Every finding on record at Timely Mission Nursing Home

Based on observation, clinical record review, staff and resident interview, the facility failed to ensure the provision of occupation and physical services for 1 of 3 resident reviewed for therapy services upon admit. (Resident #1). The facility identified a census of 33 residents.Findings include:Resident #1s Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition with decision making abilities, was able to understand and was understood by others. The resident required staff dependence with mobility and transfers and the use of a walker or wheelchair. The MDS included diagnoses of Parkinson Disease, (a progressive brain disorder that affects movement, primarily caused by the death of brain cells), fracture of left ankle, weakness and low back pain.The Care Plan initiate dated 10/13/25, indicated Resident #1 had a limited physical mobility related to weakness, and Parkinson Disease. Interventions included weight bearing (supporting body weight), assistance of 2 staff to walk, uses a front wheeled walker for ambulation, and dependent on 1 staff for locomotion in the wheelchair.The Inpatient Patient Summary Final Report dated 10/13/25 at 12:57 PM, documented consults for occupational therapy evaluation and treatment and physical therapy evaluation and treatment, activity as tolerated, Cam boot (an immobilizer to protect foot and ankle injuries) to lower left extremity with weight bearing as tolerated. Uses a front wheeled walker and wheelchair for mobility and a gait belt.Resident #1's clinical record lacked documentation the resident received physical and occupational therapy evaluation and treatment on 10/13/25.The Clinical Referral Note dated 11/10/25 signed by the physician, documented left ankle fracture that is healing, ordered physical and occupational therapy.The Physical Therapy Evaluation and Plan of Treatment dated 11/14/25, documented, patient was referred to physical therapy for evaluation and treatment. Following a fall with the left ankle fracture, patient presents with decreased strength and impaired functional mobility. Patient would like to be able to walk by herself with her walker. Patient reports pain in her left ankle at night and when moves it wrong or stand on it.The Occupational Therapy Evaluation and Plan of Treatment dated 11/14/25, documented, patient was referred to occupational therapy upon admission to this nursing facility following a fall resulting in an ankle fracture. Patient main concern is remaining safe. Patient presents with impairments in balance, mobility, strength, planning, problem solving and interpersonal interactions resulting in limitations and/or participation restrictions in the areas of cooking, self care, mobility and light housekeeping. Observation on 11/13/25 at 10:30 AM, Resident #1 sitting in recliner with feet elevated on a pillow and left foot in a cam boot.Interview on 11/13/25 at 10:30 AM, Resident #1, confirmed they did not receive physical or occupational therapies on admission to the facility. On 11/13/25 at 3:00 PM, Resident #1 family confirmed that no physical or occupational therapies were received when Resident #1 was admitted to the facility on [DATE]. On 11/17/25 at 11:00 AM, the facility Director of Nursing (DON), confirmed Resident #1's clinical record lacked any documentation of physical and occupational therapies being completed on day of admit and that the expectation is for orders to be followed and residents to receive physical and occupational therapies as ordered. On 11/17/25 at 1:10 PM, the facility Administrator stated that the expectation of the staff are to follow the physician orders for physical and occupational therapies, and that it is the responsibility of the facility to make sure that residents receive the ordered therapies.

Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual the facility failed to ensure 2 of 2 residents (Resident #20 and #19) Significant Change Minimum Data Set (MDS) assessments were completed within 14 days of identifying a significant change occurred. The facility reported a census of 30 residents. Findings include: 1. Record review of Resident #20 revealed a Physicians Order documented the resident was discharged from hospice on 11/22/23. Record review of Resident #20 revealed that a Significant Change MDS was not completed when the resident had been discharged from hospice care. During an interview on 7/30/24 at 1:21 PM, the MDS Coordinator reported when a resident goes on or off hospice she has not done anything for MDS completion for it. She reports the facility follows the RAI Manual. During an interview on 7/30/24 at 2:08 PM, the Director of Nursing reports the facility does not have a policy for MDS. She reports the facility follows the RAI Manual. Review of the current RAI Manual dated 10/2023 on page 2-25 instructed the following: A Significant Change MDS is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Significant Change MDS date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A Significant Change MDS must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing. 46875 2. Resident #19's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of clinical census revealed Resident #19 was admitted to hospice level of care on 11/30/23. Review of the clinical record revealed the facility did not complete a significant change MDS within 14 days of Resident #19 being admitted to hospice services. The facility completed an annual assessment with an ARD date of 12/28/23 on 1/11/24.

Based on clinical record review, staff interviews, resident interview and policy review the facility failed to assure that a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to promote healing of two stage two pressure ulcers for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 30 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging consideration include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #1's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS identified Resident #1 required partial/moderate assistance with sitting up and lying down in bed. The MDS identified Resident #1 was independent with transfers and ambulation150 feet using a walker. The MDS revealed Resident #1 was occasionally incontinent of bowel and bladder. The MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus, and anxiety disorder. The MDS indicated Resident #1 was not at risk for developing pressure ulcers. The MDS documented Resident #1 had a pressure reducing device for the bed. An Incident Report (IR) titled New Pressure Ulcer dated 7/9/24 documented Resident #1 complained of pain to the right buttocks. Upon examination the right inner gluteal was noted to have an open area that measured 0.5 cm (centimeters) x 0.3 cm. No bleeding noted to the open area. The IR revealed Resident #1 sat in her recliner a lot during the day and frequently did not get the right buttocks cleaned after having a bowel movement. The IR lacked documentation of a new intervention to prevent further skin breakdown/pressure areas. The Care Plan revised 7/29/24 revealed Resident #1 had a pressure ulcer on her buttocks related to not wanting to reposition. The Care Plan directed the following: a. Administer treatments as order and monitor effectiveness. b. Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvements and declines to the Physician. c. Encourage Resident #1 to reposition. d. Monitor during AM/HS cares dressing to ensure it is intact and adhering. Report loose dressing to the charge nurse. e. Monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size and stage. Resident #1's Care Plan lacked information regarding pressure reducing devices to the bed or chair related to immobility and nutritional supplements to aid in wound healing. Review of Resident #1's Kardex lacked information and direction regarding skin and pressure reduction interventions such as chair cushion, repositioning, and encouraging Resident #1 to get up and walk. The Braden Scale assessments (tool used to evaluate risk of development of a pressure ulcer) documented a score of 10-12 indicated that the resident had a high risk for pressure sore development, 13-14 meant the resident had a moderate risk, and 15-18 meant the resident had a risk for pressure ulcer development. The review of the Braden Scale assessments completed for Resident #1 from 4/2024 to 7/2024 documented scores on the following dates: 1. 7/7/24= 21 2. 4/19/24=21 Resident #1's clinical records lacked a Braden Scale assessment after the development of the stage 2 pressure ulcer. A facility form titled Wound-Weekly Observation Tool dated 7/10/24 documented Resident #1 had a stage two pressure ulcer to the right inner gluteal. The observation tool documented the area was cleansed with normal saline and a barrier cream applied. The form revealed the facility was waiting for further orders from the Physician. A facility form titled Progress Notes/Communication with the Physician dated 7/10/24 documented Resident #1 had an open area to the right inner gluteal measuring 0.5 cm x 0.3 cm. The area was cleaned and barrier cream applied. The note revealed Resident #1 sat on a cushion while in her recliner. The note documented Resident #1 frequently did not clean herself well following having a bowel movement and sat in her recliner for long periods of time to play her tablet. The Physician responded that the treatment would be for Resident #1 not to sit for long periods of time but that won't happen. The Physician did not provide/direct a treatment order for the pressure wound to the right buttocks. A Progress Note dated 7/10/24 at 10:56 AM documented fax received from the Physician regarding open area to right inner gluteal with no new orders. A Progress Note dated 7/11/24 at 1:31 AM documented Resident #1 continued to complain of discomfort to the right inner gluteal. The pressure area had redness and barrier cream applied. A Progress Note titled Skin/Wound note dated 7/11/24 at 5:17 PM documented a stage two pressure ulcer remained to the right buttock. Resident #1 reported discomfort to the area if she sat the wrong way. The note revealed the pressure ulcer was cleansed, Vaseline applied and a padded foam dressing was applied. Resident #1 reported the dressing helped a little bit. The note documented Resident #1 was educated if the dressing falls off during toileting to use the call light so the area could be redressed. The clinical record lacked a Physician order for the treatment of Vaseline and foam dressing to the pressure ulcer on the right buttocks. A Progress Note titled Nutrition/Dietary note dated 7/12/24 at 11:57 AM documented Resident #1 had a stage two pressure wound to the buttocks. The note documented Resident #1 does eat well with meals but may benefit from Arginaid (nutritional supplement used for wound healing) to assist with wound healing. Review of the clinical record revealed the dietary recommendation for Arginaid was not communicated to the Physician and was not started. A Progress Note dated 7/17/24 at 6:34 AM documented a fax was sent to the Physician requesting a treatment order for Resident #1's pressure area to the right buttocks as the area had not improved. A Progress Note dated 7/17/24 at 1:23 PM documented a fax was received with new order to apply sorbact dressing (non-absorbent wound dressing) to the pressure ulcer to right upper buttocks and to change the dressing every two days and as needed for non-adherence. A Progress Note dated 7/20/24 at 3:53 PM documented Resident #1 had her dressing changed to the right upper buttocks due to complaints of pain. The note revealed Resident #1 had a new stage two pressure ulcer to the lower coccyx and a dressing was applied to the new area. The note indicated Resident #1 had relief with the new dressing change. The progress note lacked documentation regarding the size of the new pressure ulcer and characteristics of the wound. A facility form titled Wound-Weekly observation tool dated 7/20/24 documented Resident #1 had a stage two pressure ulcer to the lower left coccyx. The tool revealed the wound was dry without any drainage. The assessment lacked documentation regarding the measurements/size of the wound, wound bed tissue, odor, periwound tissue and signs/symptoms of inflammation or infection. A Progress Note dated 7/20/24 at 3:54 PM documented a fax was sent to the Physician reporting a new stage two pressure ulcer to the lower coccyx on the left side. The note documented the facility requested a treatment order for sorbact dressing and to cover the area with a foam dressing. The Clinical Record lacked documentation Resident #1's family/resident representative was notified of the new pressure area from 7/20/24. A Progress Note dated 7/22/24 at 9:28 AM documented a fax was received with a new treatment order to apply sorbact dressing to the left side of coccyx and to change the dressing every 7 days and as needed if soiled, saturated, or falls off prior to schedule dressing change. The clinical record lacked documentation Resident #1's family/resident representative was notified of the new treatment orders. A Progress Note dated 7/22/24 at 5:33 PM documented Resident #1 continued to have an open area to coccyx and a new pad was placed in Resident #1's recliner. The note documented staff continued to encourage repositioning and walking in the hallway. Review of facility forms titled Wound-Weekly Observation Tool for Resident #1's pressure ulcer to the right buttocks revealed the pressure ulcer was measured on 7/10/24. The clinical record and wound-weekly observations tools lacked wound measurements after 7/10/24. The clinical record and the facility forms titled Wound-Weekly Observation Tool for Resident #1's pressure ulcer to the left side of the coccyx lacked wound measurements from 7/20/24 to 7/31/24. On 7/29/24 at 1:21 PM, Resident #1 reported she had a sore on her bottom and it was painful. Resident #1 reported she does not like the cushion in her recliner. She stated the cushion makes the sore on her bottom hurt more. On 7/30/24 at 10:40, Staff A, Licensed Practical Nurse (LPN) reported wounds are measured on bath days and documented either on the wound data collection form or in the skin/wound notes. On 7/30/24 at 10:30 AM, the Director of Nursing (DON) reported an Incident Report was not completed for the pressure ulcer on 7/20/24. On 7/30/24 at 12:50 PM, the DON reported Resident #1 had a chair cushion in place at the time the pressure ulcer to the right buttocks was identified. The DON reported the new skin interventions were for the staff to encourage Resident #1 to get up and walk and encourage Resident #1 to walk to breakfast. The DON reported a barrier cream was applied to the pressure area when it was first identified. The DON reported when the second pressure ulcer developed on 7/20/24 she gave Resident #1 a new air cushion but she did not think she documented it. The DON reported she would expect a physician order to be obtained for any wound treatments. On 7/30/24 at 1:28 PM, the DON acknowledged and verified she could not locate any wound measurements for the pressure ulcer to the right buttocks after 7/10/24. The DON also verified she could not locate any wound measurements for the pressure ulcer to the left lower coccyx. The DON stated she would expect pressure ulcers to be measured upon identification and weekly thereafter. The DON reported she would expect the Physician to be notified of any changes in the pressure ulcer. The DON acknowledged and verified she could not locate any family notification regarding the pressure ulcer to the left lower coccyx and the treatment order. The DON reported she had missed the email from the dietician regarding the recommendation for Arginaid and verified the recommendations were not followed up on. On 7/31/24 at 8:00 AM, Staff A, LPN reported Resident #1 does not come out for breakfast. She stated she had worked at the facility for 5 years and has not seen Resident #1 out at breakfast. She stated she eats breakfast in her room and comes out to the dining room for lunch and supper. On 7/31/24 at 9:24 AM, Staff B, Certified Nursing Assistant (CNA) stated she did not recall anything being passed in report about the need to encourage Resident #1 to get up and walk more or reposition more due to pressure ulcers. A facility policy titled Skin Integrity date 4/20 documented the policy was to ensure the resident does not develop pressure ulcers/injuries unless clinically unavoidable and that the facility provide care and services consistent with professional standards. The policy documented the facility must: *Identify whether the resident is at risk for developing or has a pressure ulcer/injury upon admission and thereafter *Evaluate resident specific risk factor and changes in the resident ' s condition that may impact the development and/or healing of the pressure ulcer/injury *Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors and if pressure ulcer/injury present, provide treatment to heal it and prevent the development of additional pressure ulcers/injuries. The policy further documented clinicians will utilize a standardized pressure ulcer/injury risk assessment tool (i.e.braden) to assess a resident ' s pressure ulcer/injury risks: -Upon admission then, -Weekly for the first four weeks after admission, then -Monthly and -Whenever there is a change in resident ' s condition Clinicians are responsible for evaluating each existing and potential risk factor for developing a pressure injury and determining the resident ' s overall risk. It is acceptable if the clinician ' s assessment places the resident at a higher risk level than the overall score of the assessment tool based on assessment factors that are not captured by the tool. The policy documented all goals and interventions to prevent pressure ulcer/injury development as well as treatment to promote healing, prevent infection and the development of new ulcers/injuries will be included in the resident ' s comprehensive care plan developed by the interdisciplinary team following comprehensive assessment. The policy directed with each dressing change or at least weekly (and more often when indicated by wound complication or changes in wound characteristics), an evaluation of the pressure ulcer/injury should be documented. At a minimum, documentation should include the date observed and: -Location and staging -Size, depth, and the presence, location and extent of any undermining or tunneling/sinus tract -Exudate, if present: type, color, odor, and approximate amount -Pain, if present: nature and frequency -Wound bed: color and type of tissue/character including evidence of healing, or necrosis and -Description of wound edges and surrounding tissue as appropriate. -If a pressure ulcer/injury failed to show some evidence of progress toward healing within 2-4 weeks, the area and the resident ' s overall clinical condition should be reassessed. Re-evaluation of the treatment plan included determining whether to continue or modify the current interventions. The resident ' s physician must be notified/consulted regarding the status of the pressure ulcer/injury and prescribe treatment going forward, if appropriate. -Residents will be assessed for evidence of pain and appropriate measures and modifications be provided to relieve and/or diminish pain.

