Every finding on record at Westview Acres Care Center

Based on observations, clinical record review, resident and staff interview, the facility failed to maintain dignity for 1 of 13 residents (#17) by not cutting a resident's fingernails when he requested. The facility reported a census of 37 residents. Findings include: Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of diabetes mellitus with neuropathy (nerve damage), anxiety, depression, and hypothyroidism (underproductive thyroid that causes weak, brittle nails). It revealed he required supervision with showering and shower transfers and was independent with all other Activities of Daily Living (ADLs) and mobility.The Care Plan dated 4/30/26 included the resident's type II diabetes mellitus and directed the nurse to trim/cut the resident's fingernails and toe nails as needed.On 7/09/26 at 9:37 AM, Resident #17 stated he asked Staff A, Certified Nurse Aide (CNA) on 7/08/26 to tell Staff B, Registered Nurse (RN) he wanted his fingernails trimmed. He also stated Staff B told him she would not cut his fingernails because he refused his heart medication that morning. His fingernails were noted to be untrimmed.On 7/09/26 at 9:48 AM, Staff A, Certified Nurse Aide (CNA) confirmed the resident requested his fingernails to be cut on 7/08/26 and she notified Staff B.On 7/09/26 at 9:51 AM, Staff B, RN stated Resident #17 requested to have his nails trimmed on 7/08/26. She also stated she asked him if he was sure he wanted staff to trim his nails because he didn't want his medications, so was he sure he wanted them to trim his nails. She further stated she asked him that because he keeps saying he doesn't have rights. She said Resident #17 responded forget it and walked away. She revealed she didn't return to ask him about his nails before she finished her shift. She further stated she assumed that if he wanted it done, he would ask again. She indicated she reported the interaction to the oncoming nurse.On 7/09/26 at 11:45 AM, the Director of Nursing (DON) stated the resident's medication refusal should not affect trimming his nails.The facility did not have a policy specific to resident dignity.

Based on clinical record review, and staff interview, the facility failed to refer 1 of 1 resident (#2) with a negative Level I Pre-admission Screening and Resident Review (PASRR), to the appropriate state-designated authority for an evaluation and determination review after the resident experienced hallucinations and delusions. The facility reported a census of 37 residents. Findings include: Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 06 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease and non-Alzheimer's dementia. It included the resident had delusions and was taking an antipsychotic medication within the 7-day look-back period.The Electronic Health Record (EHR) included a physician's orders dated [DATE] and [DATE] for an antipsychotic medication three times per day and as needed for agitation and dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; respectively.A Health Status Note Progress Note dated [DATE] at 6:09 PM indicated the resident believed she spoke to her deceased son on the phone. She also believed he was in the room beside hers.A Health Status Note Progress Note dated [DATE] at 2:45 PM revealed the resident was in her room but believed she was in her brother's room and wanted a room of her own.The EHR included five (5) previously submitted PASRRs dated [DATE], [DATE], [DATE], [DATE], and [DATE] that did not include the resident's hallucinations or delusions.The Care Plan revised [DATE] indicated the resident had increased anxiety, restlessness, and agitation and directed staff to contact a family friend to help calm her down.On [DATE] at 11:20 AM, the Director of Nursing (DON) stated the previous PASRRs included the resident's current medical diagnosis linked to the resident's behaviors. Upon realizing the previous PASRRs did not include the resident's hallucinations and delusions, the DON clarified an updated PASRR should've been submitted.On [DATE], the facility submitted an updated PASRR with the resident's delusions and hallucinations. The PASRR indicated no PASRR level II was required (no status change from previously submitted PASRRs).The facility did not have a policy specific to PASRRs.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to notify visitors and staff of and failed to follow transmission-based precautions for 1 resident (#9) who had a wound infection with a clinically significant organism (MRSA - methicillin resistant staphylococcus aureus <staph>). The facility reported a census of 37 residents.Findings include:Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated moderately impaired cognition. It included diagnoses of peripheral vascular disease, non-Alzheimer's dementia, and a right lower leg ulcer. It indicated he required setup assistance with oral and personal hygiene, supervision with dressing and shower transfers, moderate assistance with bathing, and was independent with all other Activities of Daily Living (ADLs) and mobility. It indicated the resident's wound was not present at the time of the assessment.A Health Status Note Progress Note dated 6/26/26 at 10:03 AM indicated the resident was placed on contact precautions due to identified staph infection in his wound.A wound culture dated 6/26/26 at 2:10 PM confirmed the resident's wound contained MRSA.The Care Plan dated 6/30/26 included the resident's wound infection with MRSA and directed all staff to wear a gown and gloves when assisting me with all personal cares like changing my clothes, bedding, showers.On 7/07/26 at 11:31 AM, there was no transmission-based precautions sign observed to notify staff of the resident's isolation requirement. Staff C, Housekeeping Supervisor (hskg) entered the resident's room without wearing Personal Protective Equipment (PPE) and changed his bed linen.On 7/09/26 at 11:45 AM, the Director of Nursing (DON) stated the lack of a transmission-based precautions sign was an isolated incident she wasn't aware it had not been posted.An undated document titled Airborne, Contact, and Droplet Isolation (Modified from CDC Guidelines) directed staff to wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident, resident items, or environmental srurfaces or if the resident is incontinent.

Based on electronic health record review, document review, and staff interviews the facility failed to complete and submit a comprehensive assessment related to a significant change for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 35 residents. Finding include: A review of the Electronic Health Record (EHR) for Resident #5 section Minimum Data Set (MDS) revealed the latest quarterly assessment completed on 3/13/2025. A review of the Care Plan for Resident #5 reflected a focus area Hospice initiated on 3/19/2025 due to a decline in health status. Interventions/Tasks documented the hospice services company name and a contact number for emergency services. It further describes steps to take in care of any decline and/or improvement in health. In an interview with the Director of Nursing (DON) on 6/05/25 at 11:10 am, she stated a significant change in Resident #5's health status occurred when the Care Plan was updated with the Hospice services initiated on 3/19/2025. The DON reviewed the EHR and noted there was no MDS entry made on or within 14 days of the health status change. The DON requested that the MDS Coordinator review the Resident #5's MDS section of the EHR. On 6/05/25 at 11:15 am in an interview the MDS Coordinator stated she recalled updating the Care Plan section for Resident #5 but missed submitting MDS changes at that time. She further confirmed that the significant change had to be reflected on Resident #5's MDS and she will need to complete a late submission of the MDS Significant Change update to reflect the current health status of Resident #5.

