Every finding on record at Southeast Iowa Healthcare Center

Based on observations, record review, hospital record review, facility investigative file review, employee file review staff interviews and policy review the facility failed to prepare and serve the recommended therapeutic meal in a form designed to safely meet the resident's needs and according to physician orders for 1 of 3 residents reviewed (Resident #1). This resulted in Resident #1 choking on a peanut butter and jelly uncrustable, she became unconscious, CPR was initiated, the resident gained consciousness and was sent to the hospital. She was found to have a pneumothorax. Resident #1 was given an improper textured diet when she asked for a snack; she was ordered to receive a puree diet. The facility reported a census of 50 residents. On June 26, 2026 at 10:32 AM the State Agency informed the facility the staff's failure to properly prepare and serve the therapeutic meal per orders creating an Immediate Jeopardy situation which began on June 26, 2026. The facility removed the immediacy on June, 26, 2026 at 2:57 PM when the facility staff implanted the following Corrective Actions:On June 23, 2026:The employee that was directly involved with the incident received discipline on not being more aware of residents' diets and what food related items are conforming to a given diet.A written identification system was instituted that identified the current diets each resident is on so proper food related items that are conforming to a prescribed diet are offered, will be safe for the resident to consume. This change was in effect for any staff utilizing the snack cart, starting on June 23, 2026.The DON provided education/instruction to all staff working the evening of June 23, 2026, including the staff member directly involved in the incident. This training for those individuals working that night addressed resident diet sheets (the diet identification system), which residents are on modified diets and what they are, clarification of each modified diet (foods that match the diet), the identification systems will remain on the cart, ordered (prescribed diets) shall be followed by staff.On June 24, 2026:The Administrator provided education/instruction to those personnel from the nursing, dietary and activities departments to address new diet identification system, going over diets residents are on and what those diets are, food related items that conform to a prescribed diet, accessibility by staff to the identification system on the cart, following prescribed diets by the staff.The Administrator convened a QAPI meeting to address resident diets, communication processes how diets are conveyed to employees, care planning regarding dietary related manners.The Administrator directed the Dietary Manager to review all resident care plans and directly put into the care plans the specific diet composition for a resident.The Administrator and Risk Management Director met to address resident diets and risk management identifiers regarding diets, to address quality assurance of these areas.The Administrator developed a policy/procedure regarding snack cart utilization which included staff providing snack food are expected to be aware of any resident diet and being aware of conforming food related items that can be served with it. This policy/procedure was in effect on June 24, 2026.On June 26, 2026, all employees who may be involved in passing out snacks received the education/instruction regarding diets and therefore, are considered trained effective June 26, 2026.For the next 3 months, the facility will do the following: Dietary Director or designee, shall conduct random audits of the snack cart to ensure the diet identification system being used is found on the snack cart, as expected. Dietary Director or designee, shall conduct random audits to ensure all potential changes in diets have been updated on the diet sheets in the cart diet identification system being used, so they are accurate.The scoped lowered from J to D at the time of the survey after ensure the facility implemented education about their policies and procedures. Findings include:According to quarterly Minimum Data Set (MDS) assessment tool with a reference date of 5/14/2026, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5. A BIMS score of 5 suggested she had severe cognitive impairment. Resident #1 was dependent on staff for eating and had received a mechanically altered diet within the 7-day review period. The MDS listed the following diagnoses: schizophrenia, diabetes mellitus, stroke, and anxiety. A Care Plan Problem Area with start date of 7/12/2023 documented Resident #1 received a therapeutic and mechanically altered diet. On 3/27/2024 Resident #1 had an order for a puree diabetic diet with regular liquids. Resident #1 required supervision/cueing with meals. On 7/3/2025 staff were directed to observe Resident #1 closely for difficulty chewing, pocketing food, eating very slowly or leaving meals uneaten. A second Care Plan Problem Area with start date of 6/24/2026 documented Resident #1 was at risk for swallowing issues when consuming food related items. Resident #1 was ordered to have a mechanically altered diet: puree diabetic diet. The Care Plan documented she will cooperate with staff guidance on consuming food related items that meet the parameters of her pureed diet.Review of Resident #1's Electronic Health Record (EHR) revealed the following diet order: regular liquids and house diabetic/puree. The diet order had a start date of 3/20/2024.The following Progress Notes were documented for Resident #1:On 6/23/2026 at 9:54 PM Staff A Licensed Practical Nurse (LPN) documented at 8:45 PM Resident #1 was witnessed sitting in the recliner eating a snack. At 8:50 PM this nurse heard resident state I can't breathe, and started to grab her throat. This nurse ran over to resident and alerted Staff B Certified Nursing Assistant (CNA), she's choking. Resident stood up out of recliner via assistance of two staff and the Heimlich maneuver started immediately with approximately 20 unsuccessful attempts. Staff A heard Resident #1 experiencing stridor (high pitched or whistling breathing sound) during this time. Back thrust's initiated while resident was still conscious. At 8:51 PM 911 was called. Resident #1 sat in the chair leaning forward due to her losing strength to her lower extremities. Resident leaned forward with the assistance of two staff. Oxygen (o2) checked and read 66% on room air. Supplemental o2 via nasal canula (NC) applied at 5 liters (L). Resident #1 then began to turn pallor, unresponsive, and lost consciousness. No pulse present upon palpation to left carotid artery. At 8:53 PM Resident #1 was lowered to the ground via assistance of two staff. This nurse initiated cardiopulmonary resuscitation (CPR) immediately. A blanket placed slightly under head to