Every finding on record at Stacyville Community Nursing Home

Based on record review, staff interview, and policy review, the facility failed to ensure 1 of 3 sampled residents on antipsychotic medications had diagnoses to support the justification and use of the medication and the negative side effects it can cause in the elderly (Resident #19). The facility reported a census of 24 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 8/20/25. Resident #19's MDS documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. Resident #19's MDS documented disorganized thinking (rambling conversation or unclear flow of ideas), fluctuating behavior (changing in severity), and delusions (firmly held false beliefs). Resident #19's MDS documented 1 to 3 days of verbal behavioral symptoms directed toward others (threatening, screaming, or cursing) and other behavioral symptoms not directed toward others (hitting or scratching self, pacing, rummaging) during the look-back period. Resident #19's MDS documented no physical behavioral symptoms directed toward others. Resident #19's MDS documented Resident #19 uses a walker, eats, puts on and takes off shoes, performs oral and toileting hygiene, moves in bed, and walks independently. Resident #19's MDS documented Resident #19 requires partial or moderate assistance (helper providing less than half effort) with showering, bathing, and dressing. Resident #19's MDS documented Resident #19 maintains bowel and bladder continence. Resident #19's MDS documented active diagnoses including non-Alzheimer's dementia (memory loss disorder), unspecified atrial fibrillation (irregular, rapidly beating heart rhythm), and chronic obstructive pulmonary disease (COPD) (progressive lung disease causing airflow blockage). Resident #19's MDS didn't list psychiatric or mood disorder diagnoses. A review of Resident #19's Physician's Orders dated 8/21/25 documented orders for Seroquel (antipsychotic medication) 25 milligrams (mg) at 3:00 PM and Seroquel 100 mg at supper. The orders didn't list a diagnosis for usage. A review of Resident #19's Psychotropic Medication Therapy Informed Consent Form for Seroquel dated 8/20/25 documented the reason for usage as dementia with psychotic behavior and irritability. The form documented expected benefits including improved functional ability, mood, social activities, sleep, and weight. The form documented potential side effects including blurred vision, confusion, constipation, drooling, dry mouth, involuntary movements, muscle rigidity, restlessness, sedation, sleep disturbances, and neck stiffness. The form included an Antipsychotic Black Box Warning stating administration in elderly patients with dementia-related psychosis treated with an antipsychotic drug increases risk of death. A review of a Health Status Note dated 1/19/26 at 1:58 PM documented Resident #19 reporting a night fall to morning staff. Resident #19 denied hitting Resident #19's head. Staff initiated neurological assessments per facility protocol. Vital signs remained stable, and Resident #19 denied pain. Staff implemented an intervention to keep Resident #19's bathroom light on during the night because Resident #19 doesn't call or wait for staff assistance. A review of Resident #19's Note to Attending Physician Prescriber dated 6/1/26 documented a second pharmacy request for a gradual dose reduction for Seroquel. Resident #19's physician declined the request, documenting Resident #19 continues displaying increased agitation. A review of Resident #19's Order Note dated 6/18/26 at 7:28 AM documented Resident #19 experiencing increased afternoon and evening behaviors. The note documented Resident #19 taking Seroquel 25 mg at 3:00 PM, requesting a dose increase and a potential additional morning dose. Resident #19's physician responded with an order for Seroquel 12.5 mg in the morning and 25 mg at noon to evaluate Resident #19's response. The order didn't include a diagnosis for the medication increase. Staff noted the order on 6/19/26. A review of a Health Status Note dated 7/1/26 at 7:19 AM documented Resident #19 experiencing an unwitnessed morning fall. A nursing assistant reported the fall at 7:00 AM. Resident #19 stated hitting Resident #19's head and sustaining an open area on the knee. Staff noted no head bruising or lacerations (cuts) and observed a penny-sized scrape on Resident #19's knee without bleeding. Staff initiated neurological assessments. Resident #19 reported slight neck pain while remaining in good spirits. A review of Resident #19's Order Note dated 7/19/26 at 9:49 PM documented Resident #19 becoming anxious and irritable after supper, requesting an increase in afternoon Seroquel. Resident #19's physician ordered a dose increase to 50 mg without documenting a diagnosis for use. Staff noted the order on 7/21/26. A review of Resident #19's Transfer/Discharge Report dated 7/21/26 at 7:41 PM documented Resident #19 experiencing a fall with possible left hip external rotation and increased pain. Resident #19 remained alert and oriented to self, prompting staff to transfer Resident #19 to the local emergency room. The report documented active orders for Seroquel 12.5 mg in the morning for monitoring (last administered at 7:12 AM), 50 mg in the afternoon for agitation and anxiety (last administered at 2:12 PM), and Seroquel 100 mg daily (last administered at 5:46 PM). A review of Resident #19's current medical diagnoses in the Electronic Health Record (EHR) on 8/5/26 didn't show documentation of psychiatric or mood disorders. The EHR documented a diagnosis of severe dementia with agitation upon admission on [DATE]. A review of Resident #19's Final Report written by Resident #19's physician dated 8/5/26 documented a diagnosis of psychosis (loss of contact with reality). The report documented Resident #19 doesn't experience hallucinations currently due to medication control. The report documented the medication provides benefit without evidence of excessive sedation or falls. The physician documented plans to continue monitoring and consider downward titration (gradual dose reduction). The report directed staff to continue monitoring for adverse effects, seek future opportunities for gradual dose reductions, and maintain non-pharmacological interventions. A review of Resident #19's diagnoses in the EHR on 8/6/26 documented an added diagnosis on 8/4/26 of unspecified psychosis not due to a substance or known physiological condition. On 8/6/26 at 10:43 AM Staff A, Activity Coordinator (AC), stated Resident #19 attends many activities. Staff A reported Resident #19 sometimes becomes upset, starts yelling, and occasionally struggles to understand prizes. Staff A stated Resident #19 experiences ornery days, prompting Staff A to reapproach and try again when an initial approach fails. Staff A reported Resident #19 claims residency in Florida and sometimes self-corrects. Staff A stated staff must remain in Resident #19's current reality. Staff A stated instructing Resident #19 to wait for assistance when wanting to leave causes anger, as does attempting gait belt placement for walking assistance. Staff A stated staff must predict when Resident #19 desires to leave and ensure staff assist Resident #19 first. Staff A reported Resident #19 adapted to staff and the facility, showing improvement since admission. On 8/6/26 at 10:49 AM Staff B, Certified Nursing Assistant/Certified Medication Aide (CNA/CMA), stated Resident #19 experiences confusion but functions fairly well. Staff B reported never observing Resident #19 displaying anger or yelling. On 8/6/26 at 10:50 AM Staff C, Licensed Practical Nurse (LPN), and Staff D, Certified Nursing Assistant (CNA), stated Resident #19 remains directable and pleasant. Staff C and Staff D reported Resident #19 displays increased behavioral symptoms during evening shifts while acting pleasant and sweet during morning shifts. Staff C and Staff D stated loud noises agitate Resident #19. The Medication - Drug Regimen Review (DRR) policy dated 2022 instructed a licensed pharmacist to review each resident's drug regimen at least monthly. The policy directed the Medication Regimen Review (MRR) to include evaluating resident responses to medication therapy to determine maintenance of the highest practicable level of functioning while preventing or minimizing adverse consequences. The policy directed reporting findings and recommendations to the Director of Nursing (DON), attending physician, and Medical Director. The policy defined an irregularity as any event inconsistent with usual, proper, accepted, or right approaches to providing pharmaceutical services, or impeding or interfering with achieving intended outcomes. The policy defined psychotropic drugs as any drug affecting brain activities associated with mental processes and behavior, including antipsychotic, antidepressant, antianxiety, and hypnotic categories. The policy defined unnecessary drugs as any drugs used in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of adverse consequences indicating required dose reduction or discontinuation.

