Every finding on record at Rehabilitation Centers of Independence West Campus

Based on observation, resident and staff interviews, review of the facility computerized call light response times, and facility policy review, the facility failed to answer resident call lights in a timely manner for four of five residents reviewed. (Resident #4, #5, #6, #7).The facility reported a census of 56 residents. Findings include:1.The MDS (Minimum Data Set) dated 3/3/2026 reported Resident #4 had no cognitive impairment and had diagnoses including compression fracture, anxiety and diabetes. The resident transferred from one surface to another with staff assistance and a stand up lift. Observation on 3/31/2026 revealed the resident's call light on from approximately 7:37 a.m. until 8:00 a.m. At 7:55 a.m. the resident sat at the edge of the bed and indicated he needed to use the restroom. At 8:00 a.m. staff entered the room to assist him. A review of the computerized call light audit revealed the resident's call light activated at 7:35 a.m. and remained on for 24 minutes. The resident reported it often took a long time, especially in the morning.2. The MDS dated [DATE] reported Resident #5 had no cognitive impairment and had diagnoses including spinal stenosis and vertebral disc replacement. The resident transferred with substantial/maximum assistance. Observation on 3/30/2026 revealed the resident's call light on from approximately 12:02 p.m. - 12:30 p.m. At 12:18 p.m. the resident sat in her room in the wheelchair. She indicated her call light had been on for at least 20 minutes. At 12:25 p.m. the resident continued to sit in her wheelchair and reported she waited a long time to go to the bathroom. At 12:30 p.m. Staff B, CNA (Certified Nurse's Aide) entered the resident's room to offer assistance. A review of the facility computerized call light audit revealed on 3/30/2026 the resident's call light activated at 11:59 a.m. for 33 minutes and 32 seconds. 3. The MDS dated [DATE] reported Resident #6 had intact cognition and diagnoses including dementia and hoarding disorder. The Care Plan revealed the resident resident required assistance of one staff to transfer from one surface to another. Observation on 3/31/2026 revealed the resident's call light on from approximately 7:18 a.m. - 7:55 a.m. The facility computerized call light audit revealed the resident's call light activated at 7:14 a.m. for 39 minutes and 45 seconds, at 8:25 a.m. for 16 minutes and 36 seconds and at 1:50 p.m. for 22 minutes and 12 seconds. At 7:38 a.m. the resident lay in bed and indicated she put the call light on and waited for staff to hand her the bed controller that she dropped on the floor. She also needed staff assistance to sit up in bed. 4. The MDS dated [DATE] reported Resident #7 had no cognitive impairment and diagnoses including hypertension and weakness. The Care Plan revealed the resident required staff assistance and a mechanical lift to transfer from one surface to another. Observation on 3/31/2026 revealed the resident's call light activated from approximately 7:20 a.m. - 7:55 a.m. The facility computerized call light audit revealed the resident's call light activated at 7:19 a.m. for 31 minutes and 56 seconds. On 3/31/2026 at 1:45 p.m., the resident observed in bed and reported it took staff up to an hour to answer the call light. On 3/31/2026 at 2:35 p.m. Staff A, Administrator reported the expectation for staff to respond to resident's call light in a timely manner and to do the best they could. The facility Call Light Policy revised 9/2023 included the following purpose: To ensure that there is a prompt response to the resident's call for assistance. The facility also ensures that the call system is in proper working order. The policy further revealed, Facility shall answer call lights in a timely manner.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Services Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to accurately code the use of medication on the Minimum Data Set (MDS) Assessment for 1 of 5 residents sampled (Resident #1); and failed to accurately code a determination of serious mental illness as identified on the Preadmission Screening and Resident Review (PASRR) for 1 of 1 residents sampled (Resident #18). The facility identified a census of 51 residents.Findings include:1.Resident #1's MDS dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating a severe cognitive impairment. The MDS documented Resident #1 received anticoagulant (medication that prevent blood from clotting) and antiplatelet (medication that makes the blood less sticky by stopping platelets from clumpting together) medications.The September and October 2025 Electronic Medication Administration Records (EMARs) documented Resident #1 received Aspirin (antiplatelet medication) 81 Milligrams (MG) by mouth daily and Ticagrelor (antiplatelet medication) 90 MG by mouth two times a day related to unspecified atrial fibrillation from 9/1/25 to 9/30/25 and 10/1/25 to 10/2/25. The EMARs lacked documentation Resident #1 received any medication classified as an anticoagulant. A 10/2/25 Physician Visit Progress Note listed the following medications orders:a. Aspirin Oral Tablet, give 81 MG by mouth one time a day for prophylactic atrial fibrillation.b. Ticagrelor Oral Tablet 90 MG, give 1 tablet by mouth two times a day for stroke prevention related to unspecified atrial fibrillation. The 10/2/25 Physician Visit Progress Note lacked documentation of current orders for an anticoagulant medication. During an interview on 12/09/25 at 2:15 PM the MDS Coordinator reported she thought the Ticagrelor medication was an anticoagulant. She discovered the aspirin and Ticagrelor are both antiplatelet medications. She voiced she utilized the RAI MDS Manual to code the MDS. Interview completed on 12/11/25 at 11:00 AM the MDS Coordinator explained she can reference medication books and the electronic medical record system they use also has the drug classification for each residents medication listed. The CMS LTC RAI User's Manual, October 2025, Version 1.20.1, Page 1-4 documents 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.The CMS RAI User Manual, Chapter 3, Page N-8 Item N0415 High-Risk Drug Classes directs to check if the resident had taken an antiplatelet medication in the last 7 days of the MDS seven day look back period. Page N-9 directs do not code antiplatelet medications such as aspirin/extended release as anticoagulants. 2. A 10/30/24 Notice of PASRR Level II Outcome documented Resident #18 met PASRR criteria for a serious mental illness for the diagnosis of bipolar disorder, major depressive disorder which led to significant symptoms that impact the resident's daily functioning. The MDS dated [DATE], Section A1500 failed to identify Resident #18 with a state level II PASRR to have a serious mental illness or a related condition. A 11/20/25 MDS showed a Brief Interview for Mental Status (BIMS) Score of 13/15 indicating intact cognition. Resident #18 was unable to recall the current day of the week and required cueing for memory recall. The MDS listed diagnoses of anxiety, depression, and bipolar disorder. The resident received antipsychotic, antidepressant and anticonvulsant medications. A 11/25/25 Provider Progress Note documented a Chief Complaint follow up for mental health. The History of Present Illness documented Resident #18 with a past medical history of bipolar with history of psychotic symptoms and dementia. He was last hospitalized in 2024 for an extended period of time. During an interview on 12/10/25 at 2:20 PM the MDS Coordinator reviewed section A 1500 of the MDS and stated generally the resident's physician will provide a diagnosis of serious illness or she could look at the resident PASRR. She reviews the admission paperwork, but if she doesn't see a PASRR, she still has access to it in the EHR. The level II would indicate a serious mental illness or disability disorder. The CMS RAI Manual, Chapter 3, Page A 30-32 directs to answer yes in A1500 of the MDS if the PASRR Level II screening determined the resident had a serious mental illness and continue to MDS question A1510 Level II PASRR condition.