Based on record review and staff interview, the facility failed to notify the Long Term Care (LTC) Ombudsman of a resident transfer to the hospital for 1 of 2 residents reviewed for hospitalization s (Resident #3). The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a re-entry date of 4/12/23 from an acute visit to the hospital. The MDS further documented a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment and the resident required extensive physical assistance with bed mobility, toilet use and transfers. Review of the census in the Electronic Health Record (EHR) for Resident #3 revealed the resident transferred to the hospital 4/8/23 and returned to the facility following the hospitalization [DATE]. Review of Progress Notes dated 4/12/23 revealed Resident #3 returned to the facility following a hospital stay for a left femur (thigh bone) repair. Review of the facility's Notice of Transfer Form to the LTC Ombudsman for April 2023 transfers lacked Resident #3's name regarding her transfer to the hospital. On 8/16/23 at 1:16 PM the Administrator revealed the facility did not have a written policy on submitting transfers/discharges to the Ombudsman. The Administrator further revealed it was discovered in June 2023 that the social worker was not receiving information regarding all of the facility transfers.

Based on clinical record review, staff interviews, and the 2019 Resident Assessment Instrument (RAI) manual the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) Assessment for 2 of 5 residents reviewed (Resident #21 and #23). The facility reported a census of 28 residents. Findings include: 1.The Minimum Data Set (MDS) dated [DATE] documented Resident #21 had diagnoses including diabetes mellitus, heart failure and traumatic brain injury and lacked psychiatric/mood disorder diagnoses. The MDS further documented the resident received an antidepressant 7 out of the last 7 days. Review of the Medication Administration Record (MAR) dated for June 2023 and July 2023 for Resident #21 lacked an order for and administration of an antidepressant. During an interview on 8/15/23 at 1:11 PM, the DON acknowledged the 7/5/23 MDS was coded incorrectly regarding Resident #21 and the use of an antidepressant. 48003 2. Resident #23 ' s MDS dated [DATE] documented he received an antipsychotic medication seven out of seven days in the lookback period. The June 2023 Medication Administration Record (MAR) lacked documentation of an antipsychotic medication given. During an interview on 8/15/23 at 12:59 p.m. the DON reported the MDS was marked for an antipsychotic medication because Resident #23 was on sertraline. The DON reported she would check with the MDS Coordinator as to why it was marked for an antipsychotic. During interview on 8/15/23 at 1:13 p.m. with the DON and the Administrator, the DON verbalized the MDS was marked wrong for the medication on the 6/30/23 MDS and the facility was working on submitting an amendment. On 8/16/23 at 1:37 p.m. the MDS Coordinator reported the facility follows the RAI manual for instructions on completing MDS assessments. The RAI manual page N-6 under Coding Instructions directs to code medications according to the pharmacological classification, not how they are being used.

Based on personnel file review and staff interview, the facility failed to employ a qualified director of food and nutrition services. The facility reported a census of 28 residents. Findings include: During an interview on 8/14/23 at 10:20 AM, the Dietary Manager acknowledged not having a certification in dietary management, a certification as a food service manager, an Associate ' s or Bachelor ' s degree in food service management or two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. During an interview on 8/15/23 at 10:50 AM, the Administrator confirmed the Dietary Manager employed at the facility was not qualified for the position. The Administrator denied the facility has a policy for a Certified Dietary Manager. A review of the personnel file for the Dietary Manager revealed a lack of documentation for certification as a Dietary Manager or qualifications for the position of director of food and nutrition services.

Based on observation, staff interviews and policy review, the facility failed to ensure open items were dated, covered and labeled. The facility further failed to ensure staff used proper food handling procedures to prevent possible contamination of food. The facility reported a census of 28 residents. Findings include: Observation on 8/14/23 at 10:20 AM in the main kitchen with the Dietary Manager (DM) present revealed the following: a. Open undated bag of approximately 1 gallon of cubed pepperoni. b. Open undated bag of approximately 1 gallon of chicken fried steak patties. c. Open undated bag of approximately 12 ounces of pancake mix. d. Open undated bag of approximately 12 ounces of stuffing mix. During an interview on 8/14/23 at 10:20 AM the DM revealed the items should have been dated when opened, labeled and sealed. During an interview on 8/16/23 at 3:00 PM, the DON acknowledged the items should have been dated when opened, labeled and sealed. Review of facility Food Storage policy, undated, documented under the procedure, all items must be covered, labeled and dated. The policy further documented all food that has been opened and partially used shall be dated and sealed before returning to a storage area. On 8/16/23 at 11:30 AM, Staff A, cook, was observed to be wearing food service gloves to serve the lunch meal, touching plates, ladling/tong handles and the surface of the table. Staff A used gloved hands to place bread on plates. Staff A was observed taking bread off of plates and placing the bread back into the bread container to be served to other residents. Staff A was observed to use the same gloved hand to grab green beans to remove them from a plate, and then using the gloved hand to place bread on plates. On 8/17/23 at 7:30 AM, Staff A was observed cooking breakfast without wearing food service gloves. Staff A was observed picking scrambled eggs off the head of the spatula with a bare hand and then continue to use this spatula to prepare pancakes and eggs without sanitizing the spatula or washing hands. Staff A used bare hands to remove two pancakes off a plate for one resident and place them on a plate for another resident. During an interview on 8/17/23 at 7:50 AM, Staff A acknowledged receiving training on proper food handling procedures. Staff A indicated food should be thrown away if plated in error for a resident, and food should be placed on a plate for a resident with clean and sanitized utensils, not with bare or gloved hands. During an interview on 8/17/23 at 8:05 AM, the DON acknowledged the expectation is to discard food if already plated for a resident in error. The DON further advised an expectation to wash hands and sanitize utensils after touching the head of a spatula with a hand, as well as an expectation to use utensils to plate food, not bare or gloved hands. Review of the facility Food Safety policy, undated, documented under the purpose section to ensure the facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Documented under the procedure section of the policy facility employees should never use bare hand contact with any foods, ready to eat or otherwise. The use of disposable gloves is not a substitute for proper hand washing. Hands must be washed before putting on gloves and after removing gloves as well as between tasks, between handling raw meats and ready to eat foods, and between handling soiled and clean dishes.

Based on observations and staff interviews the facility failed to ensure food was labeled with dates after opening, labeled with product after removing from original package, discarded after product expiration date and maintain clean and sanitizable cutting boards for food preparation. The facility identified a census of 24 residents. Findings include: 1. An initial kitchen tour conducted on [DATE] at 10:01 a.m., of the kitchen revealed the following items were stored in the kitchen ready for service: a. gallon of low-fat white milk- open with no open date b. gallon of chocolate milk- open with no open date c. light cranberry juice- open with no open date d. unsweetened tea- open with no open date e. grape juice-open with no open date f. shredded cabbage-open with no open date g. container of potato salad- open no open date h. bottle of orange colored dressing- lacked a label with product and no open date i. bottle of white colored dressing with dark specks- lacked a label with product and no open date j. 2 cups of banana slices on a tray with 2 slices of bananas on the tray uncovered and lacked a label k. pitcher with clear liquid lacked a label with product and lacked date. Noted to have drops of chocolate milk on the top of the pitcher. 2. The following items were stored in the milk cooler ready for service: a. 5- half and half containers unopened with [DATE] expiration date b. 3- gallons white milk unopened with expiration date of [DATE]. 3. The following items were stored in the kitchens freezer ready for service: a. bag of chicken nuggets- open with no open date b. bag of chicken strips- open with no open date c. bag of chicken breast- open with no open date d. bag of cinnamon rolls- open with no open date e. container of orange sherbet- open with no open date f. bag of rhubarb chunks- open with no open date g. bag of peas- open with no open date. 4. The following items were stored in the kitchen dry storage ready for service: a. baking powder- open with no open date with a best by date of ,d+[DATE] b. baking soda labeled with an open date of [DATE] with a best by date of [DATE] c. 6- boxes of baking soda unopened with best by [DATE] d. cornstarch labeled with an open date of [DATE] with a best by date of [DATE] e. marshmallow creme unopened with an expiration date of [DATE] f. brown sugar- open with no open date. 5. Nine cutting boards, showed visible deep grooves, discoloration and a fuzzy surface on all boards. Review of facility provided undated policy titled Food Safety Requirements-use and storage of food and beverage brought in for residents and food procurement. It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. The food service workers, cooks, dietary aides, dishwashers, food prep aides, or any person or persons who are working in the kitchen with any type of food, are responsible to adhere to the food safety requirements. Interview on [DATE] at 3:43 p.m., with the Dietary Manager revealed all items that are open should be labeled and the staff will be discarding expired items and ordering new cutting boards right away.

Based on record review, staff interviews, and policy review the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after a 180 day short stay approval expired on [DATE] for 1 of 1 residents reviewed (Resident #5). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the clinical record revealed a Notice of PASRR Level II Outcome dated [DATE] with the PASRR determination of a short term approval with specialized services with the short term approval ending on [DATE]. The clinical record lacked documentation of a new PASRR being completed after the [DATE] expiration of the short term stay. Review of the facility's provided undated policy titled Preadmission Screening and Annual Resident Review (PASRR) revealed this facility promotes and support a resident- centered approach to care. The purpose of this policy is to define and set expectations regarding the appropriate admission assessment of all individuals with intellectual disability. Its is the policy of the facility to coordinate the assessment process with preadmission screening and annual resident review PASRR program. This includes incorporating the recommendations from the PASRR level II determination. The PASRR process consists of the completion of a Level I screen per state and federal requirements as well as the review and implementation of the level II recommendations upon admission into the facility. Interview on [DATE] at 3:54 p.m., with Social Services Coordinator revealed the facility does not currently have a PASRR approval in place for Resident #5 as she was unaware it was expired until today. The Social Services Coordinator revealed she will be submitting a new PASRR today.

Based on observation, record review and staff interviews the facility failed to complete accurate Minimum Data Set (MDS) resident assessments for 2 of 2 resident's reviewed for restraints (Resident #17 and #18). Review of their MDS documented they used bed rails restraints everyday during the review, however the residents do not have restraints in place. The facility reported a census of 24 residents. Findings include: 1. Observation on 4/12/22 at 9:31 AM of Resident #17 laying in bed bed lacked the use of a bedrail restraint. The MDS with an Assessment Reference Date (ARD) of 3/5/22 documented Resident #17 used bedrail restraints everyday from 2/30/22 to 3/5/22. The MDS also documented Resident # 17 as independent with bed mobility, transfers, walking, and eating. Record review on 4/13/22 at 11:54 AM of Resident # 17's current Care Plan lacked documentation of Resident #17 use of bedrail restraints. 2. Observation of Resident #18's room on 4/12/22 at 9:23 AM lacked bedrail restraints on her bed. The MDS with an ARD of 3/5/22 documented Resident #18 used bedrail restraints everyday from 2/30/22 to 3/5/22. The MDS also documented Resident #18 needed extensive assist with bed mobility and dependent on staff for transfers, toilet use, and eating. Record review on 4/13/22 at 12:15 AM of Resident #18's current Care Plan lacked documentation of Resident #18 use of a bedrail restraints. Interview on 4/14/22 at 10:11 AM with the Administrator/MDS Coordinator revealed she thought she had to code all bedrail use for all residents as a restraint. She stated she would follow the Resident Assessment Instrument (RAI) manual guidelines for completing MDS's. Record review of the RAI Manual Version 3.0, Section P: Restraints and Alarms dated October, 2019 instructs the facility on the following definition of a restraint. DEFINITION PHYSICAL RESTRAINTS: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual, Appendix PP).