Based on record review, staff interviews, and policy review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 3 residents reviewed for catheters (Resident #6). The facility reported a census of 24 residents.Findings include:Resident #6's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 5/2/24. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #6 used a catheter (flexible tube used to drain urine from the bladder), maintained independence with toileting hygiene and toileting transfers, and frequently experienced involuntary leakage of urine. The MDS documented no active medical conditions related to the urinary system. A review of Resident #6's Treatment Administration Record (TAR) dated June and July 2026 showed a lack of documentation or physician orders related to catheter use. On 8/3/26 at 12:09 PM Resident #6 stated not having used a catheter since residing at the facility. On 8/4/26 at 11:28 AM Staff A, Minimum Data Set (MDS) Coordinator, stated Resident #6 doesn't currently maintain and hasn't maintained a catheter. Staff A stated incorrectly coding the July MDS assessment and plans to modify the assessment today to accurately reflect Resident #6's status. The Comprehensive Assessments policy dated 2022 directed staff to complete comprehensive assessments in line with criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual. The policy instructed staff to complete an admission assessment for a new or returning resident by day 14. The policy instructed staff to complete an annual assessment every 366 days unless staff completed a Significant Change in Status Assessment (SCSA) or a Significant Correction to Prior Comprehensive Assessment (SCPA). The policy directed an SCSA occurs when the care team determines a resident experienced a major decline or improvement won't resolve independently, impacts multiple health areas, and requires care plan revision. The policy directed an SCPA occurs when the care team determines a prior assessment contains a significant error, meaning a resident's overall status is miscoded or results in an inappropriate care plan.

Based on clinical record review and staff interview, the facility failed to ensure one of 3 residents (Resident #2) remained free from a medication error, failed to document the error in the clinical record, and failed to follow professional standards for reconciling controlled drugs (medications with a high potential for abuse). The facility reported a census of 23 residents. Findings include:Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of Parkinson's disease (brain disorder), depression, and sleep apnea (breathing stops during sleep). The MDS documented he received an antianxiety medication (medication used to treat anxiety) during the 7-day lookback period.On 4/20/26 at 1:58 PM, observed Staff C, Certified Medication Aide (CMA), and Staff D, CMA, performing the controlled drug count for the shift change. Staff C looked at the bubble packs for the controlled drugs and Staff D read the count off the controlled drug sheets in the binder. Staff C didn't compare the bubble pack to the sheet to ensure it was the right resident, medication, and correct count. Staff E, Licensed Practical Nurse (LPN), stood to the side of the cart observing the count next to Staff D. At 2:00 PM, when they finished the count finished, all three staff reported this as the normal process for counting controlled drugs.On 4/20/26 at 2:03 PM, the Director of Nursing (DON) reported that a staff member who just finished the controlled drug count reported they completed the count incorrectly. The DON reported staff didn't compare the bubble pack to the sheet to verify the correct drug, count, and resident. The DON reported she verbally educated the staff and planned to provide written education.Review of the facility reported incident investigation for missing controlled drugs on 10/31/25 documented Staff A, LPN, didn't sign the controlled drugs out at the time of giving the medication. The report documented Staff A gave Resident #2 a double dose of lorazepam (antianxiety medication). Resident #2 was missing another dose of lorazepam that was unaccounted for on 10/31/25. The facility's 5-day investigation documented Staff B, Registered Nurse (RN), was noted on video footage on 10/30/25 at 11:07 PM performing the controlled drug count. At 11:08 PM, Staff B punched out Resident #2's lorazepam and taped it into another resident's-controlled drug card. The investigation documented the staff's inaccurate reconciliation (matching records to actual supply) and count at shift change.Resident #2's Electronic Health Record (EHR) lacked documentation of the medication error in the chart. The chart lacked the controlled drug count sheet for October 2025 through November 2025 for the lorazepam.During an interview on 4/21/26 at 11:20 AM, the Administrator reported the controlled drug sheet for Resident #2's lorazepam during the medication discrepancy was missing. The Administrator reported staff have looked for it since the investigation but can't find it.During an interview on 4/21/26 at 12:15 PM, Staff A reported Staff F, CMA, performed the controlled drug count in the morning with Staff B. Staff A reported she didn't sign the controlled drugs out when she gave the medication. Staff A reported she went back later to sign them out and thought she didn't give Resident #2 his medication, so she gave him a dose around 8:00 PM. Staff A reported when she signed the book later, she realized she gave him another dose by mistake. Staff A reported she notified the physician (doctor). Staff A reported later when doing a count with Staff B, she noticed the controlled drug discrepancy.On 4/22/26 at 8:51 AM, the DON reported she couldn't find anything in the EHR documenting Resident #2's medication error and stated it should've been in the record.The undated Controlled Substances policy directed staff to reconcile controlled drugs upon receipt, administration, disposal, and at the end of each shift.The undated Medication Error-Incident Report Process policy directed staff that a medication error must be documented in the resident records and a medication error form must be filled out.

Based on clinical record review and staff interview, the facility failed to ensure one of one residents (Resident #2) remained free from a medication error and failed to document the error in the clinical record. The facility reported a census of 23 residents. Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of Parkinson's disease (Brain disorder causing tremors, stiffness, and difficulty with movement), depression, and sleep apnea (A condition where breathing repeatedly stops and starts during sleep). The MDS documented he received an antianxiety medication during the 7-day lookback period. Review of the facility reported incident investigation for missing controlled drugs on 10/31/25 documented Staff A, Licensed Practical Nurse (LPN), didn't sign the controlled drugs record at the time of giving the controlled drug medication to ensure accurate documentation. The report documented Staff A gave Resident #2 a double the dose of lorazepam (an antianxiety medication). Resident #2's Electronic Health Record (EHR) lacked documentation of the medication error assessment and follow-up in the chart.On 4/21/26 at 12:15 PM, Staff A, Registered Nurse (RN) reported Staff F, Certified Medication Aide (CMA) performed the controlled drug (medications with a high potential for abuse) count in the morning with Staff B, RN. Staff A reported she didn't sign the controlled drugs out when she gave the medication later that day. Staff A reported she went back later to sign the medication out as given and thought she didn't give Resident #2 his medication. Staff A then gave Resident #2 another dose around 8:00 PM. Staff A reported when she signed the book later, she realized she gave him another one by mistake. Staff A reported she notified the physician (doctor). Staff A reported later when doing a count with Staff B that she noticed the controlled drug discrepancy.On 4/22/26 at 8:51 AM, the Director of Nursing (DON) reported she couldn't find any information in the EHR documenting Resident #2's medication error, assessment, or follow-up in the chart and stated it should be there.The undated Medication Error-Incident Report Process policy directed staff a medication error must be documented in the resident records and to monitor for any adverse effects (unwanted or harmful results) caused by the error.

Based on electronic health record (EHR)review, policy review, resident, and staff interviews the facility failed to report an allegation of abuse within the required time frame to the Iowa Department of Inspection, Appeals, and Licensing (DIAL) for 1 of 1 resident reviewed (Resident #9). The facility reported a census of 22 residents. Findings Include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of renal (kidney) insufficiency (poor functioning), stroke and end stage renal disease (ESRD). The MDS documented Resident #9 received dialysis services outside of the facility. During an interview on 6/2/25 at 12:10 PM, Resident #9 reported he had money missing and someone took his money. Resident #9 reported approximately $250 missing from his room over a month ago and another $57 within the past week. Resident #9 stated he reported the missing funds to the staff on each occasion. A review of the EHR Profile tab listed Resident #9 as his own responsible party. The Care Plan Focus initiated 12/9/24 listed the facility provided Resident #9 a lock box. Resident #9 had an undetermined amount of money that he refused to let the staff count. The Intervention directed the following: a. Resident #9 would keep the lock box in his room and safeguard it. He refuses to allow staff to safely lock up the money in a secure location. b. Resident #9 refused to allow staff to count the money in his possession. The review of the facility reported incidents to DIAL lacked reports of Resident #9's missing money for 2/11/25 and 5/27/25, after he reported the incident to the staff. During an interview on 6/4/25 Staff B, Certified Nursing Assistant (CNA), revealed she knew Resident #9 reported his money missing. Staff B explained she reported it to the nurse that Resident #9 reported missing money. During an interview on 6/4/25 at 10:00 AM Staff C, Social Services, verified Resident #9 reported to him on 5/27/25 that he had $57 missing. He had the money sitting out in the open in a bank envelope in his room. Staff C reported the missing money to the Administrator the next morning. Staff C confirmed Resident #9 reported a previous incident of missing money. Staff C provided a summary/investigation of report Resident #9's missing money after he reported to him on 2/11/25. The investigation documented Resident #9 reported someone stole $400 from his room. During an interview on 6/4/25 at 10:57 AM the Administrator and Staff C reported they started an ongoing investigation on 5/27/25 for Resident #9's reported missing money. The Administrator stated she talked with Resident #9 about keeping his money locked up in his facility provided lockbox. The Administrator acknowledged she didn't report Resident #9's previous or current incidents of missing money to DIAL. A review of the undated facility Abuse Policy defined: Misappropriation of Resident property as the deliberate (on purpose) misplacement, and exploitation (wrongful temporary or permanent use of a Resident's belongings or money without the resident's consent). The policy directed staff to report all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of resident abuse shall be reported to the Department of Health and Human Services (DHHS) no later than 2 hours after the allegation is made, if the allegation resulted in serious bodily injury, or no later than 24 hours if the allegation involved neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation, but do not result in serious bodily injury. If there is a reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not facility employed the alleged perpetrator, the Elder Justice Act required the facility report the situation to law enforcement. While the federal regulations required all abuse allegations reported to DIAL within 2 hours, the Elder Justice Act has a different reporting timeframe to the police/sheriff. If the allegation of abuse (that resulted from a crime) resulted in serious bodily injury to a resident, a report must be made to law enforcement no later than 2 hours after the allegation is made. If the allegation of abuse does not result in serious bodily injury, the facility must report to law enforcement no later than 24-hours. The policy defined serious bodily injury as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, mental faculty, or required surgery, hospitalization, or physical rehabilitation. If the person in charge is the alleged abuser, the staff member shall directly report the abuse to the DHHS immediately, pursuant to the deadlines established above. If the allegations of dependent adult abuse involve a caretaker not employed by the facility (e.g., family member, visitor), a report must also be made immediately to DHHS.