Based on observation, policy review and resident and staff interviews the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed for EBP (Resident #14). The faciltiy reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #14, dated 9/9/25, documented the resident had an indwelling catheter. During an interview on 12/8/25, the resident reported he had an indwelling catheter. An observation at the same time revealed the EBP poster on the resident's door and a chest of drawers right outside his door. During an observation on 12/10/25 at 1:31 PM, Staff A, Certified Nursing Assistant (CNA), entered the room to empty the catheter drainage bag. She performed hand hygiene and donned gloves. She proceeded to empty the drainage bag. She did not don a gown as required by EBP. During an interview on 12/10/25 at 1:38 PM, the MDS Coordinator acknowledged there was an EBP poster on the resident's door, the chest of drawers outside the room contained the required PPE, including gowns, and she would expect Staff A to follow EBP. On 12/10/25 at 2:15 PM, the Infection Preventionist explained staff are to follow EBP with catheters. She further explained she would expect staff to follow EBP including to wear a gown and gloves when they emptied a catheter. Facility Policy titled Infection Prevention and Control, last revised on 7/31/24 directed staff to wear a gown and gloves during high contact resident activities as well as residents with indwelling medical devices.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to provide supervision for an ambulatory cognitively impaired resident for 1 of 2 residents identified by the facility as an elopement risk (Resident #1). On 10/17/25 around 8:11 PM, Resident #1 went out the B-wing door, walked down the facility sidewalk, across the facility graveled parking lot, across a residential street, across a hospital parking lot and into the hospital ambulance garage. The Emergency Medical Service (EMS) Personal contacted the facility to inform them that the resident was at the emergency room entrance at 8:32 PM. The facility had been unaware the resident had eloped (ran away) until contacted by the Emergency Personal. The resident was identified with cognitive impairment, impaired safety awareness, and wandering behaviors. Staff failed to determine the cause of an activated exit door alarm, and assure that all residents were safe and accounted for. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility identified a census of 52 residents.On November 4, 2025 at 2:15 PM, the Iowa Department of Inspections, Appeals and Licensing (DIAL) staff contacted to notify them the Department determined an Immediate Jeopardy (IJ) situation existed at the facility. The IJ began on October 17, 2025. The IJ was removed per past non-compliance on October 20, 2025. The facility staff removed the Immediate Jeopardy through the following actions:*Facility wide education and reinforcement completed on 10/20/25, -One-on-one and group education provided by Quality Assurance leadership on: door alarm response, immediate headcount requirements, documentation expectations,-Staff not present at initial training were educated prior to the next shift worked-Education emphasized alarm fatigue risk and requirement to verify resident location before silencing alarm-Dual-staff verification for alarm re-implemented and emphasized on 10/20/25.-Use of the Communication board implemented for documentation after door alarm activation in exit attempts events on 10/20/25-Outside motion lights tested and confirmed functional on 10/17/25-Orientation revised to include mandatory elopement and alarm-response training on 10/20/25-Weekly audits in place for alarm responses, headcounts, and documentation-audits started on 10/24/25The facility implemented their plan of correction and removed the immediacy on 10/20/25 and the scope was lowered from a J to a D. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severely impaired cognition. The MDS revealed the resident was able to be understood, rarely/never understood others, had wandering behavior that occurred daily and disorganized thinking (rambling, unclear or illogical flow of ideas, or switching from subject to subject). The resident was independent with ambulation throughout the facility with no assistive devices. The MDS included diagnoses of hypertension, (a condition in which the force of blood against the artery walls is consistently too high), Non-Azheimer's Dementia (any form of dementia that is not caused by Alzheimer's disease), and anxiety (a common mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life). The Care Plan focus area with no date, indicated Resident #1 was at risk for elopement/wandering related to dementia, resident will at times head towards the exit door but is easily redirected and at times will make statements about wanting to go home. The Interventions directed the following:a. During my wandering times or my increased confusion times, nursing staff will increase supervision with me. I usually will go with staff if they hold my hand softly.b. Engage resident in purposeful activities such as folding towels, helping put table cloths on dining room tables.c. If you see me packing up my items or wandering around with my purse, please intervene offer toileting, offer food or drink, offer purposeful activities.An Elopement Risk Evaluation completed on 5/28/25 at 1:41 PM, checked that the resident has a known history of elopement.A Behavior Note dated 7/18/25 at 7:40 PM, documented the resident became confused and started to pace the hallway immediately after supper and eloped the facility through the main entrance at 7:30 PM while the writer was passing medications on the C-hallway and the rest of the staff were helping other residents with cares. Redirection and reassurance by the staff. The staff at first tried to redirect the resident back in the building, but the resident became more agitated and started walking away from the staff. The staff decided to walk with the resident to the hospital, as the resident stated that she was going to the hospital. After walking from the facility premises to the hospital, staff were able to convince the resident to come back to the facility. A General Progress Note dated 7/20/25 at 4:30 PM, documented the resident eloped from the building through D exit door at 4:05 PM. When the door alarm went off, there was a staff member in the hallway at the time. Staff followed the resident within eye distance in order not to aggravate the resident. When it was determined that the resident was not in distressful status, the staff drew close to the resident and walked along with them to the front of the building. The staff convinced the resident that it was too hot to be outside, that they should come inside for ice water. the resident is confused, but has not tried to leave the facility since they came back inside.An Incident Report (late entry) Note dated 10/17/25 at 8:30 PM, documented door alarm sounded on B wing at approximately 8:00 PM. Dietary staff stepped outside and looked both ways but did not see anyone and silenced the alarm. At 8:15 PM, hospital staff called to report resident outside of the Emergency Department with hospital staff. Our facility staff escorted the resident back to the facility at 8:20 PM. Resident willingly returned to facility with staff. Resident is unable to describe the situation, why she left. Resident able to walk independently without assistance as per her usual. Smiling, jabbering speech as per her usual. Redness noted to bilateral anterior palms and 1.0 centimeter by 1.0 centimeter abrasion noted below right knee. A Communication with Physician (late entry) Note dated 10/17/25 at 10:00 PM, documented resident eloped from facility and walked across the street to the hospital. Hospital staff called facility to inform staff of resident arrival there. This facility staff retrieved resident without incident. Bilateral anterior palms noted redness and 1.0 centimeter by 1.0 centimeter abrasion notes to below right knee. Resident denies pain or discomfort. Alert to person. Range of motion per normal and pleasantly confused.A 10/17/25 breakdown of video footage document described the following:Resident was walking the hallway when an aide assisted resident to shower on C-wing around 6:22 PM until 6:45 PM. At 6:45 PM, an aide and resident walked to the resident room, the aide exited the room. At 7:57 PM, resident left her room and walked to the front nurse's station where an aide directed the resident to a chair near another resident so they could visit. A few minutes later, the other female resident was assisted by an aide to their room for their evening routine. At 8:10 PM, resident is seen at the front nurse's station walking towards the nurse. Resident then walked down B-wing. Nurse looks down B-wing and walked back to the nurses station. At 8:11 PM, resident is seen going out B-wing door.Dietary aide was on B-wing already and responded to the door alarm within seconds. He is seen looking outside then walking back to the nurses station around 8:12 PM. Around 8:32 PM, aide is seen picking up the phone at the front nurses station she then went and got a wheelchair right away and went over to the hospital. At 8:46 PM, staff brought resident back into the facility. At 9:35 PM, nurse entered the room to check on resident.The Elopement Investigation Updated 10/23/25 described the incident, staff reported resident did not exhibit signs of distress during the evening of 10/17/25. She recently had a shower and was wearing her red flannel pajama pants and long sleeved top with socks and white tennis shoes. On 10/17/25 at approximately 8:00 PM, Resident #1 exited the facility through the B-wing exit door, which was alarmed at the time. Staff responded to the alarm; however, the resident was not immediately observed nearby. The B-wing exit door was unlocked and could have been reentered from the outside at the time of the incident. The resident walked 250 feet toward the local hospital ambulance bay, where three Emergency Medical Technicians (EMT) staff members were standing outside under a motion-activated exterior light. This area is a waiting location where EMT often remain between calls during evening and over night shift. Shortly after the alarm was silenced, the facility was contacted by the hospital emergency department, reporting that the resident was present in the ambulance bay area. Facility staff immediately retrieved the resident and completed a head to toe assessment upon return at approximately 8:20 PM. No injuries were identified. The resident BIMS score of 1 indicates severed cognitive impairment and poor recall of the event. The resident has a documented history of confusion and exit-seeking when anxious or disoriented. Door alarm function was verified and confirmed to be operational. At the time of the incident, weather conditions were overcast skies (100% cloud coverage), light wind, and low natural visibility due to limited moon illumination at approximately 12%. Construction at the main entrance required temporary use of alternate doors, including A-wing and B-wing exits, increasing environmental and traffic variables. Resident most likely walked on the sidewalk, through the parking lot that was part gravel and part shaved asphalt, then cross the low traffic residential street, to the hospital parking lot and ambulance bay. A total of approximately 250 feet. Staff confirmed alarm sounded and was silenced once the area was checked. Staff assumed that the alarm was triggered by weather and/or visitor traffic. Staff noted alarm fatigue due to frequent non-emergency activations caused by weather and visitor traffic. This door is currently used frequently by staff due to the construction on the main entrance door.Observation on 11/3/25 at 11:30 AM revealed the facility Director of Nursing went around to all the door alarms and they all sounded and staff responded quickly to the alarms.Observation on 11/3/25 at 1:00 PM revealed Resident #1 was ambulating down the back hallway to the activity room, resident was independent in ambulation and wearing appropriate attire.Interview on 11/3/25 at 4:00 PM, Staff A, Dietary Aide, verified that on 10/17/25 about 8:00 PM, the B-wing door alarm was sounding, so he went to the B-wing door, opened door and just poked head out door, it was dark out, closed door, and did not see anyone outside. Staff A, proceeded to silence the door alarm and went to the nurses station and explained to the nurse he silenced the alarm and did not see anyone outside. Staff A, then stated that he came back to the facility about 11:00 PM, and was informed by the charge nurse that Resident #1 left the facility unsupervised and went across the street to the hospital. Staff A, explained that during the construction of the parking lot, the main entrance was not accessible to come into the facility so staff/residents/visitor were using the A and B wing doors and at times alarm fatigue would set in. Staff A noted that the door alarms are to remain on until one can verify that it was not a resident. Interview on 11/3/25 at 5:10 PM revealed Resident #1 was not able to remember going out of the facility on 10/17/25.Interview on 11/3/25 at 5:23 PM revealed Staff B, Certified Nursing Assistant (CNA), stated that on 10/17/25 she got a telephone call that Resident #1 was across the street at the hospital and that Staff B and Staff C,CNA needed to take a wheelchair over to the hospital and bring Resident #1 back to the facility. Staff B explained that when she walked over to the hospital it was raining out pretty good. Staff B said that she had to take a towel and wipe off the seat of the wheelchair. Staff B said that when they brought the resident back to the facility it was still raining and they had to walk fast and they were pushing the resident in the wheelchair. Staff B verified that the door alarms are to be kept sounding until you can verify that no resident has left the facility. Interview on 11/4/25 at 8:00 AM, Staff C, CNA, explained that on 10/17/25 her and Staff B, CNA, took a wheelchair and walked across the street to bring Resident #1 back from the hospital, and was told that Resident #1 had left the facility by exiting the B-wing door. Staff C stated that when she got to the hospital Resident #1 was sitting in a wheelchair with a blanket around her. Staff B and Staff C, did a quick head to toe assessment and that the resident had dirt on her pajama bottoms and the palms of her hands were red. Staff C, went on to say that it was dark outside and was raining pretty steadily when they went to the hospital and when they were returning to the facility. Staff C verified that the expectation from the staff is to keep the alarm sounding until you can verify who went out the door.Interview on 11/4/25 at 9:45 AM revealed Staff D, Chief Executive Officer (CEO) of the hospital, explained the following: On 10/17/25 about 8:10 PM, the husband of one of the employees from the hospital was waiting outside, and saw a lady wandering around in the parking lot of the hospital. The husband approached the lady and guided her into the emergency room registration desk, sat her down in a wheelchair and through conversation got her to say that she was from the facility across the street. The charge nurse on that shift called the facility to notify them that a resident from their facility was in the ER and that they needed to bring a wheelchair and take her back. Staff D, explained that the hospital did not due a head to toe assessment or any documentation of the incident.During an Interview on 11/4/25 at 3:15 PM, Staff E, Registered Nurse (RN), explained that she was at the nurses station and heard the B-wing door alarm sound and noticed that Staff A was already down that hallway and went to the door. Staff E stated that she went behind the front nurses station to continue to chart and Staff A came up and told her that had poked his head outside and did not see anyone. Staff E did not think anymore about it until a phone call came from the hospital across the street that there was a lady that was from the facility. Staff E, explained that she did a head to toe assessment on Resident #1 and found her anterior palms to be red. Staff E stated that the expectation from the staff is to let the alarm sound until they can verify that it was not a resident that had left the facility. Staff E explained that due to the construction of the parking lot, the main entrance was closed and staff/residents/visitor were to use the A and B wing doors and that alarm fatigue would set in.Interview on 11/3/25 at 1:15 PM, the facility Administrator acknowledged that the expectation of the staff are to follow the missing person policy and allow the alarm on the door to sound until it is verified that a resident did not leave the facility.Observation on 11/4/25 at 10:05 AM revealed the distance from where the resident left the facility through the B-wing door to the area where the resident was found by the emergency room staff was approximately 250 feet, for which the resident crossed the facility parking lot with gravel, crossed a residential street (speed limit is typically 25 miles per hour), through a cement hospital parking lot with curbs, and landscaping with gray rocks.The Channel-Wunderground Weather Station for 10/17/25 at 8:15 PM documented the temperature of 62 degrees Fahrenheit with south southwest winds at 3 miles per hour and light rain.Review of the Missing Patients dated 1/24, documented the Missing Patient Response Plan is intended to provide guidelines for patient accountability, searching for missing patients and communicating with outside agencies. This plan supplements the most current clinical services information regarding missing patients.*Refer to Missing Patients Actions Table and Missing Patient Locator Form to guide and document actions taken during the search.-Whenever a staff member discovers a patient missing or hears an alarm that may indicate a patient has left the center, the staff member immediately conducts an initial internal or simultaneous external search of the immediate area to locate the patient.-The nurse supervisor/designee acts as a search coordinator and coordinates and documents all search efforts. -The search coordinator, after confirming that a patient is missing, via the head count, immediately notifies the administrator and director of nursing, as well as all other department heads-The interior search continues; the search coordinator directs selected individuals to expand exterior search of the surrounding neighborhood to within a one-mile radius of the center. All possible hiding areas, out building, dense foliage, over growths, ravines, stores, parked cars are to be searched. -The search coordinator coordinates an intensive search of center, grounds and community.-Actions when patient is located: examine the patient and record findings in the chart, complete incident report, and take immediate actions to prevent further wandering, exit seeking and review with quality assurance committee.