Based on observations, staff interviews, document reviews, and policy review, the facility failed to implement a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to implement appropriate hand hygiene practices during resident care. The facility reported a census of 40 residents. Findings include: 1. On 7/25/24 at 11:00 AM, the Maintenance Director stated the facility did not have a current water flow diagram, a water management plan, or a process in place to identify areas in the building to reduce the risk or growth of Legionella or other waterborne pathogens. On 7/25/24 at 11:20 AM, the Environmental Services Director stated she flushed every resident toilet and turned on the water in every resident room sink for 30 seconds every day. She also stated she wasn't able to provide documentation of the completed task. During an interview on 7/25/24 at 11:20 AM, the Director of Nursing (DON) stated there hadn't been a resident room vacant for more than one month. A policy titled Legionella Water Management Program revised 7/2017 indicated the water management program included the following elements: a) A detailed description and diagram of the water system in the facility kept by maintenance. b) The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. c) The identification of situations that can lead to Legionella growth. At 1:30 PM, the DON stated the Maintenance Director reported to the Administrator and she was not certain whether the Maintenance Director was responsible for implementing the water management plan. 50471 2. On 7/24/24 at 11:22 AM observed Staff B, RN grab gloves from the medication cart, don gloves, pick up the accu check monitor, test strip, cotton ball, lancet, alcohol swab, and barrier. Staff failed to clean hands prior to donning gloves. Staff B carried items to the room of Resident #22, knocked on the residents door, waited for permission, entered when the resident voiced permission. Staff B placed the barrier on the side table realized the side table was wet from beverages, moved items off the recliner, placed barrier on the recliner, placed the accu check monitor, test strip, lancet, and alcohol swab on the recliner. Staff failed to clean hands or change gloves after moving items from wet table. Staff B realized the cotton ball was not there, Staff B obtained a Kleenex. Staff B cleansed the residents finger, used the lancet, obtained a drop of blood, placed the blood on the test strip, and covered the finger with the Kleenex. Results revealed, disposed the Kleenex, disposed the used lancet in the sharp container in the bathroom, removed soiled gloves, and hand washing completed. On 7/24/24 at 11:30 AM observed Staff B, RN grab gloves from the medication cart, don gloves, pick up medication cup with medications, pre-set insulin flex pen, and alcohol swab. The staff failed to clean hands prior to donning gloves. Staff B carried items to the room of the Resident #22, knocked on the residents door, waited for permission, and entered when the resident voiced permission. Staff B handed the resident the cup of medications, grabbed the cup of water, handed the cup of water to the resident, received the cup of water from the resident when the resident took the medications, and Staff B placed the cup of water onto the side table. Staff failed to clean hands after med administration and before insulin administration. Staff B then informed the resident about the insulin, the resident gave permission, Staff B lifted the shirt of the resident, cleansed the abdominal area, placed the insulin flex pen into the abdomen and pushed the button, administered the insulin, waited about 10 seconds removed the insulin flex pen, covered the resident with the shirt, disposed the flex pen needle into the sharp container in the bathroom, removed soiled gloves, and completed hand washing. 3. On 7/24/24 at 11:45 AM observed Staff B, RN grab gloves from the medication cart, donned gloves, picked up medication cup with medications, pre-set insulin flex pen, alcohol swab, cup of powder stool laxative, pain relief patch-12 hour, pain patch-72 hour, and pulse ox monitor. The staff failed to clean hands prior to donning gloves. Staff B carried items to the room of the Resident #18, knocked on the residents door, waited for permission, entered when the resident voiced permission. Staff B set down the cup of medications on the resident food tray, placed the pre-set insulin flex pen on barrier by the sink, poured juice into the cup of powder stool laxative, stirred with spoon, and placed the spoon back onto tray. Staff attempted to obtain a pulse ox reading, the monitor did not provide a result, picked up the cup of medications, resident took cup of medications and picked out the tablets as she prefers, Staff B provided the juice as the resident needed, the resident voiced when she completed. Staff B removed the pain relief patch-72 hour from right chest and placed new patch on left side of chest. Staff B asked the resident to lift up her dress, placed the pain relief patch-12 hour on the right hip. Staff B asked the resident where the resident preferred the insulin, the resident informed Staff B, staff administered the insulin flex pen, removed the needle disposed in the sharp container in the bathroom. The Staff B removed soiled gloves and performed hand washing. The staff failed to clean hands or change gloves between any of the different administrations. On 7/25/24 at 2:45 PM Director of Nursing (DON) stated that hand hygiene should be completed before, after, and during a procedure if needed. Including when using gloves. The facility policy titled Handwashing Policy reviewed 5/10/24 instructed staff to perform hand washing before applying gloves and after removing gloves or other PPE, or alcohol based hand gel, after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin, before moving from a contaminated body site to a clean body site during resident care, after providing direct resident care. The facility policy titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) reviewed 7/10/24 instructed staff to Use of PPE is based on the staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated).

Based on clinical record review, facility policy, and staff interview, the facility failed to have the Doctor signature on the Iowa Physician Orders for Scope of Treatment (IPOST) for 1 of 16 residents reviewed for Advance Directives (Resident # 17). The facility reported a census of 40 residents. Findings include: The Iowa Physician Orders for Scope of Treatment (IPOST) dated 12/11/23 revealed no Doctor signature for a code status of Do Not Resuscitate. On 7/23/24 at 10:05 AM the Social Worker (SW) revealed the IPOST did not get signed by the Doctor. The facility policy titled Advance Directives revised 7/18/24 instructed staff the residents attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the residents condition changes in an effort to clarify and adhere to the residents wishes. The Interdisciplinary Team will conduct ongoing review of the residents decision-making capacity and communicate significant changes to the residents legal representative. Such changes will be documented in the care plan and medical record. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS).