Based on clinical record review, observations and interviews, the facility failed to maintain proper infection control practices during a COVID-19 outbreak for 4 of 6 residents reviewed, (Resident #1, #3, #4, and #6). The facility identified a census of 24 residents. Findings include: 1. A History and Physical, dated 9/9/20, for Resident #1 documented an ongoing [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]- CoV-2 test performed 9/9/20 by the hospital showed the resident as negative for COVID 19. The Admission Record for Resident #1 showed the resident admitted to the facility on [DATE] to room [ROOM NUMBER]A with admitting [DIAGNOSES REDACTED]. An Administrative Note, dated 9/21/20 at 9:10 a.m., documented the resident on isolation due to being negative for COVID 19. During an interview on 9/21/20 at 9:30 a.m., the Director of Nursing, (DON), reported the resident is a new admission and is on 14 day quarantine on the West wing. The DON reported there were two residents, room [ROOM NUMBER] and room [ROOM NUMBER], that were in the non-COVID area. She reported the facility had 22 residents testing positive for COVID 19. During an observation on 9/21/20 at 9:45 a.m., Staff B, Housekeeper, utilized a small carpet sweeper to sweep debris from the carpet on the West wing( COVID positive care area). She stated the carpet sweeper cannot be disinfected well. She wipes it down with a Kimtech wipe, but the brissels cannot really be disinfected. She takes a small brush and brushes the hairs out of the brissels to clean. During an observation on 9/21/20 at 9:53 a.m., Staff A, Certified Nursing Assistant (CNA), coming from the COVID care area, cleansed a face shield with a Kimtech Tri Force wipe and allowed the face shield to air dry, removed her Niosh 95 (N95) mask and disposed it in the garbage touching the lid of the garbage can. Staff A removed her dirty gown touching the outside of the left sleeve with her bare hands and disposed it in the garbage. Staff A failed to perform hand hygiene before donning a disposable gown that hung on a hook on room [ROOM NUMBER] door. She donned a new N95 mask, face shield and entered room [ROOM NUMBER] to see if the resident wanted a snack. Staff A came out of room [ROOM NUMBER] and proceeded down the hallway entering room [ROOM NUMBER] wearing the same disposable gown and N95 mask. Staff A failed to perform hand hygiene, change the disposable gown or sanitize the face shield prior to entering room [ROOM NUMBER]. During an observation on 9/21/20 at 10:12 a.m., Staff A, donned a new N95 mask, sanitized the face shield and donned a disposable gown hanging on the door of room [ROOM NUMBER]. Staff A dropped a glove on the floor, picked up the glove and threw the glove in the garbage can touching the lid of the garbage can. Staff A failed to perform hand hygiene before donning new gloves to enter room [ROOM NUMBER] to check on the resident's water pitcher. Staff A came out of room [ROOM NUMBER] and removed the gown and hung on the door hook of room [ROOM NUMBER]. Without performing hand hygiene or sanitizing her face shield, went to room [ROOM NUMBER] and put on a gown hanging on the front of door 27. Staff A proceeded to go into room [ROOM NUMBER] to refresh the resident's water. During an observation on 9/21/20 at 11:47 a.m., Staff A came down the West hallway (COVID Positive area) into the West non-COVID area. She removed her disposable gown and without performing hand hygiene took a gown hanging on the door of room [ROOM NUMBER] (that had previously been worn in room [ROOM NUMBER]), put the gown on, took off her N95 mask, face shield and laid both on top of the PPE bin for room [ROOM NUMBER] without a barrier underneath. Without performing hand hygiene, she donned a new N95 mask, face shield, gloves and took a meal tray into room [ROOM NUMBER]. During an observation on 9/21/20 at 11:48 a.m., Staff B came out of room [ROOM NUMBER] wearing gloves. Took a Kimtech disinfecting wipe and proceeded to disinfect the top of the PPE bin outside room [ROOM NUMBER]. Staff B picked up the N95 mask and face shield, sanitized the surface beneath and set the N95 mask and face shield back down on top of the bin without a barrier. Staff B then proceeded to utilize the small carpet sweeper to sweep the carpeted area outside of room [ROOM NUMBER]. An Administration Note, dated 9/22/20 at 7:06 a.m., documented the Resident currently on isolation to prevent getting COVID 19. During an observation on 9/22/20 at 7:32 a.m., Resident #1 had the room door open. Resident #1 sat in the recliner. A stop sign posted on the door stated to check with the nurse before entering. The PPE bin outside resident #1's door still had a N95 mask and face shield laying on top of the bin without a clean barrier underneath. During an observation on 9/22/20 at 8:00 a.m., Resident #1's door to room [ROOM NUMBER] remained open. The resident sat in the recliner eating breakfast. During an observation on 9/22/20 at 9:36 a.m., Resident #1's room door remained open. Observed room [ROOM NUMBER] with only 1 room in between room [ROOM NUMBER] (COVID negative area) and room [ROOM NUMBER] (COVID positive area). The resident in room [ROOM NUMBER] observed on 9/22/20 at 9:30 a.m. performing a nebulizer treatment (aerolizing breathing treatment) with the room door open out into the hallway. During an interview on 9/22/20 at 9:18 a.m., Resident #1 reported his/her room door is usually open. Staff C, Licensed Practical Nurse, performed hand hygiene, correctly donned PPE and entered Resident #1's room to provide care. During an observation on 9/22/20 at 3:00 p.m., Resident #1's room door remained opened. During an interview on 9/23/20 at 10:41 a.m. the Director of Nursing (DON), stated she would expect staff to perform hand hygiene between PPE equipment change going from the COVID positive care area to the COVID negative care area and don/doff PPE as trained. A staff education, dated 6/17/20, noted to please print your name/date on this sheet (of paper) below to acknowleding that you have been given proper education on where PPE is stored and on the sequence of applying and removing PPE. Use safe work practices to protect yourself and limit the spread of contamination. The Center for Disease Control and Prevention (CDC) document how to safely remove personal protective equipment (PPE) Example 1 included in step 5 to wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. A untitled, undated paper, submitted to the Surveyor on 9/23/20 at 2 p.m. by the Infection Preventionist documented: · Charge Nurse read this at the beginning of your shift and keep in the med room and relay to your staff. · Staff: remember room [ROOM NUMBER] and #31 are negative (for COVID). You need to change or wear new full PPE whenever you enter those two rooms. · If working with all other rooms, you can continue to wear your same full PPE. Continue to wash you hands like you always have been. Your N95 (mask) is good for five uses. Please put N95 (mask) in a bag with negative residents to keep separated. A Hand Hygiene Policy, dated November 2019, provided by the facility, identified a purpose that handwashing is the single most important means of preventing the spread of infection. The Procedure directed the Staff will follow the facility's established hand hygiene procedures to prevent the spread of infection and disease to other staff, residents and visitors. In step 2 the procedure directed staff hands should be washed for 20-40 seconds using soap and water under the following conditions: a. When coming on duty. b. Whenever hands are visibly dirty. c. Before having direct contact with a resident. d. After having direct contact with a resident. e. Before performing invasive procedures. f. Before preparing or handling medications. g. Before handling clean or soiled dressings, gauze pads, etc. h. After handling used dressings, contaminated equipment, etc. i. After contact with blood, body fluids, excretions, secretions, mucous membranes or non-intact skin. j. After handling items potentially contaminated with blood, body fluids, excretions, or secretions. k. After using the toilet, blowing or wiping the nose, or smoking. l. Before putting on gloves. m. After removing gloves. n. Before and after eating. o. Upon completion of duty and before leaving the facility. Step 3 identified hand sanitizer containing at least 60% alcohol may be used when soap and water is not readily available. (Hand sanitizer should not be used when hands are visibly dirty or contaminated with blood). The Infection Prevention and Control Program Policy, dated November 2019, provided by the facility, stated written standards, policies and procedures for the program included: standard and transmission-based precautions to be followed to prevent the spread of infections. The Standard Precaution Policy, undated, provided by the facility under Personal Protective Equipment for Standard Precautions instructed staff to remove gloves promptly after use and before touching non-contaminated items or environmental surfaces and before providing care to another patient. Wash hands immediately after removing gloves. The Contact Precaution Policy, undated, provided by the facility under Contact Precautions instructed staff to wear gloves when touching the resident and their immediate environment or belongings. Remove gloves promptly after use and discard before touching non-contaminated surfaces or items. Wash hands immediately after removing gloves. 2. The Minimum Data Set (MDS) Assessment, dated 6/30/20, for Resident #3 identified a Brief Interview for Mental Status (BIMS) score of 10, indicating mild cognitive impairment. The MDS documented the resident as independent with transfer, ambulation and limited assistance with dressing and personal hygiene. The MDS listed a [DIAGNOSES REDACTED]. An Order Summary Report, signed by the physician on 8/18/20, documented an active order 6/22/20 for [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 Milligrams (gm)/3 Milliliters (ml). Three ml inhale orally three times a day related to [MEDICAL CONDITION], Unspecified. The Medication Administration Record [REDACTED]. Give 1 capsule by mouth two times a day for Pneumonia for 7 days starting 9/17/20. The MAR indicated [REDACTED]. A COVID test, dated 9/15/20, showed the resident tested positive for COVID 19. A Communication with Family Note, dated 9/18/20 at 4:06 p.m., documented Resident #3's family notified the resident tested positive for COVID 19 during routine testing. During an observation on 9/21/20 at 10:03 a.m., Resident #3 sat in the recliner in room [ROOM NUMBER] using a hand held nebulizer (aerosol generating breathing treatment). The roommate sat on the other side of the room with the privacy curtain pulled half-way between the two residents. The door to the room remained open to the West hallway. Staff E, CNA, entered room [ROOM NUMBER] wearing an N95 mask, face shield and gown while Resident #3 had the nebulizer running. Staff E brought the roommate's water pitcher out of the room and sat on top of the water cart. Filled the water mug with water, put the lid on the mug and walked back into room [ROOM NUMBER] to return the water mug to the roommate. Resident #3 continued to use the nebulizer with the privacy curtain pulled half way between the residents. Staff D, without performing hand hygiene, went over to Resident #3's side of the room and grabbed the resident's water mug. She brought Resident #3's water mug out to the water cart and placed on top of the cart. She removed the lid with her bare hands, filled with water and replaced the top of the mug. Staff E walked back into room to place the water mug by Resident #3. Resident #3 continued to use the nebulizer with the room door open. Staff E, without performing hand hygiene, went to room [ROOM NUMBER] and 24 and continued to refill water mugs without performing hand hygiene between each resident's mug. Staff E did not close the door to room [ROOM NUMBER] after exiting the room while Resident' 3#'s hand held nebulizer treatment continued. During an observation on 9/21/20 at 10:04 a.m., Staff F, Activities, came to the open doorway of room [ROOM NUMBER] while Resident #3 continued to use the nebulizer to get meal order for both resident's in room [ROOM NUMBER]. During an observation on 9/22/20 at 9:36 a.m., Resident #3 sat in his/her recliner utilizing a nebulizer breathing treatment in room [ROOM NUMBER]. The door to the room remained open to the room. During an interview on 9/21/20 at 3:10 p.m., Staff C, reported she goes in the room and sets up the nebulizer and then goes back to take the resident off of the nebulizer. She stated they had not received any direction on shutting the room doors during nebulizer treatments. If the resident wants the door open, then they leave the door open. It is up to the resident what they want. She reported she puts on a new N95 mask before going in. She goes back in and checks their pulse and lungs. Reported she does not disinfect her face shield when coming and going from the room after a nebulizer. The room doors are usually open. During an interview on 9/22/20 at 10:05 a.m. Staff G, CNA, reported the nurses have never instructed them to close down the room doors when a nebulizer is running or clean after the nebulizer is done. Staff G stated they have a lot of residents on nebulizers. During an interview on 9/23/20 at 7:23 a.m., the DON and Infection Preventionist (IP), reported they had not looked at use of nebulizers further and did not have systems in place for closing the doors, private areas or cleaning of area after nebulizer treatments. They had provided direction to staff to wear the N95 masks when resident were COVID positive and used nebulizers. Staff D, Infection Preventionist, reported 9/23/20 at 2:00 p.m., the facility did not have a hand held nebulizer policy. The Department of Health and Human Services, Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group letter dated 8/26/20 Ref: 20-38-NH COVID 19 Focused Survey for Nursing Homes contains the following: For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. A facemask is an acceptable alternative if a respirator is not available. When COVID-19 is identified in the facility, staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability). Some procedures performed on residents with known or suspected COVID-19 could generate infectious aerosols (i.e., aerosol-generating procedures (AGPs)). In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously. If performed, the following should occur: Staff in the room should wear an N95 or higher-level respirator, eye protection, gloves, and an isolation gown. The number of staff present during the procedure should be limited to only those essential for resident care and procedure support. AGPs should ideally take place in an airborne infection isolation room (AIIR). If an AIIR is not available and the procedure is medically necessary, then it should take place in a private room with the door closed. Clean and disinfect the room surfaces with an appropriate disinfectant. Use disinfectants on List N of the EPA website that have qualified under EPA ' s emerging [MEDICAL CONDITION] pathogens program for use against [DIAGNOSES REDACTED]-CoV-2 or other national recommendations. 3. The Minimum Data Set (MDS) Assessment, dated 8/18/20, for Resident #4 showed a BIMS score of 14, indicating intact cognitive functioning. The MDS documented the resident as independent in transfer, ambulation and extensive assistance with dressing and personal hygiene. The resident required limited assistance for eating. The MDS listed a [DIAGNOSES REDACTED]. A Care Plan with an intervention dated 6/11/20, documented the resident had been advised it is recommended to wear a face mask while sitting in a group and a mask had been provided to him/her. The Care Plan directed staff would encourage Resident #4 to wear a mask while in group activities. A State Hygienic Laboratory test for 2019 Novel Coronavirus RNA showed the resident tested positive for COVID 19 on 9/16/20. During an interview on 9/21/20 at 9:30 a.m., the DON reported the facility had 22 residents testing positive for COVID 19 and a census of 24 residents. During an observation on 9/21/20 at 9:31 a.m., Resident #4 sat in a chair in the front lounge without a cloth mask on. Four other random residents, not included in the sample, sat in the front lounge. None of the residents were wearing cloth masks. During an observation on 9/21/20 at 11:33 a.m., the resident sat in the front lounge along with five other residents. All the residents were socially distanced. None of the residents were wearing masks. Staff present in the dining area did not offer masks or encourage cloth masks to be worn. During an interview on 9/21/20 at 3:10 p.m., Staff C, reported the DON said since all the resident's were positive (for COVID), to let them be. We cannot force them to wear masks. Staff C stated she could not remember how long it has been since they have asked resident to wear masks. During an observation on 9/22/20 at 7:41 a.m., Resident #4 sat in a chair in the hallway at the junction of the North and West hallways. He/she did not wear a cloth face mask. During an interview at this time, Resident #4 reported the staff have never asked him/her to wear a mask. During an observation on 9/22/20 at 7:51 a.m., Resident #4 sat across a table, socially distanced from another resident. Both resident faced each other, not wearing cloth masks. Staff present in the lounge did not offer cloth mask or encourage to wear masks. During an observation on 9/22/20 at 8:04 a.m., Resident #4 sat out in the front lounge with three other random residents, not included in the sample. None of the residents wore cloth masks. During an interview on 9/22/20 at 10:00 a.m., the DON reported she had called the Iowa Department of Public Health (IDPH) on Sunday and reported the facility had challenges with residents that were not safe to be left alone in their rooms. She reported that IDPH knew they had COVID positive resident out of their rooms without masks on. During an observation on 9/22/20 at 10:10 a.m., Resident #4 sat in a recliner in the front lounge. Three other residents sitting out in the lounge socially distanced. None of the residents wore cloth masks. During an interview on 9/22/20 at 10:05 a.m., Staff G reported each resident has their own mask since this whole COVID has started. She assumed residents are to wear their mask when they are out of their room or when out in the hallways. She reported residents do wear masks if they go out of the facility, but do not wear masks when staff go in to take care of them and noted residents out in the lounge are not wearing masks. During an interview on 9/22/20 at 11:09 a.m., a representative of the Iowa Department of Public Health (IDPH) reported she had received a phone call from the DON on Sunday 9/20/20 reporting they were experiencing challenges with keeping some dementia residents in their rooms and safety issues. She reported she didn't know what else to tell them, if safety is an issue they needed to do what they had to do. She reported the facility should still try to be encouraging the resident's to wear masks when out of their rooms and when the staff are in their rooms for cares. She reported the DON reported the facility staffing at that time as good. During an interview on 9/23/20 at 11:40 a.m., the DON reported resident had been given cloth masks and provided education on wearing masks, but some said they were not going to wear them. Stated it had been a while back and she would have to look back to see when that had been. The DON stated they had not continued to try to have residents wear masks on an ongoing basis. The Droplet Precaution Policy, undated, provided by the facility documents droplet precautions are in addition to Standard Precautions plus masks and respirators. Wear a facemask, like a procedure or surgical mask within three feet of the resident. If the resident exits their room, they need to wear a facemask, avoid coming into close contact with other residents and practice respiratory hygiene and cough etiquette. The Reopening Plan Policy, undated, provided by the facility, under Phase 1 (June 9, 2020) documented residents, who have dementia, and who have an increased for falls, will be monitored. If the safety of the resident being isolated is in jeopardy, and if the resident is asymptomatic and is COV ID-19 negative, the resident will be relocated to an area that is easier for staff to observe. Resident will wear a facemask and be placed six feet or more away from others. The Department of Health and Human Services, Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group letter dated 8/26/20 Ref: 20-38-NH COVID 19 Focused Survey for Nursing Homes contains the following: · If residents have to leave their room, are they wearing a facemask or cloth face covering, performing hand hygiene, limiting their movement in the facility, and performing social distancing (efforts are made to keep them at least 6 feet away from others)? 4. The Minimum Data Set (MDS) Assessment, dated 8/25/20, for Resident #6, showed a BIMS score of 15, indicating no memory impairment. The MDS identified the resident as being independent with transfer and ambulation, limited assistance with dressing and supervision with personal hygiene. The MDS listed a [DIAGNOSES REDACTED]. A Care Plan intervention, revised 6/12/20, documented the resident had been advised that it is recommended to wear a face mask while sitting in a group and a mask has been provided. Staff will encourage to wear a mask while in group activities. A State Hygienic Laboratory test dated 9/11/20 identified the resident tested positive for COVID 19. During an observation on 9/22/20 at 7:20 a.m., Resident #6 ambulated out of his/her room into the sunroom using a walker. The resident did not have a cloth mask covering his/her mouth and nose. During an interview on 9/22/20 at 7:20 a.m., Resident #6 stated staff have never asked him/her to wear a mask when they come in his/her room or when he/she goes out of his/her room. 5. Upon entrance to the facility on [DATE] at 9:30 a.m., the DON reported the facility had 22 resident's positive for COVID 19 and a census of 24 residents. The following observations were made: · 9/21/20 at 9:31 a.m. Staff passed snacks to residents in the front lounge. Staff failed to offer hand hygiene to the five residents in the front lounge and failed to perform hand hygiene between each resident's snack pass. · 9/21/20 from 9:50 a.m. to 10:15 a.m., Observed Staff E go in and out of rooms down the West hallway to refill water mugs. Staff E went room to room touching each resident's water mug and lid without performing hand hygiene between handling each water mug and between each room. · 9/21/20 11:30 a.m., Staff E delivered lunch trays to resident rooms without performing hand hygiene between entering/exiting each resident rooms. · 9/21/20 at 12:02 p.m., therapist at the facility front entrance for screening to enter the facility. Facility thermometer did not get sanitized after utilized for the screening. · 9/21/20 at 12:10 p.m. Staff H, CNA, came out of room North 6 and delivered meal tray to room North 7 without performing hand hygiene. Staff H failed to perform hand hygiene before delivering a meal tray to room North 16. While in room [ROOM NUMBER], Staff H assisted the resident with putting on a clothing protector and adjust the resident seating position in the chair. Staff H did not perform hand hygiene and delivered another tray to room North 19. · 9/21/20 at 12:11 p.m., the DON delivered a tray to a resident's room. Observed touching the front of her medical mask twice with bare hands. Donned new gloves without performing hand hygiene and delivered a room tray to North room [ROOM NUMBER]. · 9/21/20 at 12:13 p.m., Observed Staff A, assigned to the West Wing on 9/21/20 (partial non-COVID care area), providing care for COVID negative residents prior to lunch, wore a N95 mask, face shield, gown and gloves and assisted Resident #4 and another resident not included in the sample with their lunch meals in the COVID positive area. · 9/22/20 at 7:25 a.m., the Sunroom had a cloth chair facing the outside window. A lawn chair sat outside across from the window. During an interview with the DON on 9/22/20 at 7:25 a.m., the DON reported the staff had not been trained to disinfect the chairs or area after window visits. The staff had been trained to disinfect the facility phone after window visits. The cordless phone had been disinfected after the window visit last evening, but not the chairs or the sunroom. She reported that housekeeping would come in and clean the area. At 7:30 a.m. Staff I, Housekeeping, came in to clean the sunroom and reported the staff are trained to clean after a window visits. She didn't know if the training had been documented, but the DON should know. · 9/22/20 7:31 a.m., two random residents, not included in the sample, observed out in the front lounge without cloth masks covering their faces. A nurse present in the lounge did not offer masks or direct staff to get the resident's masks. · 9/22/20 at 9:15 a.m., Staff C, left the medication cart on the COVID care area and entered into the non-COVID care area. Staff C doffed her gown draping over the back of a chair in the nurses station, then doffed the face shield and N95 mask laying on the nurses desk without a clean barrier. Performed hand hygiene and donned a new disposable gown, N95 mask and face shield to enter room [ROOM NUMBER] in the non-COVID care area. After care, exited room [ROOM NUMBER], performed hand hygiene and doffed PPE. Donned the gown that had been draped over the back of the nurses station chair, put on the N95 mask and face shield and returned to the COVID care area. Staff C did not sanitize the nurses station desk or chair. · 9/22/20 at 4:00 p.m., staff screened the surveyor to leave the facility for the day touching the thermometer to the Surveyor's forehead. After taking the Surveyor's temperature and initialing the screening form, staff walked out of the entrance area back down the North hallway without sanitizing the thermometer. · 9/23/20 at 10:05 p.m., Observed Staff E, on the West hallway perform water pass. Staff E brought dirty dishes out of room [ROOM NUMBER]A and placed on the middle shelf of the water cart. Staff E went back into room [ROOM NUMBER]A and grabbed the water mug without performing hand hygiene. She removed the lid with her bare hands and filled the mug with water and returned the water mug back to the room. She then proceeded to room [ROOM NUMBER]B without performing hand hygiene and brought the water mug out and placed on top of the water cart. She opened the lid with her bare hands and filled the mug with water, replaced the lid and returned to room [ROOM NUMBER]B. Staff E then performed hand hygiene and entered room [ROOM NUMBER] and brought out the dirty dishes and placed on the middle shelf of the water cart. Staff E went back into room [ROOM NUMBER] without performing hand hygiene and brought the water mug out to the cart and filled with water and returned back to room [ROOM NUMBER]. Staff E then performed hand hygiene. Staff E continued to complete water pass removing dirty dishes and without performing appropriate hand hygiene. During an interview on 9/23/20 at 11:40 a.m., the DON reported she would expect staff would sanitize their hands between delivering each resident's meal tray and between refilling water mugs. Staff should not handle dirty dishes and then refill the water pitchers without performing hand hygiene. She would expect that staff would don/doff PPE as trained. She reported she expected that staff would be sanitizing the thermometer after each employee or visitor is screened.