prevent injury to the back of head. Compressions continued as automated external defibrillator (AED) was obtained and applied by Director of Nursing (DON) but shock was not advised and 8 cycles of CPR initiated. At 8:56 PM Resident #1 regained pulse via palpation to left carotid artery by Staff C LPN, CPR was stopped. Resident also heard speaking inaudible words. Stridor resumed and o2 had read 92% on 5L NC. At 8:57 PM the ambulance arrived and cares resumed per 2 EMT's and 2 Firefighters. During this time, resident received suctioning, high flow supplemental o2 via NC, an intravenous (IV) was started and fluids initiated. Stridor continued with movement to bilateral upper and lower extremities were noted. At 9:10 PM the resident left the building with the ambulance crew. On 6/23/2026 at 10:45 PM Staff C documented as she was walking up the hall, she noted two staff holding Resident #1 up stating she was choking. They then sat the resident down and leaned her forward. This nurse grabbed a pulse/ox and obtained the resident's o2 and it was at 66% on room air. Supplemental oxygen was administered at 5L via NC. Resident #1 became pallor and lost consciousness and her pulse was not palpable at that time. Resident was then lowered to the floor and CPR was started. After 8 cycles of CPR, a pulse was obtained, o2 reading at that time was 92%. The EMS staff arrived and took over. On 6/24/2026 at 2:04 AM Staff A documented at 1:09 AM the nurse called to get an update on Resident #1. Hospital staff reported Resident #1 was stable upon arrival, became hypotensive after awhile and was given two pressures bags which raised her blood pressure. A chest x-ray showed a small pneumothorax and left anterior rib fractures to the resident's 2nd, 3rd, 4th, and 5th ribs due to CPR. They were unsure if Resident #1 had aspirated: noted trace secretions, atelectasis in right middle lobe. Resident was stable at that time. On 6/24/2026 at 2:50 PM staff documented the hospital staff reported Resident #1 had transferred to another hospital at 6:00 AM and admitted to an intensive care unit (ICU) level of care due to post resuscitation status. Resident was on room air, ambulating independently, alert and oriented, did not require ICU level, which meant she will be moved to a general floor today. She had a bedside swallow study completed and has been nothing by mouth (NPO) due to results. Will be completing video swallow study tomorrow.On 6/29/2026 at 1:34 PM staff documented Resident #1 was on a medical floor and has been inpatient since 6/24/2026. Therapy has worked with the resident and she has been compliant and pleasant. Intermittent O2 order for 1L but on room air. Has received as needed (PRN) Ativan (antianxiety) occasionally for anxiety. Pain control was stable. Requested results of video swallow study be sent to facility if possible. Resident #1 was on a pureed, mildly thick liquid diet. Possible physical therapy (PT), occupational therapy (OT) and speech therapy (ST) upon return, has been receiving all three therapies in the hospital. No talk of discharge date as of yet.On 6/26/2026 at 8:09 AM observed a list of resident diets on a corkboard by the nurse's station above a cooler on a cart. The first page had 3 residents listed as needing a puree diet. At 10:24 AM a snack cart had a list of residents with their diet orders listed. The first page consisted of residents on a puree diet, the second page listed residents on a mechanically soft diet and the last page listed residents on a regular diet. The list also contained what adaptive equipment they needed. At 12:13 PM observed Resident #2 and Resident #3 in the dining room being assisted by staff with their lunches. Resident #2 and Resident #3 had received their meals in a pureed form. Review of hospital documentation revealed the following notes:On 6/24/2026 at 9:00 AM Resident #1 presented to the emergency room (ER) from her nursing home. Apparently, the resident was eating a peanut butter with jelly sandwich when she had a choking episode. She went into cardiac arrest and had 4 minutes of CPR performed with return of spontaneous circulation (ROSC) (resumption of a sustained, perfusing heart rhythm). When EMS arrived, the resident had ROSC and breathing without assistance. They suctioned a fair amount of peanut butter out of her posterior pharynx. The resident was seen in the ICU this morning. She looked extremely frail. She had right upper extremity tremors. She did not respond to certain commands. She was very hard of hearing and had poor vision. She was hemodynamically stable not requiring supplemental oxygen. On 6/24/2026 at 10:55 AM Resident #1 was NPO due to a choking episode while eating at her care center; she had a history of swallowing deficits and recommendations for altered consistencies (foods and liquids), though it is unknown if these were current recommendations and/or if they were being followed. On 6/24/2026 at 5:13 PM. The note documented she presented yesterday with cardiac arrest. Resident #1 had a vagal episode with choking on some food and was unresponsive for several minutes. CPR was initiated and they had ROSC prehospital. Resident #1 had a chest CT (computed tomography) today which showed a small left apical pneumothorax and nondisplaced anterior rib fracture secondary to chest compressions. She is complaining of some pain with movement. Has required minimal medication. The facility investigative file included the following:Staff B's handwrote the following statement: after feeding Resident #1 an ice cream cup for a snack. Resident #1 said she was still hungry and wanted something else to eat. Staff A looked for a fudge round that was suggested by Staff C. There was no fudge round available on the snack cart. Resident #1 started she wanted a peanut butter and jelly sandwich. She gave Resident #1 a peanut butter and jelly sandwich to eat. She was sitting in the commons area eating. Staff A noticed Resident #1 was showing signs of wheezing. Staff B help up Resident #1 while Staff A started the Heimlich maneuver, that was unsuccessful and the resident was then laid down. The nurses began CPR. Staff B signed her statement and dated it 6/23/2026.On 6/23/2026 the DON documented following event that occurred with Resident #1 an investigation was immediately initiated. Staff A and Staff C were both interviewed, see nurse's notes for full reports. Staff B was interviewed and statement received. She reported that Resident #1 asked for an extra snack following being given ice cream and when she requested a peanut butter and jelly sandwich specifically, Staff A have her that snack. Staff B's statement was obtained and a written warning was given for lack of awareness of resident diet. Education was provided following receiving all statements. A list of resident diets was placed on the snack cart for reference for all staff. Consecutive Employee