Based on observations, resident interview, and policy review, the facility failed to respond to resident call lights in a timely manner for 5 of 5 residents reviewed (#1, #7, #13, #30, & #32). The facility reported a census of 40. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of hypertension, Non-Alzheimer's dementia, anxiety, depression, and bipolar disorder. It indicated the resident was independent in all activities of daily living (ADLs) but required moderate assistance with bathing. The Care Plan revised 12/28/23 documented Resident #13 is at moderate risk for falls and directed staff to encourage her to wear her shoes with all transfers and gripper socks when not wearing shoes. The Care Plan also directed staff to encourage her to get out of her bed and out of her room every day due to anxiety and tends to isolate herself. On 7/22/24 a continuous observation revealed Resident #13's call light was activated at 2:53 PM and staff responded at 3:16 PM. 46873 2. The MDS for Resident #1 dated 7/11/24 documented a BIMS score of 15 indicating intact cognition. On 7/22/24 at 2:21 pm, Resident #1 reported she waits a long time for her call light to be answered. She stated she looks at the clock in her room and it is often a 45 minute wait. 3. The MDS for Resident #7 dated 4/4/24 documented a BIMS score of 12 indicating mildly impaired cognition. On 7/22/24 at 2:43 pm, Resident #7 stated she felt call lights generally were a 15-20 minute response time. 4. The MDS for Resident #30 dated 5/9/24 documented a BIMS score of 14 indicating intact cognition. During observation on 7/22/24 beginning at 2:48 pm the call light of Resident #30 was noted to be triggered. At 2:53 pm, a staff member was observed exiting the room next door to Resident #30's room. The staff member looked to her left, the direction of the call light illuminated above the door, turned and walked the opposite direction. At 2:56 pm, another staff member was observed walking down the hallway and past the room of Resident #30 without stopping to answer the call light. At 3:04 pm another staff member was observed walking past the room without answering the call light. At 3:06 pm a fourth staff member walked by the room and entered another room briefly. This staff member then returned and answered the call light. The call light was answered 18 minutes into observation. On 7/22/24 at 3:57 pm, a family member of Resident #30 stated he feels the facility is low staffed. He spoke very highly of the nursing staff and stated they provide good care but he feels there are not enough CNAs. 5. On 7/22/24 at 3:13 pm, Resident #32 reported she considers the care she receives to be good but stated there are long wait times to receive help when she rings her call light. On 7/25/24 at 3:20 PM, the Director of Nursing stated staff were expected to answer resident call lights within the 15 minute requirement. The undated facility policy titled Call Light System documented the following: -Upon receiving an alert from the call light system, staff members at the nurse station shall acknowledge the call promptly. -If responding staff is unable to meet the resident needs independently they shall promptly seek assistance from appropriate healthcare providers or supervisors.

Based on employee file review, staff interview, and facility policy, the facility failed to ensure 1 of 5 staff members reviewed (Staff A, Certified Nurse Aide) completed the two hour Dependent Adult Abuse training within 6 months of their hire date. The facility reported a census of 40 residents. Findings include: Review of the employee file of Staff A, conducted on 7/24/24, revealed a hire date of 10/6/23. The employee file documented the Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse Mandatory Reporter training was completed on 7/23/24. On 7/24/24 at 10:50 am, the Director of Nursing (DON) stated Staff A had done the training in February but failed to finalize it until 7/23/24. She stated the facility is conducting an audit of all employee files for current training. The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated July 2019, documented the following: - Within six months of hire each employee shall be required to complete an initial 2-hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse. Each employee will take a 1-hour recertification training within 3 years of the initial training and every three years thereafter.