Based on observation, staff interview, and resident interview, the facility failed to maintain a clean, comfortable and homelike environment. The facility reported a census of 56 residents. Findings include: 1. Observation on 8/11/2025 at 9:00 A.M. included: a. A Hall - Wall paper border above hand rail partially removed, peeling in multiple areas. Hall carpet with a large amount of dark stains and blackened colored areas. b. A Hall - room [ROOM NUMBER], #5 - Room carpet with moderate amount of dark stains. c. C Hall - room [ROOM NUMBER], #27, #36 - Room carpet with moderate amount of dark stains. 2. Observation on 8/11/25 at 8:15 A.M. revealed the following: The center hall carpet that went into the service hallway and the kitchen revealed darkened, blackish discoloration on the carpet with areas of solid blackened spots that measured the width of the doors. The carpet leading to the dining room from the center hallway was darkly discolored with blackened spots that measured the width of the double doors. Observations of the dining room at this time revealed multiple areas of darkened areas throughout the dining room, with areas of dark, black spots scattered throughout the dining room carpet. On 8/11/25 at 8:07 A.M. during an interview with Resident #7 while sitting in the dining room, the resident stated, I don't like this dirty carpet in this dining room, it is worn out, dirty and needs cleaned. She stated, I wish you could help me with this, it makes me sick to sit in here and eat my meals. On 8/12/25 at 8:20 A.M. during an interview with Staff A, Maintenance Supervisor, Staff A stated he also had concerns with the carpet and the condition of it. He stated in the summer it was hard to keep clean because of the humidity and this year all the rain had had. He reported due to recent rainfall event water came into the building which had made the carpet wrinkle. Staff A stated he last cleaned the carpet around Christmas of 2024 and stated it really needed it again. Staff A stated they had a resident who peeled the wall paper off the A Hall walls and they were working on how to fix this. The resident pulled off the wall paper almost immediately after he repaired it. Interview with Staff F, Housekeeping Supervisor on 8/12/25 at 11:00 A.M. revealed she had worked in the building since 2022, moved here from [Name Redacted] next door. The last time the carpets were cleaned was right before Mother’s Day 2025, they spot clean the carpets regularly but it did not help. The carpet was very dirty and ground in dirt and spots. The carpet had been dirty since she transferred from the sister facility down the street.

Based on clinical record review and staff interviews, the facility failed to follow physician orders for one of three residents reviewed (Resident #2). The facility reported a census of 56 residents. Findings include:Resident #2's MDS (Minimum Data Set) dated 7/18/2025 revealed he had no cognitive impairment, had diagnoses including diabetes, absence left toes, anemia, heart failure, renal insufficiency, hypertension and had diabetic foot ulcers. The Care Plan identified the resident had a risk for alteration in skin integrity related to type two diabetes and other circulatory complications. It directed staff to administer treatments per physician orders, encourage good nutrition and hydration in order to promote healthier skin, and observe skin with ADL's (activities of daily living). A Wound Clinic Note dated 7/31/2025 included an order to provide one serving of Prostat AWC (advanced wound care), a protein supplement, one serving daily. Protein to assist with wound healing.On 8/12/2025 at 12:50 Staff B, DON (Director of Nursing) reported a staff nurse missed the wound clinic order for Prostat. It was hidden in the note dated 7/31/2025.On 8/12/2025 at 1:10 P.M., Staff G, LPN (Licensed Practical Nurse) reported she worked at the facility for 8 years. Resident #2 had a wound clinic order dated 7/31/2025. Staff G revealed she missed the Prostat order from the wound clinic, it was considered an order, and did not know how she missed it. Staff B put the order in the resident's record and notified the physician today. The facility policy titled Physician Orders/Transcription of Orders revised 7/2023 included the following: PURPOSE: To correctly and safely receive/transcribe physician's orders so correct order can be followed/administered. To ensure that patient medications, treatments, and plan of care are in accordance with the licensed providers orders.

Based on observation, resident and staff interviews, review of computerized call light response times, and facility policy review the facility failed to answer resident call lights in a timely manner for two of three residents reviewed (Resident #1, #6). The facility failed to have the call light within reach for one of seven residents reviewed (Resident #5). The facility reported a census of 56 residents. Findings include:1.The MDS (Minimum Data Set) dated 7/2/2025 reported Resident #5 had severe cognitive impairment and had diagnoses including diabetes, history of falls and fracture of the left humerus. The MDS indicated the resident had a fall with no injury since the previous assessment. The resident's Care Plan directed staff to assist the resident with transfers and ambulation with the use of a gait belt, and ensure the call light is within reach. Observation on 8/11/2025 at 9:10 a.m. revealed Resident #5 seated in her room in a recliner with a bedside table at her right side. The call light sat on the bed against the wall. The resident stated she had to go to the bathroom and attempted to lower the footrest. The surveyor summoned staff and Staff E, Certified Nursing Assistant (CNA) entered the room, applied the gait belt, and assisted the resident to the bathroom. Staff E observed the call light on the bed and stated, someone forgot to put the call light on her chair. 2. The MDS dated [DATE] revealed Resident #6 had no cognitive impairment, and the Care Plan indicated the resident had a fall risk. During an interview on 8/11/2025 at 9:20 a.m., the resident revealed staff failed to answer his call light in a timely manner. Staff , at times took up to 30 minutes to respond when he put his call light on. The resident also reported staff would enter his room, turn the call light off and state they would be right back, but failed to do so. The facility Call Light Policy revised 9/2023 included the following purpose: To ensure that there is a prompt response to the resident’s call for assistance. The facility also ensures that the call system is in proper working order. Procedures:1. Facility shall answer call lights in a timely manner2. Orient new residents as appropriate to the call light at bedside as well as the call light in the bathroom and in shower/tub rooms3. Answer call lights in a prompt and courteous manner, knocking before entering and introducing self4. When answering a call light, respond to the request. If immediate assistance cannot be provided and there is not an emergent need, call light may be turned off and resident informed that a staff member will be back to assist them shortly5. If a call light is not functional, evaluate and provide another means in order for the resident to call for assistance (i.e. bell) until the call light is fixed. Notify the administrator/maintenance director immediately for repair6. Call lights are to be placed within reach of residents for those residents who can use it. Frequent rounds and interventions per care plan must be followed for supervision of those patients who are physically and/or cognitively unable to utilize call light. (Soft touch call lights can be utilized if needed)7. Be sure that when a call light is triggered, it will either alert the staff visually, audibly, or both. 3. Review of Resident #1's MDS dated [DATE] revealed the resident had intact cognitive ability. The resident had diagnoses which included surgical repair of right and left femur, Parkinson's and congestive heart failure. The resident reported the staff failed to answer her call light timely and reported incontinence episodes as a result. The resident stated she had kept records of the call lights but only recently started the log. During an interview on 8/12/25 at 10:10 am, the resident revealed that last evening at 6:00 pm she put on her call light and the staff failed to answer her call light until 6:50 pm. Interview and review of the computerized Call Light Wait time logs on 8/12/25 at 10:30 am with Staff C-Quality Assurance/Certified Medication Aide revealed the following extended call light response times for Resident #1: a. On 8/5/25 the resident activated her call light at 10:16 am, the staff failed to answer the call light for 28 minutes and 48 seconds. b. On 8/6/25 the resident activated her call light at 8:44 am, the staff failed to answer the call light for 31 minutes and 34 seconds. At 6:21 pm the resident activated her call light, the staff failed to answer the call light for 20 minutes and 24 seconds. c. On 8/7/25 the resident activated her call light at 5:09 am, the staff failed to answer the call light for 25 minutes and 25 seconds. At 12:04 pm the resident activated her call light, the staff failed to answer the call light for 40 minutes and 10 seconds. d. On 8/9/25 the resident activated her call light at 6:36 am, the staff failed to answer the call light for 33 minutes and 6 seconds. At 1:00 pm the resident activated her call light, the staff failed to answer the call light for 19 minutes and 6 seconds. e. On 8/10/25 at 6:16 am the resident activated her call light, the staff failed to answer her call light for 19 minutes and 9 seconds. At 6:18 pm the resident activated her call light, the staff failed to answer her call light for 23 minutes and 45 seconds. e. On 8/11/25 at 8:03 am the resident activated her call light, the staff failed to answer the call light for 22 minutes and 9 seconds. At 12:36 pm the resident activated her call light, the staff failed to answer her call light for 22 minutes and 4 seconds. At 1:55 pm the resident activated the call light, the staff failed to answer her call light for 17 minutes and 2 seconds. At 6:10 pm the resident activated her call light, the staff failed to answer her light for 42 minutes and 14 seconds.

Based on resident interviews, staff interviews, and record review the facility failed to prevent financial exploitation for 1 out of 1 residents reviewed for allegations of abuse (Resident #2). The facility identified a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 1/14/25, listed diagnoses for Resident #2 which included anemia, atrial fibrillation, neurogenic bladder, paraplegia, and pressure ulcer. The MDS stated the resident required set up assistance from staff for toileting hygiene, showering, dressing, personal hygiene, and transferring. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating cognitively intact. Review of a document provided by Resident #2 to the facility revealed a twenty dollar electronic funds transfer to Staff A, Certified Nursing Assistant (CNA) on 2/19/25 at 9:01 PM. During an interview on 4/16/25 at 11:00 AM Resident #2 stated it was late February and I was warming something up in the microwave and Staff A, Certified Nursing Assistant (CNA) asked if he could borrow some money. He had a name and account and I pulled it up and sent the money electronically through Pay Pal. The application is a normal based trading application and there is a transaction number that goes through Pay Pal. I sent him twenty two dollars through the cash application. He did end up paying me back ten dollars. The day I was discharged home Staff A acted like he was sending me the money through Pay Pal and when I got home I noticed he had faked it. I still have not gotten the money back except for ten dollars. It is the principal of the matter, I am cognizant of the money but what is he doing to the [AGE] year old who is not alert. I did not report the incident right away because I thought he was going to pay it back and I wasn't trying to make trouble. I heard after the fact that staff are not supposed to do that. I connected with him and kind of felt like we were friends is the reason I did it. During an interview on 4/16/25 at 2:17 PM with Staff A, CNA stated Resident #2 did send him money through a cash application. He did send me twenty dollars and I gave him fourteen dollars back. I was going to give him ten more dollars back. I have not paid the rest of the money back to Resident #2. It has been my intention to I just do not have a pay pal account. I have not had any contact with him since he discharged to home. The loan happened through a conversation, he was fully aware and it was a gesture between friends that was blown out of proportion. I did not take anything from him it was a loan and I paid back fourteen dollars. Surveyor asked why he did not tell the Administrator the truth when she talked to him about and he stated it was obscure and I had no malice or ill intent, now since it has become so prevalent in my life I felt the need to address it so I can move past it. During an interview on 4/17/25 at 10:47 AM the Director of Nursing (DON) stated she did have a nurse come to her and report a CNA had borrowed money from a resident. She instructed the nurse to write a statement and inform the administrator. She stated her expectation of the staff is they should not take money or items from residents, it is against our policy and against the law probably. During an interview on 4/17/25 at 11:06 AM Staff B, Licensed Practical Nurse (LPN) stated she was in Resident #2 room and he asked me if Staff A was here at the facility, I told him I didn't know. The resident then told me he owed him some money and he asked him to repay him back in five dollar increments and he had not been getting his money. The next time I worked I told the DON about it. Staff B did state the different kinds of abuse as physical, verbal, neglect, sexual and exploitation and she would consider borrowing money from a resident as exploitation. During an interview on 4/17/25 at 11:34 AM the Administrator stated after Resident #2 discharged he called her and told her he had loaned Staff A twenty two dollars and he had been paid back roughly ten dollars and Resident #2 was hoping I could get something done about it. We opened an investigation and notified the police and the Department of Inspections Appeals and Licensing. During my investigation I did hear statements from other staff of the allegations so I decided the best intervention would be education to the staff since we had no proof. I would consider a resident loaning a staff member money against company policy. The facility provided a policy titled Abuse Prevention, Training and Investigations dated 12/30/20 stated the facility has a comprehensive system of practices and procedures designed to a.) prevent occurrences of mistreatment, abuse, neglect, and /or misappropriation of resident property, b) monitor, identify and investigate injuries of unknown source and any allegations of suspected abuse, and c) insure that reasonable suspicions are reported to the appropriate law enforcement and regulatory oversight agencies.