Based on electronic health record (EHR) review, clinical record review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview the facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) assessment after a resident elected to start hospice for 1 of 1 residents (Resident #17) reviewed on hospice services. The facility reported a census of 22 residents. Findings include: Resident #17's Clinical Census reviewed 6/3/25 documented hospice as their primary payer effective 4/30/25. The Health Status Note dated 4/30/25 at 12:27 PM reflected Resident #17 admitted to hospice care services. The MDS 3.0 Summary page in Resident #17 EHR revealed the facility failed to complete the SCSA MDS when hospice services had been elected. The Hospice Election Statement signed by Resident #17's Representative on 4/30/25 listed they elected hospice to start that day. During an interview on 6/4/25 at 11:08 AM Staff A, MDS Coordinator, reported she started working at the facility on 5/5/25. She acknowledged Resident #17 elected hospice prior to her starting at the facility. Staff A explained they followed the RAI manual when they completed the required assessments. Staff A reported the facility had 14 days after election of hospice to complete the SCSA assessment. Staff A acknowledged the facility didn't complete Resident #17's SCSA assessment. During an interview on 6/4/25 at 11:15 AM, the Administrator acknowledged the facility followed the RAI manual timelines when they completed the MDS assessments. The Administrator confirmed the facility didn't complete Resident #17's SCSA assessment. The LTC RAI 3.0 User's manual Version 1.19.1 October 2024 identified the manual required the facility complete a SCSA when a terminally ill resident enrolled in a hospice program or changed hospice providers and remained a resident at the nursing home. The RAI Manual specified the SCSA MDS completion date as 14 days from the determination that a significant change in resident status occurred (determination date plus 14 calendar days).

Based on clinical record review and staff interviews the facility failed to accurately document and submit an accurate Minimum Data Set (MDS) Assessment for 1 of 6 residents reviewed (Resident #6). The facility reported a census of 22 residents. Findings include: Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), diabetes, and obesity. Resident #6 received injections of insulin 7 out of 7 days during the lookback period. Resident #6's clinical record lacked documentation of insulin or even an injection given during the lookback period. During an interview on 6/4/25 at 1:43 PM the MDS coordinator reported the previous MDS coordinator coded the medication wrong. During an interview on 6/5/25 the MDS coordinator reported the facility didn't have a policy for MDS accuracy and completion. She reported the facility followed the RAI Manual.

Based on clinical record review and staff interview, the facility failed to follow physician's orders for 2 of 6 residents reviewed (Resident #6 and #11). The facility reported a census of 22 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), diabetes, and obesity. Review of Resident #6's Treatment Administration Record lacked documentation of Ozempic given on 4/4/25. Review of Resident #6's Progress Note on 4/4/25 at 3:27 PM documented the Ozempic (GLP1 medication used to treat diabetes and obesity) medication will be coming from the pharmacy that evening. Further review of the Progress Notes lacked documentation that the medication came from the pharmacy and was given. During an interview on 6/4/25 at 3:50 PM the MDS coordinator reported the medication was missed on 4/4/25. It should have been given and was missed. It didn't come in from the pharmacy. During an interview on 6/5/25 8:55 AM, the Administrator reported the facility didn't have a facility policy related to following physician orders. 2. Resident #11's MDS assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), depression and dementia. During an interview on 6/2/25 at 12:53 PM, Resident #6 reported she told the Administrator she wanted to ride the bike in therapy again. The Health Status Note dated 4/2/25 at 2:35 PM documented the doctor ordered Physician Therapy (PT) to evaluate and treat because Resident #11 wanted to use the bike in the therapy room. Resident #6's clinical record lacked PT seeing them on or after 4/2/25. During an interview on 6/3/25 at 1:14 PM the Director of Nursing reported the nursing staff who received the physician orders for therapy are supposed to notify the facility's contracted therapy group. The staff missed Resident #6's order on 4/2/25 and didn't call it in.

Based on facility record review and staff interviews, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents. The facility identified a census of 27 residents. Findings include: Review of the facilities Department of Health and Human Services Centers For Medicare & Medicaid Services form (also known as a 2567 form) with the completed complaint survey dated 2/7/25 reflected the facility received deficiencies for Resident Rights, Pharmacy Services, and Quality Assurance and Performance Improvement (QAPI). The survey investigation determined deficient practices again on the complaint and revisit investigation concluded 4/1/25. During an interview 4/1/25 at 2:35 PM the Business Office Manager, responsible for monitoring the QAPI program, explained QAPI remained ineffective due to the previous management and the continued learning curve of the current management staff.

Based on observations, clinical record review, resident interview, staff interviews and the Resident [NAME] of Rights the facility failed to allow a resident to make his own decisions and follow physician orders for 1 resident reviewed (Resident #4). The facility reported a census of 27 residents. Findings include: Resident's #4 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS indicated Resident #4 didn't walk, but used a manual wheelchair. The MDS included diagnoses of Parkinson's disease, anxiety and repeated falls. A Care Plan Focus initiated 6/23/22 listed activities of daily living (ADL). The Interventions included the following: a. Revised 2/13/25: Resident #4 used an electric wheelchair to move around the facility. He must keep his wheelchair speed at the lowest speed at all times. The staff must provide close supervision while he drove his wheelchair in hallways due to his fluctuated capabilities of his keeping his chair straight. A Rehab Communication form dated 2/6/25 signed by the medical doctor (MD) on 2/13/25 directed the following: a. Resident #4 must keep wheelchair speed at the lowest speed of 1 at all times. b. Staff provide close supervision while Resident #4 drove his wheelchair in the hallways due to his fluctuated capabilities of keeping the chair straight. Review of a facilities Corrective Action Plan dated 4/1/25 reflected a staff member failed to obtain a physician's order to discontinue Resident #4's electric wheelchair prior to taking his electric wheelchair. During an interview on 3/27/25 at 3:27 PM Resident #4 indicated his life changed drastically (his words) since the facility staff took his wheelchair away because he couldn't get around anymore. He had to wait for staff assistance which he didn't like. Resident #4 confirmed he hit walls at times but denied ever hitting residents or having caused injury to himself. Review of the facilities Residents' Rights form (not dated) instructed a resident had the right to a reasonable accommodation of needs so long as it didn't endanger the health or safety of themselves or other residents.