Warning Report for Staff B. On 6/23/2026 Resident #1's care plan was not followed regarding resident's diet while passing snacks. Action taken included education and diet lists added to snack cart. Staff B and the DON signed and dated the report on 6/23/2026.Review of Staff B's employee file revealed had orientation on 9/23/2024 at 8:30 AM. Staff B signed the Job Description Agreement on 9/23/2024. The agreement documented: I have received my current job description for my position at the facility. I understand that I am responsible for performing all of the duties and responsibilities of my job description. If I do not demonstrate these requirements competently as I am assigned, I will be subject to termination. The job description indicated a CNA: is responsible for providing personal care and assistance for residents in the facility, may be called upon to help residents with feeding, providing assistance with serving meals and snacks, feeding residents if needed, have the consistent ability to reasonably conform to all rules and polices of the facility, follow instructions well and complete daily assignments as assigned, and provide between the meal nourishment when indicated (distribute supplemental nourishment as assigned).The facility was asked to provide an orientation checklist for Staff B upon hire. On 7/1/2026 at 8:36 AM in an email correspondent with the Administration he stated they do not utilize a formal checklist but could more to the route to be more formalized. There is a setlist of curriculum the CNA training supervisor goes over with new hires for on-boarding and that curriculum does include: Care Plans, accessing the EHR for charting, introductions to residents, diets and meal serving.On 6/25/2026 at 5:20 PM Staff B stated on 6/23/2026 at about 8:00 PM she was passing snacks from the snack cart. Resident #1 had some ice cream then stated she was hungry for another. Staff C told her to give the resident a fudge round but they did not have one. Resident #1 stated she wanted a peanut butter and jelly sandwich, so she gave her one. Staff B stated about 5-10 minutes later Resident #1 was choking. Her and Staff B started to do the Heimlich maneuver, then Staff B had to initiate CPR, staff called 911 and Resident #1 went to the hospital. Staff B stated Resident #1 shakes really bad when attempting to feed herself, so she assisted her with eating the ice cream. She was able to hold the peanut butter and jelly sandwich with both hands. When asked if the resident was being supervised while eating the peanut butter and jelly sandwich, she stated the resident was sitting upright in her recliner, in the commons area where they had eyes on her at all times. Staff B denied knowing Resident #1 was on a puree diet and indicated there were not diet lists posted for staff to look at until after this incident happened. They now have the resident diet lists on the snack carts. When asked if resident diets should be followed for snacks in addition to meals, she acknowledged they should be followed for meals and snacks. Staff B acknowledged she received education on the night of 6/23/2026 about resident diets and the implementation putting the diet lists on the snack carts. The DON educated her and she signed a piece of paper indicating she received this education. When asked if the peanut butter and jelly sandwich she gave Resident #1 would be considered part of a puree diet, she stated she was not sure, she had never seen pureed food and was not sure what food would be considered pureed for residents. When she passed out snacks that night, they did not have labels on the snacks to indicate who they went to or what consistency they were. On 6/25/2026 at 5:44 PM Staff C stated on 6/23/2026 she walked up the hall to go to the medication cart when she saw Staff A and Staff B with Resident #1 holding her up. They said the resident was choking so she grabbed the pulse/oximeter because she looked pale; her oxygen saturation ready 66%, so she went to the medication room to obtain and oxygen tank. They were able to sit the resident in the chair and had her leaning forward. They had already attempted the Heimlich maneuver and back thrusts; they were unsuccessful. Staff C stated she was not present when those interventions were attempted. When she returned with the oxygen tank the resident was not responding so they laid her on the floor. Staff A felt no pulse, so she initiated CPR while Staff C applied oxygen. They completed about 8 rounds of CPR and Staff C stated she felt a pulse and Resident #1 started to regain color, was not responding to them but would look at them. At that time the EMTs arrived, started in IV on her, began suctioning her. Staff C stated prior to this incident the resident diets were printed and placed on the cork boards at the nurses' stations. She added she was unsure if all staff knew of these lists or not. They also had the lists by the medication room on the West/South halls. Staff C stated the diet lists were also on the medication carts, had been for long time but again was not sure if all the CNAs were aware of them. Staff C acknowledged a peanut butter and jelly sandwich would not be considered part of a pureed diet. She added a pureed diet was basically food that had been put in a blender and all mixed up. Since the incident, the added a diet sheet on the snack cart and ensured one is on the clips boards on the medication carts. The kitchen has also been informed they need to have different pureed snacks prepared for those on a pureed diet. What asked what kind of education had been provided, she stated they talked about the diet sheets being on the snack and mediation carts, what the residents can have based on their diet orders and what diets they are on. She received the education from the DON on the night of the incident, after they did a debriefing. On 6/25/2026 at 5:53 PM Staff A stated Staff B has just fed Resident #1 ice cream when she heard the resident stating she was still hungry which was typical for her to get more than one snack. After that she was unsure what they came up with for her additional snack. Staff A went to the nurse's station to chart, she got up to grabbed a clip board from the other medication cart. She looked over at Resident #1 and she stated she could not breathe. As she was walking over to her, Resident #1 put her hands around her throat; the universal sign for choking. She ran to the resident and yelled at Staff B that Resident #1 was choking. Staff B came to assist and that is when Staff A noticed a peanut butter and jelly uncrustable. They stood Resident #1 up and attempted the Heimlich maneuver roughly 20 times, which was unsuccessful. She added they tried everything; back thrusts, tried looking in her mouth to see if there was anything in there. As time went on the DON walked in and they told her Resident #1 was choking. At that time