Based on record review, staff interviews, and facility policy review the facility failed to report an allegation of abuse to the proper agency in a required time frame for 1 of 1 allegations of abuse reviewed (Resident #2). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 1/14/25, listed diagnoses for Resident #2 which included anemia, atrial fibrillation, neurogenic bladder, paraplegia, and pressure ulcer. The MDS stated the resident required set up assistance from staff for toileting hygiene, showering, dressing, personal hygiene, and transferring. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating cognitively intact. Review of a summary incident provided by the facility revealed Resident #2, was a resident of the facility from 1/7/2025 to 3/28/2025. After discharging to home, Resident #2 called the facility to report that he transferred $22 to a facility caregiver, Staff A, Certified Nursing Assistant (CNA) by Pay Pal at the end of February. Resident #2 reports that Staff A has paid him back $10. Document provided by the facility dated 4/1/25 revealed Resident #2 called the facility to say he gave Staff A, CNA $22 by Pay Pal at the end of February. He reports staff has paid him back $10. Review of police department call for service record revealed the facility reported misappropriation of resident funds on 4/4/25 at 1:13 PM. Review of the intake dated 4/4/24 revealed the submission date for the allegation of abuse was reported to Department of Inspections, Appeals and Licensing on 4/4/24 at 1:56 PM On 4/16/25 at 1:42 PM Staff C, Registered Nurse (RN) stated if a staff borrowed money from a resident it should be reported immediately to Director of Nursing or the Administrator and I would let the staff know it is not appropriate. On 4/16/25 at 1:46 PM Staff D, Certified Nursing Assistant (CNA) state if I heard of staff asking a resident to borrow money I would tell the Administrator and let her know and I would question what the policy is for this type of behavior immediately. On 4/16/25 at 1:59 PM Staff E, CNA stated if she heard of staff borrowing money from residents she would report it to the supervisor immediately because it is against the policy and rules. On 4/17/25 at 10:47 AM the Director of Nursing stated a nurse came to report Resident #2 had reported a staff borrowed money from him and I had her write it down immediately and inform the Administrator. I am not sure of the date it occurred but the Administrator did the follow up investigation. On 4/17/25 at 11:06 AM Staff B, Licensed Practical Nurse (LPN) stated she was in Resident #2 room when he told her Staff A owed him money. She was unsure of the dates but confirmed it was while Resident #2 was still a resident. It was around 9:45 PM at night so the next time I worked I told the Director of Nursing. She stated the DON told her to write everything down and I wrote up a statement. Then I slid it under Human Resources door. Administrator did talk to be about it and asked me detailed question about it but I am not sure of the date or if it was the same day I wrote the statement. Resident #2 was no longer in the facility by the time I reported it to the Administrator. On 4/17/25 at 11:20 AM Staff F, Human Resources stated she did not receive a written statement but when Staff B spoke to me about it and she thought it was weird, but then I told her no that is not allowed and I went and spoke to the Administrator about it and she said she needed a statement in writing . I talked to Staff A about the incident and I did not get a written statement. I do not know when this occurred. The facility did not get a written statement from me regarding talking to Staff B. I would say it is definitely not appropriate and should not happen in a facility and should be investigated. On 4/17/25 at 11:34 AM the Administrator stated I would expect the staff would notify me of a crime with injury within 2 hours and without injury within 24 hours. I would consider a resident loaning a staff member money against company policy. The facility provided a policy titled Abuse Prevention, Training and Investigations dated 12/30/20 which directed employees are required to immediately intervene to distract, halt and/or prevent harm to the extent that they can do so without placing themselves at risk of injury if they observe what they suspect is abuse or other criminal behavior to be occurring. They are also required to report allegations or suspicions of mistreatment, abuse or other crimes perpetrated by any person - including a staff member, caregiver, resident/tenant, volunteer, or visitor immediately and without hesitation directly to the person in charge of the facility at the time. If that person is not the Administrator, the employee is also required to report the allegation to the Administrator within one hour of first becoming aware. The policy directed staff every abuse allegation needs to be thoroughly investigated, including: interviewing all potential witnesses to the occurrence, interviewing all potential witnesses to the reporting of the occurrence and interviewing other persons who might have witnessed similar events where the alleged behavior could have occurred with the same likeliness as this one. Interviews may be recorded or if that is not possible a second person may sit in for taking notes to document the questions and responses. The policy directed the facility reportable occurrence decision tree may be used to assist Administrators to determine whether an occurrence is reportable as either suspected dependent adult abuse under Iowa law; mistreatment, abuse or other criminal activity under federal law; and/or is reportable under other state or federal rules or regulations.

Based on observation, record review, resident and staff interview, the facility failed to provide each resident with a palatable, well balanced diet that takes into consideration the preferences of each resident. (Resident #14). During an observation of a meal, the facility failed to maintain cold foods below 41 degrees, obtain temperatures and serve the correct portion size of pureed meals. The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 and had the following diagnoses: Diabetes Mellitus, Arthritis, and [NAME]-[NAME] Syndrome. The MDS also identified Resident #14 to be totally dependent on staff assistance with showers, toileting, lower body dressing, the MDS also identified Resident #14 required substantial/maximal assistance with upper body dressing and transfers. Interviews with Resident #14 revealed the following: 11/12/24 at 9:43 AM Resident #14 reported the food was not the greatest. They serve the same food over and over again and it just does not taste good. 11/13/24 at 8:30 AM Resident #14 sat up in her recliner in her room with only a banana and a glass of orange juice on her food tray. She stated that was all she felt like eating because they serve the same thing for breakfast every day, scrambled eggs. 11/13/24 at 9:46 AM Resident #14 reported the supper meal from last night the meat was too salty and had too much soy sauce. She did not order any alternate as it is always soup and by the time they bring it to her room, the soup is cold. She tries to avoid salt because of her high blood pressure. The Care Plan identified Resident#14 with the problem of the potential risk for altered nutritional status related to obesity, diabetes, diverticulitis and directed staff to: a. Monitor weights b. Notify the doctor/dietitian of significant weight change c. Provide diet as ordered general regular texture regular fluids d. Monitor and record intake of meals A review of the dietary Progress Notes for the past year had only one entry dated 6/19/24 at 11:53 AM, it revealed no documentation to address the resident's complaints about palatability. In an interview on 11/14/24 at 8:00 AM, the Administrator reported the facility did not have a policy for palatability. 42134 2. During an observation of the meal service on 11/13/24 beginning at 11:23 AM, 3 residents were served a puree diet. The pureed steak sandwich, potato salad, and broccoli salad were not temped prior to serving to ensure a safe serving temperature had been reached. In addition, each resident was given a 4 ounce (oz) serving of the steak sandwich rather than the 6 oz serving they should have been served. A test tray for temperature and palatability was provided on 11/13/24 at 12:05 PM. The steak sandwich and potato salad were at the expected temperatures for hot and cold food. The sandwich meat on the edge of the bun tasted cold. The inner sandwich meat tasted hot. The broccoli salad temperature was 42.1 degrees Fahrenheit. It was not tasted for palatability as it was not at a safe temperature. During an interview at the time the test tray was temped, the corporate dietician explained the standard temperature for cold food is 41 degrees Fahrenheit or colder. During an interview on 11/13/24 at 12:32 PM, Staff B, cook, confirmed all 3 puree diet residents had received a 4 oz sandwich portion. He further confirmed they should have received a 6 oz portion. During an interview on 11/13/24 at 12:35 PM, Staff B confirmed he did not check the temperature of the pureed food prior to serving to ensure a safe serving temp had been reached. During an interview on 11/14/24 at 8:00 AM, the Administrator reported the facility did not have any policies related to food temperatures, palatability, or food portions.

Based on observation, staff interview, and policy review the facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items. The facility reported a census of 48 residents. Findings include: In an observation on 11/13/24 at 1:13 PM Staff A, Laundry/Housekeeping donned gloves, failed to put on a gown, removed the laundry bin lid and put table cloths and cloth napkins in the washing machine. She then removed the gloves, shut the machine door, and started the washer. In an interview on 11/13/24 at 1:04 PM Staff A explained clothes are collected in a bin and sorted into containers. Staff wear gloves for sorting regular laundry and wear a gown, goggles, and gloves for isolation items. Isolation is done at the very end of the day. She further explained some residents have family wash their items, but the facility washes everyone's towels, sheets, dining linens, etc. In an interview on 11/13/24 at 1:16 PM the Environmental Supervisor explained she expected gloves are to be worn when sorting soiled laundry unless it is something from an isolation room, then they have to wear a gown. She was not aware of the need to wear a gown when sorting all soiled linens. The Infection Prevention and Control Program (IPCP) Guidelines, revised 9/22 educated staff handwashing facilities as well as appropriate personal protective equipment (i.e. gloves and gowns) are available in the laundry area for workers to wear while sorting linens.