Based on observation, clinical record review, resident interview, staff interview and facility policy review the facility failed to maintain a complete and accurate Care Plan based on the individual resident needs for 4 residents of residents reviewed (Residents #2, #3, #4, and #5). The facility identified a census of 27 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a function limitation in range of motion (ROM) to both lower extremities (hip, knee, ankle, foot). She used a wheelchair for mobility and required the helper to do all of the effect for sitting to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/shower transfer. Resident #2's MDS related to restorative nursing programs indicated she didn't receive at least 15 minutes a day of restorative in the lookback period. Resident #2's Restorative Nursing Recommendations form dated 3/30/24 indicated she had an exercise and a ROM program for her upper and lower body once a day for 3 5 times a week. Resident #2's Care Plan failed to address her restorative program. 2. Resident #3's MDS assessment dated [DATE] identified they used a walker and a wheelchair for mobility. Resident #3's MDS related to restorative nursing programs indicated he didn't receive at least 15 minutes a day of restorative in the lookback period. Resident #3's Restorative Nursing Recommendations form dated 2/2/24 indicated reflected he had an ambulation, an upper, and a lower ROM program scheduled for once a day, 3 5 times a week. Resident #3's Care Plan failed to address his restorative program. 3. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS indicated Resident #4 didn't walk but used a manual wheelchair. The MDS included diagnoses of Parkinson's disease, anxiety and repeated falls. A Care Plan Focus initiated 6/23/22 listed activities of daily living (ADL). The Interventions included the following: a. Revised 2/13/25: Resident #4 used an electric wheelchair to move around the facility. He must keep his wheelchair speed at the lowest speed at all times. The staff must provide close supervision while he drove his wheelchair in hallways due to his fluctuated capabilities of his keeping his chair straight. The Communication - with Family/NOK/POA Note dated 2/5/25 at 12:15 PM indicated the Assistant Director of Nursing (ADON) visited with Resident #4's Power of Attorney (POA) regarding concerns with his electric wheelchair and how he couldn't always control the chair safely. Resident #4's POA explained he recently had his medications adjusted and asked for additional time to evaluate his safety. The ADON offered 2 weeks, and the POA agreed that would be a good time to evaluate him. A Rehab Communication form dated 2/6/25 signed by the medical doctor (MD) on 2/13/25 directed the following: a. Resident #4 must keep wheelchair speed at the lowest speed of 1 at all times. b. Staff provide close supervision while Resident #4 drove his wheelchair in the hallways due to his fluctuated capabilities of keeping the chair straight. The Health Status Note dated 2/7/25 at 10:52 PM identified the staff observed Resident #4 hit the medication cart and almost another resident while trying to move between the 2. When asked if he experienced stiffness, Resident #4 reported it worsened. The note ended to evaluate that Monday if Resident #4 kept his electric wheelchair. The Health Status Note dated 2/16/25 at 6:10 PM documented Resident #4 struck the wall at a slow speed while attempting to turn after dinner, he received no injuries. The Health Status Note dated 2/18/25 at 11:28 AM indicated Resident #4 nearly missed the wall while leaving breakfast before running into the table. The Health Status Note dated 2/18/25 at 12:48 PM reflected Resident #4 ran into the table in the living room in front of the nurses' station after lunch. The Health Status Note dated 2/19/25 at 9:59 PM identified Resident #4 ran over his phone and charger that evening. During an interview on 3/27/25 at 3:27 PM Resident #4 indicated his life changed drastically (his words) since the facility staff took his wheelchair away because he couldn't get around anymore. He had to wait for staff assistance which he didn't like. Resident #4 confirmed he hit walls at times but denied ever hitting residents or having caused injury to himself. The Care Plan lacked revision following the removal of Resident #4's electric wheelchair. 4. Resident #5's MDS assessment dated [DATE] identified she had a function limitation in ROM to 1 side of her upper extremities. Resident #5 used a walker and wheelchair for mobility. Resident #5 required the helper to do more than half the effort for shower/bathe self, lower body dressing, putting on/taking off footwear, and transferring in and out of the tub. Resident #5's MDS related to restorative nursing programs indicated she didn't receive at least 15 minutes a day of restorative in the lookback period. The Morse Fall Scale dated 11/8/24 reflected a score of 35, indicating Resident #5 had a moderate risk for falling. A Transfer Training form signed by a facility representative 1/8/25 indicated Resident #5 as on a standing task restorative program 3 5 times a week. Resident #5's Restorative Nursing Recommendations form dated 1/10/25 indicated she had an ambulation, upper, and lower ROM programs scheduled for 1 a day, 3 5 times a week. Resident #3's Care Plan failed to address her restorative program or risk for falls. According to an email 3/31/25 at 2:45 PM the Administrator confirmed the facility failed to address restorative programs on the Care Plans of two (2) residents (Residents #3 and #5). In addition, the facility failed to address Resident #5 as a fall risk on her Care Plan.

Based on observation, clinical record review and staff interview the facility failed to provide restorative services to residents as a means to maintain their highest level of functioning (Residents #2, #3, and #5). The facility identified a census of 27 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a function limitation in range of motion (ROM) to both lower extremities (hip, knee, ankle, foot). She used a wheelchair for mobility and required the helper to do all of the effect for sitting to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/shower transfer. Resident #2's MDS related to restorative nursing programs indicated she didn't receive at least 15 minutes a day of restorative in the lookback period. Resident #2's Restorative Nursing Recommendations form dated 3/30/24 indicated she had an exercise and a ROM program for her upper and lower body once a day for 3 5 times a week. Resident #2's Care Plan failed to address her restorative program. Resident #2's January 2025 Restorative Flow Record identified staff documented restorative for 1/9/25, 1/14/25, 1/20/25, 1/21/25, 1/23/25, 1/27/25, 1/28/25, and 1/30/25. The record lacked documentation for the other days of the month indicating Resident #2 received or staff offered her restorative exercises. Resident #2's February 2025 Restorative Flow Record identified staff documented restorative for 2/4/25, 2/6/25, 2/11/25, 2/13/25, 2/18/25, 2/27/25, and not applicable (NA) on 2/3/25. The record lacked documentation for the other days of the month indicating Resident #2 received or staff offered her restorative exercises. Resident #2's March 2025 Restorative Flow Record identified staff documented restorative for 3/4/25, 3/10/25, 3/22/25, and 3/25/25. The record lacked documentation for the other days of the month indicating Resident #2 received or staff offered her restorative exercises. 2. Resident #3's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #3 used a walker and a wheelchair for mobility. Resident #3's MDS related to restorative nursing programs indicated he didn't receive at least 15 minutes a day of restorative in the lookback period. Resident #3's Restorative Nursing Recommendations form dated 2/2/24 indicated reflected he had an ambulation, an upper, and a lower ROM program scheduled for once a day, 3 5 times a week. During an interview on 3/27/25 at 1:50 PM Resident #3 reported the staff performed his restorative exercises when they got to it and when they had enough staff. Resident #3's Care Plan failed to address his restorative program. Resident #3's January 2025 Restorative Flow Record identified staff documented restorative for 1/20/25 and 1/27/25. The record lacked documentation for the other days of the month indicating Resident #3 received or staff offered him restorative exercises. Resident #3's February 2025 identified staff documented restorative he received lower body ROM, refused ambulation, and upper body ROM on 2/3/25. The record lacked documentation for the other days of the month indicating Resident #3 received or staff offered him restorative exercises. Resident #3's March 2025 Restorative Flow Record identified staff documented restorative for 3/10/25, 3/22/25, and 3/23/25. The record lacked documentation for the other days of the month indicating Resident #3 received or staff offered him restorative exercises. 3. Resident #5's MDS assessment dated [DATE] identified she had a function limitation in ROM to 1 side of her upper extremities. Resident #5 used a walker and wheelchair for mobility. Resident #5 required the helper to do more than half the effort for shower/bathe self, lower body dressing, putting on/taking off footwear, and transferring in and out of the tub. Resident #5's MDS related to restorative nursing programs indicated she didn't receive at least 15 minutes a day of restorative in the lookback period. The Morse Fall Scale dated 11/8/24 reflected a score of 35, indicating Resident #5 had a moderate risk for falling. A Transfer Training form signed by a facility representative 1/8/25 indicated Resident #5 as on a standing task restorative program 3 5 times a week. Resident #5's Restorative Nursing Recommendations form dated 1/10/25 indicated she had an ambulation, upper, and lower ROM programs scheduled for 1 a day, 3 5 times a week. Resident #5's Care Plan failed to address her restorative program. Resident #5's January 2025 Restorative Flow Record identified staff documented restorative for 1/20/25 and 1/27/25. The record lacked documentation for the other days of the month indicating Resident #5 received or staff offered her restorative exercises. Resident #5's February 2025 identified staff documented restorative as she refused on 2/3/25. The record lacked documentation for the other days of the month indicating Resident #5 received or staff offered her restorative exercises. Resident #5's March 2025 Restorative Flow Record identified staff documented restorative for 3/22/25 and 3/23/25. The record lacked documentation for the other days of the month indicating Resident #5 received or staff offered her restorative exercises. During an interview on 3/27/25 at 11:00 AM Staff C, Certified Nursing Assistant (CNA), confirmed the facility sustained a restorative program pending the availability of the CNAs and/or if the facility had a staffing issue. Staff C confirmed the staff didn't always complete restorative due to the said staffing issues. During an interview on 3/27/25 at 12:53 PM the Assistant Director of Nursing (ADON) indicated sometimes the CNAs got pulled to work the floor and she couldn't say if they performed the restorative tasks/exercises as assigned.