Based on clinical record review, staff interview, and facility policy review, the facility failed to revise the care plan for 1 of 16 residents reviewed for revision of care plan (Resident #23). The facility reported a census of 40 residents. Findings include: The Minimum Data Sheet (MDS) assessment dated [DATE] identified a BIMS score of 14 which indicated cognition intact. The MDS revealed the resident independent with bed mobility, personal care, transfers, toileting, eating, and dressing. The MDS revealed the resident frequently incontinent of urine and occasional incontinent of bowel. The MDS documented diagnoses that included: other and unspecified nontraumatic intracranial hemorrhage, hypertension, diabetes mellitus, cerebrovascular accident, asthma, chronic obstructive pulmonary disease (COPD), morbid (Severe) obesity, unspecified mental disorder due to known physiological condition, restless legs syndrome, and atrial fibrillation. The MDS revealed antidepressant, insulin, and diuretic. The Care Plan revised 7/18/24 revealed no documentation for tubi grip related to right lower leg pain. The care plan revealed no documentation for depression, including the resident started on antidepressant medication 3/21/24. The care plan revealed no personalized interventions or assessment for asthma and COPD. On 07/25/24 at 10:18 AM the Minimum Data Set Coordinator (MDS) stated the Doctor does their rounds at the facility Thursday, the Progress Note from visit arrived on Monday or Tuesday, orders are left on paper the day of the visit. The floor nurse documented the order(s), the management nurses processed the order(s), staff uploaded the order(s). The nurse that documented the order(s) updated the care plan and diagnosis if applicable, the management nurses verified the care plan and diagnosis are updated. The care plan should be personalized for the resident updated with depression, antidepressant medication, tubi grip, assessment and personalized interventions for asthma and COPD. The facility policy title Comprehensive Care Plan Policy reviewed 7/18/24 instructed staff to: Assessment: conduct a thorough assessment of the resident's current health status, including any changes in their condition, medications, or treatments. This assessment should be performed by a qualified healthcare provider, such as a nurse or physician. Review the resident's current care plan to determine if any revisions are needed. This review should include input from the resident, their family members, and any other healthcare providers who are involved in the resident's care. Based on the assessment and review of the current care plan, revise the care plan as needed to reflect any changes in the resident's health status or care needs. The revised care plan should include specific goals and interventions to address the resident's physical, emotional, and social needs. Review and revise the comprehensive care plan at least quarterly or as needed based on changes in the resident's health status or care needs. Revising a comprehensive care plan is an important part of the resident care in skilled nursing facility. It allows community staff to adapt the care plan to meet the resident's changing needs and improve their overall quality of life. It is important for nursing staff to follow this policy and procedure to ensure that all residents receive appropriate and timely revisions to their care plan.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a psychotropic medication (a medication that affects a person's mental state) gradual dose reduction (GDR) was appropriately attempted for 1 of 1 resident (#13) reviewed. The facility reported a census of 40. Findings include: On 7/22/24 at 4:19 PM, Resident #13 stated she slept about 5 hours during the daytime after sleeping at night. She did not know what medications she was prescribed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of hypertension, Non-Alzheimer's dementia, anxiety, depression, and bipolar disorder. It indicated the resident received an antidepressant and antianxiety medication but had not exhibited a crying episode during the previous 7-day look-back period. The Electronic Health Record (EHR) included an order dated 12/07/23 for Buspirone Hydrochloride (HCL) oral tablet 5 mg; two (2) tablets by mouth every morning and at bedtime related to generalized anxiety disorder. It also included an order dated 12/08/23 for Celexa (antidepressant) oral tablet 40 mg; one (1) tablet by mouth one time a day related to major depressive disorder. A Gradual Dose Reduction for Celexa was implemented 3/16/24 with an updated order Celexa oral tablet 20 mg; one (1) tablet by mouth one time a day related to major depressive disorder. On 5/05/24, the pharmacist recommended a GDR for Buspirone to 7.5 mg twice daily. It indicated the resident lacked documentation of signs and symptoms of anxiety during the previous 30-day look-back period. On 5/16/24, the provider response indicated continue since a decrease was likely to worsen anxiety. A Progress Note dated 5/20/24 documented a pharmacy recommendation of possible reduction in Buspar. It included a physician response to Continue since decrease likely to worsen anxiety. The Care Plan dated 12/11/23 revealed the resident had a diagnosis of anxiety and directed staff to assess for side effects related to anxiety med 1- dizziness 2-disturbed sleep 3-irritability every shift per eMAR (Electronic Medication Administration Record). A Behavior Documentation Record review revealed the resident had not experienced crying in the last six (6) months. On 7/25/24 at 1:30 PM, the Director of Nursing (DON) and the Social Worker stated behavior documentation would be located in progress notes or behavior documentation sheet in the EHR. An undated policy titled Drug Regimen Review indicated if evidence of a valid clinical reason for rejecting the recommendation is provided and the attending physician is the medical director (MD), the consultant pharmacist and DON arrange a meeting with the MD to discuss the issues. The DON or designated licensed nurse address and document recommendations that do not require a physician intervention.

Based on staff interviews, facility record review, facility policy review, and Centers for Disease Control information the facility failed to follow proper infection control practices to mitigate the risk for the spread of infectious disease. The facility reported a resident census of 33. Findings include: On 2/27/24 at 8:00 a.m. Staff C, Dietary Aide (DA), stated she has gotten COVID twice since working at the facility. Staff C stated she doesn't recall specific dates, but recalled in September 2023, not feeling well and discussed her symptoms with the cook. Staff C stated she then texted the Dietary Supervisor (DS) and reported her symptoms. The DS instructed her to take a COVID test per protocol. Staff C stated she did and it was positive for COVID. Staff C stated she texted the DS with the results and was instructed to go home per protocol. Staff C stated she was not allowed to work for several days. On 2/27/24 at 8:25 a.m. the Dietary Supervisor (DS) stated she recalled receiving a text from Staff C reporting that she was not feeling well. The DS stated she still had the text on her phone and pulled it up for review. The DS stated it was on 9/14/23 at 5:16 a.m. in which Staff C indicated she was not feeling well. The DS instructed her to take a COVID test and text her back with the results. At 6:12 a.m. Staff C texted the DS and reported she was positive for COVID. The DS instructed Staff C to go home. The DS stated over the next several days she was in contact with Staff C and 7-10 days later returned to work. According to Staff C's Timecard Report, she clocked out on 9/14/23 at 6:16 a.m. and returned to work on 9/19/23 at 6:02 a.m., just 5 days since first testing positive for COVID. On 2/27/23 at 9:30 a.m. the Director of Nursing (DON) stated she was unable to find any testing records indicating Staff C was positive for COVID on 9/14/23 or had been tested prior to returning on 9/19/23. The DON stated facility protocol for staff who test positive for COVID are that they are restricted from working at least 7 days, pending a negative COVID test within 48 hours of returning or 10 days without testing. According to the facilities COVID 19 testing policy for staff, staff who test positive for COVID 19, will be sent home for 10 days unless that staff member tests negative on day 5 in which they then can return on day 7. The following website for the Centers for Disease Control (CDC) https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assessment-hcp.html included updated guidance as of September 23, 2022. The Interim Guidance for Managing Healthcare Personnel with a respiratory disease called coronavirus disease 19 (COVID-19) (SARS-CoV-2) Infection or Exposure to SARS-CoV-2 included the following return to work criteria; a. Healthcare Personnel (HCP) who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met; 1. At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtain with in 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). 2. *Either a Nucleic Acid Amplification Test (NAAT) (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later.

Based on clinical record review, staff interview and facility policy review the facility failed to provide bed hold notice for 1 of 1 residents reviewed (Resident #25). The facility reported a census of 34. Findings include: The Minimum Data Set (MDS) assessment tool dated 5/2/23 for Resident #25 documented a Brief Interview for Mental Status (BIMS) of 6 out of 15 possible points indicating severe cognitive impairment. Review of the Clinical Census revealed Resident #25 discharged from the facility to the hospital on 3/31/23. The clinical record lacked documentation of any explanation of the bed hold notification to the resident or the resident's representative when the resident discharged to the hospital on 3/31/23. In an interview on 5/23/23 at 12:49 PM, Staff A, Social Services reported there was not a bed hold notice completed for Resident #25 for his transfer to the hospital and the nurse had forgot to complete one. In an interview on 5/23/23 at 1:12 PM, the Director of Nursing (DON) stated it was the expectation a bed hold be completed every time a resident was transferred to the hospital. The facility Bed Hold Policy, last reviewed 8/22, documented upon a resident being transferred for hospitalization or for a therapeutic leave, the resident and resident representative will be provided information on the facility Bed Hold Policy within 24 hours of the hospitalization or therapeutic leave.

