Every finding on record at Wheatland Manor

Based on clinical record review, facility policy review and staff interviews the facility failed to ensure staff used a gait belt during a transfer of a resident who required moderate assistance which resulted in an arm fracture for 1 of 3 (Resident #48) residents reviewed for falls. The facility reported a census of 44 residents. Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #48, dated 10/29/25, revealed a list of diagnoses which included hypertension, hyperlipidemia, diabetes and history of a fracture. The Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated a mild cognitive impairment. The MDS assessed the resident required moderate assistance (a helper lifted, held, or supported trunk or limbs for less than half of the effort) with transfer, toileting, and ambulation. Review of Resident #48's Care Plan, revised 7/10/25 revealed a Focus area to address The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Limited Mobility d/t (do to) multiple fractures. Interventions included, in part TRANSFER: The resident requires Ax1 (assist of 1) GB (gait belt) and FWW (front wheel walker). A handwritten Care Card (list of specific supports for residents), dated 10/21/25, posted in Resident #48 room included the following: Transfers: Ax1, GB, FWW to BR (bathroom), and Mobility: Ax1, GB, FWW. Review of an incident report dated 11/23/25 at 4:50 AM, revealed nurse notified by Certified Nursing Assistant (CNA) to come to Resident #48 room. CNA attempted to transfer resident from the bed to the commode. Resident legs went out and her arms went up and CNA heard resident's left arm make a crack and she lowered her to the floor. Resident complained of left arm pain. Review of an X-ray report, dated 11/23/25 at 7:04 AM revealed an acute mildly displaced fracture of the humeral neck/proximal diaphysis with mild medial displacement of the distal fracture fragment. Review of a written witness statement, dated 11/23/25, made by Staff A, CNA revealed was going to take Resident #48 to the bathroom but the resident could not walk, she moved the walker and bear hugged the resident to the commode. Staff A wrote the residents leg gave out and as Staff A lowered the resident to the floor, she heard the residents left shoulder crack. Staff A stated did everything she could to not have the resident hit the floor. She lowered the resident slowly to the floor. During a phone interview on 1/14/2026 at 9:33 AM, Staff A, CNA stated on 11/23/25 she assisted Resident #48. Staff A stated she did put the gait belt behind her [Resident #48] but the resident started to slide so she bear hugged the resident and attempted to transfer her to the commode. Staff A explained the residents foot hit the commode and she then lowered the resident to the ground. Staff A stated the only wrong thing she did was not getting the gait belt on Resident #48 at the time. She stated the facility did have information posted in Resident #48 room which indicated Resident #48 was an assist of one with front wheeled walker and walk to the bathroom. Staff A stated day shift staff reported they had been using a 2 person assist over the last 2 weeks. Staff A explained the transfer was going to be to the commode, which was right beside the bed and the resident started sliding off of her bed. Staff A stated her fault was not grabbing the gait belt behind the resident. Staff A stated the facility did provide education when another resident fell and they had staff sign a form stating staff would use a gait belt. Staff A explained the resident [Resident #48] had not stood up yet and her feet were on the ground and she was sliding. Staff A stated looking back she should have lifted the residents' legs back up instead of trying to get her on the commode. Staff A stated she knew to use a gait belt and always has one with her. Staff A stated she was negligent for not using a gait belt. Staff A stated she was aware of the sign in the resident's room but other staff reported they were using an assist of two and nothing had been changed on the sign in the resident's room. Staff A explained the residents walker was in front of her until she was sliding and then Staff A moved it out of the way and used her arms around the resident to lay her on the ground. Staff A stated as she was laying the resident to the ground, she let her hand slowly slide with the resident as she softly laid her on the ground. Staff A explained her hand barely went under the resident's armpit and that is when her [Resident #48] shoulder popped out. During an interview on 1/14/26 at 2:37 PM, Staff B, Registered Nurse (RN) stated she was at the nurse's station and Staff A, CNA told her she needed her and she went to Resident #48 room and the resident was on the floor. Staff B stated Staff A told her she transferred the resident from the bed to the commode and she started to go down. Staff B stated Staff A lowered Resident #48 to the floor and then she heard a crack. Staff B stated she [Staff A] did not have a gait belt on the resident when she entered the room. During an interview on 01/14/2026 at 3:07 PM, Staff C, CNA stated Resident #48 transferred with the assist of one unless something changed and then they put on the nurses note. Staff C stated a change also would have been on the Care Card that is on the wall in the resident's room. Staff C explained the Care Card provides the residents transfer status and is updated when a transfer status changes. She