Based on clinical record review, observation and interviews, the facility failed to notify the family of the active COVID 19 status of residents and staff in the facility for 1 of 6 residents sampled, (Resident #1). The facility identified a census of 24 residents. Findings include: A History and Physical, dated 9/9/20, for Resident #1 documented ongoing [DIAGNOSES REDACTED]. An Admission Record showed the resident admitted to the facility on [DATE]. The Progress Notes from 9/17/20 - 9/22/20 lacked documentation the family had been informed of the COVID status of the facility. During an interview on 9/22/20 at 10:00 a.m., the Director of Nurses reported Social Services had notified Resident #1's son on 9/17/20 of the COVID status of the facility when she met with the son to do the admission paper work. During a telephone interview on 9/22/20 at 1:10 p.m., Resident #1's son stated he did meet with Social Services outside the facility on 9/17/20 to do the admission paperwork. He had been informed that the resident would be on a 14 day isolation/quarantine as part of being a new admission to the facility. He stated he had not been informed the facility had active positive resident and staff cases of COVID in the facility or that he could check the facility website for updates on the facility. During an interview on 9/23/20 at 10:30 a.m., Staff J, Social Services, reported she had met with Resident #1's son on 9/17/20 in the back entry of the facility. The son had worn a mask while doing the admission paperwork. She thought that she had informed the son of the COVID status in the facility, but had received a phone call on 9/22/20 from the son indicating that he had not been made aware after talking with the surveyor. She said the normal process is to meet with any new admission family either in the entryway or in the gazebo. The family have to wear masks while doing the paperwork. She reported she and the Administrator usually call family personally to inform of COVID status and the Administrator then does regular updates on the website. During an interview on 9/23/20 at 12:26 p.m., the Administrator reported they would inform family prior to the admission on the COVID status of the facility, but she wasn't involved when Resident #1 had been admitted and cannot speak to that admission.

Based on clinical record review and staff interviews the facility failed to provide the resident and their representative with a summary of the baseline care plan for 1 of 1 new resident reviewed (Resident #31). The facility reported a census of 32 residents. Findings included: An admission Minimum Data Set (MDS) assessment, dated 10/2/19 documented Resident #31 was admitted to the facility 9/25/19. The MDS documented the resident scored 8 on the Brief Interview For Mental Status, indicating moderately impaired cognition. The resident's clinical record lacked documentation the resident or the resident's representative had received a summary of the resident's baseline care plan. During interviews on 10/23/19 at 2:10 p.m., the Social Worker and Director of Nursing stated a copy of a summary of the resident's baseline care plan had not been given to the family or resident's representative.

Based on observation, clinical review and interview the facility failed to assess residents for use of bed rails and obtain informed consent for the use of bed rails for 3 of 32 residents (#15, #18 and #23). The facility reported a census of 32. Findings include: 1. The Minimum Data Set (MDS) for resident #15, dated 8/23/19, indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assists with transfer, limited assist in bed mobility, extensive assist of two with walking and toileting. The Resident #15's a Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive deficits. The Care Plan for Resident #15 indicated he had self-care deficits and a high risk of falls. Resident #15 had a potential for skin breakdown due to immobility. 2. The MDS, dated [DATE], for Resident #18 included [DIAGNOSES REDACTED]. Resident #18 had a BIMS score of 14, indicating high cognitive functioning. The MDS indicated the resident needed limited assistance with the help of one for bed mobility, transfers and toileting use. The Care Plan for Resident #18, last updated on 10/2/19, indicated the resident had a self-care performance deficit related to compression fracture, limited physical mobility related to weakness and impaired cognitive functioning related to fall. In an observation of resident rooms on 10/23/19 at 7:00 AM it was discovered that Resident #15, and #18 were asleep in their beds with bed rails in the upright position. The clinical records for Resident #15 and Resident #18 lacked bed rail assessments and signed informed consents for bed rails. 3. The MDS assessment, dated 9/12/19, documented Resident #23 with intact cognition. The resident required limited staff assistance with bed mobility, transfers, ambulation, dressing, and toilet use, and used a bed rail daily. The clinical record lacked documentation of any type of side rail assessment and consent for side rail use. The resident's Care Plan lacked documentation the resident used a side rail. During an interview, on 10/21/19 at 3:56 p.m., the resident stated she requested to use the upper outer side rail at night for positioning. During an interview, on 10/23/19 at 10:47 a.m., the DON (Director of Nursing) stated side rail assessments and consents had not been obtained when a resident requested side rails, about 4 residents in the facility used side rails, other side rails had been removed. The DON stated side rail use should be documented on the resident's care plan. The DON reviewed Resident #23's Care Plan and stated the Care Plan had no documentation of side rail use. The DON stated maintenance checks and measures side rails for proper placement. During an interview, on 10/24/19 at 9:00 a.m., the DON stated the facility planned to update the policy and procedure for side rail use.

Based on clinical record review, policy review, observation and interview the facility failed to provide a sanitary environment to help prevent the transmission of pathogens for 3 of 32 residents (#15, #29 and #5). The facility also failed to conduct an annual review of policies and procedures for their Infection Prevention and Control Program (IPCP). The facility reports a census of 32 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] for Resident #15 indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assists with transfer, limited assist in bed mobility, extensive assist of two with walking and toileting. Resident #15 had a Brief Interview for Mental Status (BIMS) score of 11, indicated moderate cognitive deficits. The Care Plan for Resident #15 indicated the resident had self-care deficits, was a high risk of falls and nutritional problems, and had the potential for skin breakdown due to immobility. In an observation, on 10/22/19 at 6:45 AM, Resident#15 was sleeping in his bed, which was visible from the hallway. The resident used an indwelling catheter due to [MEDICAL CONDITION] and it was full of urine and laying on the floor next to his bed. The catheter container was not in a privacy bag. At 7:45 AM, on 10/22/19, the bag was still on the floor. In an observation, on 10/23/19 at 7:00 AM, the resident was again asleep in his bed and the catheter bag was laying on the floor. 2. The MDS for Resident #29, dated 9/17/19, indicated the resident had a [DIAGNOSES REDACTED]. Resident #29 had a BIMS score of 0, indicating severe cognitive deficits. The MDS documented the resident was totally dependent with transferring, dressing and hygiene and needed extensive assist with bed mobility. The Care Plan for Resident #29, revised on 10/8/19, indicated the resident had self-care performance deficit related to limited mobility and trauma. He had behavior problems such as undressing, grabbing at staff, communication problems and respiratory impairment all related to head injury. The Care Plan also indicated Resident #29 had a gastrostomy tube ([DEVICE]) In an observation of incontinence cares, on 10/22/19 at 9:17 AM , Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA attended to the resident's morning cares. While Resident #29 was in bed, Staff A turned him on his side as staff B used gloved hands to remove the brief and clean his peri and gluteal areas. Staff B disposed of the soiled brief, wipes and gloves in the trash. Without washing her hands or using sanitizer, Staff B went on to assist with dressing the resident. Both staff used the EZ-Lift and transferred the resident into his wheel chair. Staff B gathered up the bags that contained the soiled items with bare hands. As Staff A attended to oral cares in the bathroom, Staff B grabbed his drinking cup from the bedside, handling the cup at the rim and handed it to Staff A to use with oral cares. At 9:23 AM Staff B then took the two small garbage bags and left the room without having performed any hand hygiene. In an interview with the Director of Nursing (DON), on 10/23/19 at 3:40 PM, she stated her expectation is the urinary catheter bag not be on the floor and is hung on the bed frame lower than the bladder. She stated they had some privacy bags in the past but they became very worn and they need to order a new supply. In an interview with the DON, on 10/24/19 at 9:45 AM, she stated the expectation is for staff to perform hand hygiene after providing incontinence cares on a resident. She stated a drinking glass should never be handled by the rim and washing or sanitation of the hands is expected before leaving the residents room. In an undated document titled, Procedure for Emptying Catheter Bags, staff is directed to ensure catheter bag is below level of the bladder at all times; do not place bag on the floor. In an interview, on 10/23/19 at 9:00 AM, with the Infection Control Nurse it was discovered the infection control policies had not been updated for some time. The documents provided by the facility are not dated and the Infection Control Nurse stated the policies are in the works. She went on to say she had been at the facility for just over a year and she does not know when the policies were last updated. 3. The MDS assessment, dated 7/19/19, documented Resident #5 with short and long term memory impairment and severely impaired cognition. The resident required total staff assistance for transfers and personal care, and was always incontinent of bowel and bladder. The MDS documented the resident's [DIAGNOSES REDACTED]. During an observation, on 10/23/19 at 10:20 a.m., Staff A and Staff B, CNA's (Certified Nurse's Aide Assistant) provided incontinence care for the resident. Staff B stated the resident's brief was wet with urine. Staff B provided appropriate incontinence care. The staff turned the resident to her left side and observation revealed the resident had been incontinent of bowel movement. Staff B provided appropriate incontinence care. The staff turned the resident to her right side, Staff A removed the incontinence /positioning pad, folded the pad, and placed the pad on the floor without any barrier underneath. Observation revealed the incontinence/positioning pad had a smear of bowel movement on it. After cares completed, Staff B picked up the incontinence/bed place from the floor and placed the pad in a garbage bag. During an interview, on 10/24/19 at 9:00 a.m., the Director of Nursing stated she expected staff to place laundry in a bag and not on the floor. An undated facility policy, Infection Prevention and Control Program, directed staff to handle, store, process, and transport linens in a manner to prevent the spread of communicable diseases and infections.

Based on clinical record review, observation and staff interview, the facility failed to ensure initial and/or ongoing skin assessments and behavioral assessments and interventions for 2 of 23 residents reviewed (Residents # 15 and #31). The facility identified a census of 31 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #15 dated 5/30/18 documented [DIAGNOSES REDACTED]. The resident displayed independence with bed mobility, transfer, eating, walking in her room and supervision when walking in the hallway. The Brief Interview for Mental Status (BIMS) test documented a score of 1 that indicated severe cognitive impairment. The MDS also documented the resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 1-3 days of the 7 day look back period. Nursing staff used a behavior mood checklist document to capture the resident's behaviors. This documented showed 3 days during the 7 day look back period (5/23/18 - 5/30/18) of incidents of resident behavioral symptoms, including but not limited to yelling/ screaming, trying to leave and one check mark in other for an unknown behavior. Nurse's Notes dated 5/23/18 to 5/30/18 showed no entries. The incidents were not documented to explain the nature of the incident or the interventions used during the incident. In an interview on 8/1/18 at 1:48 PM, Staff A, Registered Nurse and Acting Director of Nursing stated resident behaviors are to be checked on the behavior calendar and then documentation is to be added to the back side of the log or into the nurse's notes. She reported they had changed their behavior calendar in mid-July and now used a behavior monthly flow sheet. She stated the new flow sheet had been messy as no standard education had been provided to everyone on how to use it. 2. The MDS assessment for Resident #31 dated 7/11/18 documented [DIAGNOSES REDACTED]. The resident displayed independence with bed mobility, transfers, walking and eating and limited assistance with dressing and toilet use. The BIMS documented a score of 7, indicating severe cognitive impairment. During an observation and interview on 7/30/18 at 1:50 PM, Resident # 31 showed several bruises on the inner aspect of her right forearm and the multiple larger bruises on her right inner thigh below and above the knee and a bruise behind her knee. She stated she was not afraid of anyone and no one had been unkind to her. She said everyone treated her kindly she just could not figure out how she got the bruises. On 7/31/18 at 10:55 AM, the resident reported she did not know how this happened and stated the nurses told her she must have fallen. She said they have not assessed or measured it even though she reported she felt worried about it. During an interview on 7/31/18 at 1:01 PM, Staff D, Licensed Practical Nurse reviewed treatment sheet and skin sheets for Resident #31 and stated there were no current treatments or recent skin assessments. Staff D stated she knew of the bruises on the resident's inner thigh and arm and she thought she had started a skin sheet. The facility could provide no nurse assessment record for the bruising or documentation that the physician had been notified at that time. The facility failed to investigate how the bruising happened. In an interview on 7/31/18 at 1:12 PM, Staff A reported if a nurse found bruises of unknown origin on a resident, she would expect them to investigate the cause, start a skin tracking sheet and notify the physician. The facility's Nursing Consultant provided a document titled Bruise/Skin Assessment found in the Director of Nurses office. The document had the resident's first name and without a date or time. Staff clipped the assessment to a skin condition audit paper a Certified Nurse Aide (CNA) completed on 7/20/18 and Staff D noted. The paper documented the CNA had observed various bruising on the resident. On 8/1/18 at 9:00 am Staff A provided Non Pressure Skin Condition Report documents created on 7/31/18 that showed staff assessed the resident's skin.