Based on observations, staff interviews and facility policy review, the facility failed to ensure food and medications were not stored together in the same refrigerator for 2 of 2 unit medication storage refrigerators. The facility reported a census of 34 residents. Findings included: On 05/22/23 at 02:40 PM, an observation of the [NAME] and East nursing station medication refrigerators revealed multiple insulin vials along with chocolate pudding containers, applesauce pouches, and liquid thickener used during medication pass. On 05/23/23 at 07:32 AM, Staff C, Licensed Practical Nurse (LPN) stated the applesauce is kept in the door of the refrigerator at the East nursing station because the residents like it cold with the medication. She stated that is where it has always been kept. On 05/23/23 at 01:00 PM, the Director of Nursing confirmed the medication storage policy specified that food was not to be stored with medications in the same refrigerator. On 05/23/23 at 01:02 PM, the facility policy titled Medication Storage in the Facility revised January 2018 instructed staff that refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications.

Based on observations, staff interview, and facility policy review, the facility failed to ensure the sanitizing solution used to clean kitchen equipment maintained proper dilution levels to adequately disinfect kitchen equipment. The facility reported a census of 34 residents. Findings include: On 5/22/23 at 11:45 AM, Staff D, Dietary Cook, wiped a food serving counter with a rag immersed in a sanitizing solution bucket. On 5/22/23 at 12:00 PM, Staff D, Dietary Cook, performed a sanitizing solution concentration check. She removed approximately two (2) inches of ribbon from a Hydrion QT-40 test strip case and submerged it into the sanitizing solution for six (6) seconds. She removed the strip from the solution and compared it to the reference chart on the back of the strip case. She verbalized the result was 0 parts-per-million (ppm). On 5/22/23 at 12:02 PM, Staff E, Dietary Cook, performed a sanitizing solution concentration check on a separate bucket. She removed approximately two (2) inches of ribbon from a Hydrion QT-40 test strip case and submerged it into the sanitizing solution. She immediately removed the strip from the solution and compared it to the reference chart on the back of the strip case. She verbalized the result was 150 ppm. On 05/22/23 at 02:16 PM, the Dietary Manager, stated the sanitizing solution was typically changed every morning, at noon, and during the night shift kitchen time. She stated the expectation was for staff to change the sanitizing solution every 4 hours unless there was increased use of the solution then it should be changed more frequently. On 5/23/23 at 03:23 PM, a review of the manufacturer's undated directions titled Procedure for Cleaning & Sanitizing Tables revealed [NAME]-based sanitizers should be 150-400 ppm and instructed staff to check the sanitizing solution often because the ppm will drop throughout the day. The undated facility policy titled Cleaning Instructions: Cloths, Pads, Mops, and Buckets directed staff to test the sanitizing solution periodically to assure that it maintains correct concentration.

Based on personnel record review, staff interviews, and facility policy review the facility failed to ensure all employees received education and training on what constitutes abuse and the facilities procedures for reporting incidents of abuse when 1 of 5 staff files (Staff B) reviewed did not complete; The State of Iowa Department of Health and Human Services (HHS), Dependent Adult Abuse Mandatory Reporter Training, within the past three (3) years. The facility reported a census of 34 residents. Findings include: Record review of Staff B, Certified Nursing Assistant, staff file on [DATE] at 1:25 PM revealed her Dependent Adult Abuse Mandatory Training was completed on [DATE] and expired on [DATE]. During an interview on [DATE] at 1:58 PM with the Administrator, she stated it was her expectation for all employees to be up to date on all training including Dependent Adult Abuse Mandatory Reporter Training. During an interview on [DATE] at 2:03 PM with the Director of Nursing, she stated it was her expectation for employees to be up to date on all training including Dependent Adult Abuse Mandatory Reporter Training. Review of the facilities policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, last reviewed on ,d+[DATE] instructed the following: Upon initial employment, each employee shall be provided with a copy of the facility ' s policies and procedures relating to abuse identification and reporting requirements. Within six months of hire each employee shall be required to complete an initial 2-hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse. Each employee will take a 1-hour recertification training within 3 years of the initial training and every three years thereafter.

Based on clinical record review, observations, and staff interviews, the facility failed to update a comprehensive person-centered care plan for 2 of 16 residents reviewed (Residents #6 and #35). The facility reported a census of 39 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition (memory). Resident #6 required the assistance of 2 staff for bed mobility, transfers, and dressing. The MDS documented the resident took a diuretic 7 of 7 days during the look-back period. On 1/11/22 at 7:32 AM observed that Resident #6 had a urinary catheter. Resident #6 confirmed he that had a catheter in place. The Health Status Note dated 1/5/22 at 6:224 PM revealed Resident #6 returned to the facility from the hospital on 1/5/22 at around 4:20 PM with a urinary catheter in place. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order said to change the urinary catheter placed on 1/4/22 every month and as needed. The Care Plan revised 12/20/21 revealed Resident #6 had benign prosthetic [CONDITION(S)] ([CONDITION(S)]), was incontinent of bladder, and had a need for help with his activities of daily living. The Care Plan lacked information related to the urinary catheter placed on 1/5/22 or interventions to care for the urinary catheter. During an interview on 1/12/22 at 2:40 PM the MDS Coordinator revealed it was an expectation on a readmission from the hospital that any new interventions or updates to the care plan would be added immediately by the nurse readmitting the resident. The MDS Coordinator acknowledged Resident #6's catheter had not been placed on his plan of care following his readmission to the facility. 2. The quarterly MDS assessment dated [DATE] identified Resident #35's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 had a BIMS score of 3, indicating severely impaired cognition. Resident #35 required substantial/maximal assistance with oral hygiene, toileting and dressing. An observation during lunch on 1/10/22 at 12:05 PM revealed Resident #35 wearing a brace to her right hand with a staff member sitting next to her, placing food on her utensils and handing her drinks. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan with a revision date 9/30/21 revealed focus areas for Resident #35 that included need for assistance with activities of daily living and a high risk for falls. The care plan lacked information pertaining to the management of Resident #35's right hand fracture and brace. During an interview on 1/12/22 at 2:40 PM the MDS Coordinator revealed it was an expectation on a readmission from the hospital that any new interventions or updates to the care plan would be added immediately by the nurse readmitting the resident. The MDS Coordinator acknowledged Resident #35's right hand brace was not on the plan of care.