stated whenever a resident is transferred a gait belt is to always to be used if the resident is an assist of one. Staff C stated there is never a time she would not use a gait belt. Staff C stated she had worked at the facility for 4 months and when she was hired the transfer policy and use of a gait belt was reviewed. During an interview on 01/14/2026 at 3:15 PM, Staff D, CNA stated staff know the transfer status of a resident is on the Care Card which is on the wall in the residents' rooms. Staff D explained the Care Card gives the residents name, room #, and information needed to care for the resident. Staff D stated she uses a gait belt and she believed it is the facility policy to use a gait belt for transfers. Staff D explained it is easier if a resident goes down or if they are unsteady with a gait belt. She added we are told to use them and it is posted on the Care Card. Staff D added, she had been told to reinforce the use of a gait belt with new trainees.During an interview on 01/15/2026 at 10:59 AM, the Director of Nursing (DON) stated she was notified on the morning of 11/23/25 Resident #48 had a fall and the CNA had not transferred the resident according to the Care Card. The DON explained Staff A, CNA had kind of bear hugged the resident and tried to transfer her to the commode and heard a crack and then lowered the resident to lowered to the ground. The DON stated the facility took the outcome of the investigation very seriously. She added the staff are constantly told to follow the Care Card as it tells how to transfer appropriately. The DON stated she had addressed appropriate transfer of residents in Staff A evaluation because she had transferred residents before without a gait belt. The DON explained she had been made aware of this by another CNA who had reported it that when she went into assist with a transfer and Staff A was not using the gait belt. The DON explained the Care Cards are in all the residents' rooms and they are there for the CNA and the nurse to easily refer to and know how residents are to be transferred/ambulated. The Care Card is updated by nurse or therapy recommendations. The DON stated there were no changes for Resident #48. She explained the resident was getting a little weaker but her transfer status had not been changed. The DON stated the resident would still transfer with one, but staff are always told they can go up with transfer assistance. She explained, for example staff could use 2 staff for a Ax1, but they cannot go down and use less assistance than what the Care Plan has documented. The DON stated Staff A, CNA was an employee of the facility and knew the policy for gait belts and the Care Card. The DON stated expected the staff to the Care Cards no matter what, and they can always request more assistance if needed. She added the gait belt is to be used for anybody who needs assistance with transfers and ambulation. Review of the facility policy titled, Transferring Residents dated 1/24/35 revealed an objective to provide safe movement of residents between surfaces, and to ensure the safety of residents and staff. The policy directed each residents individual Care Plan reflects how the resident is to move between surfaces. Pertinent Care Plan information is recorded on individual Care Cards in resident room and reflect the most recent Care Plan status. If a resident requires assistance to move between surfaces a gait must be utilized for the duration of the transfer for any resident that does not utilize a sit to stand or full body lift.

Based on observation, clinical record review and staff interviews, the facility failed to provide adequate supervision to prevent a fall which resulted in a fracture requiring a surgical repair for 1 out of 2 residents reviewed for falls.(Resident #5). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 9/25/24, listed diagnoses for Resident #5 which included orthostatic hypotension (a drop in blood pressure that occurs when standing up from a sitting or lying position), right hip fracture, and coronary artery disease. The MDS indicated Resident #5 required partial to moderate assist of staff to sit to stand, chair/bed-to-chair transfer, toilet transfer, and walk 10 feet to 50 feet. The Brief for Mental Status (BIMS) score of 15 out of 15, indicated intact cognition. The Care Plan, revised on 1/15/24 included a Focus Area to address The resident [Resident #5] has an ADL (activities of daily living) self-care performance deficit r/t (related to) R (right) Hip Fracture, Limited Mobility, Muscles Impairment. The Interventions included Mobility: A x1 (assist of 1 staff), GB (gait belt) with WC (wheelchair to follow), as tolerated, as resident requests, revision date 10/9/24. A Health Status Note, transcribed on 11/8/24 at 4:40 PM revealed at 3:10 PM, RCT (Resident Care Technician) alerted nurse that resident [Resident #5] was on the floor. Observed resident lying on L (left) side with feet towards toilet and head near sink. States he was in BR (bathroom) and fell over. Left lower extremity appears to be externally rotated. Reports increased pain to whole LLE (left lower extremity) with slight/movement of extremity. Denies other pain .Phone call placed to 911 for ambulance transport. Resident left facility at 3:30 PM to emergency room . A document titled Wheatland Manor Incident Report, dated 11/8/24 revealed RCT [Staff A] alerted nurse the resident was on the floor. The form indicated the incident witnessed by Staff