Every finding on record at West Bend Health and Rehabilitation

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to provide a criminal background check and a Single Contact License and Background Check (SING) for 2 of 5 current employees sampled (Staff B and Staff C). The facility reported a census of 43 residents.Findings include:1. The facility provided a new hire list for Staff B, Certified Nursing Assistant (CNA) documented a hire date of 10/8/2025. The Single Contact License and Background Check(SING) dated 10/6/25 indicated a possible criminal hit for Staff B which required the Department of Criminal Investigation (DCI) to clarify if the prospective employee did or did not have a criminal history. The personnel record lacked the documentation that further research from DCI had been completed. 2. The facility provided a new hire list for Staff C, Licensed Practical Nurse documented a hire date of 11/3/2025. The facility could not provide the documentation of the SING or the background check for Staff C. The personnel record lacked the documentation.Interview on 6/24/26 at 10:00 a.m. with Administrator and Business Office Manager stated Sing got a whole new system upgrade. The company's employee file program also upgraded and when this happened some parts of the personnel files were missing. They stated they reached out to Sing and the company employee data partners to see if they could get the second page of the criminal background check for Staff B and to see if they could locate Staff C's SING and background check. Received email from Administrator on 6/25/26 at 9:23 am response from the Division of Criminal Investigation (DCI) stated submissions from before the new system were wiped so we cannot send the results, also they do not resend results after 30 days. Interview on 06/25/2026 at 11:00 a.m. with Administrator stated that the company employee data system had an update, there were missing parts to the employee files. The Administrator stated she doesn't have the SING or background check to provide, she stated they are missing in the database. She stated she did not know this was an issue prior to the survey. The facility policy named Abuse: Prevention of and Prohibition Against with a revised date of 4/2025 revealed Screening: Prospective Employees:Prior to hire, the Facility will screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit such abuse, neglect, exploitation, or misappropriation of resident property. This screening will include but not be limited to:Attempting to obtain information from previous and/or current employers, whether favorable or unfavorable.Documentation of status and any disciplinary actions from licensing or registration boards and other registries. Reviewing the prospective employee's employment history, especially when there is or may be a pattern of inconsistency.The Facility will not hire or retain any person, directly or indirectly (through the use of registry, a staffing service, or an affiliated academic institution) who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Has had a finding entered into the state nurse aide registry or Office of the Inspector General database concerning abuse, neglect, mistreatment of residents and of misappropriation of their property; orHas disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.Certified Nursing Assistants (CNA) will be properly screened for criminal background and approved by the Department of Health Services, through use of their CNA Abuse Registry and Certification Verification program. All licensed employees will have their certificates or licenses verified through the applicable State Board, licensing, or certifying agency. All employees, temporary staff, prospective consultants, contractors, volunteers, caregivers, and students will be properly screened prior to working at the Facility.

Based on clinical record review and staff interviews the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 2 residents reviewed who transferred to the hospital or discharged from the facility (Resident #5). The facility reported a census of 43 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of cancer, hypertension (high blood pressure), diabetes mellitus, and depression. The MDS revealed the Brief Interview for Mental Status (BIMS) scored 11 indicating moderately impaired cognition.Review of Resident #5's Progress Notes revealed the following information:On 3/30/26 at 11:20 p.m. Resident #5 was transferred to the emergency department and admitted to hospital.On 4/2/26 at 12:20 p.m. Resident #5 readmitted to the facility.Review of Resident #5's Census tab revealed the following:On 3/30/2026 Hospital LeaveOn 4/2/2026 PrivateReview of MDS listing revealed the following:3/30/26 - discharge return anticipated4/2/26 - entryReview of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman without a date lacked Resident #5's name. Review of the facility document titled Admission/Discharge to/from report dated 3/1/26 to 4/30/26 lacked Resident #5's name. This form was attached to the Notice of Transfer Form to Long Term Care Ombudsman. Interview on 06/24/2026 at 1:42 p.m. with Staff A, Social Worker revealed she thought it was only if they were discharged to the community. Staff A verified Resident #5 was not on the list sent to the ombudsman. Staff A stated she pulled a report from the electronic health record usually at the beginning of every month for the previous month and wondered if it was the way the business office changed Resident #5's status in the census tab. Interview on 6/24/2026 at 2:39 p.m. with the Administrator stated they have identified an issue with their software, Staff A pulled a report from the electronic health record and this was missed due to the way they put Resident #5 in the census tab. The facility policy revised 10/2022 named Admission, Transfer and Discharges revealed it is the facility policy that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the facility transfers or discharges a resident, the facility ensures that the transfer or discharge is to the ombudsman per monthly report. All facility transfers and or discharges will be communicated to the appropriate ombudsman monthly.

Based on record review, staff interview and policy review the facility failed to complete a discharge summary including a recapitulation of the resident's stay for 1 of 1 resident review for discharges for closed record review (R#39). The facility reported a census of 38 residents. Findings include: The Clinical Census revealed Resident #39 was discharged on [DATE]. A Physician Order signed and dated on 2/27/25 directed staff Resident #39 could transfer to an (ALF) assisted living facility on 2/28/25 and continue current medications. Review of Progress Notes on 2/28/25 lacked documentation Resident #39 was discharged to Assisted Living, what her condition was at the time of discharge and what belongings she was discharged with. In addition the Progress Notes and the clinical record lacked documentation regarding a discharge summary/recapitulation stay that included information regarding resident status, medication reconciliation and disposition of medications at discharge. On 4/30/25 at 5 PM, Staff A, Social Services/LPN reported she typically completes the discharge paperwork including the discharge summary/recapitulation of stay but was not working at the time of the discharge. Staff A acknowledged the discharge paperwork including the discharge summary/recapitulation of stay was not completed. On 5/1/25 at 10:30 AM, The DON acknowledged the lack of documentation related to the discharge and verified the discharge summary/recapitulation of stay was not completed and would expect it to be. A facility policy reviewed 12/2023 documented it was the policy of the facility that a discharge summary shall be prepared when a resident was expected to be discharged . The policy directed the discharge summary shall include, but not be limited to, the following: a. A recapitulation of the resident's stay that includes: diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultant results. b. A final summary of the resident's status to include a description of the resident: -Identification and demographic information -Physical functioning and activity level at time of discharge -Disease diagnosis and health condition treated during residents stay -Diet upon discharge -Skin conditions -Medications -Special treatments and procedures -Discharge planning c. A reconciliation of all pre-discharge medication with the resident's post-discharge medication (both prescribed and over the counter). The policy further documented that a final summary of the resident's status at the time of discharge would be filed in the resident's medical record.

Based on clinical record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis and start of new psychotropic medications (Resident #8). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) of 05 indicating severe cognitive impairment. The MDS revealed Resident #8 had diagnoses of psychotic disorder, depression, non-alzheimer's dementia, delusional disorder and dysthymic disorder (persistent depressive disorder). The Care Plan date initiated 2/7/23 documented Resident #8 was at risk for cognition function related to delusional disorder. In addition, the Care Plan documented Resident #8 received antidepressant medication related to dysthymic disorder and antipsychotic medication for delusional disorder. The Clinical record revealed Resident #8 had the following diagnoses with effective dates: 1. Delusional disorder- effective date 2/7/23 2. Dysthymic disorder- effective date 2/7/23 A Physician Order dated 2/7/23 for Resident #8 directed staff to administer Zyprexa (antipsychotic) 5 MG (milligrams) one tablet by mouth at bedtime for delusional disorder. A Level 1 PASRR completed on 12/11/20 documented Resident #8 did not have a major mental illness. The PASRR evaluation documented Resident #8 received Celexa and Trazodone for depression. The clinical record revealed no additional PASRR evaluations after 12/11/20. The Clinical record review revealed Resident #8 did not have a Level 2 PASRR evaluation submitted following the new mental health diagnoses with the addition of new medication (Zyprexa). On 4/29/25 at 11:40 AM, Staff A, Social Services acknowledged Resident #8 PASRR had not been updated to reflect Resident #8 taking an antipsychotic medication, along with diagnoses of dysthymic disorder and delusional disorders. An undated facility policy titled PASRR documented prior to admission and upon any significant change in condition, the facility will ensure that all prospective and current residents undergo appropriate PASRR screening in accordance with federal regulation and the Iowa Department of Health and Human Services guidelines.