Based on clinical record reviews, staff interview, and facility checklists, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #14, #2, and #25). The facility reported a census of 39 residents. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition (memory). Resident #14 received anticoagulants 7 out of 7 days in the last week reviewed. Resident #14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Review Report (MRR) signed 1/7/22 documented an order with a start date of 11/2/21 for [MEDICATION(S)] 2 milligrams (mg) tablet to give every Tuesday and Thursday (T/Th). [MEDICATION(S)] 3 mg tablet started on 11/1/21 to give every Monday, Wednesday, Friday, Saturday, and Sunday (M-W-F-S-S) related to [CONDITION(S)] A-fib. The 12/21 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The laboratory results dated [DATE] showed a PT result of 35.4 seconds (reference range 9.4-11.9) and an INR result of 3.4 ratio (reference range 0.9-1.1). Additional handwritting included that the resident took [MEDICATION(S)] 3 mg on M-W-F-S-S and warfain 2 mg on T/Th with a request for new orders. The Physician responded to hold 11/10/21's warfain dose and recheck in one month. The laboratory results dated [DATE] showed a PT result of 25.3 seconds and an INR result of 2.4 ratio. The Advanced Registered Nurse Practitioner (ARNP) responded with no changes and to redraw in one month. The Health Status Note dated 1/11/22 at 3:38 PM recorded that the ARNP gave an order to obtain a PT/INR on that day. The laboratory (lab) obtained and sent to the lab. The Health Status Note created on 1/13/22 at 9:26 AM for the effective date of 1/11/22 at 3:00 PM documented that the ARNP notified of the PT/INR due on 12/10/21 with no medication changes. An order received to obtain the PT/INR on 1/11/22. The electronic and paper health record lacked documentation of a lab completed with results for a PT/INR in between 11/10/21 and 1/11/22. The Care Plan Focus revised 11/8/21 documented that the resident had an altered cardiovascular status related to [CONDITION(S)] fibrillation with pacemaker (machine surgically placed to help pump the heart) in place. The resident had [CONDITION(S)] (narrowing of the blood vessels or arteries). Be aware that on assessment that the resident has [CONDITION(S)] and [CONDITION(S)]. The Interventions revised 10/7/21 related to the Focus were as follows A. Black box warning: [MEDICATION(S)] can cause major or fatal bleeding, which is more likely to occurr during the starting period and with higher doses. Make sure to regularly monitor INR in all patients that use [MEDICATION(S)] and consider more frequent INR monitoring in those at high risk for bleeding. B. Obtain and monitor PT/INR as ordered, report results to the physician and follow up as indicated. During an interview with Director of Nursing (DON) on 1/13/21, she stated that facility was transitioning from all paper documentation to all Point Click Care (PCC) and had started in November 2021. She stated she had understood that PT/INR would populate with [MEDICATION(S)] order and cue nurses to draw PT/INR levels. The December missing PT/INR's were discovered. She stated they have transitioned back to paper tracking and notified PCC of this issue. This has been actioned planned. On 1/11/22 physician was notified that PT/INR for December was not drawn and order for a redraw was received. The results came back with INR 2.4. The physician was notified on 1/12/22 and no new orders other than redraw in one month. The facility checklist dated 7/17/18 and reviewed 11/7/19 showed that nursing must receive orders for next draw and record on the [MEDICATION(S)] flow sheet, the lab book, calendar, and nurse's notes. Orders must be obtain for next draw with each result and each time. A written statement provided by the Director of Nursing (DON) dated 1/13/22 at 11:25 AM, documented that the DON notified the provider of a missed PT/INR from 12/10/21. A new order received to draw with no medication changes at the time. On 1/11/22 the PT/INR was obtained and sent to the lab. On 1/12/22 the provider reviewed and noted no changes other than to redraw in one month. 2. Resident #2's MDS assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. Resident #2 took anticoagulants 7 out of 7 days in the lookback period. Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MRR signed 1/7/22 documentated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MRR included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MRR documented a PT/INR to be drawn every month starting on 9/25/21 related to long term use of anticoagulants. The 12/21 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The laboratory results dated [DATE] indicated a PT result of 34.8 seconds and an INR result of of 3.4 ratio. The additional handwriting completed at the facility responded that they had orders from 9/22/21 that the Physician would like the resident between 2.5 to 3.5 due to her mechanical valve. The ARNP responded the next lab draw date to be on 12/1/21 value within normal parameters, no changes. A new order written to redraw in one month. The Order Note dated 1/11/22 at 3:50 PM indicated the DON notified the ARNP of the resident's PT/INR due on 12/29/21. A new order received to draw a PT/INR on 1/11/22. The PT/INR lab obtained and delivered to the lab. The laboratory results dated [DATE] recorded a PT result of 47.0 seconds and an INR result of 4.6 ratio. On 1/12/22 the ARNP responded to hold [MEDICATION(S)] for three days then resume the normal schedule and then recheck a PT/INR in two weeks, report any bleeding. The electronic and paper health record lacked documentation of a PT/INR completed between 11/30/21 and 1/11/22. The Care Plan Focus revised 10/18/21 documented that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interventions revised 10/7/21 related to the Focus were as follows A. Black box warning: [MEDICATION(S)] can cause major or fatal bleeding, which is more likely to occurr during the starting period and with higher doses. Make sure to regularly monitor INR in all patients that use [MEDICATION(S)] and consider more frequent INR monitoring in those at high risk for bleeding. B. Obtain and monitor PT/INR as ordered, report results to the physician and follow up as indicated. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A written statement provided by the DON dated 1/13/22 at 11:25 AM, documented that on 1/11/22 at 3:54 PM a nurses note regarding notification to the ARNP of a missed PT/INR (12/29/21-1/11/22). New orders were received to immediately draw a new PT/INR. The results were received in the facility on 1/12/22 at 8:30 AM, the ARNP notified by phone of an INR result of 4.6. The ARNP arrived at the facility at approximately 9:00 AM. The resident saw the ARNP who gave orders to hold [MEDICATION(S)] 3 days then resume previous schedule, then recheck a PT/INR in two weeks. The hot charting (frequent charting) updated to monitor the resident for signs or symptoms of bleeding. 3. Resident #25's MDS dated [DATE] documented a BIMS score of 15, indicating intact cognition intact. Resident #25 took anticoagulants 7 out of 7 days in the lookback period. Resident #25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MRR signed 1/7/22 show an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/21 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The laboratory results dated [DATE] indicated a PT result of 18.7 seconds and an INR result of 1.8 ratio. A added handwritten section recorded the resident received 3 mg on Monday, Tuesday, Wednesday, Friday, Saturday, Sunday, and 4.5 of [MEDICATION(S)] on Thursdays. The Physician responded to give 1.5 mg extra of [MEDICATION(S)] that day only and recheck in one month. The Health Status Note created on 1/13/22 at 9:22 AM for the effective date of 1/11/22 at 3:00 PM documented that the ARNP notified of the PT/INR to be drawn on 12/10/21. The ARNP responded with no medication changes at that time but to draw an INR that day. The laboratory results dated [DATE] indicated a PT result of 30.4 seconds and an INR result of 3.0 ratio. The ARNP responded with no medication changes and to redraw a PT/INR in one month. The Care Plan Focus revised on 9/14/20 for Resident #25 showed documented that the resident had an altered cardiovascular status related to hypertension and A-Fib. The resident continued on long term use of anticoagulants for management of A-Fib. The Interventions related to the Focus revised on 10/07/21 indicated the following A. Black box warning: [MEDICATION(S)] can cause major or fatal bleeding, which is more likely to occurr during the starting period and with higher doses. Make sure to regularly monitor INR in all patients that use [MEDICATION(S)] and consider more frequent INR monitoring in those at high risk for bleeding. B. Administer anticoagulants as ordered. A written statement provided by the DON dated 1/13/22 at 11:00 AM, documented that on 1/11/22 the DON notified the provider of a missed PT/INR. A new order received to draw a PT/INR with no medication changes at the time. On 1/11/22 the PT/INR obtained and sent to the lab. On 1/12/22 the nurse documented the lab result was received to be addressed in the morning by the rounding provider with an INR result of 3.0. On 1/12/22, the Provider addressed the PT/INR results with no new orders other than to recheck the PT/INR in one month. During the facilities transitioning from paper documentation to all electronic in November 2021, the understanding from the training explained that PT/INRs would populate when input and cue the nurses to draw. The December's missing PT/INRs were discovered so the facility transitioned back to back to paper tracking and notifying the electronic health record company of the issue. The Facility provided PT/INR Checklist reviewed on 11/7/19 documented to obtain a PT/INR on the scheduled day and place on the Hot Chart. All Orders must be received for the next lab draw and record on the [MEDICATION(S)] Flow Sheet, the lab book, the calendar, and the nurse's notes. The nurse must obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, observations, and staff interviews, the facility failed to ensure a resident received rehabilitative services to restore their highest practicable level of physical and functional well-being for 1 of 1 resident reviewed (Resident #35) for range of motion (ROM). The facility reported a census of 39 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #35 required extensive assistance with oral hygiene, toilet use, and dressing. An observation on 1/10/22 at 12:05 PM revealed Resident #35 wearing a brace on her right hand during lunch. During an interview on 1/10/22 at 2:26 PM, Resident #35's Representative stated that she had therapy ordered for therapy for a month before they started the therapy on her hand. Resident #35's Representative stated the reason reported to her that because of a new nurse, therapy didn't started earlier. The Diagniostic Radiology form dated 12/7/21 at 12:06 PM revealed an obliquely (indirect) oriented and slightly comminuted (broken in more than two places) fracture (broken bone) of the fourth metacarpal (ring finger). The Office Clinical Notes dated 12/7/21 at 12:15 PM revealed Resident #35 received an order to start Physical Therapy. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised 9/30/21 revealed focus areas for Resident #35 that included a need for assistance with activities of daily living (ADLs) and a high risk for falls. The Care Plan lacked documentation of the resident's removable wrist brace. During an interview on 1/12/22 at 3:30 PM the Director of Nursing (DON) revealed a new nurse took the order for PT and OT on 12/7/21 but failed to notify the Director of Rehabilitation (DOR) of the order as expected. Due to the lack of communication of the order, Resident #35 did not receive PT and OT rehabilitation services as ordered on 12/7/21. The DON further revealed the expectation for therapy orders were to be copied and placed on therapy's desk. The nurse should call or text the DOR regarding the new order on the same day the order was received or the next morning if received during the night.