Resident #1 was losing strength in her legs, they sat her down, someone called 911, her oxygen saturation was 66%, she then went unconscious, turned pallor, eyes became fixed and had no pulse at that time. The put her on the floor for a flat surface and started CPR. Staff A stated they did about 8 rounds of CPR, Staff B obtained the ambubag, the DON retrieved and applied the AED, Staff C put an oxygen mask on Resident #1's face and was giving breaths. The resident remained unconscious, the AED did not advise shocks to be given, so they continued with CPR but after about 3 minutes they were able to find a pulse. They tried to keep her as comfortable as possible, were talking with her just to keep her with them until the EMTs arrived. When they arrived, they started an IV, suctioned her out, hooked her up to their AED then took her to the hospital. Prior to this incident there was a sheet of the resident's diets at the nurse's desk, but it had disappeared and had not been there for a while. She kind of knows what diets residents are on but you can look it up in the EHR and dietary start knows what diets the residents are to receive. Since this incident the DON got on the computer that night, revised the diet list on her computer and implemented three-page list of the resident diets to go on the snack cart and thought they kitchen staff were going to start passing out snacks instead of the CNAs doing it. She did received education that night on residents needing feeding assistance, residents eating in the dining room for supervision purposes, and what diets the residents are on. When asked if a peanut better and jelly uncrustable was considered part of a puree diet, she stated it was not puree consistency. On 6/26/2026 at 8:12 AM Staff D LPN stated before the incident with Resident #1 they had a list of resident diets at the nurse's desk, the diets were on the resident's care plans, she would double check the resident's chart or even ask other staff members if she had questions about diet orders. Since the incident they kept the current things in place, just added a list of resident diets on the snack cart, the list also includes adaptive equipment needed when assisting residents with their meals. She acknowledged she received education on double checking the resident's care plans, asking staff about resident diets, check the list and know what food is given prior to giving it to the resident. They also have a list in the kitchen of resident diets. On 6/26/2026 at 8:15 AM Staff E Activities and Staff F Activities stated before the incident they had a list of resident's diets behind the nurse's station. Now they have lists on the snack carts. They both received education on resident diets, what they can and can't have based on their diet orders.On 6/26/2026 at 8:20 AM Staff G Registered Nurse (RN) stated she only works Fridays through Sundays so she was trained prior to her shift. She stated before this incident with Resident #1 she would ask someone if she had questions about a resident's diet or needed to know what diet a resident was on. She added she could also check the Medication Administration Record (MAR) for diet orders, look at the Care Plan or the kitchen has menus printed out that includes the resident's diet orders. Today, she was educated on resident diets, thickened liquids and checking the MAR for diet orders.On 6/26/2026 at 8:25 AM Staff H [NAME] and Staff I [NAME] stated prior Resident #1 choking they assumed the diet orders could be found on the resident's Care Plan but heard it was hard to find where the diet order was on them. They also had a list of resident diet orders at the nurse's stations. Since the incident the kitchen staff will provide additional puree snacks for the snack cart. They are labeled what diet consistency they are and are in a tub in the refrigerator. The kitchen staff assembles the snack carts for the nursing staff to pass out the snacks to the residents at about 8:00 PM. A list of resident diets is also on the snack cart at all times for staff to utilize. On 6/26/2026 at 9:19 AM the DON stated she was working on the night of the incident with Resident #1. As she was leaving, she noticed Staff A was doing the Heimlich maneuver, Staff C came over to assess the resident's oxygen saturation then go the oxygen tank and another nurse called 911. The DON stated Resident #1 ended up losing consciousness and they were unable to find a pulse. The DON stated she got the AED and put the pads on Resident #1. By the time the EMTs arrived at the facility the resident had regained consciousness. When asked what the resident was choking on, the DON stated a peanut butter and jelly uncrustable. The DON stated Resident #1 was on a puree diet at the time of the incident. The DON indicated the bread part of the sandwich maybe considered puree but not the peanut butter and jelly part. When they obtained statements from staff that night, Staff B indicated she gave Resident #1 the sandwich because she the resident requested it after she had finished her ice cream. When asked if Staff B new of the resident being on a puree diet, the DON stated the staff member did not say if she knew or not. The DON assumed Staff B knew the resident was to receive pureed food items, she assumed she knew because she had just given her ice cream prior. When asked how was responsible for passing snacks after supper, she stated the evening shift CNAs. The dietary staff set up the snacks on the cart for the CNAs to pass them out to residents. Prior to this incident they had papers at each nurse's station of resident diets, they can also be found in the resident's EHR, the diet orders were in several places. DON acknowledged CNAs do have access to the resident profile, care plans and tasks. When asked what was all on a resident profile, she stated it's a simplified version of a care plan. It goes through things staff would need to know about the resident. She added the nursing staff do have access to the resident's diet orders. Immediately after this incident they have a revamped diet list on the snack cart. The first page is a list of residents on a puree diet, next page consists of residents on a mechanical soft diet and the last pages are residents on a regular diet. She educated all staff that were working on the night of the incident then had two staff meetings the next day with the new information. If staff were not present of those meetings they were updated prior to their next shift. The DON stated at the time of the incident nursing staff were passing snacks to residents and they will continue to do it. On 6/26/2026 at 10:37 AM the Dietary Director stated prior to his incident they printed out the resident diet list once a month unless an order changed. He would pass out the list to all the directors, left a list in the kitchen and at each nurse's station. He stated the kitchen staff get