Based on clinical record review, observation and staff interview, the facility failed to ensure a resident with an indwelling catheter received the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 2 residents reviewed who required indwelling catheters (#28). The facility identified a census of 31. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 documented [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS indicated he required the assistance of two with bed mobility and toilet use and supervision with personal hygiene. The MDS indicated the resident had an indwelling catheter and as always continent of bowel. The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. July and (MONTH) resident treatment records did not identify catheter cares for the resident. During an interview on 8/1/18 at 1:28 PM Staff B, Certified Nursing Assistant, (CNA) stated she had to complete catheter cares and would only empty the catheter bag. She reported the CNA's empty the catheter bag every shift but do not have a set schedule to perform catheter care for Resident #28. She said she would clean around the insertion site in the morning and staff would not clean again unless the resident was soiled. She reported she would check the CNA schedule every morning to see what resident she had been assigned to take care of and who needed a bath. She couldn't say how she would know if a change had occurred with a resident. The CNA could not provide any plan of care she followed for what the patient would need. She reported she just knew what do as a CNA at the facility for 2 years. During an interview on 8/1/18 at 1:46 PM, Staff A, Registered Nurse, stated she did not know why the CNA answered that way or if they had a plan of care the CNA's looked at. She could not provide a Policy Procedure for residents with indwelling catheters. The resident's care plan dated 7/5/18 documented a self-care deficit and instructed staff to provide proper perineal care and catheter care. The care plan did not direct a frequency for those cares to be provided.

Based on observation and staff interview, the facility failed to assure medications kept secured from cognitively impaired residents. The facility reported a census of 31 residents. Findings included: During observation on 7/30/18 at 12:52 PM the entrance to the medication room sat behind the desk of the nurses station. The door to medication room stood open with no staff present at the nurse's station or in the medication room. Both medication carts in the medication room stood unlocked with all the medications for all the residents of the facility accessible. Ten cupboards in the medication room sat unlocked with many more medications present. A refrigerator which held medications and insulins also had no lock. The facility's Nursing Consultant provided a list of 3 residents with cognitive impairment moved independently in the facility.

Based on observation, record review, staff and physician interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 5 residents reviewed. The facility failed to assess and address Resident #1 and Resident #2 condition declines. Staff noticed symptoms that were not addressed. Resident #2 went to the hospital with severe dehydration and expired that day. On [DATE] a hospital history and physical revealed Resident #5 had loose stools for 2 weeks. The first Nurses Note entry regarding this was on [DATE] and contained no assessment of the resident. An assessment completed and faxed to the physician on [DATE] at 11:50 p.m. was not received by the physician until [DATE]. On [DATE] the resident admitted to the hospital with [REDACTED]. Findings include: 1. A MDS with assessment reference date of [DATE] assessed Resident #2 with a BIMS score of 0 (severe cognitive impairment) The MDS did not identify behaviors including rejection of care. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident required total staff assistance with bed mobility, transfers, dressing, eating, personal hygiene and bathing. The resident did not ambulate and used a wheelchair for mobility. The resident was always incontinent of bowel and bladder. The resident was 63 inches tall and 114 pounds. The MDS did not identify a significant weight loss. A Do Not Resuscitate Request (DNR) dated [DATE] revealed the resident did not want chest compressions, defibrillation or intubation. The form identified the DNR decision would not prevent the resident from obtained other emergency care which would make the resident more comfortable which included but not limited to: pain medication, fluid therapy and respiratory assistance. A (MONTH) (YEAR) MAR revealed the resident weighed 114.2 on [DATE]. A (MONTH) (YEAR) MAR identified the resident weighed 112 on [DATE]. A (MONTH) (YEAR) MAR revealed the resident weighed 104.6 on [DATE]. The resident lost 7.4 pounds in 1 month (from [DATE] to [DATE]) which was a significant weight loss. On [DATE] the hospital weighed the resident at 97 pounds. A Nutritional Assessment sheet dated [DATE] revealed the resident usually took fluid better than food. The resident's appetite varied with the resident often eating less than 50%. The resident had no special food likes. The assessment identified that the resident received Resource 2.0 supplement 60 cc three times a day and 4 ounces of strawberry Ensure three times a day and 4 ounces of yogurt at breakfast. Review of the (MONTH) (YEAR) MAR showed staff signed they administered the Resource drink listed on the nutritional assessment. On [DATE] at 12:52 p.m. Staff B LPN (licensed practical nurse) stated she initialed she gave the resident Resource because she offered it. She stated the resident would not take the Resource. On [DATE] at 9:40 a.m. the DON stated the kitchen delivered the Ensure so those would not be on the MAR. The Resource should be recorded on the MAR. On [DATE] at 10 a.m. the food service manager stated dietary supplied strawberry Ensure to the resident. They did not document when it was given. A Clinic Nursing Home note dated [DATE] revealed the physician saw the resident. The physician ordered [MEDICATION NAME] (narcotic) for the resident for administration prior to bath for pain control on bath days. The weight listed on the clinic note was 139.2 pounds. Her [DIAGNOSES REDACTED]. On [DATE] at 11:57 a.m. the MDS nurse stated the 139.2 pounds was an error. They just noticed that yesterday. Daily food intakes revealed the following: [DATE] Breakfast 0 lunch 15 supper 0 [DATE] Breakfast 0 lunch 15 supper 15 [DATE] Breakfast 25 lunch 25 supper 85 [DATE] Breakfast 25 lunch 25 supper 25 [DATE] Breakfast 0 lunch 100 supper 50 [DATE] Breakfast 0 lunch 0 supper 25 [DATE] Breakfast 15 lunch 50 supper 75 [DATE] Breakfast 25 lunch bites supper 25 [DATE] Breakfast 50 lunch 35 supper 80 [DATE] Breakfast 0 lunch 25 supper 20 [DATE] Breakfast 0 lunch bites supper bites [DATE] Breakfast 0 lunch 0 supper 25 [DATE] hospital/expired There were no fluid intake records. Nurses Notes dated [DATE] at 2 a.m. revealed the resident's condition appeared worse. The resident's eyes looked sunken and dark and the resident's feet were cold and blue. Respirations 40. The nurse was unable to feel pulses as the pulse was too weak and she could not obtain a blood pressure. Staff notified the DON (director of nursing). On [DATE] at 2:10 p.m. the DON stated Staff C RN did call her saying the resident was not doing well. She said she called the resident's family. The DON told Staff C to find out if the family wanted the resident transferred to the hospital. The DON stated she could not fully recall the details of the call. On the same date at 4:45 a.m. Staff C notified the resident's family of the resident's condition and they wanted the resident hospitalized for [REDACTED]. During an interview with Staff C on [DATE] at 8:12 a.m. when asked, why she didn't get an ambulance sooner than 4:45 a.m. when she charted at 2 a.m. that she was unable to obtain a pulse or blood pressure. Staff C stated, she didn't think the resident was that bad yet. Staff had other things to do besides just sit there and watch the clock go by, and there are other residents to care for and things to get done. An ED (emergency department) physician final report dated [DATE] revealed the resident arrived at the ED after staff found her unresponsive at the nursing home. When the emergency services personnel arrived the resident was hypoxic with oxygen in the low 80's. The resident had dryness and chapping of the mucus membranes. The resident's pupils were 2 mm (millimeters) and nonreactive. The resident's blood work on [DATE] at 6:23 a.m. revealed the following: Sodium 189 (HI) normal is 133 to 146 Chloride 150 (HI) normal is 97 to 109 Carbon [MEDICATION NAME] level 16 mMo/L (LOW) normal is 20 to 34 BUN (blood urea nitrogen) 99 (HI) normal is 10 to 28 Creatinine 3.71 (HI) normal is 0.6 to 1.2 Lactic Acid level 11.2 (HI) normal is 0.5 to 2.0 The resident was diagnosed with [REDACTED]. Nurses Notes identified the resident was back at the facility on [DATE]. No actual arrival time was documented but an entry dated [DATE] at 2 p.m. revealed the resident's family was at her bedside. On the same date at 2;20 p.m. revealed the resident admitted to Hospice care. On the same date at 2:50 p.m. staff was unable to obtain an apical pulse. The resident expired. Prior laboratory work dated [DATE] revealed the following: Sodium 144 Chloride 113 BUN 31 Creatinine 1.12 On [DATE] at 1:20 p.m. the ED physician stated with a sodium level of 189 he would guess that the resident had not drank fluids in the previous 4 to 5 days, if not longer. She could have been that way a couple weeks if she had occasional water. Staff should have been able to tell she was dehydrated for 3 to 5 days before the hospital. The resident was comatose when she arrived at the ED. He stated after the resident received 1 liter of fluid she as awake and following staff. The hydration made her responsive. Staff Interviews: On [DATE] at 1:34 p.m. Staff C, RN stated on the day the resident went to ED, the resident started making sounds like a sheep and she had never done that before. The day nurse and she thought the resident had pain and the resident got barely anything for pain control. Staff C stated she tried to give the resident crushed Tylenol on first rounds, and the resident was dry which was strange because the resident was usually incontinent of urine. Staff C repotted the resident looked gaunt like she could die. On the next round (between 2 a.m. and 4 a.m.) she checked the resident's vital signs and they were low, she didn't think the resident would make it. She called the resident's daughter who wanted her transferred to the hospital. The resident looked like she was dying. Staff C stated the resident was responsive up until 1 a.m. On [DATE] at 3 p.m. Staff A, CNA stated the 2 days before the hospital the resident did not eat or drink at all. On [DATE] at 12:25 p.m. Staff D, CNA stated the resident spit food out and got worse in the last week or two (2). The resident would holler and scream. The resident screamed with increased movement. Her mouth was dry but she slept with it open. She normally had deep sunken eyes. The resident could ask for drinks. On [DATE] at 12:14 p.m. Staff E, CNA stated the resident resident was eating and drinking less. When staff gave her a drink, she would plug the hole of the cup. She was not eating or drinking more frequently more and more to the end. She complained a lot when she was touched or moved. Even when she wasn't touched, she said ow. She was very stiff. On [DATE] at 1:32 p.m. Staff F, CNA stated the resident was in a lot of pain at the end. She made noises and acted funny for about a week before she passed away. She didn't want anything to eat or drink for a couple of weeks. On [DATE] at 1:17 p.m. Staff I, CNA reported the resident's drinking and appetite had decreased. On [DATE] at 12:08 p.m. Staff J, RN stated a few days before the resident expired she was in pain, her eating and drinking decreased and she held her lips together. She stated on the same date at 3:44 p.m. when she signed for Resource drink on the MAR that meant the resident drank it. On [DATE] at 3:07 p.m. Staff G, CNA stated the resident's eating and drinking decreased and the resident refused to eat and held her mouth closed. On [DATE] at 2:54 p.m. Staff H, stated the resident went down hill. The resident barely ate anyway but the week the resident expired, she would just have a spoon of food in her mouth and would spit it out. The resident wasn't as responsive and made sounds. The day before she expired the resident uncrossed her legs which was unusual because they were always crossed, then the next day they were crossed. Physician Interview: On [DATE] at 12:22 p.m. the resident's regular physician stated she would expect assessment and notification of changes in intakes and significant weight loss and documentation of the information. She stated she saw the resident on [DATE] and the resident seemed pretty normal then. The physician did not receive any information about changes at that time. When asked about Staff C's explanation for the 2 hour gap between a condition change and ambulance call, the physician stated that was not a good excuse. 2. A Minimum Data Set (MDS) with assessment reference date of [DATE], assessed Resident #1 with a brief interview for mental status (BIMS) score of 0 (severe cognitive impairment). The MDS did not identify behaviors including rejection of care. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident required extensive staff assistance with bed mobility, transfers, dressing, eating, personal hygiene and bathing. The resident did not ambulate and used a wheelchair for mobility. The resident was occasionally incontinent of bladder. The resident was 58 inches tall and 104 pounds. The MDS identified a weight loss of 5% or more in the last month or 10% in the last 6 months. The resident was not on a physician prescribed weight loss regimen. A (MONTH) (YEAR) Medication Administration Record (MAR) identified the resident weighed 95.4 pounds on [DATE] and 90 pounds on [DATE] (significant weight loss of 5% in 2 weeks). A Nutritional Assessment sheet dated [DATE] revealed the resident's fluid intakes varied. The resident's food intake was less than the desired amounts and the resident had significant weight loss. The assessment identified that the resident received Resource 2.0 supplement 60 cc twice a day and Breeze supplement with meals and milk shake at bedtime. Staff increased fats all as accepted by resident. The assessment did not identify food likes other than a history of preferring morning servings . Review of the (MONTH) (YEAR) MAR showed no Resource drink listed. Review of (MONTH) (YEAR) and (MONTH) (YEAR) MARS showed the Resource was discontinued on [DATE]. On [DATE] at 9:40 a.m. the DON stated the kitchen delivered the Breeze supplement and milkshakes so those would not be on the MAR. The Resource should be recorded on the MAR. A Clinic Nursing Home Note dated [DATE] revealed the physician saw the resident and documented she was slowly deteriorating overall and her weight was 94.4 pounds. Her [DIAGNOSES REDACTED]. Daily food intake records identified the following: [DATE] breakfast 35%, lunch 0 and supper 0 [DATE] breakfast 0 lunch 0 and supper 0 [DATE] breakfast 0 lunch 0 and supper 0 [DATE] breakfast 0 lunch 0 and supper 0 [DATE] breakfast 0 lunch 0 and supper 0 [DATE] breakfast 0 lunch fluid only and supper shake [DATE] breakfast shake lunch shake and supper 0 [DATE] didn't get anything for all three meals [DATE] expired There were no fluid intake records. Nurses Notes dated [DATE] at 1:30 p.m. revealed the physician saw the resident. The next entry was dated [DATE] at 5 p.m. and revealed the resident had a mental/physical status decline. The facility notified the resident's responsible party of the change. The entry identified the resident did not eat or drink anything that shift. The resident did not respond to verbal or tactile stimuli. There was no signs or symptoms of pain/discomfort. Staff provided the resident with comfort care and repositioning every 2 hours. Nurses Notes dated [DATE] at 9 p.m. revealed the resident continued non-responsive. Nurses Notes dated [DATE] at 1 a.m. identified the resident resting with eyes closed. No response to interaction. Respirations 16 and shallow. At 11 a.m. the resident rested with eyes closed. Non-responsive. No intake. The resident's skin was pale with mottling. At 1 p.m. the resident rested with agonal (difficult breathing prior to [MEDICAL CONDITION]) breathing. On the same date at 2:10 p.m. staff found the resident expired. There was no assessment or physician notification of lack of intakes and declines after [DATE]. Physician Interview: On [DATE] at 10:58 a.m. the physician stated he would expect notification of no intakes and a significant weight loss. He stated he would also expect assessment and documentation regarding the resident during that time. He stated the resident was slowly failing over a long period of time. The lack of intakes reflected her end of life condition related to her advanced dementia. Staff Interviews: On [DATE] at 3 p.m. Staff A, CNA (certified nurse aide) stated the resident always tootled around in her wheelchair but the 1 to 2 weeks before she died she didn't. She also did not eat or drink. She would not even open her eyes, she just laid her head on the table. Staff reported it to nurses and they said to try and give her a milkshake but she did not take it. The resident used to resist care at bedtime but the week before she died she did not resist. On [DATE] at 12:52 p.m. Staff B, LPN (licensed practical nurse) stated the resident did not seem to have pain. She just wanted to sleep. She would push her tongue over the cup opening when staff tried to give her a drink . She would pocket food or not let it in her mouth. The day she passed away a CNA tried to give her a drink but she didn't want anything. On [DATE] at 1:34 p.m. Staff C, RN (registered nurse) stated the week or 2 preceding the resident's death the resident lost a lot of weight. Staff had kept the resident in her room and the resident did not eat or drink. On [DATE] at 12:25 p.m. Staff D, CNA stated the day before the resident expired she was not very responsive and looked like she was dying. In the week or 2 preceding the death, the resident refused food and drink more. She refused a little more, more often until eventually she took nothing. On [DATE] at 1214 p.m. Staff E, CNA stated the day before the resident expired she was up in her wheelchair. She stated the resident slept all day and did less 'tooting in the wheelchair. Before she expired the resident just sat there. Staff E thought the resident was alert the day before she expired. She stated gradually the resident didn't eat or drink anything. More so the last 4 to 5 days. Then it got to where the resident would fake sleep through the meal. On [DATE] at 1:32 p.m. Staff F, CNA stated a week before the resident passed away she just shut down, got quiet and wouldn't talk. She declined eating and drinking for a couple weeks. Staff F stated the resident received the milkshake for a long time because of weight loss. That was hard for staff to get down the resident too. On [DATE] at 3:07 p.m. Staff G, CNA stated before the resident expired she became dead weight. The resident was sleepier than usual. She would refuse food and liquid and hold her mouth closed. The resident loved Mexican food and tacos and would always eat that. On [DATE] at 2:54 p.m. Staff H, CNA stated the week before the resident expired she went downhill. She would sleep in her chair instead of watching staff like she usually did. Staff H noticed something was wrong. A couple days before she passed, she refused food and they tried to give her shakes and liquids. The last week before she expired the resident did not urinate at all. The resident usually urinated heavily on his shift. Staff H told the nurse. 3. A MDS with assessment reference date of [DATE] revealed Resident #5 with a BIMS score of 13 (no cognitive impairment). The resident required limited staff assistance with bed mobility, transfers and dressing. The resident had [DIAGNOSES REDACTED]. Nurses Notes dated [DATE] (no time listed) revealed staff received a return fax related to numerous loose stools. Staff received orders to obtain a stool specimen to rule out [MEDICAL CONDITION]. There was no information available that an assessment was completed or any previous entry documented about loose stools. The [DATE] fax revealed the resident had loose stools since [DATE] and had a loose stool every time she used the bathroom. The resident had a low grade temperature of 100.6 degrees and the resident was lethargic. There was no abdominal assessment. Nurses Notes dated [DATE] at 10 a.m. revealed staff sent a stool sample to the clinic. The entry did not contain any information about an assessment. Nurses Notes dated [DATE] at 9:25 a.m. revealed staff notified the resident's responsible party about a status change. the responsible party wanted the resident sent to the hospital. The entry did not contain information regarding an assessment. On [DATE] the DON provided a cover page to a fax which contained the date [DATE]. The fax stated to see attached nursing assessment due to recent GI (gastrointestinal) changes. The fax contained a nursing assessment dated [DATE] at 11:50 p.m. The assessment revealed the resident had dim to absent bowel sounds on the left side and the resident had multiple incontinent stools that were yellow mucus with increased odor. The resident had pain rated at 7 on a scale of 0 for no pain to 10 the worst pain. Staff gave Tylenol ([MEDICATION NAME]) at 10:30 p.m. for resident moaning. The resident's abdomen was distended and tender to touch. The resident hollered out when staff palpated the right lower quadrant. A PRN Medication Administration Record (MAR) identified staff administered Tylenol on [DATE] at 23. The entry did not say why or if it was effective On [DATE] at 9:50 a.m. the DON stated staff sent the fax on [DATE] at 11:50 p.m. to the Buffalo Center clinic. When the clinic personnel arrived the next morning ([DATE]) they faxed it at 7:43 a.m. to the Forest City Clinic because the physician was not in Buffalo Center on [DATE]. The physician saw the fax and returned it with a response on [DATE] at 11:35 a.m. The response questioned if the resident wanted the hospital. Nurses Notes revealed on [DATE] at 10:05 a.m. the resident left the facility for the hospital per ambulance. A hospital History and Physical (H & P) dated [DATE] revealed the resident presented to the ED with abdominal pain. She had the pain for 2 weeks but it was worse lately. The H & P revealed the resident had [MEDICAL CONDITION] most likely infectious. A CT of the abdomen included ischemic and infectious etiologies. The H & P also identified an inguinal rash with satellite [MEDICAL CONDITION] present. There was no documentation available from the facility to identify they assessed the inguinal rash. On [DATE] at 12:25 p.m. the DON confirmed she could not find anything about the facility assessing the inguinal rash. Nurses Notes dated [DATE] at 3 p.m. revealed the resident returned to the facility. Observation on [DATE] at 9:45 a.m. show the resident seated in a wheelchair in her room. The resident stated she had diarrhea that was going on all the time before the hospital. The resident stated it wasn't that bad and she just thought it was from the food she was eating. The resident stated she can't have tomato and that the facility makes a lot of food with tomato. On [DATE] at 11:51 a.m. the DON reported the resident's groins were clear. On [DATE], the facility abated the Immediate Jeopardy by providing education to the professional nursing staff which included nursing assessment, communication to family and providers, change of condition detection and signs and symptoms of dehydration. The scope and severity of the deficiency was lowered from a J to a D with the need for ongoing monitoring to ensure nursing assesses residents with change of condition.