Based on clinical record review, staff interview and facility policy review the facility staff failed to follow professional standards of practice as they allowed staff to compound (mix together) treatment ointments/creams prior to application for one (1) resident reviewed (Resident #1). The facilities identified a census of 27 residents. Findings include: Resident #1's March 2025 Treatment Administration Record (TAR) form included the following physician orders: a. Ordered 12/31/24: Clotrimazole Betamethasone cream 1 0.05% (for fungal skin infections of the skin) apply to affected areas topically (applied to the skin) every 12 hours as needed (PRN) for a rash until healed. b. Ordered 1/20/25: Nystatin powder (for fungal or yeast infections of the skin) apply topically to bilateral under breasts every 12 hours PRN for wound care. During an interview 3/27/25 at 10:03 AM Staff A, Licensed Practical Nurse (LPN), confirmed she compounded Resident #1's Nystatin and Clotrimazole treatment powder and cream on 2 separate occasions. The amount of each of the medications she compounded/mixed had been based on a guess/estimate of each medication. Staff A confirmed Staff B, LPN, redirected her related to compounding as an unacceptable standard of practice. Resident #1's clinical record lacked an order to compound the Nystatin and Clotrimazole treatments. According to an email dated 3/31/25 at 3:03 PM the Administrator confirmed compounding the 2 treatments didn't follow acceptable practice and/or out of the scope of practice for staff/nurses to have mixed creams/ointments and powders prior to application on residents.

Based on staff provide photograph, resident, and staff interviews, the facility failed to have a licensed nurse awake and capable of rendering nursing service for 1 day reviewed. On 1/22/24, residents and the facility saw observed Staff C, Licensed Practical Nurse (LPN), sleeping in the front lounge. The facility reported a census of 28 residents. Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A photo, (not time stamped) revealed Staff C as she sat reclined in a chair in the front lounge of the facility with her eyes closed. The view out the front picture window revealed it as dark outside. During an interview on 1/23/25 at 12:35 PM Resident #12 indicated she observed Staff C as she slept in the front lounge of the facility while on duty the evening prior. 2. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 1/23/25 at 12:35 PM Resident #9 indicated the previous evening (1/22/25) she attempted to speak with Staff C, Licensed Practical Nurse (LPN), as she slept in a recliner in the front lounge area of the facility. Resident #9 aroused Staff C and asked her if one (1) of her duties included the management of the dining area at which time the nurse stated, no, I am in charge of meds and that is all. At that point a staff member called Staff D, LPN/Assistant Director of Nursing (ADON), who arrived at the facility and escorted Staff C out of the building. According to a written statement dated 1/27/25 at 3:00 PM Staff E, Certified Nursing Assistant (CNA), confirmed she witnessed Staff C sleep while in work status. Review of a time card revealed Staff C worked 1/22/25 from 1:52 PM until 6:29 PM. An email from the Administrator on 1/31/25 at 10:16 AM reflected Staff C didn't take a scheduled break, as it depended on their workflow. The Administrator added it is not acceptable to sleep/mediate in the lounge area of the facility.

Based on clinical record reviews, staff interviews, the Iowa Nursing Board Chapter 6 regarding the Nursing Practice For Registered Nurses (RN)/Licensed Practical Nurses (LPN), the Iowa Department of Inspections, Appeals, and Licensing (DIAL) website page related to the RN/LPN Role & Scope, audio of a submitted video, and employee records, the facility failed to have competent staff to work at the facility. The facility had an LPN perform intravenous (IV) medications via a peripherally-inserted central catheter (a IV that provide medications into a large vein that can stay in for multiple months) for 1 of 1 residents reviewed (Resident #15) without an Iowa approved certification. In addition, the unqualified facility staff diagnosed a resident, they didn't know when to properly intervene when two (2) residents expressed erratic behaviors, and used an unsecure social media platform to communicate with clinic staff about resident's conditions. The facility reported a census of 28 residents. Findings include: 1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of wound infection and personal history of a pulmonary embolism (blood clot in the lung). Resident #15 received an antibiotic during the lookback period. Resident #15 received on admission and while a resident IV medications of antibiotics via a central line (PICC). Resident #15's April 2024 Medication Administration Record (MAR) included the following orders: a. Daptomycin (antibiotic) intravenous solution reconstituted (daptomycin) dated 4/13/24. Use 100 milliliters (ML) intravenously one time a day for 750 milligrams (MG) in sodium chloride (NaCl 0.9%) related to an infection following a procedure, other surgical site, initial encounter for 23 days. i. Signed as administered by Staff D, Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) on 4/26 and 4/27. b. Ertapenem Sodium (antibiotic) Injection Solution Reconstituted (Ertapenem Sodium) dated 4/12/24. Use 10 ml intravenously one time a day for skin and soft tissue infection for 23 days. i. Staff D signed on 4/26 and 4/27, indicating they administered the medication. c. Sodium Chloride (PF) Injection Solution 0.9 % (Sodium Chloride) dated 4/12/24. Use 3 ml intravenously every 12 hours for line care infuse 3 ml into venous catheter every 12 hours. i. Staff D signed the 8:00 PM record on 4/15, 4/20, 4/22, 4/26, and 4/29. ii. Staff D signed the 8:00 AM record on 4/26 and 4/27. The Health Status Note dated 5/6/24 at 1:13 PM written by Staff D indicated the provider order to remove the PICC line. The line got removed under sterile technique with pressure held for 3 minutes and a pressure bandage applied to the site. Resident #15 tolerated the removal without any complications. Staff D's Nursing Certificate of Completion dated 10/14/22 indicated they received 2 contact hours of PIV insertion and discontinuing in the Radiology Practice. The certificate indicated the facility designed the activity based on the Minnesota Board of Nursing rules for continuing education in which 1 contact hour equaled 60 minutes of learning activity. Staff D's Mayo Clinic Certificate of Completion dated 5/2/23 reflected they successfully completed the 2023 Nursing Competency: Central Lines. The certificate listed contact hours as not applicable (N/A). The bottom of the certification included the certificate denoting general completion only. The recipient is responsible for verifying that it meets requirements for practice-specific licensing or credentialing organizations. An email from the Administrator on 2/5/24 at 3:45 PM indicated Staff D learned from the Iowa Board of Nursing, she needed to take an IV class in Iowa or have approval from the Iowa Board of Nursing. The DIAL website page related to RN/LPN Role & Scope reviewed on 1/23/25 included a section labeled Expanded Intravenous Therapy Course for the LPN. Iowa law and Administrative Rule allows the LPN to perform IV therapy functions. The IV therapy course is currently offered by some Iowa Community College Continuing Education (CE) Department and other Board approved CE providers. The IV Therapy course content is based on the latest standards of practice. An approved Iowa Board of Nursing provider of nursing CE must offer the course. As of September 2021, the providers who have access to curriculum included 7 colleges in Iowa, and one specialty infusion service in Omaha, Nebraska. The list lacked any programs outside of the 8 listed, including the Mayo Clinic of Minnesota. 2. During an interview on 1/21/25 at 2:03 PM Staff A, Registered Nurse (RN), confirmed on an unknown date, she reported a change of condition for Resident #1 to Staff B, Licensed Practical Nurse (LPN). Staff B, who hadn't been in the building to perform an assessment, proceeded to diagnosis Resident # with a TIA (Transient Ischemic Attack/Stroke). Staff A confirmed the nurse's scope of practice failed to include the ability to self-diagnosis a resident. Staff A explained the task remained the responsibility of a physician. In addition, Staff A confirmed she knew Staff B used Snapchat (a non secured platform) to report condition changes and requests to the physician and/or their nurses. A video submitted by Staff A made on 10/3/24 at 12:49 PM of a conversation with Staff B and an unknown Board Member indicated Staff B admitted to diagnosing Resident #1 with a TIA because a physician indicated the resident would have another TIA within a couple days. The diagnosis upset Staff A because Staff B hadn't even been in the building. 3. According to an email 2/4/24 at 3:50 PM Staff B indicated the facility management staff/board failed to educate her on how to manage residents with erratic, psychological behaviors and/or suspected illegal drug use/abuse while they resided at the facility. 4. According to an undated and untimed typed statement from Staff D, LPN/ Assistant Director of Nursing (ADON), they confirmed Staff B informed her she used the platform Snap Chat (not secured) to communicate with hospital staff and receive physician orders for a resident housed at the facility at that time. According to an email dated 2/6/25 at 8:10 AM the Interim Administrator confirmed any social media as inappropriate communication with hospitals.