Based on observation, record review and staff interview, the facility failed to follow physician orders for 1 of 5 residents reviewed for medications (Resident #15). The facility reported a census of 38 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #15 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident had diagnoses including Alzheimer's disease. The Care Plan dated 12/24/24 identified the resident took an antibiotic. The interventions included administering medication as ordered. The Consultant Pharmacist letter to the Physician questioned if the Nitrofurantoin should be held while the resident took another antibiotic. The physician ordered to hold the medication while the resident was on another antibiotic dated 7/8/24, and noted by the facility 7/10/24. A Medication Review Report dated 4/16/25 showed the resident continued with the order to hold the Nitrofurantoin while on another antibiotic with the date of 7/10/24. The April 2025 Medication Administration Record (MAR) showed the resident took the antibiotic Ciprofloxicin 250 mg 2 times a day for 1 week starting on 4/23/25 and ending on 4/29/25. The April 2025 MAR showed the resident on Nitrofurantoin 50 mg daily, and the resident received the medication while on the Ciprofloxicin 4/23/25 to 4/29/25. On 5/2/25 at 10:50 a.m. the Infection Preventionist (IP) confirmed the resident's prophylactic antibiotic should be held while on another antibiotic. The facility policy Physician's Orders revised 10/2024 documented all physician's orders would be followed with a written order.

Based on observation, staff interview, and clinical record review the facility failed to provide appropriate catheter care for 1 of 2 residents reviewed (Resident #140). The facility reported a census of 38 residents. Findings include: The Clinical Census revealed Resident #140 was admitted to the facility on [DATE]. Resident #140 did not have an admission MDS (Minimum Data Set) completed. The Care Plan dated 4/29/25 identified Resident #140 had an indwelling catheter due to a CVA (cerebrovascular accident/stroke). The Care Plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. On 4/28/25 at 11:27 AM observed Resident #140 sitting in her recliner in her room, her catheter bag was hanging on the garbage can without a dignity bag and the catheter tubing touching the floor. On 4/29/25 at 1:44 PM observed Resident #140 sitting in her recliner in her room and her catheter bag was hanging on the foot rest of the recliner without a dignity bag. On 4/30/25 at 7:50 AM observed Resident #140 lying in bed and her catheter bag hanging from the bed without a dignity bag. On 4/30/25 9:20 AM observed Resident #140 sitting in her wheelchair in the dining room, the catheter bag was hanging under the wheelchair and the catheter tubing was touching the floor. On 4/30/25 11:50 AM observed Resident #140 sitting in her wheelchair at the dining room table eating lunch, the catheter bag was was hanging under the wheelchair and the catheter tubing was touching the floor. On 4/30/25 at 11:59 PM, the DON (Director of Nursing) reported she would expect the catheter bag to be covered with dignity bag, the catheter bag not to be hung on a garbage can and for the catheter tubing not to be touching the floor. The facility policy revised 12/2023 titled Catheter Drainage Bag directed the staff to position the drainage bag below the level of the resident's bladder and without resting on the floor. Ensure tubing allows for unobstructed drainage of urine.

Based on observation, record review, and staff interview, the facility failed to to ensure a medication error rate of less than 5%, with 2 errors of 33 medications passed for an error rate of 6.06% for 2 of 6 residents (Resident #5, and #21). The facility reported a census of 38 residents. Findings include: 1) The Medication Administration Record for April 2025 showed Resident #5 had the order for Humalog Kwikpen 10 units subcutaneous (subq) 3 times a day, at 8 and 11 a.m. and 5 p.m. During a medication pass on 4/30/25 at 7:45 a.m. Staff B Licensed Practical Nurse (LPN) administered Humalog insulin 10 units subq via the Kwikpen, into Resident #5's right abdomen and removed (the needle) immediately. According to Humalog Kwikpen instructions revised July 2023 the instructions included inserting the needle into the skin, pushing the dose knob in all the way and continuing to hold the dose knob while slowly counting to 5 (before removing the needle). 2) The Clinical Physician's Orders showed Resident #21 had the order for Novolog 10 units 2 times a day. During medication pass on 4/30/25 at 8:36 a.m. Staff B gave Resident # 21 Novolog 10 units via insulin pen, and left the needle in for 2 seconds. On 4/30/25 at 12:12 p.m. the Director of Nursing (DON) stated she wasn't sure how long the needle needed to be left in after injecting insulin with the pen. At 2:04 p.m. the DON stated the insulin pen should remain injected for at least 5 seconds. On 5/1/25 at 11:53 a.m. the DON stated she had talked to Staff B about the use of the insulin pens.

Based on observation, record review, and staff interview, the facility failed to provide infection control practices for personal devices for 1 resident (Resident #27) and during medication pass for 2 of 6 residents (Resident #27 and #8). The facility reported a census of 38 residents. Findings include: 1) On 4/28/25 at 10:57 a.m. Resident #27 had a humidifier (adds moisture to the air by releasing water vapor into the area) in her room. The resident said it was so dry and stuffy. The humidifier had a thick coating of dust on the outside and appeared dirty inside. The Care Plan included the intervention to please check the water in the humidifier due to it being dry in Resident #27's room, dated 4/1/25. On 4/29/25 at 9:01 a.m. entered Resident #27's room with the Administrator. She acknowledged the humidifier needed cleaned and stated she would have maintenance clean it. On 4/29/25 at 2:07 p.m. the resident's humidifier had been cleaned. 2) The Physicians Clinical Orders showed Resident #27 had orders for: a. Chlortrimazole topically to her lower lip, b. Fluticasone 2 sprays to each nostril, c. Latanoprost 1 drop right eye. On 4/30/25 at 8:01 a.m. Staff D Certified Medication Aid (CMA) took Resident #27's Clotrimazole cream, Latanoprost eye drops, and Fluticasone nasal spray to her room and sat them on the resident's bedside table without a barrier. After administering, Staff D returned the items to the med cart. On 5/1/25 at 10:30 a.m. Staff D said she should have used a barrier. 3) The Clinical Physician's Orders showed Resident #8 had the order for Fluticasone 1 spray each nostril daily. On 5/1/25 at 8:12 a.m. Staff C Registered Nurse (RN) took Resident #8's Fluticasone nasal spray in the box to the resident's room and sat it on the resident's tray table without a barrier. When finished administering, Staff C returned the spray in the box to the med cart. On 5/1/25 at 8:14 a.m. Staff C said she should have used a barrier.