the snack cart ready and the nursing staff pass out snacks at night to the residents. Since the incident they have added the diet list to the snack cart for the nursing staff. They have started to do more puree snacks and leaving them in the refrigerator; labeled either puree or mechanical soft. Nursing staff will still pass out snacks to residents. Currently they have three residents that receive a puree diet. When asked if a peanut butter and jelly uncrustable would considered part of puree diet, he said not but they could have pureed it for the resident. On 6/26/2026 at 11:35 AM Staff J CNA stated she had recently been educated on resident diets and what they have with each diet. They have a paper list of diets located at the nurse's station and in the kitchen. When asked what she would do if she did not know what diet a resident was on, she stated she would ask the kitchen staff, look at the list in the kitchen, ask the nurse or go the clip board where the diet lists are and look at that. The facility provided a document titled Dietary Orders with a vision date of 10/18/2025. The purpose of this document is to have a process in place that addresses the expectation of following resident dietary orders. The facility personnel who are in the role of providing medical based care regarding dietary orders, are expected to provide directe care communicated via a written dietary order. If there is concern regarding a dietary order, the dietary manager and/or the consulting dietitian, shall be consulted with the concern regarding the order. The dietary manager and/or consulting dietitian shall then contact the physician or designee, to discuss the concern regarding the order. The physician or designee, shall be the final arbiter in determining if a dietary order is changed, modified, delayed, or remains as directed. If a resident declines to participate with a specific diet order, the physician or designee, shall be notified of the resident's decision to refrain from participating with the order. The resident's decision to decline in participating with a diet order shall be documented in the clinical chart of the resident. If a resident has a BIMS score 13 or higher, education shall be attempted to persuade a resident to participate with the given order.The facility provided a document titled Dietary Diets with a revision date of 6/29/2026. The purpose of this document is to have a process in place that addresses the expectation of following resident prescribed diets. A resident's prescribed diet (regular, mechanical soft, pureed) shall be followed by staff working with the resident. An offered food item to a resident shall be conforming to the resident's current diet. Prescribed diets shall be directed by those individuals qualified by the State of Iowa to prescribe diets. Staff members shall receive education on diets starting at hiring orientation and when deemed necessary, continued education on diets shall also be provided. Residents shall be informed by the dietary director or dietitian or speech therapist, what type of diet is being used and discuss how that diet affects the resident individually. Resident Representatives shall also be notified if there is any change to a current diet of a resident. The facility provided a document titled MDS Care Plan with a revision date of 10/18/2025. The document indicated the MDS care plan shall also be developed by the facility's care team with resident/resident representative involvement. The MDS care plan shall be reflective of assessment results from the MDS and/or current clinical functioning of the resident. The care plan will identify the potential problems, goals to be achieved, and intervention strategies to be employed (by whom or by when) to meet the goals, alleviate problems and determine if new problems are occurring in order to be addressed by the overall care team. Facility staff shall be expected to follow the identified care plan for any specific resident that has a care plan(s).The facility provided a document titled Physician Orders with a revision date of 10/18/2025. The purpose of the document was to have a process in place that addresses the expectation of following physician orders. The facility personnel who are in the role of providing physician directed medical care, based upon documented physician order, are expected to provide by the best of one's ability and available existing resources, the physician directed care communicated via a physician order. If there is concern regarding a physician's order, the DON or designee, shall be consulted with the concern and the DON or designee, shall then contact the physician or designee, to discuss the concern regarding the order. The physician or designee, shall be the final arbiter in determining if an order is changed, modified, delayed, or remains as directed. If a resident declines to participate with a specific physician order, the physician or designee, shall be notified of the resident's decision to refrain from participating with the order. The resident's decision to decline in participating with a phys[TRUNC

Based on clinical record review, list of residents with personal accounts maintained by the facility, facility policy review, resident and staff interview, the facility failed to provide quarterly personal account statements to 1 of 1 residents sampled (Resident #1). The facility reported a census of 50 residents. Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #1, dated 12/18/25, revealed an admission date of 12/30/24. The Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicated Resident #1 had a moderate cognitive impairment. During an interview on 1/5/26 at 10:25 AM, Resident #1 reported the facility assisted her in managing her money. Resident #1 reported she had not received a quarterly statement, and she had not requested a statement. Review of the list of residents with personal accounts maintained by the facility revealed a total of 46 (including Resident #1) resident personal accounts managed by the facility. During an interview on 01/07/2026 at 2:50 PM, the Administrative Assistant reported she was responsible for maintaining the resident fund accounts. The Administrative Assistant reported she did not provide quarterly account statements to the residents and would only print out statements for the residents or their representatives when they asked. She explained there were some residents who asked for a statement, but she did not keep track of which residents had received one. The Administrative Assistant reported Resident #1 had not received a quarterly statement, but she would print one for the resident if the resident asked her.Review of the facility policy, titled Resident Trust Fund, dated 10/17/25, revealed in part .quarterly statements regarding Resident Trust funds shall be available to the resident and/or the legal resident representative.