A, RCT. A witness statement made by Staff A, RCT dated 11/8/24 revealed she assisted Resident #5 off the toilet to a standing position to assist with toilet hygiene. After assisting with cleaning Resident #5 up, he requested she place his watch on the charger in the room. Staff A left the resident unattended in the bathroom to place the watch on the charger in the window in his room. While at the window she heard the resident fall. A Diagnostic Radiology report dated 11/8/24 at 7:30 PM, revealed Resident #5 sustained a fracture of the left femur including trochanter and proximal femoral shaft (left hip fracture). During an interview on 01/08/25 at 1:12 PM, the Director of Nursing (DON) stated she was the nurse the day Resident #5 fell . The DON stated while at the desk, an RCT came up and stated Resident #5 was on the floor, he was lying on the floor with head towards toilet and feet towards sink resident told her he was standing up and he fell over. The DON stated at the time of the fall she spoke with Staff A and she stated he just fell over. Then another nurse was in the room and he mentioned he wanted to have his watch charged and Staff A admitted that she left him unattended. The DON confirmed Resident # 5 Care Plan at the time of the fall directed staff to provide assist of one with gait belt and walker for transfers and ambulation. The facility policy is to not leave a resident unattended with transfers if they require assistance from staff. During an interview on 01/08/25 at 03:05 PM, the DON stated the expectation of the staff is to follow the gait belt policy and the residents care plan when provide assist with transfers and ambulation. The residents also have a care card in the resident room above the bed and they match the computer care plan. The care card tells them the transfer status of the resident and how they ambulate. The DON stated she would expect the staff to follow the care card. During an observation on 01/09/25 at 8:57 AM, Staff B, RCT and Staff C, RCT provided assistance to Resident #5 with a partial assist mechanical lift to aid in a transfer. With the two staff assisting, Resident #5 gripped the handles of the mechanical lift and able to bear weight on both lower extremities to complete the transfer. During an interview on 01/09/25 at 9:07 AM, Staff AC, RC stated they know how to transfer a resident by the care card in their room. They are expected to follow it and transfer the resident as it is written on the card. If a resident should be a transfer of one with a gait belt and walker she would never leave the resident unattended. A facility policy, dated 12/6/23, titled Transferring/Ambulating Resident With A Gait Belt policy Objective To provide increased security for resident and staff during transfers, and to prevent injury transfer and ambulation of residents. The Procure directed staff to; 1. Use the gait belt during transfer or ambulation of all residents that require hands-on assistance, except for those using a mechanical sit to stand or full body lift. 5. Use the bait belt for duration of transfer and ambulation to stabilize resident, holding gait belt near middle of resident's back. 6. Walk alongside resident and slight behind. The policy did not address leaving a resident unattended during transfer or ambulation.

Based on observation, staff interview, and facility policy review, the facility failed to check the temperature of cabbage served and further failed to perform hand hygiene when picking up an item from floor during meal service for 1 of 1 meal services observed. The facility reported a census of 41 residents. Findings Include: On 1/30/24 at 12:00 PM, Dietary Supervisor checked the temperature on the following items being served: grilled turkey sandwich, sweet potato fries, coleslaw, and Jell-O, just before meal service. Noted an additional item, steamed cabbage, kept on the stove top that had been served for residents whom required mechanically altered and soft food. The Dietary Supervisor had not obtained a temperature reading of the cabbage prior to service to ensure a safe to eat cooking temperature. On 1/31/24 at 12:15 PM, Staff G, Dietary Aide, delivered plates to the residents from the kitchen steamtable. During meal service, a Resident's Diet Card had fallen on the floor, Staff G picked the card up from the floor and placed it on a clean counter, Staff G then grabbed a resident's plate and continued to deliver meals. No hand hygiene performed between touching dirty item on floor and clean plate delivered to a resident. On 1/31/24 at 12:38 PM, the Dietary Supervisor reported they forgot to get a temperature on the cabbage served to residents on mechanically altered/soft diets. On 2/02/24 at 10:30 AM, the Dietary Supervisor stated the expectation of staff to sanitize Resident Diet Cards if dropped on the floor, and perform hand hygiene before food service resumed. The Dietary Supervisor reported the intention to educate Dietary Staff on what to do when item falls on the floor. The Dietary Supervisor stated all food served, should have temperature checks and agreed the cabbage should have been checked prior to service. The facility policy titled, Bare hand contact with ready-to-eat-foods, dated March 2006, informed staff are required to perform hand hygiene after handling soiled equipment or utensils. The facility policy titled, Food Temperatures, dated March 2006, instructed that temperatures will be taken and recorded for all items at the meals.

Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to provide residents with privacy and dignity during transport to the shower room when residents were pulled backwards in a shower chair with skin exposed for 3 of 3 residents reviewed for dignity (Residents #9, #21, and #95). The facility reported a census of 41 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment, dated 12/29/23 for Resident #9, revealed the Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of intact cognition. Resident #9 identified dependent on staff for transfers and bathing. Diagnoses included right femur fracture, cancer, and arthritis. The Care Plan, revised 1/15/24, revealed Resident #9 with an Activities of Daily Living (ADL) self-care deficit and required assistance of one staff for bathing and instructed staff to provide sponge bath with a full bath or shower cannot be tolerated. The Certified Nursing Assistant (CNA) Task charting revealed Resident #9 received a shower/bath on 1/30/24. On 1/30/24 at 10:46 AM, observed Resident #9 sitting in a shower chair, a bath blanket covered his front, but his naked backside/buttocks remained visible. Resident #9 pulled backwards in the shower chair, with buttocks exposed, from his room, through the hallway, past resident rooms and various staff, to the shower room. 2. The MDS, dated [DATE] for Resident #95, revealed a BIMS score of 0 out of 15, indicative of severe cognitive impairment. Resident #95 identified dependent on staff for transfers and substantial/maximal staff assistance with bathing. Diagnoses included non-Alzheimer's dementia and Cerebral Vascular Accident (CVA) or stroke. The Care Plan, revised on 1/12/24, revealed Resident #95 with an Activities of Daily Living (ADL) self-care deficit and informed that Resident #95 required assistance of one staff with bathing. The Certified Nursing Assistant (CNA) Task charting revealed Resident #95 had received a shower/bath on 1/30/24. On 1/30/24 at 07:50 AM, observed Resident #95 sitting in a shower chair, a bath blanket covered resident's front, but his upper legs and sides of buttocks remained visible. Resident pulled backwards in the shower chair with areas exposed, from his room, through the hallway, past the dining room full of residents, to the shower room. On 2/02/24 at 01:05 PM, Staff E, CNA, reported that a sheet is used to cover residents in the hallway while transferred to the shower room so that nothing is showing and stated they would stop and cover a resident if private areas had been exposed. Staff E stated the shower chairs do not have foot pedals and indicated this is the reason chairs are pulled backwards, so resident's feet don't hit the floor. 34821 3. The MDS Assessment for resident # 21 dated 12/7/23, listed diagnoses of Alzheimer's disease and anxiety. The MDS reflected Resident #21's BIMS score of 00 (severe cognitive impairment). The MDS identified Resident #21 dependent on staff for transferring and mobility in the halls. The Care Plan for Resident #21 dated 1/30/24, directed staff propels Resident #21 in her wheelchair. On 1/30/24 at 1:07 PM Staff B, CNA, pushed Resident #21 up the hall from her room past 2 occupied rooms on the 300 hall as she sat in the shower chair while her bare thigh shown. On 1/30/24 at 8:56 AM, Staff B, CNA and Staff A, CNA reported they never really used the shower room on the 300 hall due to the poor water pressure. On 2/01/24 at 2:40 PM, the Director of Nursing (DON) reported she expected if the CNA's used the bath chair for resident transportation to the shower, then keep the resident's skin covered for dignity. She stated she'd preferred to walk the resident or use their own wheel chair for transportation. The DON confirmed the CNA's pulled the resident backwards in the shower chair because it lacked foot pedals. The DON conformed a dignity problem. The facility provided the Admission Packet that included an undated Resident [NAME] of Rights, which directed at point A.: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in the section. A facility must treat each resident with respect and dignity and care for each resident in a manner and environment that promotes the rights maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, staff interview and Resident Assessment Instrument (RAI) Manual review, the facility failed to code 2 out of 5 Minimum Data Set (MDS) Assessments correctly for residents reviewed (Resident #5 and #20). The facility reported a census of 41 residents. Findings Include: 1. The Minimum Data Set (MDS) for Resident #20 dated 11/15/23, showed she took an antidepressant medication in the seven day look back period. The Medication Administration Record (MAR) dated November 2023, failed to include documentation Resident #20 took an antidepressant during the reference period. On 1/31/24 at 1:56 PM, the Director of Nursing (DON), confirmed Resident # 20 failed to utilize an antidepressant at the time of the MDS dated [DATE]. 