Based on record review and staff interview, the facility failed to treat each resident in a manner that promoted dignity and respect for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had diagnoses including non-Alzheimer's dementia. The Care Plan dated 9/16/24 identified Resident #4 at risk for depression related to wanting to return back to the community, with the goal to remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood. Interventions included monitoring/documenting/reporting signs/symptoms of depression to the nurse/doctor including hopelessness, anxiety, sadness, and negative statements. A facility report by the Administrator and Interim Director of Nursing (DON) documented receipt of a reported incident on 12/9/24 at approximately 12:30 p.m. Staff B Certified Nursing Assistant (CNA) notified them during walking rounds (at 6 a.m.) on 12/7/24 she heard Staff G CNA say Resident #4 had been on the call light non-stop for the last 4 hours to go to the bathroom. Later, Staff B went to get the resident up for lunch. Resident #4 said she heard that guy complaining about taking her to the bathroom so she figured she would just stay in bed and pee the bed rather than have someone complain about her. In a statement signed 12/9/24, Staff A CNA said during walking rounds on Saturday (12/7/24) Staff G was cussing about every resident for example, for 1 resident he said he was full of f***ing s**t when referring to a bowel movement. As walking rounds continued they approached Resident #4's room. Staff G CNA said Resident #4 was f***ing annoying because she was up every hour for the last 4 hours asking to go to the bathroom and not doing anything. On 12/12/24 at 9:29 a.m. Staff B CNA stated Saturday 12/7/24 she did not feel good and heard something about how Resident #4 had been on her light a lot to go to the bathroom. Staff B was training a new girl Staff H CNA on her first day down north hallway. She went to get people up for lunch and Resident #4 still laid in bed in her white pajamas. Staff B said let's get up and go to the bathroom and Resident #4 said no. Staff B asked why and the resident said she heard Staff G complaining about her that morning and she wasn't going to pull her light, and she didn't want to go to the bathroom. Staff B said she was there to get her dressed and get cleaned up. When Staff B pulled back the blankets, Resident #4 was soaked. They walked her to the bathroom and then changed her clothes and cleaned her up so that she didn't feel sticky, and got her ready for the day. Staff B told Staff F Registered Nurse (RN) about it on Saturday. She didn't know if it got addressed so she talked to the DON on Monday. She just wanted to make sure they took care of, that something was said. On 12/12/24 at 12:49 p.m. Staff E CNA stated she went on walking rounds Saturday morning. Staff G swore and talked about the resident and call light use. Staff E said Staff G said Resident #4's name and that she was annoying. On 12/16/24 at 8:50 a.m. Staff H CNA stated it was her 1st day working at the facility. She went on walking rounds that morning. Staff G said Resident #4 was annoying on the call light and swore when he said it loudly, and they were right outside her room. Staff G said negative things about other residents also. She was working with Staff B and they went to get Resident #4 for lunch. She was still in bed and soaked. Resident #4 said she heard the staff saying she was annoying and didn't want to be a burden, so she just wet herself. Staff B said she was not a burden and they were there to help her. She then let them help her to the bathroom and help her get cleaned up. On 12/16/24 at 8:58 a.m. Staff I CNA stated on walking rounds she had to get a drink of water and when resumed rounds they were by room [ROOM NUMBER] and Staff G said Resident #4 had been f***ing annoying all night on the call light. Staff I said Staff G always used profanity. On 12/13/24 at 12:52 p.m. G CNA denied using profanity during walking rounds or saying that Resident #4 was annoying. He said they had a chaotic night with a lot of call lights and residents awake. He commented that was annoying. He didn't say any specific person was annoying. On 12/16/24 at 2:07 p.m. the Administrator stated they changed the way they do report. They did a verbal report in the break room, then a walk through to check the residents. They terminated Staff G. The Resident's [NAME] of Rights dated 2/07 included the right to considerate and respectful care and to be treated with honesty, dignity, respect and with reasonable accommodation of individual needs except where the health, safety or rights of the resident or other individuals in the facility would be endangered. It was recognized that every resident was an individual with feelings, preferences, personal needs and requirements.

Based on record review and staff interview, the facility failed to ensure staff followed professional standards for administering medication for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had diagnoses including non-Alzheimer's dementia. On 12/12/24 at 9:29 a.m. Staff B Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) stated she worked the day shift Saturday (12/7/24). When they went to get Resident #4 for lunch there were pills on Resident #4's table, so Staff B asked the nurse and they were from that morning. She said Staff F Registered Nurse (RN) left them in her room. He usually didn't do that but he was an agency worker. Staff B had the resident take the medications. The December 2024 Medication Administration Record (MAR) showed Staff F signed off giving Resident #4, 9 medications on the 12/7/24 MAR for the a.m. On 12/12/24 at 1:38 p.m. Staff F stated he did leave Resident #4's medications in her room that day, and the CNA/CMA found them and gave them to her. On 12/12/24 at 3:30 p.m. Resident #4 stated they would at times leave her medications in her room for her to take when she was ready. On 12/16/24 at 2:07 p.m. the interim Director of Nursing (DON) stated Resident #4 had not been assessed for self administration of medications. The facility policy Administration of Medications dated 7/2017 documented directions included: Only licensed and medical and nursing personnel may prepare, administer and record medication administration. Medications must be given in accordance with the resident's service plan. The nurse or medication technician administering the medication must record such information on the resident's MAR before administering the next resident's medication. Should a drug be withheld, refused, or given other than the time scheduled time, the staff administering must indicate the reason on the MAR.

Based on record review and staff interview, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 3 residents reviewed (Resident #1) and failed to ensure linens and clothing soiled by incontinence were changed promptly.The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident depended on staff for toilet hygiene, bathing, personal hygiene, and transfers. The MDS documented the resident was always incontinent of bowel and bladder. The resident had diagnoses including traumatic spinal cord dysfunctiob, diabetes, and hemiplegia/hemiparesis (weakness/paralysis of 1 side of the body. The Care Plan initiated 6/28/23 identified Resident #1 had hemiplegia/hemiparesis related to trauma to C7 (vertebrae of the neck) as a result of a fall. The hemiplegia included the right dominant side. The Care Plan identified the resident: a. At risk for diarrhea. b. Had a urinary tract infection dated 10/31/24. c. Had an ADL self care deficit related to Parkinson's, and history of trauma to C7. Interventions included the resident required 2 staff assist for toileting needs, hoyer lift for transfers or bedpan to be utilized. The resident required substantial/maximal assist of 2 staff participation to reposition and turn in bed. d. The resident had bladder incontinence related to a diagnosis of overactive bladder and use of diuretics. Interventions included the resident wore a disposable brief, to check as required for incontinence, wash rinse and dry perineum. The Clinical-MDS page dated 12/11/24 at 11:03 a.m. documented the resident resided in room E (East) 11-B. On 12/11/24 at 12:45 p.m. Resident #1 laid in bed, gave little response, and kept her eyes closed. At 4 p.m. staff checked, changed and repositioned Resident #1. Staff gave her a drink of water and asked if she felt comfortable. The resident had her eyes open, but did not respond. The nursing schedule for 11/22/24 showed Staff J Certified Nursing Assistant (CNA) assigned to the East hall on the 2-10 shift from 4-9 p.m. The POC Response History for urinary incontinence showed Resident #1 documented continent only 1 time between 11/12/24 and 11/22/24. On 11/22/24 the resident had documentation of incontinence at 1:53 p.m. and 9:59 p.m. The resident had nothing documented between the 2 times. On 12/12/24 at 11:04 a.m. Staff C CNA stated on 11/22/24 Staff J CNA was assigned Resident #1 and did not change her. They found her saturated in urine. On 12/12/24 at 1:38 p.m. Staff F Registered Nurse (RN) stated one day he had instructed Staff J CNA to change Resident #1, and about 1/2 hour later she said she had. But the way they found her, Staff J couldn't have. He did talk to her about it. On 12/12/24 at 11:21 a.m. Staff D Licensed Practical Nurse (LPN) stated Resident #1 was declining and Staff F RN told CNA Staff J to change her. But the 6 p.m. to 6 a.m. shift CNA found her in a soaked bed. When she asked Staff J about it, she said she checked her and she was dry. When asked how she checked her, she said she checked her pad in the front. Staff D asked if Staff J rolled her and checked the back side and she said no. Staff D told her she had to check in the back to make sure residents were not incontinent. On 12/16/24 at 12:56 p.m. Staff J stated she worked 11/22/24 from 4 p.m. to 9 p.m. She said Staff F was the day shift nurse and he did ask her to check Resident #1. She remembered she did, and Resident #1 was dry. She said on the evening shift, they didn't have as many staff, so they all went where they were needed. Staff J was sure she would have gone down to the resident's room again, but didn't specifically recall it. Staff J stated Resident #1 needed repositioning every 2 hours so they would have checked her in the back. When asked who they were, she could not recall. She said Staff F worked until 6 p.m. so they would have checked her between 4 and 6 p.m A statement received 12/9/24 at 3:36 p.m. from Staff A CNA included throughout the weekend it was a trend for a resident to have a wet soaker, but their brief would be dry. A wet sheet but a dry soaker. Or they would be absolutely drenched when they went to their room at 7-8 a.m. None of the scenarios were acceptable. When they approached the night shift about it, they blamed the 2-10 shift, stating they were like that when they got there. They left it at that, because they had conflict with them all weekend. Staff A reported it to the interim Director of Nursing (DON) that day. She also reported to nurses all weekend. In one specific case a resident had been put to bed in her day clothes. This specific resident did not refuse cares. The night shift said 2-10 put her to bed that way. On 12/16/24 at 8:58 a.m. Staff I CNA stated they had found residents with a dry brief but wet bed pad and/or sheet. If they asked about it, night shift blamed the 2-10 shift. She said last week a resident was wet from her hair down. She said another resident had a dry incontinent pad, but the under pad and sheet were wet. On 12/16/24 at 2:07 p.m. the Administrator stated they should change all wet linens, but they may not be able to tell if the bed pad or sheet were wet with the lights down low and wearing gloves.