Based on clinical record review, staff and provider interviews, and policy review the facility failed to contact the provider, and provide intervention for health condition changes noted with a pre-dialysis assessment prior to transfer to a scheduled dialysis appointment on [DATE] for 1 of 3 residents reviewed (Resident #1) who was assessed as lethargic, pulse of 47, and pulse oximeter (oxygen level) 87% on room air. Resident had been diagnosed with Covid-19 on [DATE] and had been experiencing loose stools, lack of appetite, weakness, and confusion. Resident arrived at the Dialysis Center, 30 miles from the facility, non-responsive, with diminished lung sounds, Blood Pressure (BP) ,d+[DATE] and required immediate transfer to the local emergency room (ER) for stabilization of life-threatening conditions. These circumstances posed Immediate Jeopardy to resident health and safety that began on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE] at 1:25 p.m. The facility took appropriate steps to remove the immediacy on [DATE] at 4:35 p.m. by taking the following actions: *Ensuring ALL nurses working for the facility were educated on the Family and Physician Notification policy. *Providing a table with parameters with over 100 situations for staff to use as guidelines for when Physicians need to be notified of resident condition changes to use along with nursing judgement and the Electronic Health Record computer system parameters. *Ensuring ALL nurses signed acknowledgement of receiving and understanding the training provided. The facility reported a census of 57 residents. Findings include: According to a discharge assessment-return anticipated Minimum Data Set (MDS) dated [DATE] Resident #1 admitted to the facility on [DATE] and discharged to a short-term acute hospital on [DATE]. The MDS documented diagnoses that included Diabetes Mellitus, end stage renal disease, non-displaced intertrochanter femur fracture (hip fracture), and an unstageable pressure ulcer. The resident had moderately impaired decision making and evidence of an acute change in mental status from the resident's baseline which included a continuously present altered level of consciousness. The resident's usual performance at the end of the stay was coded as dependent, helper does all the effort, for toileting, shower, and transfer and required substantial assistance to roll form right to left and return to lying on back in bed. Review of Resident #1's baseline Care Plan initiated on [DATE] identified the resident admitted to facility for care related to end stage renal failure and after care following a right femur fracture. Cognitive status described as alert and oriented to person, place, time, and situation. Dialysis on Monday/Wednesday/Friday leave facility at 5:45 a.m. transportation by a local transport service to and from the facility. A focus area identified laboratory confirmed Covid-19 with a goal to avoid hospitalization with a target date of [DATE]. Interventions included: monitor vital signs including SPO2 (oxygen levels) every shift, keep head of bed elevated, encourage fluids and good nutritional intake. Review of a facility document titled Advance Directive Acknowledgement dated as signed by Resident #1 on [DATE] specified that resident requested resuscitation. Review of an electronic Physician Order form for Resident #1 revealed an order dated [DATE] for Cardiopulmonary Resuscitation (CPR), full code. Review of electronically recorded Vital Signs (VS) included the following: [DATE] 5:35 a.m. pulse 47 beats per minute (bpm) [DATE] 2:35 p.m. pulse 113 bpm, O2 (oxygen) 87% room air [DATE] 2:10 p.m. pulse 98 bpm, 92% room air [DATE] 10:44 a.m. pulse 76 bpm, 95% room air [DATE] 7:05 a.m. pulse 78 bpm, 98 % room air [DATE] 5:27 p.m. pulse 80 bpm, 99% room air Review of electronic Progress Notes for Resident #1 included the following documentation: [DATE] at 4:13 p.m. Dialysis center contacted about resident's positive Covid-19 test today, they will complete dialysis as usual. [DATE] at 4:30 p.m. Staff A, Licensed Practical Nurse (LPN) secured communication with Physician included: notification Covid-19 positive. 5:05 p.m. Response: resident not a candidate for Covid-19 treatment, directed to treat signs and symptoms or send to emergency room (ER) if worsens. 5:12 p.m. Response addendum-send resident to ER if difficulty breathing, confusion, etc. [DATE] at 1:21 p.m. Oriented to person, place, and time. [DATE] at 1:44 p.m., the Director of Nursing (DON) communicated through a secured message with the Advanced Registered Nurse Practitioner (ARNP) resident not dizzy, but is pale, somewhat confused and voice very soft. Barely eating and drinking. Resident Covid-19 positive. May have you see on Thursday ([DATE]). Resident is also a full code. [DATE] at 5:30 a.m. Staff B, LPN noted resident with very loose watery stools. Coccyx area dark purple in color. [DATE] at 5:37 a.m. Staff B, LPN completed a dialysis assessment. Temperature 98.7, pulse 47 and irregular, Respirations 16, and O2 level 87 % on room air. Level of consciousness: lethargic. [DATE] at 7:56 a.m. Staff A, LPN noted dialysis center called to inform resident had not had dialysis. Resident was unable to follow commands, unresponsive, cool to touch. Sent to ER by ambulance. Review of a fax communication from the dialysis center revealed a note created by the Dialysis Nurse on [DATE] at 7:51 a.m. The note included the following: Resident #1 arrived at the facility for treatment. Resident very pale and moaning, right eye is closed and left eye is open but staring off, does not blink when wave hand in front of face. Resident nonresponsive to commands, blood sugar 127, BP ,d+[DATE], respirations shallow, lungs clear but diminished. Left hand is cool to touch. Noted to have reaction only to painful stimuli, such as moving via mechanical lift to transport to ER. Dialysis Provider was notified and ordered for resident to be sent to local ER for evaluation. Resident was transported by ambulance to the local ER. Staff A, LPN was notified of the transfer and reported that resident had tested positive for Covid-19, knew the resident was not doing well and expected this. Review of an Emergency Department (ED) note dated [DATE] at 7:27 a.m. revealed resident arrived to dialysis unresponsive. Resident not answering questions appropriately upon arrival to ED. Does moan in pain. Resident assessed to have Atrial Fibrillation, colovaginal fistula (an opening between the vagina and the colon), and bilateral pneumonia. The summary noted that given the high probability of imminent or life-threatening deterioration of the resident's condition without intervention, the resident was immediately assessed, monitored and treated. Resident was admitted to the hospital for ongoing care. In an interview on [DATE] at 11:29 a.m. the Dialysis Nurse stated that Resident #1 had arrived for dialysis at approximately 6:15 a.m., and she was immediately concerned. Stated the resident appeared very pale, unresponsive to commands, responsive only to painful stimuli, unable to obtain a blood pressure with the automatic machine, able to get a blood pressure of ,d+[DATE] with a manual cuff. Stated she had notified the Dialysis Provider who ordered Resident #1 to be sent to ER by ambulance, no dialysis. Further stated she had contacted the facility and informed Staff A, LPN of condition and reported emergency transfer. Staff A commented that she knew resident wasn't doing good and expected her to need to go to the ER. The Dialysis Nurse stated Staff A's response had surprised her, wondered why the facility hadn't called the provider or the dialysis center to notify of condition change rather than transporting to dialysis in poor condition. In an interview on [DATE] at 1:05 p.m. the Administrator stated on [DATE] she had come in at 2:00 a.m. to work as a Certified Nursing Assistant (CNA) and had assisted Staff B, LPN to get Resident #1 ready for dialysis in the morning. She recalled that the resident had very loose stools, wasn't eating, weak, sleepy, much like the other resident's with Covid-19. Stated as she finished cares she heard the entrance door sound indicating that transport had arrived and was not in the room when Staff B completed her assessment. The Administrator estimated that transport arrived at 5:45 a.m. She described that the transportation service was a single driver and the resident was transported in her wheelchair in a van. In an interview on [DATE] at 1:35 p.m. Staff B, LPN stated that she had assisted the Administrator complete cares and get Resident #1 ready for dialysis in the early morning on [DATE]. Further informed she had completed the pre-dialysis assessment and had concerns about the resident's health status. Additionally, had noted at this time that resident's coccyx was deep purple in color, which had not been there the day before. Stated she was glad that Resident #1 was going to dialysis where they knew her better than they knew her at the facility. Added that the doctors at dialysis knew her better because the facility hadn't really gotten to know her baseline as she had been diagnosed with Covid-19 the day after she had arrived. Stated resident had informed them she gets sick really fast when her dialysis schedule is altered, as it was for the Christmas holiday. Responded that transportation was just a single driver, and no further assessment would be provided during transfer. Recalled that when she took vitals her hands were so cold, always cold, so assumed that was why the oxygen level was so low. During an interview on [DATE]/at 10:46 a.m. Staff A, LPN stated she had notified the provider of Covid-19 positive test on [DATE], he had responded unable to treat with medication for Covid-19 and instructed with a change of condition to send to the ER. Staff A, LPN worked the day shift on [DATE] and had received report from Staff B, LPN who had completed the pre-dialysis assessment. Staff A stated that she would have called the provider right away for a pulse of 47, oxygen level of 87% on room air, and resident lethargic, to report condition change. Responded that the direction she had received from the provider when resident initially diagnosed with Covid-19 was to notify the provider of condition change and send to ER for further evaluation. Further interview on [DATE] at 11:51 a.m. Staff A responded that she had not been surprised when the Dialysis Nurse had informed her the resident had not had dialysis and required emergency transfer to the ER for evaluation and treatment because Staff B had informed her of her assessment at report. Again, stated that she would have called the provider to report the change in condition prior to sending to dialysis. In an interview on [DATE] at 3:40 p.m. the DON stated that she would have expected Staff B, LPN to notify the provider of a change in condition after pre-dialysis assessment prior to sending the resident with transportation with a pulse rate of 47, Oxygen level of 87% on room air, confusion and weakness. Responded that the transportation provided was just transportation without medical assistance or assessment provided during transport. Stated typically takes 30 minutes to transport to the dialysis center from the facility. Responded that Resident #1 was a full code, requested CPR. She added, the facility had identified a concern and discussed what could have been done differently that day. In an interview on [DATE] at 3:40 p.m. the Assistant Director of Nursing (ADON) stated that she would have expected the provider to be notified on [DATE] of the condition change noted during the pre-dialysis assessment prior to transferring to dialysis. In a phone interview on [DATE] at 10:58 a.m. the Primary Provider's Nurse stated she had talked to the provider, he had reviewed and would expect to have been notified of the condition change, specifically the low oxygen level, confusion, lethargy and would have instructed the facility to send Resident #1 to the ER. Stated resident had been a patient of the provider while living at home prior to admission to facility and was very familiar with her. Review of an undated facility policy titled, Family and Physician Notification relating to an accident or change in medical condition included the following: The facility will immediately notify the resident, the resident's responsible party and the physician of a change in the resident's medical condition which includes a deterioration in health. The charge nurse working at the time will notify the physician, notification will also include the results of a full body assessment and vital signs. Documentation will be recorded in the resident's medical record. Vital signs that are to be reported immediately to the physician included a resting pulse of less than 55 bpm. Review of Resident #1's profile page in the electronic record revealed that the following vital signs were alerted in red, and displayed a yellow triangle which contained an exclamation point to the left of the vital sign: Pulse: 47 bpm [DATE] at 5:35 a.m. O2: 87% [DATE] at 2:35 p.m. In an interview on [DATE] at 9:35 a.m. the DON responded that vital signs that are out of parameter will alert red in the clinical record as had Resident #1's pulse and oxygen level. The DON reviewed the facility policy and stated that the policy failed to identify a parameter for notification for oxygen level. Continued interview with the DON and the Corporate Nurse Consultant, at 9:40 a.m. the Corporate Nurse Consultant stated the standard alert for oxygen levels is 90%, anything less than 90% would trigger red in the electronic record and require reassessment, follow up, and provider notification.

Based on clinical record review, policy review, and staff interview, the facility failed to notify the physician of a change in condition for 1 of 7 resident's sampled (Resident #49). The facility identified a census of 55 residents. Findings include: Resident #49's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 7 indicating severe cognitive loss. The Resident required extensive assistance of two staff for bed mobility, transfer, dressing, and toilet use. The MDS listed a diagnosis of diabetes mellitus. The Care Plan dated 8/15/23 documented Resident #49 had a diagnosis of diabetes mellitus and directed the staff to monitor/document/report signs and symptoms of hyperglycemia (hyperglycemia is excessively high blood sugar which can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart): increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace indicating a medical emergency - usually related to diabetic ketoacidosis (DKA, a condition where the blood sugar stays elevated too long that can be life threatening), acetone breath (smells fruity), stupor (unresponsiveness from which a person can be aroused only by vigorous, physical stimulation), and coma (unresponsiveness). An Order Summary Report signed by the Provider on 9/25/23 documented an active physician order for accu-checks (blood sugar check) daily in the morning related to type two diabetes mellitus and to notify the physician for blood sugars less than 80 or greater than 350. The Order Summary Report also detailed Resident #49 received Metformin Hydrochloride (anti-diabetic medication) oral tablet 500 milligrams (MG) by mouth two times a day related to his diabetes. A Progress Note dated 10/06/23 at 4:30 PM written by Staff B, Registered Nurse (RN) documented Resident #49 wife reported the Resident was not himself and was mixed up. Staff B did a blood sugar with a result of 409 after resident #49 had drank a reduced sugar Mighty Shake. The Resident's wife requested an hour of sleep (HS) blood sugar be done. The Progress note lacked documentation of notification to the physician. The 10/06/23 progress notes lacked documentation of an hour of sleep blood sugar being completed. The Point of Care (POC) Response History for meal intake on 10/06/23 documented Resident #49 ate 75% (percent) of his supper meal after his blood sugar had been elevated to 409. The POC Response History for snack intake documented Resident #49 received an evening snack on 10/06/23 after supper. The 10/06/23 Point Click Care (PCC) Blood Sugar Summary lacked documentation of the Resident's 409 blood sugar or an evening follow-up blood sugar. During an interview on 10/18/23 at 3:55 PM the Corporate Nurse Consultant reported the facility did not have a facility policy on blood sugar parameters. On 10/18/23 at 4:00 PM Staff A, Licensed Practical Nurse (LPN) reported they do not have a policy on specific blood sugar parameters. She reported they generally report blood sugars less than 70 and greater than 350 to the physician. She reported in reference to Resident #49 with a blood sugar of 409, she would have notified the physician. She reported the nurses use a secure conversation portal to contact the Advanced Registered Nurse Practitioner (ARNP) and she usually gets back to the facility within a day. A Review of the Electronic Medical Record, Point Click Care System under Miscellaneous lacked documentation of any notification to the physician or new physician orders for the blood sugar of 409 as of 10/18/23. During an interview on 10/18/23 at 4:40 PM the Administrator reported no one at the facility was going to question the blood sugar further because the facility hadn't done anything about it. On 10/19/23 at 9:19 AM the Director of Nursing (DON) reported the nurse related Resident #49's blood sugar that day to drinking the mighty shake. She reported the facility owns this one. They had not notified the physician of the high blood sugar and she does expect the nurses to notify the physician for a blood sugar greater than 400. The Family and Physician Notification Relating to Accident or Change in Medical Condition Policy revised 4/12 provided by the facility detailed the facility will immediately notify the resident, the resident's responsible party, and the physician of a change in the resident's medical condition. The Policy Procedure directed the facility must immediately consult with the resident's physician for the following: a. A significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); b. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of a treatment. The Policy further detailed the charge nurse (or assigned person) working at the time of the significant change in condition will notify the physician. The notification will include the results of a full body assessment, vital signs, and description of the accident, if applicable. The documentation of the significant change in condition will be recorded in the resident's medical record and will include: the date, time of the change of condition, a description of the change noted in the resident's condition, full assessment of the resident including vital signs and the resident's physical and mental status at the time of the change in condition. The Procedure further directed attached guidelines to reference to determine the urgency of notifying the physician of changes in medical condition: a. Symptom or Sign of confusion directed with abrupt significant change from usual associated with fever, onset of abnormal neurological signs or abnormal BUN (blood, urea, nitrogen - blood test), electrolytes or other blood test. b. Symptom or Sign, Glucose, immediate notification with any high or low blood sugar accompanied by persistent change from usual level of consciousness or responsiveness; non-immediate notification blood sugar <60 or greater than 400 in a diabetic on oral hypoglycemic or insulin medications unless consistent with usual pattern or per physician parameters.