Based on schedule review, time card review, staff interview and facility policy review the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. In addition, the facility failed to designate a RN as the Director of Nursing. The facility reported a census of 28 residents. Findings include: 1. Review of staffing calendars provided by the facility from the conclusion of their re certification survey on 9/17/24 that identified staff concerns with inadequate RN staff hours. The facility failed to provide 8 hours of RN coverage on the following dates: 12/4/24, 11/1/24, 11/11/24, 11/18/24, 11/19/24, 11/25/24, 11/26/24, 10/7/24, 10/19/24, 9/1/24, 9/2/24, 9/8/24, 9/16/24, 9/23/24, 9/30/24, 8/10/24, 8/11/24, 8/14/24, 8/18/24, 8/19/24, 8/24/24, 8/31/24, 9/19/24, 9/20/24, 9/27/24 and 9/28/24. An email dated 1/29/25 at 5:08 PM indicated the administrative staff confirmed they failed to staff 8 hours of RN coverage per day. 2. A Quick Confirm License Verification Report form dated 12/13/23 at 5:51 PM revealed Staff B Single Contact License & Background Check form dated Staff B's, Licensed Practical Nurse (LPN)/Interim DON, employee file identified an active LPN license from 6/5/19 thru 10/15/24. The employee file revealed the facility hired Staff B on 12/13/23 as a part time charge nurse, then on 4/15/24 the facility promoted her to the Interim DON position. ON 10/10/24, the facility terminated Staff B for failure to follow the nursing standards of practice. During an interview on 1/30/25 at 2:10 PM Staff B confirmed during her employment at the facility the Provisional Administrator and the Board of Directors directed her to perform tasks outside of her scope of practice as an LPN, such as flushing PICC lines and confirmed the management staff failed to properly train her as a DON.

Based on interviews, employee records reviews, and clinical record reviews, the facility failed to provide an effective leadership to follow the required Federal Regulations and state rules of a long-term care nursing facility. The facility failed to follow the Federal Regulation to have a Registered Nurse (RN) designated as the Director of Nursing (DON). The provisional Administrator designated Staff B, Licensed Practical Nurse (LPN), as the Interim DON knowing she didn't have her RN. In addition, the facility failed to ensure proper chain of command regarding concerns with the DON. The facility reported a census of 28 residents. Findings include: 1. An undated Job Description form for an Administrator identified their supervisor as the Board of Directors. The description indicated the Position Authority and Accountability of the Administrator instructed the Administrator oversees the total operation of the facility. They initiate planning, organization, direction and control over financial and material resources in order to assure residents receive the highest possible quality of care. They function independently with extensive autonomy, within the constraints of policy, and procedure as established by the Board of Directors. The General Functions include the following: a. Assumed accountability for compliance with Federal, State and other regulations within scope of control and of which informed. b. Observed safety hazards and emergency situations, and reports to appropriate person or takes corrective action according to establish procedures, works safely without danger to self or others. c. Assured the facility operated according to established company policy and procedure In compliance with all applicable federal, state and local regulations. d. Interpreted company policies, procedures, job descriptions and other guidelines in order to meet the specific needs of the facility, while at the same time maintaining the intent and integrity of the company's practices. e. Implemented, enforced, and abided by the policies and procedures necessary to the operation of the facility. f. Assured that facility staff implemented programs and services to have met the health, nutritional, and psycho social care and activity needs of the residents. g. Serve as an in-house expert with regard to federal and state regulations and laws, company policy and procedure, and effective business and management practices. Staff B's, Licensed Practical Nurse (LPN)/Interim DON, Employee Performance Evaluation (Clinical) dated 4/15/24 reflected the Administrator moved her to the Interim DON until further notice. The evaluation listed Staff B's goals as a. Train as a Director of Nursing b. Learn Federal and State Guidelines c. Take management courses to better job performance The Director's/Supervisor's comments documented Staff B excelled quickly and had the potential to become the DON full time permanently if she obtained her Registered Nurse (RN). The unsigned Director of Nursing Orientation form dated 2020 reflected the Supervisory Responsibilities included rules/regulations regarding Federal and Iowa Code Chapter 58. 2. During an interview on 1/21/25 at 2:03 PM Staff A, Registered Nurse (RN), confirmed she drew up a dose of liquid Morphine/Roxanol with no witness present for Resident #1 (on a date unknown) and took it with her to the Administrator's office. Upon arrival and after a dispute Staff B, Licensed Practical Nurse (LPN) / Interim Director of Nursing, took the syringe from Staff A, went to Resident #1's room and gave her the medication without direct knowledge of the syringe contents. A forwarded email written by Staff A on 10/2/24 at 9:48 AM indicated at around 10:30 AM on 10/1/24 she went to the previous Administrator's office to ask where to locate the funeral home in a resident's chart. The Interim DON arrived at the facility around 11:00 AM and took over the care for the resident. Staff A felt uncomfortable giving the resident morphine due to her condition and the family's continuous denial to allow the resident to have the morphine. Staff B gave the resident the morphine and then called Staff A to her office. While in the office Staff A felt Staff B degraded her as a nurse, told her she wasn't a strong, confident nurse, and she question too much stuff. This resulted in Staff A feeling uncomfortable with talking with Staff B. A mp4 (video file) owned by Staff A created 10/3/24 included audio with a black screen of a conversation between her, Staff B, and an unnamed board member. During the meeting the unnamed board member and the Interim DON, Staff A received guidance to show her confidence in front of a family. The unnamed board member instructed Staff A to go to the clinical management regarding a clinical related concern. He said if the staff member had concerns with the Interim DON for something other than clinical such as she was smoking pot, then she could go to the Administrator for this. The Interim DON agreed that if there was an issue bigger than the clinical then she could go to the Administrator. During the meeting, the unnamed board member discussed the provisional Administrator would be leaving the facility soon due to not fulfilling her educational requirements. 3. According to an email dated 2/4/24 at 4:50 PM sent to Staff B regarding if the facility management staff/board educated her on how to manage residents with erratic, psychological behaviors and/or suspected illegal drug use/abuse while they resided at the facility. Staff B replied on 2/4/25 at 5:26 PM she had a total of 2.5 shifts of training from an actual nurse total for her time spent there, so her answer to the question was no. An Invoice dated 5/3/24 indicated the facility got billed for 5 hours of DON training.

Based on facility record review and staff interviews, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents. See F727 for additional information regarding RN coverage. The facility identified a census of 28 residents. Findings include: The Recertification, Complaint, Incident survey dated 7/17/24 included a deficiency for F727 regarding sufficient nursing staff. The facility's submitted Plan of Correction listed a correction date as 8/16/24. The plan indicated the facility failed to schedule a Registered Nurse for at least 8 consecutive hours a day for 10 days out of 90. The facility reviewed the RN coverage for the rest of the schedule with the Staffing Coordinator for lack of RN coverage. The Administrator created advertisements, with the local newspaper, flyers in local businesses, posted to social media, and raised the starting wage for an RN. The facility requested RN coverage through staffing agency until the RN/ADON could start employment. The monitoring section indicated the Administrator, DON, or Staffing Coordinator would monitor the daily schedule to ensure the facility had 8 hours of RN coverage. After 8/16/24 the facility would use an audit tool weekly for 8 weeks. The DON applied for an RN waiver as of 8/14/24. The QA / Quality Assurance Performance Improvement (QAPI) meeting minutes dated 8/16/24 listed the facility census as 30 residents with 51 staff. The staffing section reflected the facility had 51 staff and they had flyers hung up to recruit. The August 2024 Quality Improvement Plan of Action forms lacked a plan regarding nursing staff. The QA / QAPI meeting minutes dated 9/9/24 indicated the facility's census as 31 residents with 55 staff. The section labeled Old Business reflected a review of the previous deficiencies progress. The documentation lacked documentation related to the nursing staff.