Based on clinical record review, staff interview, and family interview the facility failed to notify the physician and failed to notify the family/power of attorney of change for 2 residents reviewed for notification, (Resident #18 and #143) regarding a decrease in medication and an unresponsive episode . The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 documented diagnosis of renal insufficiency, hypertension, and congenital malformation of the spinal cord. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. A facility Progress Note on 12/4/23 at 5:45 PM named Condition Follow up revealed a nurse was called to Resident #143 ' s room by the Certified Nursing Assistant (CNA). Resident #143 was unresponsive to verbal stimuli, sternal rub performed and Resident #143 continued to be unresponsive. Staff continued to monitor and use verbal commands in attempt to get Resident #143 to respond. After five minutes Resident #143 responded to verbal stimuli. Resident #143 was back to baseline upon responding. A facility Progress Note on 12/5/23 at 1:54 AM named Condition Follow up revealed that during cares, Resident #143 appeared to have another unresponsive episode, however, Resident #143 woke up within seconds of it starting. Review of Electronic Health Records (EHR) lacked documentation of notifying the physician of the unresponsive episodes. On 3/7/24 at 9:15 AM interview with Staff B, Registered Nurse (RN) stated she should have notified the physician regarding the unresponsive episode. On 3/7/24 at 9:20 AM an interview with the DON revealed she could not find any documentation of physician notification in the EHR. 48003 2. During an interview on 3/4/24 at 3:36 PM, Resident #18's Power of Attorney (POA) reported she doesn't always get notified of changes. The POA reported she was not notified when Resident #18's antidepressant medication was decreased in November and found out about the decrease a month later when the facility notified her of the change to increase it back. Review of the EHR lacked documentation of notification to the daughter for the decrease in the antidepressant medication on 11/22/23. On 3/7/24 at 10:53 AM, the Administrator reported the facility did not notify the daughter with the order to decrease the antidepressant on 11/22/23.

Based on clinical record review, family and staff interviews, and policy review, the facility failed to accurately complete a comprehensive care plan and failed to follow the care plan for 2 of 12 residents reviewed (Resident #14 and #20). The facility reported a census of 44 residents. Findings include: 1. Resident #14's Minimum Data Set (MDS) Admission assessment dated [DATE] documented the resident had diagnoses of Atrial Fibrillation, Diabetes, hyperlipidemia, depression and Bell's Palsy. The MDS further documented the resident received insulin, diuretic, antidepressant and anticoagulation medications during the look back period. Review of the Resident #14 Progress Notes documented resident frequently had inappropriate behaviors towards staff. Review of the Resident #14's Care Plan lacked documentation of high-risk medications adverse consequences and what the staff should monitor while the resident was on the medications. The care plan further lacked documentation of inappropriate behaviors and direction of interventions to do when the Resident was having behaviors. During an interview on 3/6/24 at 3:10 PM, the Administrator and Director of Nursing reported the staff discuss residents needs at meeting and so staff should know what to do for the residents therefore do not always warrant it to be on the care plan. Review of the facility policy titled Comprehensive Person-Centered Care Planning with a revised date of 1/2022 documented the facility IDT will develop and implement a comprehensive person-centered care plan for each resident will include resident's needs identified in the comprehensive assessment. 49056 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of aphasia, cerebrovascular accident, and depression. The MDS showed a Brief Interview for Mental Status (BIMS) was not completed due to Resident #20 was rarely understood. Observation on 3/4/24 showed Resident #20 had a fall in the room from the wheelchair. An Incident Report dated 3/4/24 revealed Resident #20 was in the room and had taken shoes off and was not wearing gripper socks. Review of the Care Plan dated 12/2/2019 revealed Resident #20 was not to be left alone in the room. Interview on 3/5/24 at with Administrator revealed Resident #20 was in the wheelchair when the fall occurred and in the room alone.

Based on clinical record review staff interviews and policy reivew, the facility failed to revise the resident's care plan for 3 of 12 residents reviewed (Resident #2, #6, #8). The facility reported a census of 44 residents. Findings include: 1.The Minimum Data Set (MDS) Assessment completed for Resident #2 on 2/3/24 documented the diagnoses of hypertension, diabetes, Non-Alzheimer's dementia, Multidrug-Resistant organism and urinary infection. A review of Resident #2 Urine Culture dated 1/20/24 documented the resident has Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. A review of the care plan with a revised date 2/3/24 lacked documentation of directions for staff for the MRSA in the urine. During an interview on 3/6/24 at 3:10 PM, the Administrator and Director of Nursing reported the staff discuss residents needs at meeting and so staff should know what to do for the residents therefore do not always warrant it to be on the care plan. Review of the facility policy titled Comprehensive Person-Centered Care Planning with a revised date of 1/2022 lacked direction for revising of care plans to reflect the resident's current needs between comprehensive assessments. 2. Resident #6's annual MDS Assessment completed 9/29/23 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further documents on Section V for Care Area Assessment Summary that mood state and pain were triggered the summary indicated both would be addressed on the care plan. Review of Resident #6 Care Plan lacked documentation for depression, pain and interventions for those areas of care. An Office Clinic Note dated 11/22/23 documented diagnosis of depression and pain. During an interview on 3/5/24 at 8:41 AM, Resident #6 verbalized she has depression and had it for a long time. She reported she talks with her roommate when she is feeling down because she feels the staff does not know what to do when she is having a down day. 3. The MDS Assessment completed for Resident #8 on 2/14/24 documented the diagnoses of hypertension, anemia, heart failure, Multidrug-Resistant organism (MDRO) and urinary infection. Review of Resident #8's care plan lacked the MDRO and interventions for the plan of care. During an interview on 3/7/24 at 9:45 AM, the MDS Coordinator reported Resident #8 has ESBL in the urine and she finished her antibiotic but the facility has not retested her urine to determine if it is still present.

Based on record review, staff and resident interviews the facility failed to provide professional standards by not administering medication prescribed by a physician for 1 of 8 residents reviewed (Resident # 19). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 19 documented diagnoses of diabetes mellitus, atrial fibrillation, and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. During interview with Resident #19 on 3/4/24 at 2:59 PM he stated he knew he had received a new order for medication, but had not received it yet. Resident #19 voiced he called the pharmacy to see if the medication was ready. Resident #19 revealed his legs have been hurting at night. Review of physician fax form dated 2/28/24 revealed the facility received an order for Gabapentin 900 milligrams (mg) at night for neuropathy. Review of Progress Notes dated: On 2/28/24 revealed the Pharmacy was faxed and Resident #19 notified of new orders. On 2/29/24 at 5:17 PM revealed Resident #19 had not received any medication changes as the medication had not come from the pharmacy. The facility refaxed the pharmacy, the family was notified of medication changes. On 2/29/24 at 8:48 PM revealed the medication had not arrived from the pharmacy. On 3/1/24 at 12:07 PM revealed the facility is waiting for delivery of medications. On 3/2/24 at 8:49 PM revealed the medication is on order from the pharmacy the physician was aware of. On 3/3/24 at 7:39 PM facility awaiting medication from the pharmacy, the primary care provider was faxed. Review of Medication Administration Record (MAR) dated March 2024 revealed Resident #19 received the medication the night of March 4th, 2024. Interview on 3/6/24 at 8:50 AM with DON revealed Resident #19 is adamant to utilize a different pharmacy than the facility pharmacy. Resident #19 ' s pharmacy does not deliver on a routine basis, the DON revealed she knows they deliver two days a week, but does not know what days they are. Interview on 3/6/24 at 8:54 AM with Resident #19 revealed that he received his medication the last two nights and his legs feel good and they do not hurt throughout the day. Interview on 3/7/24 at 10:10 AM with the DON revealed the expectation of staff is to notify the physician and get further orders if medication is not available from the pharmacy.