Based on record review and staff interviews, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents reviewed. Resident #2 had evidence of pain that was not controlled by scheduled Tylenol ([MEDICATION NAME]). Facility census was thirty-four residents. Findings include: 1. A MDS with assessment reference date of [DATE] assessed Resident #2 with a BIMS score of 0 (severe cognitive impairment) The MDS did not identify behaviors including rejection of care. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident required total staff assistance with bed mobility, transfers, dressing, eating, personal hygiene and bathing. The resident did not ambulate and used a wheelchair for mobility. The MDS did not identify the resident with pain indicators. A Do Not Resuscitate Request (DNR) dated [DATE] revealed the resident did not want chest compressions, defibrillation or intubation. The form identified the DNR decision would not prevent the resident from obtained other emergency care which would make the resident more comfortable which included but was not limited to: pain medication, fluid therapy and respiratory assistance. A (MONTH) (YEAR) Medication Administration Record [REDACTED].) at 8 a.m., 6 p.m., and 12 p.m. and every 4 hours as needed for pain. The (MONTH) (YEAR) MAR indicated [REDACTED]. A Clinic Nursing Home Note completed by the physician on [DATE] revealed an order for [REDACTED]. Nurses Notes: Nurses Notes dated [DATE] at 9:30 p.m. revealed staff reported the resident saying ow and hollering out with movement of any kind. The resident was very stiff and difficult to do range of motion with. The resident receives scheduled Tylenol ([MEDICATION NAME]). Nurse's Notes dated [DATE] at 5 p.m. revealed the resident showed signs and symptoms of pain/discomfort. At times the resident would holler out ow and have a facial grimace. At times the resident would stiffen her body out. Nurse's Notes dated [DATE] at 1 a.m. the resident hollered out with with movement and transfers. The resident stated ow when moved. The resident was awake for most of the night, talking out loud. Staff repositioned the resident every 2 hours. At 4 p.m. of the same date the resident continued to yell out with any movement and said ow and straightened her body out. On the same date at 8 p.m. the resident yelled with any movement. She said ow or just screamed and straightened her body. Staff continued to administer scheduled Tylenol ([MEDICATION NAME]). On the same date at 10:40 p.m. the resident rested in bed with no hollering at that time. Nurse's Notes dated [DATE] at 6:30 p.m. and documented by Staff C, RN (registered nurse) the resident moaned continuously in the gerichair and pulled her legs up towards her chest. Staff gave Tylenol but the resident spit some of it out. Staff could not determine where the resident's pain was and the intensity due to the resident's nonverbal status. Nurse's Notes dated [DATE] at 2 a.m. The resident's condition appeared worse. The resident's eyes looked sunken and dark and the resident's feet were cold and blue. Respirations 40. The nurse was unable to feel pulses as the pulse was too weak and she could not obtain a blood pressure. Staff notified the DON (director of nursing). On [DATE] at 2:10 p.m. the DON stated Staff C, RN did call her saying the resident was not doing well. She said she called the resident's family. The DON told Staff C to find out if the family wanted the resident transferred to the hospital. The DON stated she could not fully recall the details of the call. On the same date at 4:45 a.m. Staff C notified the resident's family of the resident's condition and they wanted the resident hospitalized for [REDACTED]. The resident was diagnosed with [REDACTED]. Nurses Notes Notes dated [DATE] identified the resident back at the facility, no actual arrival time was documented. An entry dated [DATE] at 2 p.m. revealed the resident's family at her bedside. On the same date at 2;20 p.m. revealed the resident admitted to Hospice care. On the same date at 2:50 p.m. staff documented unable to obtain an apical pulse, resident expired. Staff Interviews: On [DATE] at 1:34 p.m. Staff C, RN stated on the day the resident went to ED (emergency department), the resident started making sounds like a sheep. The resident never did that before. The day nurse and Staff C thought the resident had pain. The resident got barely anything for pain control. Staff C tried to give the resident crushed Tylenol. On [DATE] at 3 p.m. Staff A, CNA stated the 2 days before the hospital she had pain. Even if staff just touched the resident she would say ahh loudly as if in pain. The resident always had her legs crossed and when staff placed her legs on the pillow she would scream. On [DATE] at 12:52 p.m. Staff B, LPN (licensed practical nurse) stated she could tell the resident was in pain. She stated sometimes staff was not able to get the resident to take Tylenol and it was not effective anyway. In the 1 to 2 weeks prior to her death, the resident had more pain. When asked why she wrote a 0 by the resident's pain level on the (MONTH) MAR indicated [REDACTED]. She stated she approached the former MDS nurse to report the resident had more pain and she more or less told Staff B that she didn't know what she was doing. Staff B had to go through the MDS nurse to get more pain medication for the resident. Staff B stated she did a pain assessment on the resident. Later on [DATE] the doctor came to the facility and the MDS nurse took the physician into her office and told her she never saw any of the things that Staff B identified on the pain assessment so the physician did not change the resident's pain medication. A pain assessment dated [DATE] revealed the resident had the following indicators of pain: noisy labored breathing, long periods of hyperventilation, cheyne stokes respirations, repeated troubled calling out with loud moaning and groaning, crying, facial grimacing, rigid, fists clenched, pulling or pushing away, striking out, unable to distract or reassure. The total of the assessment was 10. An increased score suggested an increase in pain. The MDS nurses documented on the form that the physician reviewed the pain assessment on [DATE]. On [DATE] at 12:25 p.m. Staff D, CNA stated in the last week or 2, the resident would holler and scream. The resident screamed with increased movement. On [DATE] at 12:14 p.m. Staff E, CNA stated the resident was feisty with any type of care. She complained a lot when she was touched or moved. Even when she wasn't touched, she said ow. She was very stiff. On [DATE] at 1:32 p.m. Staff F, CNA stated the resident was in a lot of pain at the end. The resident made noises and acted funny for about a week before she passed away. She didn't want anything to eat or drink for a couple of weeks. On [DATE] at 1:17 p.m. Staff I, CNA stated the resident seemed to have more pain. She would holler out. On [DATE] at 12:08 p.m. Staff J, RN stated a few days before the resident expired she was in pain. She had pain when she was rolled up or gotten up. She only had pain with movement On [DATE] at 3:07 p.m. Staff G, CNA stated the resident was more resistive and seemed to have pain. Staff G could just tell she was in discomfort. On [DATE] at 2:54 p.m. Staff H, stated the resident went down hill. The day before she expired the resident uncrossed her legs which was unusual because they were always crossed. The next day they were crossed. When interviewed on [DATE] at 3:58 p.m. Staff K, CNA stated a couple weeks before the resident expired she seemed to have more pain. She reported the former MDS nurse was told but blew it off. The resident would just sit there and scream in pain . When Staff asked if she hurt the resident said yeah. Staff K, stated she didn't think everyone believed the resident. The resident also grimaced when she was rolled and make noises indicating discomfort.