Based on clinical record review, policy review and staff interview, the facility failed to complete a full assessment on a resident that exhibited confusion with a blood sugar of 409 for 1 of 5 residents sampled (Resident #49). The facility identified a census of 55 residents. Findings include: Resident #49's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 7 indicating severe cognitive loss. The Resident required extensive assistance of two staff for bed mobility, transfer, dressing, and toilet use. The MDS listed a diagnosis of diabetes mellitus. The Care Plan dated 8/15/23 documented Resident #49 had a diagnosis of diabetes mellitus and directed the staff to monitor/document/report signs and symptoms of hyperglycemia (hyperglycemia is excessively high blood sugar which can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves, and heart): increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace indicating a medical emergency usually related to diabetic ketoacidosis (DKA, a condition where the blood sugar stays elevated too long that can be life threatening), acetone breath (smells fruity), stupor (unresponsiveness from which a person can be aroused only by vigorous, physical stimulation), and coma (unresponsiveness). An Order Summary Report signed by the Provider on 9/25/23 documented an active physician order for accu-checks (blood sugar check) daily in the morning related to type two diabetes mellitus and to notify the physician for blood sugars less than 80 or greater than 350. The Order Summary Report also detailed Resident #49 received Metformin Hydrochloride (anti-diabetic drug) oral tablet 500 milligrams (MG) by mouth two times a day related to his diabetes. A Progress Note dated 10/06/23 at 4:30 PM written by Staff B, Registered Nurse (RN) documented Resident #49 wife reported the Resident was not himself and was mixed up. Staff B did a blood sugar with a result of 409 after resident #49 had drank a reduced sugar Mighty Shake. The Resident's wife requested an hour of sleep (HS) blood sugar be done. The Progress note lacked documentation of notification to the physician. The 10/06/23 progress notes lacked documentation of a full assessment or a follow-up hour of sleep blood sugar. The Point of Care (POC) Response History for meal intake on 10/06/23 documented Resident #49 ate 75% (percent) of his supper meal. The POC Response History for snack intake documented Resident #49 received an evening snack on 10/06/23. The 10/06/23 Point Click Care (PCC) Blood Sugar Summary lacked documentation of the Resident's 409 blood sugar or an evening follow-up blood sugar. During an interview on 10/18/23 at 3:55 PM the Corporate Nurse Consultant reported the facility does not have a facility policy on blood sugar parameters. A Review of the Electronic Medical Record, Point Click Care System under Miscellaneous lacked documentation of any notification to the physician with an assessment for blood sugar of 409 as of 10/18/23. During an interview on 10/18/23 at 4:40 PM the Administrator reported no one at the facility was going to question the blood sugar further because the facility hadn't done anything about it. During an interview on 10/19/23 at 8:58 AM Staff A reported she would go down and look at the resident to see what they are having for signs and symptoms, but she wouldn't necessarily do a full set of vital signs. She reviewed the Family and Physician Notification Relating to a Change in Medical Condition Policy and asked what that policy was dated. She indicated she wasn't aware of the facility policy to assess the resident and probably would not have done a full assessment in the situation with Resident #49. On 10/19/23 at 9:12 AM the Quality Assurance/Certified Medication Aide (CMA) reported they had a policy for low blood sugar but she didn't know if they had a policy on high blood sugar reporting. Normally the DON reviews the charting, she didn't know what the process was for ensuring the physician was notified of change of condition. She reported as a CMA if a family member reported a change in a resident she would report that to the nurse to address. During an interview on 10/19/23 at 9:19 AM the Director of Nursing (DON) reported she was unaware the facility policy required a resident with a blood sugar greater than 400 to have a head to toe assessment. She reported the policy was from 2012 and she felt the policy was antiquated. She verbalized she is not sure she would do a full head to toe assessment for a resident with a blood sugar over 400 or expect her nurses to do a full assessment. She explained the facility owned this one as the facility had not followed up. She reported they would be reviewing the facility policy and re-educating the nurse involved as well as providing full nursing education. The DON reported the Advanced Registered Nurse Practitioner (ARNP) had been notified of the Resident's situation on 10/18/23 and had increased Resident #49's blood sugars to twice a day to monitor his condition. The Family and Physician Notification Relating to a Change in Medical Condition Policy revised 4/12 provided by the facility detailed the facility will immediately notify the physician of a change in the resident's medical condition. The Policy Procedure directed the facility must immediately consult with the resident's physician for the following: a. A significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); b. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of a treatment. The Policy further detailed the charge nurse (or assigned person) working at the time of the significant change in condition will notify the physician. The notification will include the results of a full body assessment, vital signs, and description of the accident, if applicable. The documentation of the significant change in condition will be recorded in the resident's medical record and will include: the date, time of the change of condition, a description of the change noted in the resident's condition, full assessment of the resident including vital signs, and the resident's physical and mental status at the time of the change in condition.

Based on observation, clinical record review, staff and resident interview's the facility failed to answer call lights in a timely fashion for 1 of 7 resident reviewed (Resident #18). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #18 dated 9/26/23, listed diagnoses of diabetes mellitus, arthritis, and falls. The MDS reflected a Brief Interview of Mental Status (BIMS) score of 15, indicated intact cognition. The MDS identified Resident #18 required extensive assist of one staff for transferring and dressing. The MDS continued to reflect she needed set up assistance for eating. The Care Plan for Resident #18 reflected a target date of 1/15/24, revealed She wanted to eat meals in her room. The Care Plan identified a goal she will maintain her daily preferences with staff assistance. On 10/17/23 at 8:06 AM, Resident # 18 sat in her recliner. Resident #18's tray table held her breakfast tray and sat out of her reach by several inches. She reported she turned on her call 15 minutes ago due to her inability to reach her breakfast tray. The red light above her recliner chair illuminated. On 10/17/23 at 8:08 AM, the Marquee (call light system box) at the nurses station read Resident #18's call light on. The MDS nurse and Staff A, Licensed Practical Nurse, (LPN) at the nurses station worked on the computer. On 10/17/23 at 8:11 AM, Staff C, Certified Nurses Aid (CNA) walked down the hall, Resident #18's call light remained on. On 10/17/23 at 8:24 AM, the Marquee at the nurses station continued to read Resident #18's call light on. On 10/17/23 at 8:28 the MDS Nurse entered Resident #18's room. On 10/17/23 at 8:35 AM, Staff D, CNA walked into Resident #18's room checked the call light and turned the call light off. On 10/18/23 at 3:08 PM, Staff F, CNA, and Staff E, CNA. reported at times call lights are on longer than 15 minutes. Staff F stated it happened more after the meals, when so many of the residents wanted to go to bed. Staff F, stated it can take longer when two CNA's are needed to care for one person, the others may have to wait a little longer. On 10/19/23 at 9:00 AM, Staff A, confirmed she expected call lights answered in 15 minutes or less. She revealed Resident # 18 reported to her at times her call lights took too long for staff to answer. Staff A reported the Quality Assurance staff reviewed the logs and posted notes that a call light on over 15 minutes is unacceptable. On 10/19/23 at 9:43 AM, the Director of Nursing (DON) reported she expected staff respond to call lights within 15 minutes. She stated she's unaware if the facility held a policy on the the call lights or it's just the expectation. On 10/23/23 at 11:22 AM, Qualify Assurance staff reported she reviewed the call light and educated the staff as needed. The Facility assessment dated 2023 on page 6, point #2, revealed staff personal required: Staff to resident ratio: 1-13 ratio of staff to resident for CNA care giver on 1st and 2nd shift. 1-30 nurse ratio on 1st shift and 2nd shift with 1 Certified Medication Aid (CMA). 3rd shift 1 to 20 CNA and 1 to 60 nurse to resident ratio .

Based on record review and interviews, the facility failed to ensure ordered laboratory tests were completed for 1 out of 12 residents reviewed for laboratory services( Resident #3). This had the potential to affect the health and well being of the resident. Findings include: Review of the Electronic Medical Record (EMR) revealed Resident #3 was admitted to the facility on [DATE]. Review of the EMR under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence in the EMR this was completed. Review of the Dermatology Physician Assistant (PA) Progress Note located in the EMR under the Progress Notes tab dated 03/18/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence the resident had the lab drawn for the BP. Review of Resident #3's Progress Notes located in the EMR under the Progress Notes tab dated 04/06/22 revealed labs were drawn for a CBC, BMP [Basic Metabolic Panel], TSH (to measure [CONDITION(S)] function), Lipids (to measure cholesterol levels), HgBA1C (to measure diabetic control), [MEDICATION(S)] levels (for seizures). There was no evidence of any results of the above ordered labs. Review of the Physician After Care Visit Note located in the EMR under the Progress Notes tab dated 05/26/22 revealed the physician requested a lab be drawn for Pemphigoid Antibody panel BMZ (Basement Membrane Zone antibodies), IGG (a different antibody test), BP 180 and BP 230 Antibodies. There was no evidence in the EMR the labs were completed as ordered. Interview on 6/29/22 at 1:59 PM with the Director of Nursing (DON) revealed any laboratory results would be in the miscellaneous tab and progress notes. The labs would be shared with the provider who ordered them. The nurses would review them and send them on. The results and the communication with the physician would be in the progress notes and sometimes written directly on the lab results. The DON indicated she would look for the missing laboratory results. No further information was provided before the exit of the survey.