Based on clinical record review, resident interview, staff statements and review of Resident Rights, the facility staff failed to treat one (1) resident with dignity and respect while speaking with them (Resident #9). The facility reported a census of 28 residents. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 1/23/25 at 12:35 PM Resident #9 indicated the previous evening (1/22/25) she attempted to speak with Staff C, Licensed Practical Nurse (LPN), as she slept in a recliner in the front lounge area of the facility. Resident #9 aroused Staff C and asked her if one (1) of her duties included the management of the dining area at which time the nurse stated, no, I am in charge of meds and that is all. Resident #9 described the staff member's tone of voice as not pleasant and the failure of staff to help all Residents eat in the dining area as no big deal which pissed her off. At that point a staff member called Staff D, LPN/Assistant Director of Nursing (ADON), who arrived at the facility and escorted Staff C out of the building. According to a written statement dated 1/27/25 at 3:00 PM Staff E, Certified Nursing Assistant (CNA), confirmed she witnessed Staff C as she failed to treat an unknown resident with dignity and respect on 1/22/25 as she rolled her eyes at the resident when she requested pain medication. Review of the undated facility's Residents' Rights form instructed each resident had the right to be treated with respect and dignity.

Based on clinical record review, staff interview and facility policy review the facility staff failed to follow professional standards of practice for 1 resident reviewed (Resident #1). Staff A, Registered Nurse (RN), drew up liquid morphine, Roxanol (pain medication), without a witness in a 1 milliliter (ml) syringe. Staff B, the Interim Director of Nursing (DON)/Licensed Practical Nurse (LPN), took the syringe from Staff A and administered it to Resident #1. The facility identified a census of 28 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated they received an opioid medication during the lookback period. During an interview on 1/21/25 at 2:03 PM Staff A, Registered Nurse (RN), confirmed she drew up a dose of liquid Morphine/Roxanol with no witness present and for Resident #1 (on a date unknown) and took it with her to the Administrator's office. Upon arrival and after a dispute Staff B, Licensed Practical Nurse (LPN) / Interim DON, took the syringe from Staff A, went to Resident #1's room and administered the medication without direct knowledge of the syringe contents. During an interview on 1/30/24 at 2:10 PM Staff B confirmed she administered the liquid Morphine/Roxanol as stated above. A Controlled Substances policy dated 2024 directed the facility staff reconciled (review) controlled substances upon receipt, administration, disposition (disposal), and at the end of each shift.

Based on record review, facility provided education, policy review, staff and Pharmacist interviews the facility failed to provide 1 of 6 residents (Resident #1) their prescribed medications. After Resident #1 received another resident's medications, she went to the local hospital. Due to Resident #1's level of sedation, the hospital admitted her. The facility reported a census of 31 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 13, indicating intact cognition. The MDS lacked documentation of neurological, psychiatric, or mood disorders. An untitled statement, dated 4/11/24 reflected on 4/11/24, Resident #1 received another resident's medications consisting of: a. Benztropine mesylate (anticholinergic, helps decrease muscle stiffness and improves walking ability in people with Parkinson's disease) 0.5 milligrams (mg) b. Atorvastatin 40 mg (blocks an enzyme in the body needed to make cholesterol) c. Clozapine 300 mg (antipsychotic, change activity of substances in the brain) d. Cranberry 500 mg (intended to help prevent urinary tract infections) e. Flomax 0.4 mg (helps relax muscles in the prostate and bladder so urine can flow easily) f. Senokot 8.6 50 (increases activity in the intestines to cause a bowel movement) g. Sertraline 150 mg (increases the amounts of serotonin, a natural substance in the brain that helps maintain mental balance) Resident #1, Medication Review Report dated 4/8/24 indicated he didn't take the following medications: a. Benztropine mesylate 0.5 mg b. Atorvastatin 40 mg c. Clozapine 300 mg d. Cranberry 500 mg g. Sertraline 150 mg The Health Status Note dated 4/11/24 at 10:18 PM reflected Staff H, Licensed Practical Nurse (LPN), received a call related to Resident #1 sleeping in his chair since supper and the staff had hard time waking him. Staff G, Registered Nurse (RN) stated Resident #1 kept asking for his supper time medications before supper. Staff G gave Resident #1 the wrong medications, but he remained stable at that time. Staff H notified the on-call doctor that Resident #1 received the wrong medication. The on-call doctor instructed to monitor him, if his oxygen and vitals got worse send him to the emergency room (ER). Record review of Resident #1 Progress Note dated 4/12/24 a 4:24 AM documented: Resident #1 is being monitored due to being given the wrong medications, routine checks completed with vital signs and between checks resident had emesis (thrown up) and has also not urinated. Record review of Resident #1 Progress Note dated 4/12/24 at 9:28 AM documented his respirations (breaths) have increased to 36 per minute (normal 12 20 breaths per minute). Call placed to on call doctor to get ok to transfer. Record review of a Notice of Resident Transfer/Discharge for Resident #1 dated 4/12/24 documented he went to the hospital because he received the wrong medications. Record review of Resident #1 MDS log in his Electronic Health Record (EHR) informed he discharged on [DATE] and returned on 4/14/24. Record review of Resident #1 Discharge Summary from the local hospital dated 4/14/24 documented discharge diagnoses of: a. Acute COVID infection b. Inadvertent dose of antipsychotic medication, patient given dosing error causing a fair about of sedation An emailed statement completed by Staff E, Certified Nurse Aide (CNA), dated 4/15/24 at 3:16 PM reflected on 4/11/24, the facility had an agency nurse that night. Around 4:30 PM Resident #1 went to the nurses' station and asked for night time medications. At 4:45 PM, Resident #1 returned to the nurses' station, the Staff E looked up and saw Resident #1 receive more medications. When they questioned the nurse why he received more medication, as they thought he only got one thing of medication at night, the nurse responded he hesitated to give him the medication. The nurse got the Staff E at 5:15 PM that evening and went to Resident #1's room. They found him asleep in his wheelchair. Staff E told the nurse this was uncommon for Resident #1 because he hadn't eaten dinner yet. He usually ate dinner, went to his room, then got ready for bed. When they attempted to wake up Resident #1, he wouldn't wake up. The nurse didn't do anything about it, until 9:00 PM. At that time, he called the Director of Nursing (DON). Staff E expressed the nurse should have called sooner and double checked who he gave medication to. An emailed statement written by Staff B, Certified Medication Aide (CMA), on 4/15/24 at 3:49 PM identified when Staff G got to the facility, he asked the aide what time they give the evening and bedtime medications. He continued asking the aides who each resident was and where he could find them. Before 5:00 PM, he started giving medications in the lobby area and gave Resident #1 his Tylenol, he normally received at supper. Staff B explained she worked with 2 other staff who stopped to check the monitor, when they saw Staff G give Resident #1 a cup full of medications and asked him his name. He told him, here take these, they are your bedtime medications. Staff E asked Staff G what he gave Resident #1 as he only received 1 medication at supper. Staff E asked Staff B how many medications he received at supper, Staff B reported Resident #1 usually got 1 medication not a whole cup full. Staff B stopped Staff E and took her to Resident #1's room, when they arrived he asked if Resident #1 acted normal for him being that zonked out. Staff E got Staff B and the other staff, together they went into Resident #1's room. After looking at Resident #1, then went and told Staff G that wasn't normal for him. Staff E questioned Staff G if he gave Resident #1 his correct medications, he responded that he did give him the correct medications. He questioned why Resident #1 wanted his bedtime medications so early. Resident #1 appeared in a deep sleep, snoring, and he didn't respond to the sternum (breast bone) stimulation (deep pressure rub). The staff carried him from his chair to his recliner to prevent him from falling on the floor. The CNAs had concerns Resident #1 didn't receive the correct medications, so they reached out to the on-call nurse. Before the nurse arrived, Staff G went to Staff B and Staff E remarking that he didn't know if he gave Resident #1 the correct medications. He explained he just used the last name, not realizing the facility had 2 residents with that name. They had different first names but the first name of one matched the last name of the other. A handwritten statement by Staff D, CNA, on 4/15/24 indicated Resident #1 went to the desk to get his evening pill. Then around 5:00 PM, Staff G asked who was Resident #1. Staff D told Staff G, Resident #1 was in his room. When Staff E said, he already gave Resident #1 his medications at the nursing station. She questioned if he was looking for a different resident with the same last name as Resident #1's first name. Staff G reported he didn't give him his medications because he had them. Staff E reiterated that she saw him give Resident #1 medications. Staff G left and gave Resident #1 his medications. Then he, Resident #1, became sleepy. An undated handwritten statement by Staff F, LPN, identified on 4/11/24, she followed the agency nurse who gave Resident #1 the wrong medications. When she started working she did huddle with the CNAs and immediately went to Resident #1's vital signs. Resident #1 had increased respirations, so they check his vitals every 15-30 minutes, making sure to check his respirations and pulse every time. Staff F reported she checked the depth of his breaths and didn't find him having shallow breaths. Around 2:30 AM Resident #1's respiratory rate returned to his normal limits, so she decreased checking on him to every 30 minutes to an hour. Staff F checked his blood pressure that night 2 times with a result of 115/62 (average person - 120/80), in addition she checked his oxygen level which never dropped below 91% (average person greater than 90%). Around 4:00 AM as the staff changed him, they called Staff F into his room as he vomited. The staff cleaned him and noted his respirations increased. As Staff F called Resident #1's name, he opened his eyes but didn't verbally respond. When Staff F checked his vitals, everything remained stable except his elevated respiratory rate. Staff F believed the repositioning may have cause the increased respiratory rate. Staff F received report from Staff G around 11:30 PM that night. He gave a vague report and bounced around a lot. When talking about what happened, he stated Resident #1 repeated his name multiple times and asked multiple times for his medication. He could receive it as early as 3:00 PM and he previously asked for Tylenol, which he didn't usually do. Staff F checked the medication cart and found Resident #1's medications given. Staff G left after he gave report. During an interview on 7/15/24 at 12:50 PM Resident #1's Pharmacist explained she found Resident #1 received clozapine concerning as it is an antipsychotic medication and sedation would be concerning. She added based on how much he received (300 mg) it would take its full effect in two (2) hours to get to the peaks and every 12 hours it would go down and be out of his system in 3 days. She reported every person is a little different with how their body processes medications and because he used a lot of those medications, it shouldn't cause many issues. During an interview on 7/16/24 at 4:20 PM the DON reported the on-call nurse came in and assessed Resident #1 on 4/11/24. She seen him tired, but it was also bedtime. She added she came to work the morning of 4/12/24, the night shift reported nothing changed with him throughout the night as he slept, but she chose to send him out that morning as he didn't act like his normal self and she felt he needed evaluated. During an interview on 7/17/24 at 11:39 AM the Administrator confirmed she expected every resident get the right medications every day and errors like that shouldn't happen. The undated document titled, Medication Orders and Potential Errors provided by the facility to all staff after Resident #1's medication error on 4/11/24 instructed nurses on how to conduct a proper medication pass and to report a concern without fear. The Medication and Treatment Administration policy instructed all medications and treatments must have orders to administer. Make sure to complete the five (5) rights when administering medications: a. Right medication b. Right dose c. Right time d. Right route e. Right resident