Based on record review, staff interview and policy review the facility failed to complete a discharge summary including a recapitulation of the resident's stay for 1 of 1 resident review for discharges for closed record review (Resident #40). The facility reported a census of 44 residents. Findings include: The electronic chart in Point Click Care (PCC) in the census section documented Resident #40 was on therapeutic leave on 12/11/23 and discharged on [DATE]. Review of Resident #40 Progress Notes documented on 12/14/23 at 10:19 AM the facility received a phone call from the Resident's son stating they are keeping the resident at home and no longer wanting the room to be held. Further review of the Progress Notes documented on 12/11/23 the Social Worker documented the plan was for Resident #40 to discharge to the assisted living and the resident was working with therapy to improve the ability to return to the community living. The Progress Notes and Assessments in PCC lacked a discharge summary recapitulation of the residents stay including disposal of medications. Resident #40's a PCC document of a fax communication to the Physician dated 12/15/23 documented FYI- Resident #40 discharged home on 12/14/23 per family request. During an interview on 3/7/23 at 10:37 AM, the Administrator reported the facility did not have a discharge order and the resident/family was not educated on medications and discharge instructions upon discharge. She reported the facility did not complete a discharge summary.

Based on observation, record review, staff interview and policy review the facility failed preform proper hand hygiene and proper personal protective equipment guidelines to prevent the spread of potential infection and germs during peri cares for 1 of 2 residents reviewed (Resident #8). The facility reported a census of 44 residents. Findings include: The MDS Assessment completed for Resident #8 on 2/14/24 documented the diagnoses of hypertension, anemia, heart failure, Multidrug-Resistant organism (MDRO) and urinary infection. During an observation on 3/6/24 at 12:41 PM, Staff A, Certified Nursing Assistant (CNA) assisted Resident #8 to the toilet. During hand washing Staff A when finished washing her hands pulled two paper towels out, turning off the faucet, then used the same paper towels to dry her hands. Staff A applied gloves and a gown then set up the washcloth and towel. She then walked the resident into the bathroom. Staff A then took off her gloves and gown and hand sanitized her hand then left the room to grab a chair protector for the wheelchair. When returning to the room Staff A hand sanitized her hands and applied new gown and gloves. Staff A proceeded to do peri care on the resident. Staff A used one area of the wash cloth to wipe each area of the front, wiping from front to back. Staff A then with the dirty wash cloth held in her gloved hands set it on the floor without a barrier. Staff A then with the same dirty gloves started pulling drawers in the bathroom and pulled out a container of wipes. Staff A with the same dirty gloves pulled out wipes from the container. Staff A then cleaned the back side of Resident #8 using the wipes only once each wipe. Staff A then took off her gloves, used hand sanitizer and applied new gloves to assist the resident's pants up. Staff A then walked the resident to her wheelchair. Staff A used a Santi cloth to disinfect the toilet then take off her gloves, used hand sanitizer and applied new gloves. Staff A then took off her gown and gloves, hand sanitized and applied new gloves to gather the garbage and washcloth which she put in a bag to take to laundry. Once done Staff A removed her gloves and washed her hands. When finished with rinsing the soap off she pulled paper towels out, turned off the faucet with the paper towels, and used the same paper towels to dry her hands. Review of the building layout showed Resident #8 shared a bathroom with 3 other residents. During an interview on 3/7/24 at 9:45 AM, the MDS Coordinator reported Resident #8 has ESBL in the urine and she finished her antibiotic but the facility has not retested her urine to determine if it was still present. Review of the facility policy titled Hand Hygiene with a revised date of 7/14 documented Hand washing/ hand hygiene is generally considered the most important single procedure for preventing the transmission of infection. It further documented for specific handwashing and waterless hand hygiene procedures, this facility refers to CDC's most current guidelines.

Based on resident interview, resident council minutes and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes for 2 of 2 residents, (Resident #4 and #5). The facility identified a census of 40 residents. Findings include: During an interview on 1/5/24 at 8:49 a.m. a friend of Resident #4 indicated while she participated in a Zoom meeting with the resident on the computer she timed the resident's call light as on for 25 minutes. The resident had also told her she timed her call light on for 20 minutes up to 30 minutes at times. During an interview on 1/11/24 at 12:35 p.m. Resident #5 and a family member indicated the resident waited so long for staff response to her call device which made the wait frustrating due to her blindness. The resident indicated a couple months ago she pressed her call device button 12 times and staff failed to respond so she started to call out for help which caused a feeling of having been scared. Review of the facilities Resident Council minutes dated 7/25/23 and 6/27/23 indicated some residents in attendance felt the facility needed more staff on the evening shift as a means to meet their individual needs. The facilities Call Light/Bell policy indicated the call light/bell had been a means of communication with the nursing staff. The procedures included the following directive: a. Staff answered the resident's light/bell within a reasonable time frame.

Based on clinical record review, staff interviews and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 1 resident reviewed (Residents #1). The facility failed to change a suprapubic catheter and bag per the physician orders. The facility reported a census of 45 residents. Findings include: Resident #1's Minimum Data Set, dated dated dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS identified Resident #1 required assistance of one person with bed mobility, transfer, and toilet use. Resident #1 had an indwelling catheter. Resident #1 ' s MDS included diagnoses of neurogenic bladder (lack bladder control due to neurologic dysfunction), cerebral palsy, and multiple sclerosis. A Physician Order dated 10/6/20 directed staff to change Resident #1's suprapubic catheter (tube used to drain urine from the bladder) every 14 days and as needed (PRN) for dislodgement or decreased urinary output/sediment. A Physician Order dated 10/7/20 directed staff to change Resident #1's catheter bag every 14 days and PRN for leakage, accumulation of sediment, or discoloration of bag. The Care Plan dated 12/16/20 identified Resident #1 had a suprapubic catheter due to diagnosis of neurogenic bladder. The Care Plan directed staff to change the catheter bag and tubing as ordered. The Progress Note dated 4/23/23 at 1:10 AM documented Resident #1's suprapubic catheter and bag were not changed due to no supplies in house. The April and May 2023 Treatment Administration Record (TAR) revealed Resident #1's suprapubic catheter and bag were not changed from 4/9 to 5/6/23. The clinical record lacked documentation that the Physician was notified the suprapubic catheter and bag was not changed per the physician order. The July 2023 TAR revealed on 7/1/23 Resident #1's suprapubic catheter and bag was not signed off and blank indicating the catheter and bag was not changed per physician order. The clinical record lacked documenation on why the suprapubic catheter and bag was not changed on 7/1/23. The June and July 2023 TAR revealed Resident #1 's suprapubic catheter and bag were not changed from 6/18 to 7/12/23. A facility policy titled Guidelines for Replacing Catheters and Catheter bags revised 6/11/10 documented the purpose was to provide professional nursing care, prevent unnecessary trauma and risk of infection to the resident who required the use of a urinary catheter. A facility policy titled Physician Orders revised on 8/2021 documented it is the policy of the facility to accurately implement orders (treatment, procedures) upon the written orders of a person duly licensed and authorized to do so in accordance with the resident 's plan of care. On 7/18/23 at 10:00 AM, the Director of Nursing (DON) acknowledged and verified Resident #1's suprapubic catheter and bag was not changed per physician order on 7/1/23. The DON stated the catheter and bag were changed on 7/12/23 after the surveyor pointed it out. On 7/19/23 at 10:00 AM, the DON stated she expected staff to follow the physician orders and document when the catheter was changed. The DON stated she expected staff to notify the supplier when supplies are not available and to notify the Physician if the catheter was not changed per physician order.

