated they expected that the care plan should address the use of all [CONDITION(S)] medications. The facility provided Resident Assessment Instrument (RAI) and Care Planning policy, dated 11/16/2020, noted the purpose was to provide an ongoing assessment of information necessary to develop a plan of care, to modify the care plan, to provide the appropriate care and services for each resident based on the resident's functional capacity, individual history, patterns, preferences, and choices. The policy provided that the assessment process would include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. The policy directed the facility staff to develop and implement a comprehensive care plan.

Based on clinical record reviews, observations, policy review, resident, and staff interviews, the facility failed to update the comprehensive care plan with a change of condition for one (#15) of twelve residents reviewed and failed to enable resident participation in care plan conferences for one (#22) of six residents reviewed. The facility reported a census of 31 residents. Findings include: 1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a significant change in status assessment. The MDS indicated hospice level of care. Resident #15 required limited assistance of one person for bed mobility. Resident #15 required extensive assistance of one person for transfers, locomotion, toilet use, and personal hygiene. Resident #15 required total assistance of one person for bathing. Resident #15's MDS documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. During an observation on 2/22/22 at 1:00 PM, Staff D, Certified Medication Aide (CMA), and Staff E, CMA, transferred Resident #15 from a wheelchair to a recliner, using a gait belt. Resident #15's Care Plan Focused area dated 12/12/20 indicated that the had a self-care deficit related to weakness as evidenced by requiring assistance with activities of daily living (ADLs). The Focused area included the following interventions 1. Resident #15 was indpendent with grooming and staff were to encourage oral hygiene. dated 4/20/21. 2. Resident #15 required an assist of one dated 12/12/20. 3. Resident #15 was independent with locomotion dated 12/12/20. 4. Resident #15 was independent with toilet use dated 12/12/20. During an interview on 2/24/22 at 12:21 PM, Staff F, CMA, stated Resident #15 was independent before but now he needed assistance with all ADLs since starting on hospice. The undated Care Plan Frequent Update policy, documented that the resident's Care Plan would be updated whenever there was a change in the plan of care. During a follow-up interview on 2/23/22 at 2:32 PM, the Director of Nursing (DON) confirmed Resident #15's care plan wasn't updated with the significant change in status. The DON explained that their expectation was for staff to update the Care Plan with a significant change. 2. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment for decision-making. During an interview on 2/21/22 at 3:55 PM, Resident #22 stated she didn't recall attending any care conferences. Resident #22's electronic and paper clinical record lacked documentation of the resident attending or declining to attend her Care Plan conferences on the following dates: 2/2/21, 5/18/21, 8/10/21, and 2/8/22. During an interview on 2/23/22 at 4:05 PM, the Social Worker confirmed that Resident #22 was not invited to care conferences. During an interview on 2/23/22 at 4:14 PM, the DON stated they expected all of the residents should be invited to care conferences.

Based on records review, interviews, and observations, the facility did not ensure specific diagnosis for the use of an anti-anxiety medication. In addition, for the use of [CONDITION(S)] medications, the facility did not ensure monitoring of specific target behaviors; development and implementation of individualized non-pharmacological interventions; and attempting gradual dose reduction (GDR) for 1 of 4 residents (Resident #11) reviewed for unnecessary medications. The facility reported a census of 31 residents at the time of the survey. Findings include: Resident #11's quarterly Minimum Data Set (MDS) dated [DATE] included diagnoses of depression and end-stage [CONDITION(S)] ([CONDITION(S)]). The MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the use of antianxiety for three of seven days in the lookback period and antidepressant medications for seven out of seven days in the lookback period. The orders showed that on 12/1/2020, Resident #11 started on [MEDICATION(S)] tablet 0.5 milligram (mg) by mouth 1 hour before [CONDITION(S)] every Monday, Wednesday, and Friday related to anxiety. The orders also show that since admission on 8/25/2020, Resident #11 has been on [MEDICATION(S)] tablet 10 mg by mouth 1 time a day related to major depressive disorder. The medical diagnoses section of Resident #11's clinical records listed diagnoses including major depressive disorder, [CONDITION(S)], and dependence on renal [CONDITION(S)]. The list lacked diagnosis indicating anxiety disorder. Resident #11's Care Plan revealed the following: A. Resident #11's Care Plan Focused area dated 12/13/20 indicated he was a fall risk related to impaired balance, poor safety awareness, and the use of medications that increase fall risk. The Care Plan listed the following interventions 1. Anticipate Resident #11's needs and provide prompt assistance dated 12/13/20. 