Based on observation, record reviews, staff and resident interviews the facility failed to provide palatable food temperatures for 1 of 1 meals observed. The facility reported a resident census of 35. Findings include: The facility policy titled Food Temperatures dated 09/01/09 directed all hot food items must be served to the resident at the temperature of at least 140 degrees Fahrenheit at the time the resident receives the food. During an interview on 02/15/21 at 11:15 AM, Resident #28 stated the food is always cold and doesn't like sending it back due to long wait times for another tray. During an interview on 02/15/21 at 11:49 AM, Resident #21 stated the food is not very good and it is cold when received, after voicing concerns to staff still receiving cold food. During an observation on 02/16/21 at 11:38 AM, Staff E delivered two room trays to residents rooms, then the Dietary Supervisor took food temperatures on a test tray. The results of the test were that the broccoli was 112 degrees Fahrenheit and the mashed potatoes were 134 degrees Fahrenheit. Surveyor tasted food on test tray, the mashed potatoes were just warm, and the broccoli was cold. During an observation on 02/16/21 at 12:03 PM, Staff A, Cook took post food temperatures and the sliders (small meat sandwich) (alternate) were 125 degrees Fahrenheit. During an interview on 02/16/21 at 12:25 PM, Resident # 28 stated the slider they had for lunch was just warm with a dried out bun. Resident voiced concern to dietary regarding food quality. During an interview on 02/18/21 at 8:00 AM, the Dietary Supervisor confirmed food on residents trays should have temperature at or above 140 degrees Fahrenheit. Stated brought a plate back on 02/16/21 after serving noon meal noticed that sliders were cold, buns dried out, and broccoli cold.

Based on observation, record review, and staff interviews, the facility failed to demonstrate proper hand hygiene for food handling and inappropriate levels of chemical disinfectant used in cleansing of food serving carts. The facility reported a census of 35 residents. Findings Include: 1. During observation on 02/16/21 at 11:22 AM, Staff A, Cook was serving the noon meal, dropped a marker cap on the floor, picked up the cap off the floor, put the cap back on the marker, and placed marker in the side pocket of uniform top. Staff A continued to put food on residents' trays without stopping to perform hand hygiene. Staff A reached into pocket during food service took out marker to label the lids of Styrofoam containers on three separate occasions, without performing hand hygiene entire time. During an interview on 02/18/21 at 7:56 AM, the Dietary Supervisor (DS) stated he would expect Staff A to wash her hands after she dropped the cap to the marker. He confirmed he watched her pick it up off the floor and put it back in her pocket and then used it multiple times to label the food containers and continued serving without washing her hands. The facility provided a policy last revised 5/20 titled Handwashing which directed staff to wash hands after completion of a dirty task, prior to beginning a clean task. 2. During observation on 02/16/21 at 12:08 PM, staff would wheel meal service carts carrying two trays of food out of kitchen and delivered trays to residents. After delivery of trays, carts were brought back to kitchen by staff where Dietary Supervisor (DS) would wipe them down and sanitize them with a rag obtained from a bucket of disinfectant. The cook would then refill the cart with two trays and the process would repeat until meal service was complete. At the end of meal service the DS checked the sanitizer solution in the bucket with the disinfectant and stated it was 0 parts per million (ppm). The Dietary Manager (DM) stated the test strip should read at least 200 ppm. During an interview on 02/18/21 at 7:56 AM, the DS stated the sanitizer that is used to wipe the carts down should have been 150-400 parts per million (ppm) He advised that he had checked earlier on 02/16/21 at 9:30 AM, and it was at the right level then. The Product Specification Document the facility provided dated 04/09/20 instructions for use when sanitizing food contact surfaces by using Oasis 146 Multi-Quat Sanitizer to sanitize pre-cleaned hard non-porous surfaces of food processing equipment. The policy states the Oasis 146 Multi Quat Sanitizer is an effective sanitizer when used at 150 ppm- 400-ppm active quat.

Based on observation, document review and staff interviews the facility failed to perform hand hygiene when Staff B pulled her medical mask below the chin, blew her nose, pulled the medical mask back up, and proceeded to provide resident care for three residents not included in the survey sample during medication administration. The facility identified a census of 35 residents. Findings include: During observation on 02/17/21 at 2:32 PM, Staff B, Licensed Practical Nurse, (LPN), removed her goggles and reading glasses, laid them on top of the medication cart without a barrier underneath, then pulled her medical mask by the front of the mask below her chin and used both hands to blow nose. After disposing of the tissue, pulled her medical mask back up over her nose, adjusted the mask, touched the front of the mask, and put reading glasses on. Staff B went on to touch computer mouse, knocked on a door and entered into room [ROOM NUMBER](random resident not included in the survey sample), picked up dirty mask in room and threw into trash. Staff B informed the resident she would bring her a new mask. Staff B exited room [ROOM NUMBER] without performing hand hygiene and walked up the hallway to the medication room touched the doorknob on the medication room door with surveyor following and observing. Staff B retrieved a new medical mask, carton of Med Pass supplement and returned to the medication cart outside of room [ROOM NUMBER]. Staff B prepared the supplement without performing hand hygiene prior to preparation and entered room [ROOM NUMBER] with the supplement and medical mask. Staff B placed the medical mask and the supplement down on the bedside table, walked to the sink, turned on the faucet with her bare left hand, ran water over both hands, flicked hands in the sink after approximately five seconds, and turned the faucet off with her bare left hand. Staff B touched the front of her medical mask to adjust her mask, and then proceeded to hand the resident in room [ROOM NUMBER] a tissue per the resident's request so the resident could wipe her mouth. Staff B then touched the front of her medical mask and her glasses before assisting the resident to put on the medical mask and pinched the nosepiece of the mask to adjust for the resident. Staff B touched the faucet with bare left hand, washed hands for less than 5 seconds, and shut the faucet off with a paper towel. Staff B exited room [ROOM NUMBER], went to medication cart, pulled her mask down below her chin, blew her nose, and performed hand hygiene with an alcohol based hand rub (ABHR). Staff B removed her used medical mask throwing it in the trash and donned a new medical mask without performing hand hygiene. Staff B reported her nose just kept running. Throughout the observation, Staff B wore her reading glasses without protective eyewear in and out of room [ROOM NUMBER]. Staff B's goggles remained on top of the medication cart. During an observation on 02/17/21 at 2:41 PM, Staff B entered room [ROOM NUMBER] (random resident not included in the survey sample) wearing the medical mask that had been applied without performing hand hygiene to provide medication administration. Staff B wore only her prescription eyeglasses. The protective goggles remained laying on top of the medication cart. During an observation on 02/17/21 at 2:45 PM, Staff B entered room [ROOM NUMBER] (random resident not included in the sample) to ask the resident about pain level. Staff B took a tissue, wiped the resident's mouth, and threw away the tissue. Without performing hand hygiene, Staff B exited room [ROOM NUMBER] and walked to the medication cart. Staff B unlocked the medication cart, opened the narcotic sign out book, unlocked the double lock box inside the medication cart and set up the resident's medications without performing hand hygiene. Staff B entered room [ROOM NUMBER], picked up a dirty dish from the floor, placed it on the resident's sink counter, and proceeded to administer the resident's medications. Staff B exited room [ROOM NUMBER] and performed hand hygiene. Staff B pulled at the front of her medical mask, pulled mask down below her chin. She blew her nose on a tissue, disposed of the tissue, pulled her medical mask back up over nose by the front of the mask, and performed hand hygiene with an ABHR only after she had handled the mask with dirty hands. During a phone interview on 02/18/21 at 10:11 AM, Staff B reported she had received training from the facility on hand hygiene and use of personal protective equipment. She reported her allergies [REDACTED]. During an interview on 02/18/21 at 10:55 AM, Staff C Certified Medication Aide, (CMA), reported she had received education from the facility on hand hygiene. She reported that hand hygiene should be done before and after handling/changing a dirty (medical) mask, blowing your nose, as well as when entering/exiting a resident's room. During an interview on 02/18/21 at 11:01 AM, Staff D Registered Nurse, (RN), reported she had received education on hand hygiene when she started at the facility. She reported the front of the medical mask should not be touched or pulled down below the chin and when a (medical) mask are dirty, hand hygiene should be performed prior to applying a new (medical) mask. She reported staff should perform hand hygiene before and after blowing their nose. During an interview on 02/18/21 at 11:04 AM, the Director of Nursing, (DON), reported she expected staff to follow infection control guidelines regarding hand hygiene. The Infection Prevention and Control Program (IPCP) Guidelines, revised 11/2017, provided by the facility, under Hand Hygiene directed the staff to perform hand hygiene as follows: -- When coming on duty; -- When hands are visibly soiled (wash with soap and water); -- Before and after direct resident contact; -- Before and after performing any invasive procedure (i.e. finger stick, blood sampling); -- Before and after handling peripheral vascular catheters and other invasive devices; -- Before and after entering isolation precaution settings. -- Before and after assisting a resident with personal care (i.e. oral care, bathing); -- Before and after eating or handling food (hand washing with soap and water); -- Before and after inserting indwelling catheters; -- Before and after changing a dressing; -- Upon and after coming in contact with a resident's intact skin (i.e. taking a pulse or blood pressure or assisting a resident with transferring/ambulation); -- After personal use of the toilet (hand washing with soap and water); -- Before and after assisting a resident with toileting (hand washing with soap and water); -- After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus (virus that causes illness), salmonella, shigella, and Clostridioides difficile (microorganisms that cause disease) hand washing with soap and water; -- After blowing or wiping nose; -- After contact with a resident's mucous membranes and body fluids or excretions; -- After handing soiled or used linens, dressing, bedpans, catheters and urinals; -- After handling soiled equipment or utensils; -- After removing gloves. -- After completing duty.

Based on observation, record review and staff interview the facility failed to follow a care plan for 2 of 12 residents reviewed (Resident #29 and #31). The facility had a census of 37 residents. Findings include: 1. Resident #29's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had severe memory loss, required extensive staff assistance for daily cares, and had [DIAGNOSES REDACTED]. The MDS also showed the resident at risk for pressure ulcers and had a pressure reducing device in the bed and chair. The Care Plan dated 11/11/16 showed the resident had potential for pressure ulcer development related to immobility secondary to a stroke. Interventions for this concern included to off load (not have the feet/heels touching anything, lifting them up) the resident's feet when in bed. Observations on 4/15/19 at 10:07 a.m. and 2:05 p.m. revealed the resident lying in bed with their feet lying directly on the bed. Observation on 04/16/19 at 6:45 a.m. and 1:23 p.m. revealed the resident lying in bed with their feet and heels lying directly on the bed. Observation on 4/17/19 at 07:10 a.m. revealed the resident lying in bed, on the back side, with their feet and heels lying directly on the bed sheet An interview on 4/17/19 at 9:02 a.m. Staff C and Staff D, both Certified Nursing Aides (CNA) reported the resident does not have any special cares for the feet/heels while in bed. They both indicated the Kardex is on the computer and Kiosk and informs the aides what cares to provide for each resident. An interview on 4/17/19 at 9:55 a.m. the facility RN (Registered Nurse) Consultant reported the Nursing Care Plan directed staff to float the resident's feet and noted the Kardex for the Nursing Aides failed to identify the resident needed to have the feet floated. The Consultant reported she did not know why the Nursing Aide Kardex did not have that information. She reported the Care Coordinators are responsible for the care plans and would expect staff to follow the care plan. The RN Consultant also noted the resident at risk for pressure ulcers as identified on the care plan. An interview on 4/17/19 at 10:02 a.m. the Director of Nursing (DON), RN, noted the resident's Nursing Care Plan identified staff to float the resident's feet, while the Aides Kardex did not mention this care. 2. Review of Resident #31's Minimum Data Set (MDS) assessment dated [DATE] showed the resident with intact, required extensive to total assistance with daily cares, had [DIAGNOSES REDACTED]. Record Review showed admittance to Hospice cares dated 4/4/19. Observation of the resident's Record Review on 4/15 and 4/16/19 showed the resident's Care Plan dated 3/15/19 failed to identify the admittance to Hospice Cares. The Care Plan also identified the OT and PT therapies were working with the resident. Observation on 4/16/19 at 1:00 p.m. revealed the Hospice Nurse visiting the resident. The Nursing Notes (Progress Notes) dated 4/4/19 failed to document the resident admitted to Hospice Services. The only note indicating Hospice Services were provided during 4/4/19 and 4/15/19 included a note on 4/5/19 where the resident would not attend an appointment due to having Hospice Services. A Nursing Note for Communication dated 4/11/19 showed a care conference with Hospice completed. An interview on 4/16/19 at 12:40 p.m. Staff A, Licensed Practical Nurse(LPN), reported the care plans are updated when there are significant changes and when the routine MDS reports are due. An interview on 4/16/19 at 1:05 p.m. Staff B, Certified Nursing Aide/Medication Aide (CNA/CMA), who also in charge of Infection Control and the Quality Assurance Program, reported the whole team will update and care plan as needed. She reported the Social Worker is usually responsible for updating the changes concerning the admittance of the resident to Hospice Cares. Staff B also noted the Therapies were discontinued and should have been updated on the care plan. A Social Service Note dated 4/16/19 showed the significant change for the resident in receiving Hospice Cares. An interview on 4/17/19 at 2:30 p.m. the DON reported the care plans did not have to be updated in a certain amount of time.