Based on clinical record reviews and staff interview, the facility failed to refer one out of one resident reviewed (Resident #25) for a level II evaluation, following a change in psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition (memory). Resident #25's MDS documented an overall mood score of 12, indicating moderate depression. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Preadmission Screening and Resident Review (PASRR) dated 8/27/20 for Resident #25 indicated a notice of a negative level I (one) screen outcome. The resident had no major mental illnesses or mental disorders. [MEDICATION(S)] documented as the only prescribed [CONDITION(S)] medication. The outcome determined no level II (two) condition - level I negative. The referral was approved. The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission MDS assessment dated [DATE] documented a BIMS a score of 14, indicating intact cognition. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident used an anti-anxiety medication for one out of seven days in the lookback period. The resident used anti-depressant medication for six out of the seven day lookback period. The initial Psych Visit Note dated 9/11/20 documented a history of physical abuse from the resident's husband who was admitted to facility at some time as the resident. Resident #25 stated she was anxious and that her anxiety increased in the afternoon and evenings,due to the resident's husband history of returning home drunk and becoming abusive. Resident #25 rated her depression level at 7 of 10 and her anxiety at 10 of 10. Resident #25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident agreed to try selective serotonin reuptake inhibitor (SSRI) medication for anxiety and depression before the use of benzodiazepines. Resident #25's medications on 9/11/20 included 1. [MEDICATION(S)] 50 MG once per night for depression and anxiety 2. [MEDICATION(S)] 5 MG tablets twice a day 3. [MEDICATION(S)] SR ([MEDICATION(S)] SR) 150 MG tablet once per day. The Medication Review Report (MRR) signed by the Physician on 1/7/22 recorded the resident saw a psychiatric services company for Psychiatry and Psychotherapy. The (MRR) included orders for 1. [MEDICATION(S)] ([MEDICATION(S)]) tablets 0.5 MG every morning and evening for anxiety 2. [MEDICATION(S)] tablet 3 MG taken at bedtime for [CONDITION(S)] 3. [MEDICATION(S)] tablet 10 MG twice a day for dementia 4. [MEDICATION(S)] 7.5 MG tablet taken at bedtime related to Major depressive disorder 5. [MEDICATION(S)] 100 MG tablet at bedtime for depression. The Care Plan Focus revised 5/26/21 documented the resident experienced years of domestic abuse resulting in anxiety and depression. The resident's husband lived with her when they first moved into facility, but days after their admission he became violent with me. Due to the violence the staff removed her husband from the resident's room for her safety. The resident missed her husband but experienced relief that she didn't have to worry about him finding her and becoming physically violent towards her anymore. On 5/21/21 the resident's clinical record received an updated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Trauma informed care. The Care Plan included the following Interventions. 1. Interventions revised on 10/7/21 A. Administer anti-anxiety medications as ordered by the physician, monitor for side effects and effectiveness every shift (q-shift). B. Administer anti-depressant medications as ordered by the physician for management of anxiety and depression. C. Monitor then document any side effects or effectiveness q-shift. D. The resident had a fear of men due to her past abuse from her husband. E. The resident knew that her husband couldn't hurt her anymore as he passed away, but she still had memories that haunted her. F. The resident consults with psychiatric services to address her anxiety and depression. The resident started attending psychiatric services on 9/11/20. They address the resident's psychiatric needs and order the proper medications as needed. The resident attends the services once a month. G. The resident's anxiety increases in the afternoon and evening hours due to the resident's husband history of returning home drunk and becoming abusive. H. Please administer anti-anxiety medication as ordered then monitor for side effects and effectiveness. 2. Interventions revised on 11/29/21 A. The resident started attending psychiatric services once a month on 10/9/20. The Psychiatrist helps the resident with her anxiety and fear. In an interview on 1/12/22 at 2:50 PM, the Assistant Director of Nursing (ADON) stated that the Level I PASSR needed to resubmitted anytime the resident added or changed a psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interviews, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing (Resident #7). The facility reported a census of 38 residents. Findings include: The MDS (Minimum Data Set) 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 partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III 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). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations 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 soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 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. According to the Minimum Data Set (MDS) assessment tool with an assessment reference date of 11/17/20, Resident #7 has a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #7 requires extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Non-Pressure Skin Condition Report revealed Resident #7 developed an abrasion wound on her left upper buttocks, identified on 11/7/20. The wound measured 1.5 centimeters by 1.5 centimeters. The record indicates staff assessed the wound weekly. and according to the treatment administration record, is treated by cleansing with soap and water and applying [MEDICATION(S)] daily. The last weekly assessment recorded is on 1/13/21, noting the wounds are reducing in size and healing. According to a Braden Scale-For Predicting Pressure Sore Risk dated 12/10/20, Resident #7 scored 11 points (at high risk to develop a pressure sore). A hospital integumentary (skin) admission assessment from 12/8/20 at 12:03 a.m. documented Resident #7 had a stage II pressure ulcer in the medial sacrum area that measured 1.5 centimeters in length by 2.0 centimeters wide. In an interview on 7/28/21 at 9:41 a.m., Staff N, facility skin nurse, reported on 12/7/20 Resident #7 admitted to the hospital and returned to the facility on [DATE]. Staff N reported she was unaware that hospital staff identified a stage II pressure ulcer over the resident's sacrum area. Staff N stated no facility staff identified the wound or called the physician to obtain an order to treat the wound at that time. On 1/11/21 Staff N did identify the wound as an unstageable 2.0 centimeter by 1.5-centimeter purple area (black eschar) surrounded by a dark red ring over her coccyx area (Wound/Skin Healing Record). Staff N stated she conferred with Staff T and together they decided the wound was pressure related, however, they failed to use a weekly pressure ulcer record skin sheet to document the wound. Staff N states she notified the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff N concedes the pressure ulcer identified at the hospital on 12/7/20 is not monitored or treated by the facility from 12/10/20 through 1/11/21. Staff N states none of the wounds, including the pressure ulcers on the heels and coccyx are addressed in Resident #7's care plan. According to the Wound/Skin Healing Record, Resident #7's coccyx wound is again assessed on 1/13/21, noting a 1.5 centimeter by 1.0 cm open area with black eschar and a surrounding area of discolored skin (purple) measuring 7 centimeters by 7 centimeters. Stage not determined. In an interview on 7/27/21 at 11:09 a.m. Staff B states she completed the Nurses' Admission assessment dated [DATE] when Resident #7 returned to the facility from the hospital. The assessment includes what Staff B determines as a moisture associated skin damage (MSAD) wound 3.0 centimeters by 3.0 centimeters on the coccyx area. Staff B states she consulted with Staff N, skin nurse, and asked whether it was the same wound as the original abrasion to upper left buttocks noted 11/7/20. Staff B states Staff N told her it is. Staff B states she places [MEDICATION(S)] over the wound, because that is what the hospital had done. No treatment orders obtained. In an interview on 7/27/21 at 1:38 p.m. Staff U, hospice nurse, states her agency first initiated hospice services for Resident #7 on 1/2/21. Staff U states she does not recall whether she assessed Resident #7's buttock wound or whether she just reviews the facilities notes, but documents a 3.0 centimeter by 3.0-centimeter superficial abrasion to left buttock. Staff U states a sore is identified on Resident #7's coccyx on 1/11/21 and they were able to get Resident #7 an MA55 air mattress (low air loss mattress) to reduce pressure.