2. The MDS for Resident #5 dated 1/3/2024, showed she took an antidepressant medication in the seven day look back period. The MAR dated December 2023, failed to include documentation that Resident #5 took an antidepressant during the month of December. The MAR dated January 2024, failed to include documentation Resident #5 took an antidepressant during the reference period. On 1/31/24 at 3:25 PM, Resident # 5 The DON confirmed Resident # 5 failed to use an antidepressant medication for awhile now. She reported the facility marked that in error. The DON reported they followed the Resident Assessment Instrument (RAI) Manual and lacked policies. The RAI Manual dated 10.2023, directed to check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Based on clinical record review, staff interview, and facility policy review, the facility failed to follow Physician's Orders when a resident's Fentanyl pain patch had been omitted for greater than one day for 1 of 2 residents reviewed for psych/opioid medication review (Resident #19). The facility reported a census of 41 residents. Findings Include: The Minimum Data Set (MDS), dated [DATE] for Resident #19, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicative of moderate cognitive impairment. Resident required scheduled and as needed pain medications, had pain frequently, and occasional pain interference with therapy activities. Diagnoses included: displacement fracture of the 7th vertebra (neck fracture), arthritis, disorder of bone density, and neuropathy. The Care Plan, initiated 12/28/23, revealed a Focus Area for acute pain related to fracture and chronic pain related to bone density disorder with a goal that resident will verbalize adequate relief of pain, and an intervention to administer analgesia (pain medication) as per orders. The Medication Administration Record (MAR), dated January 2024, listed an order for Fentanyl transdermal patch 12 micrograms (mcg) per hour and instructed staff to apply one patch every 72 hours for pain related to neck fracture, remove the old patch per schedule. The MAR revealed a patch had been removed on 1/21/24 at 10:25 PM, no new patch applied until 1/23/24 at 6:26 AM, approximately 32 hours without pain relief patch. Review of progress notes revealed the following entries: a. On 1/20/24 at 10:11 AM: Pharmacy faxed request for valid prescription from the prescriber on Fentanyl patch. b. On 1/21/24 at 10:25 PM: Resident out of patches. c. On 1/23/24 at 6:26 AM: New patch applied last night. On 1/31/24 at 3:00 PM, Director of Nursing (DON) confirmed Resident #19's Fentanyl patch had been removed on 1/21/24 and applied on 1/23/24 when resident had been out of patches. DON informed Pharmacy delivers medications every evening Monday through Friday, and as needed for emergencies. DON provided the list of Emergency Kit Medications kept at the facility which included Fentanyl 12 mcg transdermal patch. DON informed that if they had been notified Resident #19 lacked Fentanyl patches, they would instruct staff to apply patch from the Emergency Kit. The facility provided a list of Emergency Kit medications, updated 11/13/23, which included one Fentanyl 12 mcg/hour patch stored in the facility. The undated facility policy titled, Administering Medications, instructed medication to be given within one hour of the prescribed time of administration and if administration does not occur within this timeframe, the physician should be notified.

Based on clinical record review, observations, staff interviews, and facility policy review the facility failed to provide a call light within reach of a resident in his room for one out of twelve resident reviewed (Resident 10) and one of 3 unlocked bathrooms failed to have a call light in one of the unlocked facility restrooms. The facility reported a census of 41 residents. Findings include: 1. The Minimum data Set (MDS) Assessment for Resident #10 dated 11/1/23, included diagnoses of non-Alzheimer's dementia and hypertension. The MDS identified Resident #10' Brief Interview for Mental Statues as 00, severe cognitive impairments. The MDS reflected Resident #10 required supervision for toileting and substantial assist for transfers. The Care Plan for Resident #10 dated 3/2/23, directed to encourage the resident to use bell to call for assistance. The following observations revealed the following situations for Resident #10 and access to his call light: a. On 1/29/24 at 11:15 AM, Resident #10 sat in the wheel chair (W/C) in the middle of his room and failed to have a call light in reach. His head hung down, looked asleep. b. On 1/30/24 at 9:59 AM, Resident #10 sat in the (W/C) in his room and faced the sink. The call light hung behind the bed, by the wall, out of reach. c. On 1/30/24 at 10:54 AM, Resident #10 sat in his room in his W/C. The call light hung behind the side of the bed out of his reach. 2. On 1/29/24 at 10:57 AM, the unclosed and unlocked bathroom by the front door lacked a call light. On 1/30/24 at 9:56 AM, the bathroom door by the entrance door remained unlocked and failed to have a call light. On 1/31/24 at 10:00 AM. the unlocked bathroom by the front door lacked a call light. On 1/30/24 at 9:56 AM, Staff D, Registered Nurse (RN) reported the bathroom door broke about 3 months ago and the facility just didn't replace the lock. On 2/01/24 at 12:19 PM, the Director of Nursing (DON) reported she expected the call lights within reach of the residents and she confirmed the bathroom near the front door lacked a call light. The facility provided an undated procedure titled Responding to Call Light, and directed assure resident's call light system is accessible to him/her at all times while the resident is in room.