Based on observation, record review, staff interviews and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents are reported immediately to managerial staff per facility policy and to the Iowa Department of Inspections & Appeals within 24 hours or the next business day (Resident #1, #7 #8, #9, #14, #15, #16, #17). This was scoped as widespread immediate and serious jeopardy since multiple staff witnessed a CNA (certified nursing assistant) mistreat residents and then did not report to managerial staff or the Iowa Department of Inspections and Appeals. This delay placed all residents at risk for abuse and mistreatment since the staff member continued to care for residents and was not seperated from the residents living at the facility. The facility reported a census of 38 residents and the sample consisted of 22 residents. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 6/12/17, indicated Resident #1 had unspecified dementia without a behavior disturbance, anxiety and [MEDICAL CONDITION]. The assessment indicated the resident had fluctuating disorganized thinking and independent with activities of daily living. A Care Plan with a nursing [DIAGNOSES REDACTED]. The approaches included the following: Assist with dressing at night. Assist with grooming as requested. Assist with perinea cares in the morning, evening and as needed. During an interview 8/18/17 at 9:24 a.m., Staff B confirmed the resident complained that Staff C had been rude, yelled at him/her and would not assist the resident as he/she requested. During an interview 8/18/17 at 9:40 a.m., Staff R, CNA confirmed the resident complained the pregnant staff member (Staff C had been the only staff pregnant at the time) would never assist him/her and that she had been mean. During an interview 8/29/17 at 10:43 a.m., Staff A, CNA confirmed there had been a time the resident cried and upset because had not wanted Staff C to put him/her to bed because he/she had been scared of her. Staff A stated the resident stated she had been so mean. 2. A MDS assessment form dated 5/15/17, indicated Resident #7 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 14, as non-ambulatory, dependent on 2 staff members with transfers, dressing and toilet use. The assessment indicated the resident experienced occasional bladder incontinence. A Care Plan with nursing [DIAGNOSES REDACTED]. The approaches included the following: The resident uses the commode for the bathroom. The resident uses the EZ (mechanical) stand lift for all transfers. During an interview 8/18/17 at 11:29 a.m., the resident confirmed Staff C as unkind and further described as follows: When the resident requested to be transferred from the bed to the chair, the staff member responded by, I don't think so. The staff member had sworn at him/her and witnessed by Staff M, CNA. When Staff M heard Staff C swear at the resident she stated, I cannot believe she talked to you that way. An example of swearing had been further described as follows: We cannot get you on and off (commode) all the time whenever you damn well please. As the interview continued, the resident stated he/she could not understand how the staff member worked with residents because she had not been nice. When the staff member was pregnant, she was real moody so the resident thought it had just been the pregnancy. The resident stated when the staff member left and came back, she/he felt real nervous because did not know how she/he would be treated because she had just been a (bi ch- expletive). Another example had been further described as follows: When the resident requested to get up for the day he/she received morning cares, urinated and went to eat breakfast. After breakfast the resident again requested to go to the bathroom to have a bowel movement. When Staff C arrived she got the resident up and then yelled why can't you poop and pee at the same setting because it took too much to get the resident on and off of the commode. The resident stated this caused her/him to feel like crap (worthless, rubbish). The resident stated, to this day, when able to defecate and urinate at the same time, she/he thinks, Staff C would be so proud of me. During an interview 8/18/17 at 9:24 a.m., Staff B confirmed she observed Staff C as she yelled at the resident and said Why can't you poop and pee at the same time ? During an interview on 8/2/17 at 10 a.m., Staff Q, CNA, confirmed she observed Staff C yell at the resident and said Why can't you poop and pee at the same time ? The staff member denied having heard Staff C swear and/or threaten the resident. The staff member stated she reported the incident to an unknown staff member. The interview with the resident continued and the resident confirmed she also witnessed the staff member around other residents and mean in the lounge area. An example of this behaviors had been further described as follows: When Resident #7 said, Jesus, Jesus why did I have to come here. Staff C said, you know why. Because this is the best place for you and then the staff member turned her back to the resident and said within ear reach of other residents, I do not know why in the f k (expletive), he/she had to say that. 3. Review of a MDS assessment form dated 6/14/17, Resident #8 had [DIAGNOSES REDACTED]. The assessment indicated the resident could make self understood and understood others. The MDS identified the resident had a BIMS score of 0. A score of zero represented a severe cognitive impairment and the resident had fluctuating inattention and disorganized thinking, physical and verbal behavior towards others 1-3 days and other behavior symptoms not directed towards others 4-6 days. The assessment indicated the resident required extensive assistance of 1 staff member with toilet use, personal hygiene and dressing, required limited assistance of 2 staff with transfers, ambulation and locomotion and as occasionally incontinent of urine and frequently incontinent of bowel. According to a Care Plan with nursing [DIAGNOSES REDACTED]. The approaches included and directed the staff to do the following: Explain what you are doing before you are doing it. Provide 1 to 1s as needed. During an interview 8/29/17 at 10:43 a.m., Staff A, CNA stated on the 6 a.m. to 2 p.m. shift during a weekday, she observed Staff C toilet the resident in the shower room across from the Medicare Coordinator's office due to the resident incontinent of feces and quite agitated and screaming. The resident refused to remain seated on the toilet to enable proper cleansing so Staff C pulled the resident's hands away from his/her pants and pushed his/her hands down in an inappropriate manner. Staff C yelled at the resident and said J .s Ch st (expletive), knock it off. Staff A stated that encounter went on for a couple of minutes. At that point the Director of Nursing (DON) walked into the shower room, asked what had been going on and took over for Staff C who exited the room. 4. Review of a MDS assessment form dated 5/25/17, Resident #9 had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS score of 12, non-ambulatory and dependent on staff with bed mobility and transfers. According to a Care Plan with nursing [DIAGNOSES REDACTED]. During an interview 8/18/17 at 9:40 a.m., Staff R, CNA, confirmed that Staff C said to the resident God d it (expletive). Roll over. The resident could not roll over very well due to [MEDICAL CONDITION](stroke). 5. A MDS assessment form dated 7/29/17, identified Resident #14 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 15. A score of 15 identified the resident had no cognitive problems. The MDS indicated the resident could not walk, required extensive assistance of 2 staff members for bed mobility and depended on staff for transfers, dressing, toilet use and personal hygiene. A Care Plan with nursing [DIAGNOSES REDACTED]. During an interview on 8/29/17 at 12:25 p.m. the resident confirmed Staff C being unkind and a bi h (expletive). Resident #8 stated When the staff member repositioned the resident she roughly pulled on the resident's clothes to do so to the point the resident could hear the threads as they tore. The resident told the staff member to take it easy. The resident stated Staff C yelled and swore at him/her. 6. A MDS assessment form dated 7/9/17 indicated Resident #15 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 0, had fluctuating disorganized thinking and as non-ambulatory and dependent on 2 staff with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. A Care Plan with nursing [DIAGNOSES REDACTED]. The approaches included and directed the staff to: Explain all procedures before doing anything to the resident. The resident will have intermittent outbursts and reassure at times. During an interview 8/11/17 at 9:45 a.m., Staff D, Certified Nursing Assistant (CNA) stated she observed Staff C, CNA become upset with the resident during cares because the resident had been combative. Staff D stated she saw Staff C grab the resident' arm and leg and yanked him/her across the bed. Staff D then just walked out of the resident's room because she had been so upset. Staff D stated she failed to report the incident to any other staff member and/or management person. The resident yelled ouch. 7. A MDS assessment form dated 8/13/17, indicated Resident #16 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 15 and independent with transfers and ambulation but required extensive assistance of 1 staff member with bathing. A Care Plan with nursing [DIAGNOSES REDACTED]. The approaches included the following: The resident is not always compliant with bathing 2 times a week. Assist the resident to destinations. Remind the resident to pick up feet when walking, slow down and think. Staff will be matter of fact and direct with cares. Approach the resident in a positive manner. During an interview on 8/18/17 at 9:24 a.m., Staff B,CNA confirmed she witnessed Staff C grab the resident's arm, yanked it and said Come on. The staff member stated she reported the incident to Staff P, Registered Nurse (RN). During an interview 8/18/17 at 11:18 a.m., Staff P stated she had no allegations of abuse involving Staff C (swearing the F .k (explicit) word to a resident and/or having yanked a resident's arm) During an interview on 8/2/17 at 10 a.m., Staff Q, CNA stated she observed Staff C grab the resident's arm, yanked it and said let go. The staff member stated she reported the incident to an unknown nurse. During an interview on 8/29/17 at 11:30 a.m., the resident could not recall any staff member having grabbed or yanked his/her arm. The resident, however, recalled an incident during the showering process when a long brown haired lady, medium height and a little more than skinny had been rough with him/her during the shampooing process. The resident stated it made him/her feel not very good. The resident told her to stop but she refused. The resident stated she/he did not report the incident to any staff member. An observation on 8/30/17 at 2 p.m., identified Staff C with a short to medium height status, smaller stature, shoulder length brown hair with highlights. 8. A MDS assessment form dated 7/28/17 indicated Resident #17 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 14, had continuous disorganized thinking and required extensive assistance of staff with bed mobility, transfer, ambulation, toilet use and personal hygiene. A Care Plan with nursing [DIAGNOSES REDACTED]. The Care Plan identified the resident had an impaired physical mobility and required assistance with all transfers and ambulation. During an interview 8/18/17 at 9:24 a.m., Staff B, CNA stated she witnessed Staff C blatantly swear at the resident. Staff B stated that Staff C said Stand the f k (expletive) up. During an interview on 8/29/17 at 11:40 a.m., the resident stated he/she could not recall any staff members having been rough, disrespectful and/or unkind. Then he/she went onto say They have a country western change over and she won a Cadillac. During an interview on 8/18/17 at 7:17 a.m., Staff H, CNA stated she witnessed Staff C raise her voice and hollered (yelled) at the residents and appeared rough with residents during their cares. Staff H explained Staff C would walk with residents and if the resident could not walk fast enough, she would then drag the resident so the resident would walk faster. Review of the policy and procedures titled Abuse (not dated) included the following: Abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. That also included the deprivation by an individual, including a caretaker of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. Verbal abuse is defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within ear distance, regardless of their age, ability to comprehend or disability. Mental abuse included but had not been limited to humiliation, harassment, and threats of punishment or deprivation. Mistreatment meant inappropriate treatment or exploitation of a resident. All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should have been reported to the Iowa Department of Inspections ad Appeals no later than 2 hours after the allegation had been made, if the events that caused the allegation involved abuse and resulted in serious bodily injury or not later than 24 hours if the events that caused the allegation involved abuse but do not result in serious bodily injury. Note: At the time of the complaint investigation, the complaint was coded at a L, immediate and serious jeopardy. On 8/11/17, the Administrator had suspended Staff C. By 8/18/17, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the F level. The Administrator provided and finished dependent abuse training on 8/18/17, to all facility staff and agency staff. The Administrator provided additional training and review of the Residents' Bill of Rights and the facility Mission Statement that employees may not be supervised by blood relatives or relatives by marriage. Staff C is a relative to the Director of Nursing and staff did not report the actions of Staff C to the Director of Nursing or the Administrator, do to fear of losing job. As of the 9/1/17 exit conference, the facility needed to: · Continue to educate staff of the abuse, dignity and resident rights to employees. · Continue to monitor staff to ensure the policy and procedures are followed and alleged abuse is reported per facility policy.

Based on observation, record review, resident, staff and physician interviews and review of the policy and procedures, the facility failed to provide timely resident assessments and interventions when a resident had a change in condition (Resident #1, #2, #3 and #4). The sample consisted of 5 residents and the facility identified a census of 38 residents. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 6/12/17 indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, had fluctuating disorganized thinking and as independent with all Activities of Daily Living (ADL's). A Care Plan with nursing [DIAGNOSES REDACTED]. A Fall Incident Report form dated 4/8/17 at 1:45 P.M. revealed the resident rolled out of bed with no injuries. Observation of photos on 8/17/17 at approximately 3:35 p.m. revealed the following photos as time stamped on a cell phone and described as follows: On 4/16/17 at 9:40 a.m. - A dark red bruise with a white center on the resident's left middle upper shoulder. On 4/16/17 at 9:40 a.m. - The entire posterior left arm region discolored yellow on the top portion and purple along the bottom. On 4/16/17 at 9:40 a.m. - A dark purple bruise on the inner aspect of the resident's right arm. Review of the resident's medical record identified no assessment and/or interventions for the above described areas. During an interview on 8/17/17 at 10:41 a.m., Staff S, Registered Nurse (RN) stated she never witnessed any bruising on the resident post fall. During an interview on 8/17/17 at 10:47 a.m., Staff P, RN confirmed she performed full body assessment post falls and never witnessed any bruising. During an interview on 8/17/17 at 10:54 a.m., Staff T, Licensed Practical Nurse (LPN) stated she never witnessed any substantial bruising on the resident but she had never completed a full body assessment because she had never been informed of such bruising. During an interview on 8/17/17 at 1:50 p.m., Staff U, Restorative Aide, confirmed she observed a bruise on the resident's hip but could not recall if the bruise had been following a fall. Review of the Nurse's Notes and a fax form revealed the following entries as dated and described: On 4/29/17 at 4:04 p.m. - Per Nurse's Notes, A fax had been sent to a Physician pertaining to a green crust draining from his/her reddened eye. On 4/29/17 at 4:04 p.m. - Per a Fax Form, The resident had green crust on the tear duct area of the left eye. The tear duct had been red and the resident reported the area itched at times. The resident received Fresh Kote eye gtts 2 times a day. (BID) On 5/1/17 at 9 a.m. - A telephone order had been received for [MEDICATION NAME] one drop (gtts) to the left eye 4 times a day (QID) for one week due to [MEDICAL CONDITION]. There had been no further assessment of the eye status. On 5/2/17 at 2:40 p.m. - Staff spoke with a Physician about the resident's eyes and the [MEDICATION NAME] ordered 5/1/17. The physician ordered [MEDICATION NAME] gtts to both eyes QID for 1 week. The record identified no further assessments of the resident's eye status prior to discharge on 6/15/17 in the resident's medical record. Review of the Nurse's Notes revealed the following entries as described: On 6/5/17 at 8:30 a.m. - Received a telephone order from a physician to obtain a urinalysis (UA) with a culture and sensitivity (C&S) due to increased confusion, frequency and incontinency. There had been no further assessment of the resident's actual urine pain with urination and/or vital signs. On 6/5/17 at 10 a.m. - staff obtained a UA and sent it to the Physician. There had been no further assessment of the resident's actual urine pain with urination and/or vital signs. On 6/5/17 at 11 a.m. - results of the UA obtained and the physician informed. On 6/6/17 at 3 p.m. - the physician observed the results of the UA and requested to await the results of the C&S. From the above entry and until 6/9/17, the record noted no further assessment of the resident's actual urine pain with urination and/or vital signs. On 6/9/17 at 9:45 p.m. - the facility received the results of the C&S and informed the physician. The notes indicated no further assessment of the resident's actual urine pain with urination and/or vital signs. From the above entry until 6/12/17 at 10:50 a.m. no further assessment of the resident's actual urine pain with urination and/or vital signs. The note indicated the resident sent for an appointment due to a fall and never returned. A Urinalysis with Microscopic Auto form dated 6/5/17 at 10:29 identified the following abnormal values: 1 + bacteria and mucus in the urine. 3-5 Squamous [MEDICATION NAME] Cells and White Blood Cells in the urine. (normal values 0-5) 2. Resident #2 had a MDS assessment with a reference date of 5/29/17. The MDS indicated the resident had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 0, fluctuating inattention and disorganized thinking and ambulated independently. The BIMS score of 0 identified the resident with a severe cognitive impairment. A Care Plan with Nursing [DIAGNOSES REDACTED]. Review of the Nurse's Notes, Patient Communication Form and a Fall Incident Report identified the following entries as dated and indicated the following: On 5/23/17 at 4:20 p.m. the following entry in the Nurse's Notes - The resident returned from an physician appointment with a new order to discontinue [MEDICATION NAME] eye gtts (antibiotic) and start Tornado ophthalmic suspension 1 gtt to the right eye 4 times a day (QID) until clear. There had been to assessment related to the status of the eye. Review of the resident's medical record indicated no further documentation about the resident's eye status thru 8/1/17. On 7/26/17 at 8:10 a.m. the following entry on a Fall Incident Report Form - The resident had been found on the floor by staff and complained of knee pain. On 7/26/17 entries revealed the resident's left pupil a delayed at 8:10 a.m., 8:25, 8:40, 8:55, 9:10, 9:40, 10:10, 11:10, 12:10 p.m., 1:10 p.m 3:10 p.m., 6:10 p.m., 10:10 p.m. and on 7/17/17 at 8:10 as delayed. On 7/26/17 at 9:33 a.m. the following communication/directive to the facility staff from the physician - The facility staff called and stated the patient fell that morning and hit his/her head. The staff stated the resident's pupil delayed. Per verbal order the Physician directed the staff to watch the level of consciousness, if more tired than usual and to continue to observe the pupils. An appointment reserved for him/her in case there had been changes. review of the resident's medical record revealed [REDACTED]. 3. Resident #3 had a MDS assessment with a reference date of 4/25/17. Resident #3 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 9, had fluctuating disorganized thinking, non-ambulatory, and dependent on 2 staff with toileting and had a bladder indwelling catheter. A Care Plan with nursing [DIAGNOSES REDACTED]. The approaches included the following: Make sure to measure output. Catheter irrigation as needed if bleeding or not functional. Review of the Nurse's Notes included the following documentation: On 4/27/17 at 10 p.m. - Foley draining dark red blood with clots. On 4/27 at 11 p.m. - The Foley catheter continued to drain dark red blood with stringy red clots. On 4/28 at 12:45 a.m. - Foley continued with frank blood in the catheter bag. On 4/28 at 2 a.m. - Foley continued with dark red blood. On 4/28 at 3 a.m. - The resident complained of pressure and the need to void. The nurse performed a catheter irrigated with continued return of dark red clots. On 4/28 at 4:50 a.m. the nurse irrigated the catheter with no clots observed. The note indicated the blood in the urine was described as a lighter color. On 4/28 at 8 a.m. - frank blood remained in the catheter bag. On 4/28 at 9:30 p.m. - 275 cubic centimeters (cc's) of frank blood noted in the catheter bag. On 4/29 at 3 a.m. - Foley continued to drain dark red fluid without clots. On 4/30 at 9:30 a.m. - Foley catheter irrigated with 275 cc output. The note had no documented description of the urine. On 5/1 at 2:45 a.m. - Foley drained yellow urine. On 5/1 at 12 p.m. - Foley drained yellow urine. Review of the resident's medical record identified no further documentation about the Foley catheter and/or urine until 8/7/17 at 3:35 a.m. At this time, the resident hollered for assistance to urinate. The staff member explained to the resident he/she had a catheter which drained clear yellow urine. 4. Resident #4 had a MDS assessment with a reference date of 6/12/17. The MDS indicated the resident had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 11 which identified a moderate cognitive impairment. The MDS indicated identified the resident as non-ambulatory, required extensive assistance of staff with toilet use and experienced frequent episodes of urine incontinence. A Care Plan with the Nursing [DIAGNOSES REDACTED]. The approaches included the following: Provide me with morning, evening and PRN perineal cares. Consult with the physician. A Lab Result Report dated 6/15/17 at 7:40 a.m revealed the resident had greater than a 100,000 colonies of Escherichia Coli (bacteria-generally found in the colon). Review of the facilities Nurse's Notes included the following entries as dated: On 6/12/17 at 6:30 p.m. - Temperature (T) 98.7 (normal 98.6) degrees, blood pressure (B/P) 160/94 (elevated), pulse (P) 79 (normal 60-100), respirations (R) 20 (normal 16-20), oxygen saturation rate 02 sat 94% at room air (normal 97-100%). Alert and oriented (A&0) times 3 (person, place and time), pleasant affect. Incontinent of bladder with frequency noted. Abdominal soft and non-tender, bowel sounds (BS's) active times 4 quadrants (of abdomen). The resident had no complaints of pain or discomfort. The record identified no further assessment of the resident's urinary status. On 6/12/17 at 10:30 p.m. - T 98.6, 158/89, 82, 20, 02 sat 94% at room air. Alert and oriented times 3, pleasant affect. The resident rested in bed without complaints of incontinency. The note indicated no further assessment of the resident's urinary status. On 6/13/17 at 2:30 a.m. - T 97.5, 159/88, 97, 20, 02 sat 91% at room air. Resting in bed eyes closed no complaints. There had been no further assessment of the resident's urinary status. On 6/13/17 at 6:30 a.m. - T 99, 141/89, 82, 20, 02 sat 92% at room air. No complaints of pain/discomfort. Skin warm and dry. Good appetite. Usually continent of bladder during the day. Dribbles so wore pull ups. A&O times 3, got confused at times. The record identified no further assessment of the resident's urinary status. On 6/13/17 at 8 a.m. - Per Physician obtain a UA and C&S due to being more incontinent with increased frequency and T. On 6/13/17 at 8:30 a.m. - UA obtained and sent to the clinic. No further assessment of the resident's urinary status. On 6/13/17 at 10:30 a.m. - T 97.5, 140/78, 69, 20, 02 sat 93% at room air. No complaints of pain/discomfort, pleasant and cooperative. The record indicated no further assessment of the resident's urinary status. On 6/13 at 2:30 p.m. - T 98.4, 140/80, 78, 20, 02 sat 93% at room air. No complaints of anything. The record and notes indicated no further assessment of the resident's urinary status. On 6/13/17 at 11:35 p.m. - Resident resting in bed at that time. Scheduled pain medication provided. Resident denied pain. Respirations deep and easy. The record and notes identified no further assessment of the resident's urinary status. On 6/14/17 at 3:45 a.m. - Resident rested quietly thus far in the shift. Had offered no complaints and incontinent of bladder. The resident changed and perineal care provided. The resident denied pain. The record and notes indicated no further assessment of the resident's urinary status. On 6/14/17 at 3:30 a.m. - T 98.6, 121/71, 80, 18, 02 sat 93% at room air. The resident had no complaints of pain/discomfort, A&O times 3 with moments of confusion. Continent of bowl and bladder with periodic dribbles. The record and notes identified no further assessment of the resident's urinary status. On 6/15/17 at 5 a.m. - Resting quietly in bed with eyes closed. No complaints of pain/discomfort. The resident A&O times 3 and incontinent of bladder. Fluids encouraged. The notes and record identified no further assessment of the resident's urinary status. On 6/15/17 at 6 p.m. - The resident pleasant throughout the shift. There had been no further assessment of the resident's urinary status. On 6/15/17 at 9 p.m. - T 98.6, 174/98, 71, 20, 02 sat 97% at room air. No complaints of pain/discomfort. A&O times 3. Fluids encouraged. The record and notes identified no further assessment of the resident's urinary status. On 6/16/17 at 6 a.m. - No complaints of discomfort. A&O times 3. Incontinent of urine. Fluids encouraged. The record and notes identified no further assessment of the resident's urinary status. On 6/16 at 6:30 p.m. - T 98.9, 187/97, 80, 18, 02 sat 90% at room air. Complained of slow response to orientation questions. Lung sounds with fine crackles at bilateral bases, no cough, and shortness of breath or wheezing. Heart rate strong without noted abnormal sounds. A trace of [MEDICAL CONDITION] noted on the bilateral lower extremities. Denied pain or other concerns at that time. The note and record identified no further assessment of the resident's urinary status. On 6/17/17 at 3:15 a.m. - No concerns noted. No complaints of pain or discomfort. A&O times 3. The record or notes identified no further assessment of the resident's urinary status. On 6/17/17 at 9 a.m. - The resident refused to eat any breakfast or take medications. Increased confusion noted with a decreased mental and physical status. T-100, 119/60, 79, 18 O2 sat 90% at room air. The notes and record identified no further assessment of the resident's urinary status. On 6/17/17 at 10 a.m. - Updated the Physician and received an order for [REDACTED]. On 6/19/17 at 10:10 a.m. - T 98.4, 111/65, 72, 18, 02 sat 91% at room air. Denied pain or discomfort. A&O times 3. Denied shortness of breath. Ate 2 pancakes without difficulty. No further emesis. Resident stated he/she felt much better. Resident continued receiving Bactrim DS. The note and record identified no further assessment of the resident's urinary status. On 6/19/17 at 2:20 p.m. - A telephone order received to change the resident antibiotic from Bactrim DS to [MEDICATION NAME] (antibiotic) 250 mg twice a day for 10 days. The note or record identified no further assessment of the resident's urinary status until from the above entry until 7/27/17 at 11:30 a.m. after a failed catherization attempt to obtain a UA. The nurse obtained an order to flush and irrigate the catheter and send to the ER (emergency room ) if unsuccessful. On 7/27/17 at 12:40 p.m. - The resident was transported to the ER. On 7/27/17 at 8:50 p.m. - The resident returned to the facility with a new order [MEDICATION NAME] mgs twice a day for a UTI (urinary tract infection). A written statement provided by a physician dated 8/17/17, identified the following: The physician expected staff to assess the resident's vital signs, mental status and gastrointestinal complaints when a resident exhibited signs and symptoms of a UTI. The physician expected staff to continue the assessments until the resident had gone 24 hours asymptomatic. UA results had been available the same day if sent to the clinic. If the results had been sent to the hospital the results had been available the following day, unless on Friday in that case the results had been available on Monday. The physician expected the facility staff to call him right away with abnormal results. If the facility had not received results from a UA he would have expected them to call the clinic for the results but not the hospital. Signs and symptoms of a UTI included a change in condition, frequency, dysuria, incontinence, fever and chills. On 6/13/17 the resident exhibited signs and symptoms of a UTI, however the physician had not been consulted until 6/17/17 and at which time he started the resident on an antibiotic. The physician confirmed he would have expected staff to have consulted him earlier. On 6/19/17 the physician changed the antibiotic ordered on [DATE] as a result of the C&S report but the facility did not assess the resident's urinary condition and/or health status until 7/27/17 which ultimately resulted in an emergency room visit. The physician confirmed he would have expected staff to have properly assessed the resident. A policy and procedures titled Timely Mission Nursing Home Procedure on Charting Change of Condition with Resident (not dated), included the following: a. Needed to chart and take vitals every 4 hours for the first 24 hours with the assessment of the residents. 1. Bowel sounds 2. Lung sounds 3. Response to stimuli verbal or tactile. 4. Orientation. 5. Any unusual behavior and interventions utilized. 6. Doctor and family notification. b. Needed to continue charting every shift for 48 hours at a total of 72 hours and longer if the condition did not improve c. When you charted DO NOT leave a time gap in charting . Chart findings also at the end of the shift and the beginning of the shift. A form titled STAFF NURSES (not dated) directed the staff when residents are assessed the following things needed to be done: a. Blood pressure, pulse, respirations and temperature. b. Lung sounds. c. Bowel sounds x (times) all 4 quadrants (of abdomen). d. Oxygen saturation level. e. Blood sugars. f. Mental status. g. Skin color. h. Skin dry or diaphoretic. i. Dependent [MEDICAL CONDITION].