Based on record review, staff and resident interviews the facility did not ensure that all residents were free from sexual abuse (Resident #2, #3). The sample consisted of 4 residents and the facility reported a census of 46 residents. Findings include: 1. According to record review, Resident #1 had an original admission date of [DATE] and had [DIAGNOSES REDACTED]. According to review of the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 8 (of 15 points) on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive decline. The assessment described Resident #1 as being independent with bed mobility, transferring, and ambulating, eating, dressing and personal hygiene. The Care Plan identified a problem with the resident Exhibiting behaviors in public. The interventions directed the staff to do the following: * Resident #1 is stand by the assistance of one staff in the hallways and common areas. If staff observe Resident #1 trying to make inappropriate comments or actions towards another resident, please politely remove resident from the situation. * Identify and explain only once concept of behavior at a time. * Provide a please do not disturb sign for resident's door. * If resident disrobes in public, offer a blanket/towel and attempt to assist resident to get redressed in a private area * If resident makes sexual comments, inform resident that it is not appropriate conversation and redirect resident to something else. * Remain calm and avoid overreacting. Do not argue, use logic or deny resident of his/her needs. Do not scold resident. * Nurse to complete a behavior note each shift and report to the DON (director of nursing) and administrator as soon as possible if the resident has inappropriate contact with another resident. * The nurse will provide information on what is correct behavior daily. *Use simple, concrete language. * When cognitive impairment is not severe, identify and describe the appropriate behaviors with resident. 2. Resident #2's medical record was reviewed. Resident #2 had [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #2 had both long term and short term memory difficulties and had a moderate decline in cognitive skills for decision making. The assessment identified Resident #2 as independent in transferring, ambulation, eating and toilet use, but required staff assistance with dressing, personal hygiene and bathing. The Progress notes for Resident #2 dated 8/16/16 indicated an incident report. The reported identified another resident grabbed Resident #2 in the crotch and she/he walked up the hall and seen on camera. 3. Resident #3 had [DIAGNOSES REDACTED].>dementia, anxiety, [DIAGNOSES REDACTED], [MEDICAL CONDITION] and [MEDICAL CONDITION], and chronic obstructive [MEDICAL CONDITION] disease. According to the MDS dated [DATE] Resident #3 scored 4 (of 15) on the BIMS, indicating severe cognitive decline. The assessment tool also described Resident #3 as requiring extensive staff assistance with transferring, ambulation, toilet use, dressing, personal hygiene and bathing. During an interview on 9/1/16 at 12:05 p.m. Resident #3 stated he/she was in the dining room (seated in a wheel chair) when Resident #1 pulled up beside him/her and started feeling him/her in the groin area. Resident #3 stated it took him/her by surprise and he/she told Resident #1, Don't ever touch me there again. The Progress Notes dated 8/16/16 at 1:30 p.m. (by the social worker) for Resident #3 identified a late entry. The entry identified a male resident in the front dining room that touched her/him inappropriately in the groin area. The resident immediately became upset and swatted at the other resident ' s hands. During an interview on 09-01-16 at 1:06 p.m. Staff A stated the day of the incident (8/16/16), Resident #3 reported to her that Resident #1 grabbed me in the crotch. Staff A added that the video camera footage was reviewed which confirmed the incident Resident #3 described as well as a second incident in which Resident #1 attempted physical contact with Resident #2. Staff A reported Resident #1 required a lot of redirection and monitoring and had a history of [REDACTED]. She added this was the first incident of Resident #1 involving other residents.

Based on clinical record review and interviews, the facility failed to plan for and implement care plan intervention(s) to ensure one (1) of four (4) residents received adequate supervision from hazards in the environment (Resident #1). The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderately impaired decision making skills. The assessment identified Resident #1 required two staff to assist with transfers, walking in his/her room, and for toilet use. Resident #1 completed a balance test for transition and walking which identified his/her balance as not steady and only able to stabilize with staff assistance. Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented no falls since admission and the resident received hospice services. The admission fall risk assessment revealed the resident scored 12 points indicating the resident was at moderate risk for falls. The fall risk assessment identified the resident had [DIAGNOSES REDACTED]. The Care Plan identified a bed and chair alarm was initiated 11/7/13, to help alert staff when up and unattended and instructed staff to apply alarm when in bed, recliner and wheelchair. The Care Plan revealed the resident as at risk for falls related to unaware of safety needs. The interventions directed staff to apply anti-slip material in the recliner and wheelchair directly in contact with resident, assist with toileting, ensure call light was within reach, apply a personal chair and bed alarm to alert staff when up and ensure low bed was in lowest position. The CNA (Certified Nurse Aide) plan of care instructed staff to apply the resident's alarm when in bed, recliner and wheelchair. Therapy Recommendations dated 12/3/13, directed staff to transfer the resident with assistance of one staff from the bed to the wheelchair and ambulate to the toilet with a wheeled walker and gait belt. The recommendation also identified to ambulate the resident to the dining room with a wheeled walker, gait belt and follow with the wheel chair. In addition the recommendations revealed to transfer with two staff if the resident appeared weak. An Incident Report dated 12/1/13, revealed the resident fell at 8:45 p.m. Staff found the resident on the floor sitting in front of the recliner with the resident's legs extended outward. The resident stated he/she slid out of the recliner. Staff assessed the resident and found no injury. An Incident Report dated 12/3/13, revealed the resident fell at 2:35 p.m. Staff found the resident laying on his/her back in the bathroom. The resident's roommate reported the resident slid down the door. Three (3) staff assisted the resident to stand with a gait belt. The report documented the resident denied pain with range of motion. Staff A, Licensed Practical Nurse, LPN instructed staff to check on the resident hourly. An Incident Report dated 12/4/13, revealed the resident fell at 9:37 a.m. Staff found the resident with his/her feet in the bathroom doorway and head towards the head of the roommate's bed. The resident reported he/she walked to the bathroom and fell , and complained of left leg pain. The report indicated the resident's bed and recliner had alarms, the resident had a walker nearby and had shoes on. The Progress notes dated 12/4/13, documented the resident transferred to the emergency room following a fall in the room. An emergency room report dated 12/4/13, revealed the [AGE] year old resident fell after walking to the bathroom at the nursing home. The resident had a previous history of a stroke with his/her balance affected chronically, had a previous left hip fracture with repair. The resident failed to bear weight and complained of left leg pain. The hospital CT report dated 12/4/13, revealed the resident had a proximal left femoral peri-prosthetic fracture (left hip). The Progress notes dated 12/13/13, documented the resident was readmitted to the facility following left hip fracture surgical repair. The Progress notes dated 12/23/13, documented the resident transferred to the hospital due to wound dehiscence. The Progress notes dated 12/26/13, documented the resident readmitted to the facility. Progress notes dated 1/4/14, documented the resident passed away. Staff notified family, physician and hospice. During interview on 1/7/14 at 2:50 p.m., Staff A, Licensed Practical Nurse reported she was working on 12/3/13 when Resident # 1 fell . Staff A reported around 2:30 p.m. she had been informed of Resident #1's fall in the bathroom. Staff A reported no alarm sounded for Resident #1 and she wasn't aware that Resident #1 had any alarms at that time. Staff A reported the roommate's alarm sounded and that's what alerted staff. Staff A reported she had been told Resident #1 had been on his/her back propped up on the door and resident's roommate mentioned the resident slid down the door. Staff A reported everything looked normal so staff (Staff C and Staff E) assisted the resident up and took him/her to the toilet. Staff A reported she completed vitals at this time. During interview on 1/8/14 at 12:08 p.m., the Administrator revealed when the resident fell on [DATE], Staff A, LPN failed to provide an appropriate assessment and follow up. Staff A suggested hourly checks according to the incident report with no documentation supporting staff implemented the checks. Staff A failed to identify the lack of a wheel chair alarm at the time of the fall. The resident fell on [DATE] and 12/4/13, after self-transferring from the wheel chair and attempting to ambulate to the bathroom. Both investigations revealed a lack of a wheel chair alarm at the time of the falls. An alarm tracking sheet had been started on 12/4/13 at 10:52 a.m. for Resident #1. The sheet directed staff to check if the alarm had been in place; and to verify the functioning of the alarm. Staff charted the alarm had been on and functioning when in bed, wheelchair and recliner from 12/4/13 to 12/31/13. During interview on 1/7/14 at 4:00 p.m., Staff B, registered nurse, RN reported being the resident's RCC (Resident Care Coordinator). Upon admission, they determined the resident needed safety alarms added to the bed, wheel chair and recliner. The resident was admitted with a history of falls and fractures at a prior facility. Staff B responded to the resident's fall on 12/4/13 and determined the resident had no wheel chair alarm in place at the time of the fall. During interview on 1/8/14 at 10:30 a.m., Staff C, certified nurse aide, CNA reported working on 12/4/13 when the resident fell . Another resident reported the resident fell in the room. When Staff C along with Staff D, CNA entered the resident's room, he/she failed to hear an alarm sound. The wheel chair had no alarm in place. The resident lay on the floor, partially in the bathroom. Staff C observed the resident earlier that morning in the dining room, seated in the wheel chair with no alarm. During interview on 1/8/14 at 10:50 a.m., Staff D, CNA verified no wheel chair alarm sounded when he/she entered the resident's room. Staff D observed the resident on the floor. Staff D observed the resident earlier that morning in the dining room, seated in the wheel chair and observed him/her-self propel the wheel chair, leaving the dining room. During interview on 1/7/14 at 2:30 p.m., Staff E, CNA reported working on 12/3/13, second shift. The resident had a bed and chair alarm. On 12/3/13 it appeared the resident transferred from the wheel chair which sat at the bathroom door. Staff E responded to the roommate's alarm and found the resident on the floor. The wheel chair failed to have an alarm when the resident fell at approximately 2:30 p.m. Staff A, LPN, assisted Staff E and another aide to get the resident off the floor and on the toilet. Staff E indicated Staff A failed to assess the resident prior to getting the resident up from the floor.