Based on observation, record review and staff interview the facility failed to provide adequate assistance to prevent accidents by transferring a resident without the use of a gait belt for 1 out of 2 residents reviewed with a fall (Resident #27). The facility identified a census of 36 residents. Findings include: Resident #27's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. The MDS showed the resident required extensive assist of one staff with transfers and toileting. The assessment showed the resident with diagnoses of [CONDITION(S)], hypertension (high blood pressure) and depression. Observation of Resident #27 on 9/21/21 at 10:00 AM, noted the resident sitting in a recliner chair propped up with pillows. Resident states she did not have a belt on with her last fall during the transfer. The Care Plan last revised on 8/26/21 indicated Resident #27 with limited physical mobility related to weakness, history of Pneumonia with [CONDITION(S)] and needs assistance with activities of daily living. The interventions/tasks directed staff to ambulate with 2 staff and a gait belt and walker to be used for all transfers and ambulation. Review of the Progress Notes from 9/15/21 at 4:46 PM, reveal a nurse was called to Resident #27's room by a Certified Nursing Assistant (CNA). Resident #27 observed lying on her left side just inside her doorway on the floor. The CNA reported while ambulating the resident from the bathroom to her wheelchair the resident attempted to sit down before reaching her wheelchair. During an interview on 9/21/21 at 3:00 PM, Staff A, CNA stated on 9/15/21 Resident #27 was in bed and she wanted to toilet. Staff A put a gait belt on the resident and took her to the bathroom. Staff A reported she took the gait belt off the resident and was leaving the room when the resident stated she was done. Staff A explained, this is when she forgot to put the gait belt back on Resident #27. Staff A assisted the resident to stand, get her pants up and went to get the wheelchair and that is when she realized she didn't have gait belt back on the resident and it was to late. Resident #27 was already transferring and then resident fell down. During an interview on 9/22/21 at 12:30 PM, Staff B, Registered Nurse (RN) stated when she entered Resident #27's room on 9/15/21 after the fall, she noted the resident not wearing a gait belt. The facility policy on a gait belt directed any resident who is a hands on assist should be assisted with a gait belt to transfer unless there is an exception related to injury. During an interview on 09/22/21 at 1:27 PM, the Director of Nursing (DON) stated she was aware of Staff A, CNA not using the gait belt and an employee counseling was provided to her after the incident on 9/15/21. The DON explained the expectation for any resident who needs assistance with transfers will have a gait belt on when staff perform the transfer. The facility provided an undated procedure titled Gait Belt (Ambulation Belt) with the objective to provide increased security for the resident and staff and to prevent injury during ambulation and movement of residents. The procedure directed staff to use the ambulation belt during ambulation or movement of residents who need hands on assistance.