2. Encourage proper footwear as resident allows dated 4/20/21. 3. Educate on proper techniques for picking up things from the floor dated 1/8/21. 4. Use call light before showing so staff may assist with setting up the bathroom for a shower dated 2/7/21. 5. Reminders Resident #11 to slow down when ambulating about the facility. dated 7/6/21. The Care Plan section related to Fall Risk interventions lacked review, analysis, and/or evaluation of medications that increase fall risk. B. Resident #11's Care Plan Focused area dated 3/29/21 identified the use of antianxiety medication related to anxiety before [CONDITION(S)] treatments. The Goal section with a target date of 3/9/20 explained for Resident #11 to have less than 4 behaviors per month. The interventions included the following 1. The target behaviors were frustration, mood changes, repeated, statement of moving to a different location and/or facility dated 3/29/21 2. Administrator the anti-anxiety medication as ordered by the physician dated 3/29/21 3. Monitor for effectiveness and side effects/adverse reactions including clumsiness, slow reflexes, confusion, disorientation, dizziness, lightheadedness, forgetfulness, impaired judgement, memory loss, and blurred or doubled vision dated 3/29/21. C. Resident #11's Care Plan Focused area dated 12/13/20 indicated Antidepressant medication usage. Resident #11's connected goal dated 12/13/20, indicated that Resident #11 would be free of adverse effects from medication use through the next review date. The second goal dated 12/29/20 connected to this Focused area indicated Resident #11 was to have less than 4 behaviors per month. The interventions related to this Focused area included 1. Target behaviors dated 12/29/20 were being withdrawn, tearful, not stating his needs when the call light is answered. 2. The staff were to alert the physician/nurse practitioner regarding any abnormal findings within medication use as indicated dated 12/13/20. 3. Use non-pharmacological interventions such as one on one (1:1) visits, offer a snack, offer wheelchair rides, offer music, offer to call a friend or family. (Play or have Resident #11 teach the staff how to play Dungeons and Dragons - his favorite game) dated 12/29/20. 4. Observe for any adverse reactions of [CONDITION(S)] medications such as unsteady gait, and frequent falls dated 12/13/20. The assessment notes (Fall Risk Screening Tool), showed Resident #11's history of falls on the following dates: 1/5/2021, 2/7/21, and 7/4/21. However, there lacked evidence to show evaluation of Resident #11's medications in relation to the falls as indicated by the fall risk care plan. In addition, assessments for Resident #11's falls on 1/5/21 and 7/4/21 did not consider the use of [CONDITION(S)] medications. The pharmacist's review for Resident #11's medications, documented recommendations for a gradual dose reduction (GDR) of the [CONDITION(S)] medications were declined with rationale, as follows: 1. [MEDICATION(S)] 0.5 mg 1 hour prior to [CONDITION(S)] Monday, Wednesday, Friday - On 5/20/21, GDR was declined with nursing comment that Resident #11 really dislikes [CONDITION(S)] - resident doesn't want to make any changes. The prescriber responsed on 5/20/21 - no changes. - On 6/23/21 The facility sent a second Physician Recommendations fax directing that Resident #11's medication review for [MEDICATION(S)] 0.5 mg one tablet before [CONDITION(S)] was declined for a GDR on 5/20/21 with the provider's response of no change. The fax indicated that the Centers for Medicare and Medicaid Services (CMS) regulations require a clinical rationale to be provided by the provider indicating how a dose reduction would cause the resident distress, decline, or documentation of past failures. The facility noted the prescriber's response on 6/28/21 as Resident #11 had continued issues with anxiety before [CONDITION(S)]. - On 12/23/21, the GDR was declined with the nursing comment of Resident #11 continued to have increased anxiety going to [CONDITION(S)]. The order was recommended by [CONDITION(S)]. The prescriber's response noted directed that Resident #11 had chronic problems with anxiety. 2. [MEDICATION(S)] 10 mg daily - On 2/19/21, the prescriber declined the GDR with a response of no change. - The Physician Recommendations fax dated 3/19/21 directed that Resident #11's medication review for [MEDICATION(S)] 0.5 mg one tablet before [CONDITION(S)] was declined for a GDR on 2/19/21 with the provider's response of no change. The fax indicated that CMS regulations require a clinical rationale to be provided by the provider indicating how a dose reduction would cause the resident distress, decline, or documentation of past failures. The prescriber noted the Medical Director Report on 3/24/21 with the response that Resident #11 remained depressed, continue [MEDICATION(S)] 10 mg. - On 8/20/21, the prescriber declined the GDR due to Resident #11 had continued depression and he remained socially withdrawn. Resident #11's February 2022 Administration Note related to Behaviors lacked documentation. Observations and interview with Resident #11 showed the following: On 2/22/22 at 10:48 AM, Resident #11 was in pleasant mood, in room resting in bed. Resident #11 stated he admitted to the facility in August 2020. Resident #11 added that he went to [CONDITION(S)] but denied any signs of anxiety before going to [CONDITION(S)]. Resident #11 stated that the facility and the [CONDITION(S)] center were in coordination regarding his cares and treatments. Resident #11 denied concerns regarding his care and treatments. On 2/23/22 at 8:37 AM, noted Resident #11 in pleasant mood, working on his computer. Resident #11 explained he was waiting to go to [CONDITION(S)]. When asked about anxiety before going to [CONDITION(S)], Resident #11 again denied anxiety. Resident #11 remarked, there was a time before when I was feeling, not really anxious, but just the thought of going to be on [CONDITION(S)] for the rest of my life. When asked about how the antianxiety and antidepressant medications were helping and if a gradual dose reduction was attempted, Resident #11 verbalized that nobody talked about it since he started taking the medications. Resident #11 further stated, You know 1 less pill would be good. I am willing to try for a reduction or maybe even stop. Interviews with staff showed lack of indications of behaviors, as follows: On 2/23/22 at 8:49 AM, Staff A, Certified Nurse Aide (CNA), acknowledged being assigned to care for Resident #11 many times. Staff A reported that Resident #11 was pretty much independent and denied observing any behaviors by Resident #11. On 2/23/22 at 08:52 AM, Staff B, Certified Medication Aide (CMA) reported that Resident #11 didn't have any symptoms of behaviors. Staff B added they almost always work on Resident #11's hall, taking care of him but didn't observed any behaviors. Staff B said, the nurse would know about the behaviors more. Staff B verified by looking at the computer screen that Resident #11 used an antidepressant since 8/20 and an antianxiety medication since 12/1/20. On 2/24/22 at 3:01 PM, the Director of Nursing (DON) stated, Resident #11 did not have anxiety symptoms here. It was always during [CONDITION(S)]. The DON acknowledged that there was no evidence of the presence of behaviors or behavioral monitoring as they happened in the [CONDITION(S)] clinic. The DON verified that there was no attempt to reduce the [CONDITION(S)] medications. Policy review The Drug Regimen Review policy dated 12/20, indicated that a Medication Regimen Review (MRR) included evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning to prevent or minimize adverse (abnormal) consequences related to the medication therapy. The policy defined irregularity as any event that was inconsistent with the usual, proper, accepted, or right approaches to providing pharmaceutical services, or that impedes or interferes with achieving the intended outcomes. The policy also defines [CONDITION(S)] drug as any drug that affects brain activities associated with mental processes and behavior, including anti-anxiety and antidepressant. The policy further defined an unnecessary drug as any in duplicate medication therapy, excessive duration, lack of adequate monitoring, without indications for its use, or in the presence of adverse consequences. If defined as an unnecessary mediction the policy indicated that the dose should be reduced or discontinued, or any combinations of the foregoing items.

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to obtain an evaluation by the Department of Human Services (DHS) prior to hire to determine if an employee with a criminal history and dependent adult abuse could work in the facility for 1 of 5 current employees sampled (Staff C, Certified Nurse Aide CNA). The facility reported a census of 31 residents. Findings Include: The personnel file for Staff C, CNA, documented a hire date of 11/5/2020. A background check request was filled out and signed on 9/16/20. The personnel file lacked results of the completed background check. On 2/24/22 at 1:47 PM the Administrator stated that Staff C was hired by the previous owners and the files were transferred over to the new owners. The Administrator admitted that they overlooked the background check and they did not have one for Staff C. The Administrator explained that they received a fax from the Iowa Department of Human Services (IDHS) on 2/24/22 after the interview and it indicated that Staff C may work at the facility. The Administrator reported that they requested a background check on 2/24/22. During a review of the schedules dated January 2022 and February 2022 the schedule identified that Staff C worked 18 shifts in the 30-day review timeframe. The dates identified were 1/24, 1/25, 1/26, 1/27, 1/31, 2/1, 2/2, 2/3, 2/7, 2/8, 2/10, 2/14, 2/15, 2/17, 2/21, 2/22, 2/23, and 2/24 of 2022 for the hours of 2:00 PM until 10:00 PM each listed date. The Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/20 directed the facility to screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The check should be completed on all current employees and other individuals engaged to provide services to residents who have criminal convictions or founded abuse determinations subsequent to hire. The policy continued documentation that the facility would make reasonable attempts to request and obtain information from previous employers and/or current employers that may be indicative of a history of abuse, neglect or mistreating residents.