Based on observations, clinical record review, staff interviews, the facility failed to revise a Care Plan for 4 of 4 residents reviewed (Residents #5, #31, #20, and #30). The facility reported a census of 38. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #5 was independent with bed mobility, transfers, walking and toileting. Resident #5 used a walker and a wheelchair. The MDS included diagnoses of diabetes mellitus, intellectual disabilities, bipolar, depression, hypertension, chronic kidney disease and absence of left toe. A Physician Order dated 08/11/2021 directed staff to administer Eliquis (anticoagulant) 5mg (milligrams) by mouth two times a day for clot history. Review of Resident #5's Care Plan dated 11/11/2022 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. The facility policy titled Comprehensive Person-Centered Care Planning revised March 2022 stated it is the policy of the facility to develop a comprehensive person centered care plan for each resident that include measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The policy further stated the medical records designee will conduct a quarterly assessment to ensure that the comprehensive care plan has been developed to address care areas triggered and other risk factors identified. During an interview on 12/28/2022 at 3:00 p.m. Staff A, Registered Nurse (RN) verified the anticoagulant medication, eliquis was not addressed on the care plan and agreed it should be. Staff A, RN reported Resident #5 had been on the eliquis since 08/11/21. 44475 2. The MDS dated [DATE] revealed Resident #31 had a BIMS score of 15 which indicated intact cognition. The Medication Review Report dated 11/28/22 and signed by a physician revealed the following: a. An order for furosemide 20 mg daily. b. An order for melatonin 6 mg at bedtime. The Care Plan with an intitated date of 08/28/29 lacked specific side to monitor the resident for with the use of furosemide or melatonin. In an interview on 12/29/22 at 9:47 AM, the Administrator reported that specific side effects of furosemide and melatonin should be listed on the resident's care plan. 3. The MDS dated [DATE] for Resident #20 revealed a BIMS score of 15 which indicated intact cognition. The same MDS revealed the resident took opioids for 7 of the last 7 days and was on a scheduled pain medication regime. The Medication Review Report dated 10/18/22 signed by a physician revealed the following: a. The resident had a diagnosis of polyarthritis. b. An order for hydrocodone-acetaminophen 5-325 milligrams (mg) daily. c. An order for melatonin 6 mg at bedtime. The Care Plan with an intitated date of 08/28/22 lacked specific side effects to monitor the resident for with the use of hydrocodone-acetaminophen or melatonin. In an interview on 12/29/22 at 9:47 AM, the Administrator reported that specific side effects of hydrocodone-acteminiophen and melatonin should be listed on the resident's care plan. 4. The MDS dated [DATE] for Resident #30 revealed a BIMS score of 15 which indicated intact cognition. The Medication Review Report dated 10/18/22 signed by a physician revealed the following: a. The resident had a diagnosis of hypertension (high blood pressure). b. An order for furosemide 40 mg twice daily. The Care Plan with an intitated date of 04/25/22 lacked specific side effectsto monitor the resident for with the use of furosemide. In an interview on 12/29/22 at 9:47 AM, the Administrator reported that specific side effects of furosemide should be listed on the resident's care plan.