Based on record review and staff interview the facility failed to have anti-anxiety medications ordered for the limited time of 14 days for 2 of 4 resident's reviewed (Resident #8 and 14). The facility also failed to provide a written rationale for 3 of 4 residents reviewed (Resident's #8, #14 and #29) for anti-anxiety medication extended for 6 months. The facility identified a census of 37 residents. Findings include: 1. Resident #8's Minimum Data Set (MDS) assessment showed the resident had severe memory loss, required extensive assistance with daily cares, and had [DIAGNOSES REDACTED]. The Physician order [REDACTED].) every 8 hours as needed (prn) for anxiety. The medication showed a start date of 5/1/18. The Care Plan revised on 5/18/18 showed the resident used anti-anxiety medication ([MEDICATION NAME]/[MEDICATION NAME]) related to an anxiety disorder. An intervention for this concern included to administer anti-anxiety medications as ordered by the physician and attempt medication reduction to the lowest dose possible, as able. The pharmacy, physician and nurses will review the medication as needed. A Physician's Telephone Order dated 3/28/18 documented the resident's last day of Hospice Care 3/27/18. Status stable, continue same orders. The Pharmacy Progress Notes dated 7/10/18, 8/7/18, 10/9/18, 11/9/18 and 12/12/18 lacked written rationale or provided recommendations. The Pharmacy Progress Note dated 9/12/18 indicated on 8/31/18 the resident's schedule [MEDICATION NAME] dose reduced to 0.5 mg three times a day. no usage this month. No recommendations. The Pharmacy Progress Note dated 1/8/19 noted, I will address her psychotic medications again this month for a possible GDR (gradual dose reduction). The note lacked any written rationale for extending the anti-anxiety medication. The physician, pharmacist, and nurse failed to review the prn anti-anxiety medication after the resident discharged from Hospice care. An interview on 1/23/19 at 3:15 PM the Director of Nursing (DON) reported the Pharmacist does monthly reviews and the medications should be reviewed. The DON did not know if the prn anti-anxiety medication is requested for more than 14 days, or that a written rationale for this extension must be provided. When interviewed on 1/23/19 at 3:15 PM the facility's Consultant Pharmacist reported the physician requested the resident have the anti-anxiety medication available as needed. The Pharmacist remarked a written rationale for this rationale had not been written. He also noted (some) physicians have had difficulty understanding the requirements needed for this medication. On 1/24/19 at 7:20 AM the DON reported they could not find documentation where the prn anti-anxiety medication had been ordered for 14 days for residents #8 and #14. She noted since they haven't used them lately it apparently got dropped to review and have the 14 day limit and for any rationale for any time extensions. 2. Resident #14's MDS assessment dated [DATE] showed the resident had memory intact, independent with cares except for dressing and hygiene. The assessment tool showed the resident had [DIAGNOSES REDACTED]. The POS dated 1/17/19 directed staff to administer [MEDICATION NAME] tablet 0.5 mg. every 12 hours as needed. The start date for this medication showed 9/27/16. The Care Plan revised on 6/26/17 showed the resident received an anti-anxiety medication as needed for anxiety. The intervention for this concern included to review the continued need for the medication with prescriber and attempt dose reduction as warranted. The Pharmacy Progress Notes for Medication Review showed no recommendations for the anti-anxiety medication from 11/9/117 to 1/8/19, except on 8/7/18 the note showed to keep the psychiatric medications the same. The notes failed to show any written rationale for extending the anti-anxiety medication. The physician, pharmacist, and nurse failed to review the prn anti-anxiety medication after a timely period. An interview on 1/23/19 at 3:15 PM the facility's Consultant Pharmacist reported the physician failed to provide a written rationale for this extended period use of the anti-anxiety medication. 3. Resident #29's MDS assessment dated [DATE] showed the resident had memory loss, required extensive assistance with daily cares, and had [DIAGNOSES REDACTED]. The POS dated 1/17/19 directed staff to administer [MEDICATION NAME] tablet 0.5 mg. every 8 hours as needed for anxiety. The start date for this medication showed 9/13/18 with an end date of 3/13/19. The Care Plan revised on 9/24/18 showed the resident received an anti-anxiety medication as needed for anxiety. The intervention for this concern included to administer the medication as ordered. A facsimile (fax) dated 9/13/18 showed a Note to the Attending Physician/Prescriber requested a 6 month prn anti-anxiety order for the resident. The Physician did not provide a rationale for this extended use of the prn anti-anxiety medication. A Pharmacy Progress Note dated 10/9/18 showed a 6 month order for the prn anti-anxiety medication. The note failed to provide a rationale for this time extension. An interview on 1/23/19 at 3:15 PM the facility's Consultant Pharmacist reported the physician failed to provide a written rationale for this extended period use of the anti-anxiety medication.