Based on clinical record review, staff and provider interviews, facility investigation records, and policy review the facility failed to implement root cause analysis and provide interventions for 1 of 3 residents reviewed (Resident #8) to prevent future falls. Resident #8 had a Fall on [DATE] that resulted in admission to the hospital for a subdural hematoma (brain bleed) that may have been an injury caused from the fall or the reason the fall occurred, Resident #8 passed away on [DATE]. The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) for Resident #8 dated, [DATE] revealed she was rarely/never understood and had short-term and long-term memory problems. Resident #8 needed extensive assistance of one staff for bed mobility, transfers, walking in her room, locomotion on and off the unit, dressing, and toilet use. It documented she takes a daily antidepressant and anticoagulant. It listed diagnoses of atrial fibrillation (A-Fib), chronic diastolic congestive heart failure (CHF), dementia, depression, anxiety, and hypertension. Record review of Resident #8 Care Plan on [DATE] last revised on [DATE] instructed staff - Resident #8 turns her pressure alarm off when in bed, so she has a motion alarm to alert staff when she is up by herself. Record review of an untitled document, completed by an unknown employee, dated [DATE] of the facilities investigation for Resident #8 Fall revealed the following: a. On [DATE] at 2040 a call was received and was notified of Resident #8 fell and went unresponsive for a few minutes but slowly started to respond. Resident #8 sustained a laceration to the back of her head, and is going to the hospital. b. On [DATE] the investigation into the fall was completed. A phone discussion with Resident #8's Physician documented Resident #8 sustained a brain bleed and the Physician was unable to tell if the bleed was there first and caused the fall or if the fall caused the bleed. c. On [DATE] Resident #8 passed away. Record review of a Witness Statement dated [DATE] by Staff B, Certified Nurses Aide (CNA) revealed the following: On [DATE] at around 9:10 PM Staff B was directed to assist Resident #8 to bed by Staff C, CNA. Staff B took Resident #8 to the restroom. I assisted her to bed, ensured her call light was clipped to her so it would go off, lowered the bed, and put her walker by the bed. I left the door open and the bathroom light on. She put another resident to bed and then heard a loud thump and found Resident #8 on the floor by the bathroom with blood coming from her head. Record review of a Witness Statement dated [DATE] by Staff C, CNA revealed the following: On [DATE] at about 8:45 PM she heard a loud noise and there was no alarm going off, she went to check on Resident #8 and found her on the floor. She then documented after helping with the fall she noticed Resident #8's alarm was not on. Record review of the local dispatch log to the facility, titled Call Summary Report dated [DATE] at 9:36 PM documented the following: a. [DATE] at 8:36 PM a call was received for a [AGE] year old who fell and is unresponsive at this time. b. [DATE] at 8:37 PM Unit is responding c. [DATE] at 8:41 PM Unit is at the scene. Record review of a local Emergency Medical Service (EMS) report for Resident #8 dated [DATE] documented the following: Upon arrival Resident #8 was sitting on the floor, alert but confused, has bruising around her nose, and a laceration to the back of her head that was not bleeding, her heart rate and respirations were normal. Her blood pressure was elevated at ,d+[DATE] and she had no signs of a coma per the Glasgow Coma Score of 15 that was completed. Record review of Resident #8 History and Physical, Final Report completed by the local hospital on [DATE] informed the following: Resident #8 had a laceration on the back of her head, she was taken back to have a CT scan and discovered to have a subarachnoid hemorrhage, small, and a subdural hematoma, about 6.5 millimeters (mm) in diameter to the left front of her head. Discussed with another provider Resident #8 is not a surgical candidate, and there is a good chance that if they can reverse her blood thinner medication, this will come around. Anticipate she will probably survive this, but it is certainly a precarious situation, and the family is aware of that. Plan is to send her back to the nursing facility in 4 days. Record review of Resident #8 Progress Note, Final Report completed by the local hospital on [DATE] informed the following: Early in the morning Resident #8 became comatose and continues to be comatose. She does not respond to painful stimulus or anything basically. Record review of Resident #8 Certificate of Death filed on [DATE] documented she died on [DATE] at 3:57 AM at the local hospital. The immediate cause of death as a subdural hematoma due to or as a consequence of fall and atrial fibrillation on anticoagulation. During an interview on [DATE] at 12:10 PM with the facilities prior Director of Nursing, Staff D, Registered Nurse (RN) revealed she worked at the facility for a couple months and completed Resident #8 [DATE] fall investigation. She informed Resident #8 would get up routinely when she wasn't supposed to since she needed assistance. She informed the fall that took place on [DATE] there should have been an alarm in place and she can't recall if it was not working or if Resident #8 turned the alarm off. She is unsteady when she would get up, so the alarm was in place to alert staff when she was up. She did not have many falls, usually she would be out in the lobby, she would stand up and we would assist. I talked to Resident #8's Physician and he could not tell if the brain bleed was prior to the fall or if the fall caused it. During an interview on [DATE] at 11:05 with Resident #8's Physician revealed, Resident #8 was was on a blood thinner medication. When she got the the emergency room (ER) her Computerized Tomography (CT) scan showed a Subdural Hematoma (brain bleed), and called the neurosurgeon and determined Resident #8 was too old to have surgery. Resident #8 went unconscious a couple hours later then passed a couple hours after that. He revealed the Subdural Hematoma could have contributed to why the fall occurred, but you would never know unless a CT scan was completed right before the fall. It could have been there prior to the fall, but when you hear Resident #8 hit her head, that's probably some of the cause of it too. Record review of an undated policy titled Falls Policy instructed staff each fall incident is followed up with an action plan determined by the details of the fall. The residents Care Plan is to be updated in the computer, with an intervention related to the fall. Falls and near falls are monitored on a continuous basis and tracked monthly as a number of falls under Risk Management in the computer.