Based on staff interviews, chart reviews and policy review the facility failed to provide needed care or services by not notifying the resident's physician of acute decline in health status for one of three residents reviewed, (Resident #1) which resulted in immediate jeopardy to resident health and safety. Resident #1 had an emesis event on 9/30/20 at 7:30 pm and was visibly not feeling well. The resident was diaphoretic, pale, moaning, and breathing heavy. The resident had no bowel sounds at that time and was complaining about pain in her lower abdomen which was tender to the touch. Resident #1 was given Tylenol, a suppository, and an injection of [MEDICATION NAME] for comfort. The resident became lethargic but able to answer questions per her baseline. At 2:00 am the resident began to decline further, continuing to be restless and moan. Vital signs were abnormal and oxygen levels were low. Resident #1 was placed on oxygen at 5 liters with no improvement. The resident passed away at 3:55 am. The residents physician was notified through a fax sent containing a copy of the nurse's Progress Note. The physician signed the fax on 10/4/20. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/29/20 for Resident #1 showed a Staff Assessment for Mental Status was completed and showed the resident to have severely impaired cognition with impaired long term memory and memory recall. The MDS showed the resident required limited assistance with walking in the corridor and Resident #1 used a walker for assistance. Review of the Nurses Progress Note dated 10/1/20 at 4:37 am by Staff A Registered Nurse ( RN), showed Resident #1 had a large emesis event of food and brown liquid at 7:30 pm. Vital signs at this time were, blood pressure 95/68, pulse 110-120, oxygen 95% on room air, and temperature 97.8. The resident was assisted to bed. At 7:45 pm the resident came to the nurse's station and was visibly not feeling well, resident was diaphoretic, pale, moaning, and breathing heavy. The nurse assessed the resident's blood sugar. Blood sugar was 187 at that time. Vitals signs were taken and were, blood pressure 100/76, pulse 115-130, oxygen 95% on room air, respiration rate 25, and temperature 97.5. Resident #1 was complaining of pain in the lower abdomen, which was tender to touch. The nurse documented the resident had no bowel sounds auscultated at this time. Staff A RN notified Staff B Director of Nursing (DON) of resident's change in condition at 8:58 pm The DON advised Staff A to keep resident as comfortable as possible due to DNR status. The resident was given a suppository and Milk of Magnesia. The resident continued to complain about abdominal pain, at which time the resident was given Tylenol at 9:50 pm. The resident was anxious and agitated due to pain being uncontrolled and a intermuscular (IM) of [MEDICATION NAME] was administered at 10:03 pm to assist the resident to relax and slow her breathing. Resident #1 vital signs at 11:26 pm were blood pressure of 120/75, oxygen at 98% on room air, pulse at 130, temperature of 97.6, and respiration rate of 30. Resident #1 was lethargic but able to answer questions per baseline. Staff A notified the residents guardian of resident's change in condition at 10:13 pm, at which time he stated to keep her comfortable and no further measures were to be taken. The resident rested in bed with her eyes closed, but continued to moan at times and was still somewhat restless. Resident #1 continued to rest in bed and at approximately 2:00 am the resident's condition began to deteriorate. During multiple attempts to obtain vital signs residents blood pressure was 151/99, respiration rate of 46, temperature of 97.8, and oxygen was reading 66% on room air. Attempted to warm up the residents fingers and obtain oxygen saturation but was unable to do so. Oxygen at 5 liters was placed on the resident through nasal cannula in the mouth, due to mouth breathing. The resident's oxygen saturation continued to remain below 70%. Staff A notified the DON at 3:09 am of resident's rapid deterioration. At 3:55 am the resident ceased to breath and no heartbeat was auscultated for at least one minute. The DON was notified of resident's passing, and the resident's guardian was notified at 4:25 am. During interview on 1/11/21 at 3:50 pm Staff A RN stated Resident #1 started not feeling good at 7:30 pm, before the incident the resident was acting her normal self and walking around the facility. Staff A RN stated the resident was having a lot of pain and was very restless. Staff A RN contacted the DON to report the condition of the resident and asked if it was possible to send the resident to the emergency room and the DON informed Staff A RN not to send the resident out that she was a Do Not Resuscitate (DNR). Staff A RN stated the DON stated she would be coming to the facility to assist with situation but the DON did not arrive until after Resident #1 passed away. During interview with Staff C Licensed Practical Nurse (LPN) on 1/12/21 at 11:45 pm she stated she was informed by other staff members that Resident #1 was in pain and didn't seem right, stating the resident was very sweaty. Staff C stated Staff A was the on duty nurse and that the two of them had a conversation about the resident's condition. Staff C LPN stated Staff A called the DON and the POA twice. Staff C stated the resident only had an order for [REDACTED]. Staff C stated she was unsure if Staff A contacted the physician. Staff C LPN stated a DNR does not mean not to call the physician. During interview on 1/12/21 at 12:00 pm Staff D Certified Nurses Aide (CNA) stated Resident #1 was fine throughout the day and ate her supper. Around 7:30 pm the resident vomited, by 8:30 pm the resident needed two staff members to help her ambulate. Staff D stated before this event, the resident would walk around the facility by herself with her walker. Staff D stated the resident had said her stomach hurt and she was rolling side to side moaning in pain. Staff D stated Staff A did give the resident Tylenol and her [MEDICATION NAME] but it did not work. Staff D stated Staff A did call the DON and the POA. Staff D stated the phone conversation was overheard and Staff A informed the POA the resident was in pain and that there was nothing at the facility to help her. Staff D stated her shift ended at 10 pm but stayed until around 11:30 pm as Resident #1 was less restless when somebody would sit with her. During interview with Staff E CNA on 1/12/21 at 3:50 pm she stated she was informed of Resident #1's condition at start of her shift at 10 pm by Staff D. Staff E stated Resident #1 was very pale, clammy and not looking very good. The resident would roll side to side. Staff A went into the resident's room several times and took her vitals. The resident informed Staff E that her stomach hurt and then she would sit up, hold her side and then lay back down. During interview with Staff A on 1/12/21 at 3:50 pm Staff A stated the physician was not called due to the DON stating to wait and that the DON would call the physician when she came in. Staff A stated she felt the residents condition was acute and that she should have been sent to the emergency room but the DON and POA informed her not to transfer her out. Staff A stated she did inform the POA there was no medication at the facility to make the resident comfortable. The DON did not arrive to the facility until after the resident passed away and informed Staff A to fax the nurse's Progress Note documentation to the physician as notification of the event. Staff A stated she was in contact with the DON throughout the event through phone conversations and text messaging. Review of the text messages between Staff A and the DON showed Staff A informed the DON on 9/30/20 at 8:12 pm the resident was in a lot of pain and requested to transfer the resident to make sure the resident didn't have an obstruction. The DON responded No we cannot. Staff A informed the DON on 9/30/20 at 9:48 pm the resident was given Tylenol and an [MEDICATION NAME] injection because the resident was anxious and upset from the pain. Staff A texted she had nothing else to give her to keep her comfortable, she is moaning in pain. The DON responded at 9:49 pm she will be fine. Give it time. Staff A informed the DON at 11:26 pm the resident was still moaning and breathing heavier than normal and still in pain. Staff A informed the DON on 10/1/20 at 2:11 am the resident's oxygen level was 67 percent and her heart rate was 200. The DON responded, She could have aspirated and has pneumonia, relax this has happened before. Staff A responded at 2:13 am that she thinks the resident did aspirate because her right lung sounds like she has some rhonchi. The DON responded to try some oxygen, calm down she still doesn't need to go anywhere, she is a DNR. The DON responded on 10/1/20 at 2:17 am just wait and use some oxygen for now. We will need to call the Physician later when I come in. At 2:20 am Staff A texted she isn't responding to me, verbal or sternal rub right now. The DON texted back she doesn't respond when she sleeps often. Staff A texted at 2:23 am she doesn't look like she is sleeping, eyes open and glazed. She has cheynes stroke type breathing. The DON responded at 2:24 am Ok she is a DNR and you put oxygen on her so remain calm, I will be there in 30 minutes or so. The DON texted at 2:25 am She has no quality of life and would have to be isolated if sent out, must think about the bigger picture. The DON texted at 2:50 am her IPOST states comfort measures only, so don't worry Staff A notified DON on 10/1/20 at 2:53 am she is gone, no heartbeat. Review of Iowa Physician order [REDACTED].#1 was a DNR with comfort measures only, use medication by any route, positioning, wound care, and other measures to relive pain and suffering. Use oxygen, suctioning and manual treatment of [REDACTED]. Patient prefers no transfer to hospital for life sustaining treatment. Transfer if comfort needs cannot be met in current location. Review of Progress Note dated 9/27/20 at 5:33 pm showed Resident #1 had a chocking episode after stuffing bread and ground meat into her mouth all at once, the physician was notified of the episode via fax. Review of Speech Therapy communication dated 7/23/20 noted Resident #1 had a [DIAGNOSES REDACTED]. Review of Pain Level summary for the month of September 2020 showed the resident only had pain documented once and scored at 2, (1-3 is minor pain). Review of the Order Summary report, showed Resident #1 had an order for [REDACTED]. During interview with Resident #1's physician on 1/13/21 at 10:50 am he stated he was not notified of the situation until receiving faxed notification on 1/4/20. Physician stated a DNR does not mean not to treat or evaluate the situation, he stated he would have expected at least a phone call to discuss the evaluation and possible treatment of [REDACTED]. The physician stated being a DNR can be a judgement call but always needs an evaluation with at least a phone call to determine the next course of action. Review of the facility Change in Condition policy updated 6/2018, showed When to report to Medical Doctor; Immediate notification of any symptom, sign or apparent discomfort that is acute or sudden in onset, unrelieved by measures already prescribed, abrupt onset of severe abdominal pain, abdominal tenderness, absent bowel sounds with severe abdominal pain, abrupt new onset of wheezing, rales, or rhonchi, nausea with recent change in condition, new severe pain. Review of the facility Residents Rights policy dated 8/2007, showed the nurse will notify the residents attending physician when there is a significant change in the residents physical, mental or psychosocial status. During interview on 1/12/21 at 2:20 pm the DON stated she was notified about the residents change in condition and she informed Staff A that Resident #1 was an DNR and to make her comfortable. The DON stated the resident had a similar event in the past and she came out of it fine and thought it was like that again. The DON stated the nurse should have called the physician. During interview on 1/13/21 at 1:35 pm The DON stated she never told Staff A not to call the physician, stated she did tell her to call the physician and the POA. The DON stated she was texting back and forth with Staff A offering help but never thought about asking if the physician had been called. Interview with Staff F on 1/13/21 at 2:40 pm showed the facility was aware of the incident and conducted their own investigation. During their investigation it was found there was concern with the lack of physician notification. Staff F stated the DON was educated along with all nursing staff on residents DNR status, notifying the physician and obtaining medication for comfort. Review of the Education to Nurses pertaining to DNR status and documentation in Point Click Care (PCC) dated 11/9/20 states; Residents family wishes them to remain in facility and kept as comfortable as possible without being sent to hospital or higher level of care at this time. The resident is DNR status and emergency room physician notified and aware of situation, DON notified and aware of resident's condition. If necessary you may attempt to request other medication for comfort and if needed a staff member will pick up or request pharmacy to deliver to facility when necessary due to limited emergency medication kit contents. Abatement: The facility was notified of the Immediate Jeopardy and given the IJ template on 1/13/21 at 1:20 pm. The facility abated the immediate jeopardy on 11/9/20 by taking the following actions: Education to Nurses pertaining to DNR status and documentation in PCC: a. Residents family wishes them to remain in the facility and kept as comfortable as possible without being sent to the hospital or higher level of care at this time. b. The Resident is a DNR status and ER physician notified and aware of situation. c. DON notified and aware of resident's condition. d. If necessary attempt to request other medication for comfort and if need a staff member will pick up or request pharmacy to deliver to facility when necessary due to limited emergency medication kit contents. e. Pharmacy may be paged by calling Hospital ER at night. The facility educated nursing staff on the Change of Condition Policy with a 1 hour inservice on 1/13/21.