Based on staff interview, clinical record review, and facility policy review, the facility failed to ensure accurate information reflected current resident status for 2 of 2 residents (Resident #3 and Resident #4) reviewed for quarterly assessments. The facility report a census of 50. Findings include: 1. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/16/25, under Section O. Special Treatments, Procedures, and Programs; Subcategory: Respiratory Treatments, documented in F1. that Resident #3 required an invasive mechanical ventilator while a resident at the facility. Review of the assessment under Section N. Medications; Subcategory: Insulin, documented that Resident #3 received insulin injection on 1 of the 7 days during the look back period. Review of the Care Plan, revised on 10/21/25, lacked indication that Resident #3 utilized an invasive mechanical ventilator or administration of insulin injections. Review of Active Orders, dated 1/07/25, revealed that Resident #3 had the following orders: a. Trulicity (dulaglutide) (once-weekly injection prescribed with diet and exercise to manage blood sugar in adults and children with type 2 diabetes, GLP-1 receptor agonist) pen injector 0.75 milligrams (mg) per 0.5 milliliter (mL) given subcutaneously once a day on Tuesdays for diagnosis of type 2 diabetes mellitus. Start date: 6/06/25. b. CPAP (Continuous Positive Airway Pressure) (a non-invasive machine that delivers pressurized air) with instruction to apply per setting every night while the resident sleeps, for diagnosis of obstructive sleep apnea. Start date: 2/13/25. Review of the Active Orders, dated 1/07/25, lacked orders for Resident #3 to utilize an invasive mechanical ventilator and lacked orders for insulin administration. During an interview on 1/07/26 at 2:30 PM, the MDS Coordinator reported that Resident #3 has never had an invasive mechanical ventilator but utilized a non-invasive CPAP machine and stated that the documentation of an invasive mechanical ventilator had been made in error. 2. Review of the MDS quarterly assessment, dated 10/23/25, under Section N. Medications; Subcategory: Insulin, documented that Resident #4 received insulin injection on 1 of the 7 days during the look back period. Review of the Care Plan, edited on 10/27/25, revealed a Focus area for Resident #4's diagnosis of diabetes mellitus and received anti-diabetic medication. An intervention directed, in part: a. I receive insulin injections, monitor and rotate injection sites. Administer medications as ordered, obtain labs and blood sugar checks as ordered, and report abnormal to the physician. Start date: 8/05/24. b. Staff may take my blood sugars/administer insulin in dining/day area if I refuse to go to a private area. Start date: 8/05/24. Review of Active Orders, dated 1/07/25, revealed that Resident #4 had the following orders: a. Trulicity (dulaglutide) given subcutaneously once a day on Tuesdays for diagnosis of type 2 diabetes mellitus. Start date: 6/24/25. b. Tradjenta (linagliptin) (medication used, along with diet and exercise, to improve blood sugar control in adults with type 2 diabetes) 5 mg tablet, with instructions to give one tablet by mouth daily for diagnosis of type 2 Diabetes Mellitus. Start date: 5/24/19 Review of the Active Orders, dated 1/07/25, lacked orders for Resident #4 to receive insulin administration. During an interview on 1/07/26 at 2:30 PM, the MDS Coordinator confirmed documentation of insulin injection for Resident #3 and Resident #4 related to the order for once weekly Trulicity injection. At 2:47 PM, the MDS Coordinator stated that the medication Trulicity was not an insulin injection and insulin administration coded for Resident #3 and Resident #4 was made in error. The MDS Coordinator reported that she would immediately modify/revise the MDS assessments with the corrected information. During an interview on 1/08/26 at 11:00 AM, the Director of Nursing (DON), stated the facility had no residents with an invasive mechanical ventilator. The DON confirmed that coding the medication Trulicity as insulin injection had been done in error. Review of the facility policy titled, MDS Assessments, dated 5/03/2019, directed the following, in part: a. The MDS assessment shall be completed by the nurse overseeing Care Plans and MDS's.b. The MDS shall be completed for the clinical occasions for a resident as directed by state and federal regulations. c. Any MDS assessment shall have input from existing staff members who contribute to the care of the resident. d. The MDS assessment shall follow the RAI guidelines. e. The MDS nurse or DON, shall ensure the completed MDS assessment is submitted electronically to CMS per regulation requirements.

Based on observation, record review, staff interviews, and the manufacturer's instructions, the facility failed to use the manufacturer approved needle to inject the insulin for 1 of 1 residents reviewed for insulin administration (Resident #15). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 with intact cognition based on a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS list of diagnoses included diabetes mellitus, and indicated Resident #15 received insulin injections 7 out of 7 days. Review of the Physician Orders revealed an order for Admelog U-100 Insulin (Lispro) solution- give 6 units subcutaneous with meals. During an observation 1/7/26 at 11:07 AM, Staff D, Licensed Practical Nurse (LPN) prepared Resident #15 lunch insulin. Staff D wiped off the Admelog insulin pen hub with an alcohol pad and then inserted an insulin syringe and withdrew 6 units of insulin from the pen. Staff D stated they didn't use the needles for the pens because of the cost. During an observation on 1/7/26 at 11:12 AM, Staff D, took resident's blood glucose which was 140 mg/dl (milligrams per deciliter) and then injected the insulin into Resident #15 right arm. During an interview on 1/7/26 at 1:55 PM, Staff D queried why they used an insulin syringe instead of the needles for the insulin pens, and Staff D stated she thought the insurance didn't pay much for the insulin pen needles. Staff D asked how long she used the insulin syringes for the insulin pens, and Staff D stated she was trained to do it that way when she got hired. During an interview on 1/8/26 at 7:31 AM, Staff A, Registered Nurse (RN) queried on what needle Staff A used for Resident #15 insulin pen, and Staff A stated she drew up the insulin from the pen into a syringe because the needle for the insulin pen was not a safety needle and it was safer to draw the insulin using the insulin syringe. Staff A stated she believed Resident #15 was the only resident who was prescribed the insulin pen. During an interview on 1/8/26 at 11:19 AM, the Director of Nursing (DON) queried on Resident #15 insulin pen, and the DON stated Resident #15 is the only resident with a pen because the DON preferred the vials. The DON stated she felt the vials were less room for error versus the pens with the priming and holding in place. The DON stated she knew Resident #15 received the correct insulin and didn't think there would be an issue with drawing the insulin out of the pen with the insulin syringe. The Manufacturer Instructions for Admelog Solostar Insulin pen dated 2025 revealed:Do not use a syringe to remove insulin from the your pen. The Facility Insulin Preparation and Administration Policy updated 10/17/25 did not address following the manufacturer instructions for insulin administration.