Based on observation, clinical record review, resident, staff and a nurse Practitioner interview and facility policy review, the facility failed to properly assess and intervene when for a resident with skin breakdown that warranted a thorough assessment (Resident #2). The facility identified a census of 46 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment form dated 9/2/15, Resident #2 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. The resident required the assistance of two staff with bed mobility and transfers; and one staff assistance for ambulation, toilet use, and personal hygiene. The MDS identified the resident at risk for developing pressure ulcers, with one unhealed stage 1 pressure ulcer and as on no turning/repositioning program. According to a Braden Scale dated 8/24/15, 9/1/15, 9/8/15, 9/15/15 and 10/15/15, the resident scored an 18 which placed him/her at a mild risk for skin breakdown with an expected treatment plan as follows: a. Protect the heels b. An individualized turning schedule at least every 2 hours. c. Management of moisture, nutrition, friction and shear. d. Pressure reduction device if chair/bed fast. e. Advance to the next risk level if other major risks factors. Review of an initial care plan dated 8/26/15, indicated the resident had a history of [REDACTED]. Review of a Nursing History and Assessment form dated 8/26/15 at 3:30 p.m., revealed the resident as admitted to the facility with a 6 cm x 4 cm spongy area of the right heel. A geomat had been placed in the wheel chair and a pressure mattress on the resident's bed. The documentation failed to reveal a treatment to the area and a thorough assessment. Review of Care Plan dated 9/9/15 and 9/30/15, the resident had a potential for impaired skin integrity related to a reoccurring hip and heel ulcer ; and as admitted to the facility with a 6 centimeter (cm) x (by) 4 cm spongy area on the right heel. The approaches included the following: a. Examine the skin daily and report problems. b. Consult with the physician. c. Dressing changes per orders daily. d. Pressure reduction mattress on the bed frame. e. Wore a pressure red boot when not weight bearing. f. Encourage the resident to eat 3-4 ounces of meat and/or an equivalent at all meals. g. Monitor for signs and symptoms of [DIAGNOSES REDACTED]. The resident ' s record lacked any assessment after 8/26/15, until 12 days later on 9/8/15. Review of the facilities wound documentation for the resident revealed the following as dated (a-m): a. On 9/8/15 - 6 x 4 red mushy area with a decline in status. The resident ' s record lacked any assessment after 9/8/15, until 13 days later on 9/22/15. b. On 9/22/15 - The center area measured as a stage II ulcer at 7 x 4.5 with the entire area measuring at 7 cm x 7 cm and a decline in status. A Clinic Nursing Home Note dated 9/22/15 and signed by a physician, indicated the resident as admitted to the facility with a soft mushy right heel which developed into a 7 cm x 7 cm ulcer that had been debrided and very superficial. The resident ' s record lacked any assessment after 9/22/15, until 12 days later on 10/5/15. c. On 10/5/15 - 7 x 7 area with a 4 x 5 black eschar area and rhythmus. The documentation failed to reveal an intervention or physician notification. d. On 10/12/15 - 7 x 7 area with a 4 x 5 black eschar area with odor and placed on an antibiotic on 10/13/15. The Treatment Administration sheets from 9/8/15 to 10/13/15 revealed no change in treatment. e. The facilities wound documentation for the resident revealed on 10/19/15- admission to a hospital. A hospital Progress Note dated 10/19/15 at 3:08 p.m., documented the following: One wound noted - type (unstageable pressure ulcer complicated by [MEDICAL CONDITION] and diabetes - location (right medial heel) - size and depth (5.3 cm x 7 cm area with 50 % black eschar in center of wound and peripherally around eschar is a pink to red wound bed). Periwound callous with some duskiness noted intermittently - characteristics (no increased periwound redness or warmth noted - color (black, red) - discharge (scant amount, foul smelling and sero-sanguineous) a wound culture obtained. A Discharge Summary form dated 10/21/15, indicated the resident as admitted to the hospital on [DATE] for [MEDICAL CONDITION], foot pain-swelling and Type II diabetes mellitus with a foot ulcer. On admission at the hospital, the resident had been started on [MEDICATION NAME] and wound care nurse followed up with the resident. Once the wound culture returned, they added [MEDICATION NAME] to help cover. The resident stayed at the hospital for 3 days and his/her wound improved with less [DIAGNOSES REDACTED] and less eschar tissue. f. The facilities wound documentation for the resident revealed on 10/21/15, readmitted to the facility with a 4 x 4 black eschar area. g. The wound documentation dated 10/28/15 revealed surrounding tissue red but intact and with no odor and minimal drainage. h. The wound documentation dated 10/30/15, noted new orders from the wound clinic. A MD (medical doctor)/Nursing Communications form dated 10/30/15, indicated the resident's wound ulcer measured 4.5 cm x 6 cm [MEDICAL CONDITION] cm received new orders for a decubitus/right heal from the wound clinic. An addendum on the form dated 11/3/15 indicated the area with red drainage and a musky smell with a denial of pain and a dressing change. An Advanced Wound Center progress noted dated 10/30/15, revealed the following documentation: a. A diabetic ulcer on his/her right medial heel. b. Acquired 9/16/15. c. 4.5 cm x 6 cm with a depth of 0.7 cm. d. A small amount of sero-sanguineous exudate. e. No odor. f. 26-50% moist black eschar g. Pink granulation at 1-25%. h. [MEDICAL CONDITION]. i. The wound documentation dated 11/2/15, identified 7 cm x 5 cm, black eschar, no odor, a moderate amount of sero-sanginous drainage and the resident denied pain. j. The wound documentation dated 11/6/15 identified 7 cm x 5 cm, musky odor, and increased amount of sero-sanguineous drainage. k. The wound documentation dated 11/9/15 revealed 7 cm x 7 cm, soft black eschar, musky odor, an increase in drainage and afebrile. l. The wound documentation dated 11/10/15 revealed a physician had been notified with a plan for the resident to have been assessed at the wound clinic on 11/11/15. m. The wound documentation dated 11/11/15 revealed no measurements, soft mushy black eschar, musky odor, an increase in sero-sanguineous drainage and admitted to the hospital. An Advanced Wound Center progress noted dated 11/11/15, revealed the following documentation: The resident has a diabetic ulcer on his/her right medial heel. The ulcer measured 11.5 cm x 8 cm with a depth of 1 cm. There is a small amount of sero-sanguineous exudate. There is no odor, and 51-75% moist black eschar. There is pink granulation at 1-25%, [MEDICAL CONDITION] and deteriorating. The area had been acquired 9/16/15. During an interview with a Nurse Practitioner 11/3/15 at 8:27 a.m., he/she confirmed the following information: He/she would have expected a thorough assessment of the area at least weekly. The assessment should have included measurements, depth, surrounding skin tissue, odor and etc. If the area increased in size a Physician or Nurse Practitioner should have been notified as that would have been considered a condition change. The area could have been prevented or a least decreased in size with proper assessments and interventions. She stated the core issue of the area had been diabetes mellitus and circulatory issues. She identified the rule of thumb with that type of ulcer had been you only see the tip of the iceberg as one would not know what had been underneath the area. The Nurse Practitioner reported the acquired date of 9/16/15, was incorrectly. She stated she did not know (not aware) the resident had been admitted to the facility with a spongy area on his/her heel. The Nurse Practitioner reported when she saw the resident on 10/30/15, she could not believe the change (to the area), and had to convince the hospital to admit him/her due to infection. She reported labs or a fever may not be present for older adults. During an interview 11/12/15 at 2:05 p.m., the Director of Nursing (DON) confirmed the Identified Skin Concern sheet as the same expectations for a diabetic wound ulcer. During an interview 11/12/15 at 2:52 p.m., Staff A, Certified Nursing Assistant (CNA) confirmed he/she had not been aware the resident had any skin issues on admission. Rather he/she became aware when giving him/her a shower on an unknown dated and a chunk of skin had been hanging. During an interview 11/12/15 at 3:21 p.m., Staff B, CNA confirmed he/she had not been aware the resident had any skin issues on admission and that he/she became aware when the resident's foot had been wrapped. According to the facilities Identified Skin Concerns form (not dated), the purpose had been to provide residents with a pressure sore the necessary treatment and services to promote healing, prevent infection and prevent a new sore from developing and to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. The procedures included the following: a. Initial documentation 1. Preventative measures in place. 2. Type of wound. 3. Location. 4. Stage. 5. Measurements. 6. Drainage. 7. Wound base/phase. 8. Odor. 9. Surrounding skin. 10. Conditions that may have caused unavoidable pressure sores and/or any risk factors unable to control. b. Following the original assessment, a thorough head-to-toe assessment of the resident's skin should have been completed weekly. The documentation should have included the following: 1. Any new preventative measures put in place. 2. Type of wound. 3. Location. 4. State/tissue layers involved. 5. Measurements. a. Diameter in cm's. b. Depth in cm's. 6. Drainage. 7. Wound base/phase. a. Sinus tract or undermining. 8. Odor. 9. Surrounding skin. 10. Response to treatment and treatment changes. 11. Any further exploration of conditions that may have caused unavoidable pressure sores and/or any risk factors unable to control. c. A copy of the skin report would have been discussed with the Administrator and orders would have been obtained from a physician by nursing.