Based on observation, record review and staff interview, the facility failed to plan for and direct services designed to alert staff of supervision needs and provide adequate supervision for two (2) of four (4) residents reviewed. The facility failed to implement alternate interventions for Resident #1 when staff became aware the resident could disable alarms. The resident disabled his/her alarms on 2/6/12 and sustained a fracture. The facility failed to implement alternate interventions for Resident #4 when it became known the resident could disable alarms. The resident disabled his/her alarm and fell . Facility census was forty-five (45) residents. Findings Include: 1. A Minimum Data Set (MDS), with assessment reference date of 2/6/12, assessed Resident #1 with impaired short term memory and moderately impaired decision making skills. The resident required extensive staff assistance with bed mobility, transfers and toileting. The resident independently ambulated in the room and corridor with a walker. A "balance during transitions and walking" assessment identified the resident as unsteady but able to stabilize without human assistance while walking, turning around, moving on and off toilet and surface to surface transfers. The resident was frequently incontinent of urine. The resident had [DIAGNOSES REDACTED]. A change of condition report post fall/trauma form, dated 1/6/12 at 5:15 a.m., revealed staff found the resident on the floor with bed alarm not sounding. Following the incident, staff applied nonskid socks and nonskid strips in front of resident's chair. On 3/5/12 at 10:35 a.m., the surveyor asked Staff B (Director of Nursing) why the alarm did not sound when the 1/6/12 incident occurred. Staff B stated the resident would shut off the bed alarm occasionally and stated she would find out more information regarding the 1/6/12 incident. On the same date at 11:38 a.m. Staff B stated she phoned the charge nurse about the 1/6/12 incident and the charge nurse stated the resident walked from the bed to the bathroom and then back to his/her chair. The charge nurse working on 1/6/12 assumes the resident shut the alarm off because the alarm was on prior to the fall. A change of condition report post falls/trauma form, dated 1/14/12 at 9:05 p.m., revealed staff found the resident lying on his/her left side on the floor. The resident's bed alarm sounded. Following this incident, the facility implemented a new intervention of a personal alarm and directed staff to apply it in the evening and take it off in the morning. An incident report, dated 2/6/12 at 6:05 a.m., revealed the resident fell in the resident's room. The resident sustained [REDACTED]. The resident attempted to ambulate without assistance from his/her bed to the bathroom. Staff sent the resident to the hospital for examination. A fall investigation form, dated 2/7/12, revealed the resident's alarms were in place prior to the fall and the resident unhooked the alarms prior to getting up. In the summary portion of the form, Staff L (charge nurse) stated he reviewed the details of the incident. The alarms were present prior to the fall but the resident unhooked them. Staff L checked after the incident and both alarms functioned when tested . A hospital discharge summary, dated 2/13/12, identified the resident with a intertrochanteric fracture of the left hip requiring surgical intervention to repair the fracture. Following surgery, the resident required four units of blood due to anemia and postoperative blood loss. The resident returned to the facility with instructions to remove stitches and staples in 2 weeks Staff Working When the 2/6/12 Incident Occurred: On 3/5/12 at 5:42 p.m., Staff M (nurse aide) stated she worked the night of the incident. She stated every time staff went in the room on rounds the night of incident, staff had to reapply the alarms because the resident removed them. The resident used a bed and body alarm and the resident would take off the body alarm and the resident taught him/her/(self) to turn off the bed alarm. Staff M stated they let the charge nurse (Staff L) know about the resident removing/turning off alarms. On 3/5/12 at 5:51 p.m. Staff L (charge nurse) stated the night of the incident staff heard the resident messing with the alarms. Staff L stated that is why the resident used 2 alarms because the resident was cognitive enough to remove them. Staff L stated even though the resident had a call light available, the resident would try to go by self. On 3/6/12 at 9:28 a.m., Staff I (nurse aide) stated the resident could shut off the bed alarm and unhook the body alarm. Staff I stated that night prior to the fall, the resident had shut off and unhooked the alarms 1-2 times on rounds. Staff I stated Resident #1 could turn off the bed alarm and unhook it; and she had reported this to the nurse. Other staff: On 3/6/12 at 9:33 a.m., Staff J (nurse aide) stated prior to the 2/6/12 incident the resident would unclip the body alarm and turn off the bed alarm by pushing the button to turn it off. After the 2/6/12 incident, staff changed the bed alarm to a 3 button push shut off instead of one button shut off. Staff J stated the nurses knew of the resident's ability to disable alarms because the resident disabled/unhooked them more than once. On 3/6/12 at 11:30 a.m. at a mini meeting with the surveyor, the facility confirmed staff changed the bed alarm from a one button push shut off device to the three button push bed alarm following the 2/6/12 fall with fracture. On 3/6/12 at 10:15 a.m. Staff K (nurse aide) stated she knew of the resident removing the body alarm and then hooking it back up. The resident would shut the bed alarm off. Staff K stated she filled in on the overnight shift a couple months before the 2/6/12 fall and caught the resident walking in his/her room without alarms sounding. Staff K reported it to charge nurses. On 3/5/12 at 11:10 a.m., Staff D (nurse aide) stated prior to 2/6/12 she heard the resident could unhook the personal alarm but had not actually seen the resident do it. On 3/6/12 at 9:18 a.m., Staff H stated prior to the 2/6/12 incident the resident took alarms off. On 3/5/12 at 9:49 a.m. observation showed the resident in a recliner in room with body alarm clipped to right shoulder of the resident's shirt with the alarm box pinned to the recliner within easy reach to the resident. Observation showed, on the same date at 10:15 a.m. two staff transfer the resident from recliner to wheelchair. The resident stood from the recliner with much verbal cueing and physical assistance from the staff. On 3/6/12 at 10:40 a.m. observation showed the resident in the recliner with feet up and alarm pinned to the top of the resident's left shoulder and alarm box pinned to the front of the recliner easily accessible to the resident. After the surveyor expressed concerns regarding the resident's ability to disable and unhook alarms, on 3/6/12 at 2:35 p.m. Staff C stated the facility added a chair pad alarm and would also use the body alarm. Staff B stated today the facility ordered new alarm boxes that required a code to disable the alarm and also new clips that are not easily removed. The care plan in place before and after the 2/6/12 fall and fracture incident, dated 11/8/11, did not identify the resident's capability to remove and disable alarms and did not contain interventions for staff to follow to assist in the prevention of resident removal/disablement of alarms. Review of the resident's record did not identify documentation concerning the resident's capability to disable/unhook alarms. 2. A Minimum Data Set (MDS) with observation end date of 2/16/12 assessed Resident #4 with brief interview for mental status score of "14" (cognitively intact). The MDS revealed the resident required extensive assistance of staff with transfers, bed mobility, ambulation in and out of room and toileting. A balance during transitions and walking test identified the resident as unsteady and only able to stabilize with human assistance when moving from seated to standing position, walking, turning a round, moving on and off toilet and surface to surface transfers. The resident used a walker and wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The MDS identified one fall without injury since the prior assessment. An incident report, dated 2/17/12 at 2:30 p.m. stated the resident did not want to wait for help and slid off the bed. The resident did not sustain injury. A fall investigation form dated 2/21/12 at 2:20 p.m. documented the resident stated he/she got tired of waiting and unhooked the body alarm. Observation showed, on 3/5/12 at 10:43 a.m., up in wheelchair with alarm clipped in middle of back. On 3/6/12 at 10:42 a.m. observation showed the resident up in wheelchair with alarm clipped in middle of back. A care plan dated 8/29/11 in place before and after the incident did not identify the resident's ability to unhook alarms. After the surveyor expressed concerns regarding the resident's ability to unhook alarms, on 3/6/12 at 2:35 p.m. Staff C stated the facility added a chair pad alarm and would also use the body alarm. On 3/6/12 at 11:30 a.m. the Director of Nursing stated the facility ordered new chair pad alarms that required a code to disable and when they arrived the resident would get one. Staff Interviews: On 3/6/12 at 9:28 a.m. Staff I stated the resident unhooks the alarm and unhooked it over the past weekend. Staff I informed the charge nurse. On 3/5/12 at 5:42 p.m. Staff M stated the resident unhooks the alarm and it is reported to the charge nurse. On 3/6/12 at 10:05 a.m. Staff G stated the resident tried to unhook the alarm and Staff G has told the resident not to. On 3/6/12 at 9:33 a.m. Staff J stated the resident has unhooked the body alarm when in bed. On 3/6/12 at 10:15 a.m., Staff K stated the resident unhooks the alarm. Staff K stated she caught the resident attempting to put self to bed about 3 to 4 months ago after unhooking alarm.