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to provide assistance with nail care for 1 of 2 residents sampled (Resident #42). The facility reported a census of 50 residents. Findings include:Review of Resident #42's Minimum Data Set (MDS) assessment, dated 11/13/25, revealed an admission date of 9/18/2020. The Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicated a moderate cognitive impairment. The list of diagnoses included schizophrenia (a mental health disorder causing a causing a disconnect with reality), diabetes and chronic obstructive pulmonary disease. The MDS indicated Resident #42 utilized a wheelchair and walker for mobility, and required partial to moderate staff assistance for showering and set up assistance for eating and oral hygiene. Review of Resident #42's Care Plan, dated 11/19/25, revealed a Problem area to address I am independent with ADL's (activities of daily living) assist me as needed. During an observation on 01/05/26 at 10:50 AM, Resident #42 sat in a wheelchair by the main nurse's station. Resident's fingernails noted to be long, edges appeared jagged and a brown like substance noted under some of the fingernails. During an interview on 01/05/26 at 2:40 PM, Resident #42 reported the staff did not trim his fingernails, and said that they needed to be done. The resident reported his toenails were worse, and proceeded to pull off his socks. Resident #42 toenails noted to be long and edges appeared jagged. Resident #42 stated nursing staff did not cut or trim his toenails and denied a podiatrist or other physician had trimmed his toe nails. Review of the clinical record revealed a Physician Note, dated 11/10/25 which ordered in part: Podiatry (foot doctor) visit annual dx (diagnosis) DM2 (diabetes mellitus type 2) (okay if in- house podiatry but if not, needs to go out). Further review of the record lacked documentation of podiatry care for Resident #42. During an interview on 01/07/26 at 8:09 AM, Staff A, Registered Nurse (RN), stated nursing staff trimmed and filed residents' finger and toe nails. She explained if a resident was diabetic, the resident was usually referred to a Podiatrist for toenail care. Staff A explained that the Certified Nurse's Aides (CNAs) would let the nurses know if a resident's nails needed to be done typically on bath days. Staff A reported that she was the nurse responsible for Resident #42 today. Staff A reported she had trimmed and filed Resident #42's fingernails in the past, but has never done his toe nails. She reported Resident #42 had not refused nail care in the past to her knowledge. During an interview on 01/07/26 at 9:16 AM, Staff B, CNA, reported she was the shower aide for the residents and completed showers and bed baths yesterday on residents yesterday (1/6/26) including Resident #42. Staff B reported she would notify the nurses verbally and circle on the Shower Sheet form if a resident needed toe or finger nails trimmed. Staff B thought she circled that Resident #42 needed his nails trimmed on 1/6/26, but said she may not have due to being busy.During an interview on 01/07/26 at 9:24 AM, the Director of Nursing (DON) confirmed the CNAs notified the nurses when a resident needed their nails done. The DON pulled out the 1/6/26 Shower Sheet form for Resident #42, completed by Staff B, CNA. Staff B documented the resident did not need his fingernails or toenails done. The DON reported since Resident #42 was diabetic, staff would refer the resident to a Podiatrist for toenail care. The DON confirmed Resident #42 did not have an appointment with the facility's Podiatrist, and said she would get the resident set up with an appointment. Review of the facility policy, titled Podiatry and Nail Care, dated 10/17/25, revealed the policy included in part .If nails require trimming and/or cutting, only member of the professional nursing staff shall perform that task. If nail care requires outside intervention, then the resident shall be referred to the appropriate outside setting to receive the appropriate nail care services .Residents who are non-diabetic may have their toe nails trimmed or cut by a member of the professional nursing staff. If it is determined that the resident requires a podiatrist to perform the task or to address other foot issues, then referral to the podiatrist shall occur for the task to be completed. Residents who are diabetic, shall see a podiatrist at least annually for toenail and/or foot care.

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to provide intervention to relieve symptoms of constipation for residents with 3 days or longer without a bowel movement for 2 of 2 residents sampled (Resident #13 and #47). The facility reported a census of 50 residents. Findings include:1.Review of the Minimum Data Set (MDS) assessment for Resident #13, dated 12/2/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS indicated continent of bowel and bladder. During an interview on 1/5/26 at 11:36 AM, Resident #13 reported concerns of constipation. Resident #13 reported going three or more days without a bowel movement and without nursing giving her any medication to help. She reported requesting medication to help, but did not receive any. Review of the electronic health record (EHR) revealed a list of diagnoses which included, in part gastro-esophageal reflux disease, functional dyspepsia (chronic indigestion characterized by bloating, feeling full quickly and pain or burning), and constipation. Review of the electronic health record (EHR) revealed the following Physician Orders:a. Aluminum-Magnesium Hydroxide-Simethicone (Milk of Magnesia- MOM) suspension; 400-400-40 milligrams (mg)/5 milliliters (ml), 15 ml oral every 4 hours PRN (as needed) for functional dyspepsia. Start date 11/25/25. b. Miralax powder, oral, 17 grams per dose once daily PRN for constipation. Start date 11/25/25.c. Bisacodyl suppository 10 mg 1 suppository once a day PRN per bowel management regimen, if MOM or Miralax ineffective for constipation Start date: 11/25/25. Review of the Care Plan revealed a lack of an addressed Problem area. Review of the EHR revealed:a. Resident #13's did not have a bowel movement (BM) on 11/26/25, 11/27/25 and 11/28/25. The resident had a BM on 11/29/25. During this time, Resident #13 received MOM 15 ml on 11/26/25 at 12:09 AM.b. Resident #13 did not have a BM on 12/7/25, 12/8/25, or on 12/10/25. No documentation recorded on 12/9/25. Resident #13 had a BM on 12/11/25. Review of the December 2025 and January 2026 revealed no documentation to indicate a PRN administered for constipation.c. Resident #13 did not have a BM on 12/28/25 or 12/30/25. No documentation recorded on 12/29/25 or 12/31/25. Resident #13 had a BM on 1/1/26. Review of the December 2025 and January 2026 revealed no documentation to indicate a PRN administered for constipation.During an interview on 1/7/26 at 8:01 AM, Staff C, Certified Medication Aide (CMA) reported the nursing staff had a paper tracking system for BMs that would then be entered by the Certified Nurses Assistant (CNAs) into the EHR. The CNAs were responsible for documenting the BMs. Staff C explained the nurses would track and follow the facility's bowel protocol. If no BM, nursing staff would administer a Bisacodyl tablet orally on the third day, a Bisacodyl suppository on the fourth day, and an enema on the fifth day. During an interview on 1/7/26 at 9:24 AM, the Director of Nursing (DON), stated the facility had a Bowel Protocol which included a Bisacodyl tablet on day three without a BM, a suppository on day four without a BM and an enema on day five if no BM. The DON explained the nursing night tracked the residents' BMs and notified the day shift if a resident needed an intervention. The day shift was responsible for the administration of medications related to the bowel protocol. The DON was unsure why Resident #13 had not received any medication to relieve constipation. 2. Review of Resident #47 MDS, revealed the resident had a severe cognitive impairment, incontinent of bowel and dependent for all activities of daily living. Review of Resident #47 Care Plan, dated 12/3/25, revealed a Problem area to address I have chronic constipation, with an Approach that directed staff to follow the facility bowel protocol. Review of the EHR revealed the following Physician Orders: a. Bisacodyl tablet 5 mg oral, 1 tab as needed for constipation. Start date: 9/21/23. b. Bisacodyl 10 mg suppository, 1 suppository as needed for constipation. Start date: 9/21/23. c. Enema (sodium phosphates), 19-7 grams per 118 ml, 1 enema rectal as needed for constipation. Start date: 9/21/23. Review of the EHR revealed:a. Resident #47 did not have a BM recorded on 12/28/25, 1/1/26, 1/2/26. No documentation recorded on 12/29/25, 12/30/25, or 12/31/25. The resident had a BM on 1/3/26. The December 2025 and January 2026 MAR's indicated Resident #47 received an enema on 1/2/26. b. Resident #47 did not have a BM recorded on 1/4/26, 1/6/26. No documentation recorded on 1/5/26. The resident had a BM on 1/7/27. Review of the January 2026 MAR revealed no documentation present to indicate a PRN medication administered. During an interview on 1/7/26 at 11:16 AM, the DON reported an inability to find any information on why Resident #47 did not receive intervention prior to 1/2/26 enema. Review of the facility's policy, titled Bowel Movements, dated 10/17/25, revealed in part .The facility shall address bowel movement protocol as follows regarding bowel movements:On day 3, if no movement the use of milk of magnesia/bisacodyl/senna shall be attempted. On day 4 if no movement, use of a suppository unless otherwise care planned. On day 5 if no movement, use of an enema and notify physician of no bowel movement. If resident declines protocol, document and offer an alternative.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure hand hygiene completed as part of infection control techniques during wound care for 1 of 1 (Resident #47) reviewed. The facility reported a census of 50.Findings include:Review of Resident #47 Minimum Data Set, dated [DATE], revealed had a severe cognitive impairment, incontinent of bowel and bladder, dependent for all activities of daily living and at risk for pressure ulcers.Review of the electronic health record (EHR) revealed the following Physician Orders:a. Apply Calmoseptine to coccyx wound daily, dated 1/6/26.b. Cleanse wound right thorax mid-back, apply Calcium Alginate to wound bed, apply skin prep to surrounding skin and cover with Mepilex once a day, dated 12/26/25.During an observation on 1/7/26 at 3:12 PM, Staff A, Registered Nurse (RN) performed hand hygiene (used an alcohol-based hand rub), donned personal protective equipment and entered Resident #47's room to perform wound care of a coccyx wound and right mid-back wound. The Director of Nursing (DON) also present. Staff A sanitized the over the bed table and set up a clean field for wound care supplies. Supplies included 4 by 4 gauze pads, wound cleaner spray, Calcium Alginate (type of medicated pad) cut to size, Mepilex dressing (type of wound cover), Skin Prep pads, and Calmoseptine Ointment.With the Resident #47 laying in her bed, on her right side, Staff A, RN loosened the resident's incontinent brief and noted the resident had a bowel movement. After cleaning up the resident, Staff A removed the soiled brief, and the DON started a fresh brief under the resident. Resident #47 buttocks noted to have a small pinpoint opening on the gluteal fold near the sacral (lower back) area. Staff A removed her gloves and donned another pair of gloves without performing hand hygiene. Staff A applied Calmoseptine ointment to wound on the coccyx and then finished applying a new incontinent brief. Staff A removed her gloves and donned another pair of gloves without performing hand hygiene. Staff A and the DON worked together to unbutton the resident's shirt and roll the resident to her right side. Staff A removed a dressing dated 1/6/26 from the resident's mid-back. The removed dressing had blood-tinged drainage. Staff A kept the same pair of gloves on and sprayed wound cleanser on the mid-back wound bed and surrounding tissue. Staff A used 4 by 4 gauze to dab the area dry, and then applied Skin Prep to the area surrounding the wound bed. Staff A applied Calcium Alginate to the wound bed and covered the mid-back wound with Mepilex. During an interview on 1/7/26 at 4:36 PM, Staff A, RN, reported she had received monthly training in infection control. She reported hand hygiene should be done with any glove changes. Staff A explained that sometimes she used alcohol wipes to perform hand hygiene. Staff A reported she had the alcohol wipes sitting on the bedside table and used the wipes after performing perineal care on the resident. During an interview on 1/8/26 at 10:29 AM, the DON reported staff were to perform hand hygiene when changing gloves.Review of the facility policy, titled Handwashing Policy, dated 2/2024, revealed in part .If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands in other clinical situations .Other clinical situations refer to circumstances involving resident contact and cares. Situations include but are not limited to: After contact with a resident's intact skin . After removing gloves . After contact with body fluids or secretions, mucous membranes, non- intact skin, and wound dressings if hands are not visibly soiled; and/or before dressing changes.Review of an undated policy, titled Treatment/Wound Care Policy, revealed, in part . Perform hand hygiene .Position the resident and lay the clean towel/chux down .Perform treat .Gloves .Remove dirty dressing and place in bio bag take off dirty gloves .hand hygiene/sanitize .cleanse wound from the wound area in a circular motion outward (cleanse one wound at a time; remove gloves and sanitize between all wounds).