Based on observations, record review and staff interview the facility failed to transport clean laundry while maintaining infection control practices for 2 of 2 observations. The facility reported a census of 37 residents. Findings included: During an observation on 01/23/19 at 12:29 PM Staff A (laundry aid) pushed an uncovered tub of folded towels, wash clothes and incontinent pads from the West hall to the East hall closet. On 01/23/19 at 12:32 PM Staff A pushed the uncovered folded laundry cart 1/2 full from the East hall back down to the West hall put away wash cloths and incontinent pads in the West hall closet. During an observation on 01/23/19 at 12:56 PM Staff A pushed an uncovered hanging laundry delivery rack down the West hall. During an observation on 01/23/19 at 1:05 PM - 1:20 PM Staff A pushed a 4 wheeled uncovered hanging clothes rack down the East 100 Hall into the (new) 400 Hall and then came up the 200 Hall. Observation showed the clothes rack carried personal laundry on clothes hangers with Name Markers on the rod to separate the resident's clothing. Staff A delivered clothes to resident rooms from the clothes rack as Staff moved the uncovered rack down the 3 hallways. During an interview on 1/24/19 at 08:35 AM Staff A reported not using the covers on the clean hanging laundry or the tub of clean laundry during transport in the building. During an interview on 1/24/19 at 08:51 AM the Director of Nursing stated the clean laundry in the hall cart is covered, but the clothes brought right up from the laundry room don't need to be covered just to the resident room. During an interview on 01/24/19 at 09:09 AM the Laundry Supervisor stated she expected the laundry covered during transport. The Infection Control policy statement undated, stated the primary purposes of the facility's infection control policies and procedure are to establish guidelines to follow to provide safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on document review and interview, the facility failed to ensure staff obtained a urine specimen in a timely manner to treat Resident #3's urinary tract infection. The facility reported a census of 39. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED]. Progress Notes dated 7/20/15 at 10:56 a.m. revealed Resident #3 had increased confusion and urinary frequency. The staff sent a fax to notify the physician. Physician Facsimile signed by the physician on 7/20/15 and received at the facility on 7/20/15 at 4:21 p.m. revealed an order to obtain a urine sample, staff noted the order on 7/20/15, and double noted the order on 7/21/15. Progress Notes dated 7/21/15 at 12:53 a.m. revealed staff filled out a lab slip. Progress Notes dated 7/23/15 at 9:41 a.m. revealed staff received the results of the urine sample and faxed the results to the physician. Progress Notes dated 7/23/15 at 8:28 p.m. revealed staff received a telephone order at 6:00 p.m. to start Keflex (antibiotic) 500 milligrams by mouth 4-times a day for 10 days to treat a urinary tract infection. Medication Administration Record [REDACTED] During an interview on 8/18/15 at 2:48 p.m., Staff B reported the delay in obtaining the urine specimen was due to the facility not having specimen cups on hand. Staff B reported when the staff receives an order for [REDACTED].

Based on staff interview and record review the facility failed to administer rectal suppositories at reasonable times to promote bowel movements for residents who were cognitively impaired and unable to speak of their individual preferences for 6 of 10 residents reviewed in the open sample (Residents #'s 1, 5, 7, 8, 9, and 10). The facility census reported a census of 38 residents. Findings include: 1. Resident #5's Admission Record [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set ((MDS) dated [DATE], documented the resident was always incontinent of bowel and bladder with no toileting program in place to manage the resident's bowel continence. The MDS also documented the resident had a Brief Interview for Mental Status (BIMS) score of 2 meaning the resident was severely cognitively impaired. The resident required extensive assistance of 2 staff for bed mobility, total assistance of 2 staff to transfer, no ability to walk, total dependence of 2 staff to toilet, extensive assistance of 2 staff for personal hygiene, and total assistance of 2 staff for bathing. physician's orders [REDACTED]. Resident #5's June 2013 Medication Administration Records (MAR) documented the resident received a [MEDICATION NAME] suppository on on 1 occasion between the hours of 10:00 p.m. and 6:00 a.m. Resident #5's July 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 2 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #5's August 2013 Medication Administration Records (MAR) documented the resident received a [MEDICATION NAME] suppository on 1 occasion between the hours of 10:00 p.m. and 6:00 a.m. 2. Resident #7's MDS dated [DATE], documented [DIAGNOSES REDACTED]. The MDS also documented the resident was always incontinent of bowel and bladder with no toileting program in place to manage the resident's bowel continence. Resident #7 had a BIMS score of 3 meaning the resident was severely cognitively impaired. The resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 2 staff to transfer, no ability to walk, total dependence of 2 staff to toilet, extensive assistance of 1 staff for personal hygiene, and total assistance of 2 staff for bathing. POS dated 7/12/13, documented an order for [REDACTED]. Resident #7's June 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 2 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #7's July 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 3 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #7's August 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 2 occasions between the hours of 10:00 p.m. and 6:00 a.m. 3. Resident #8's POS dated 7/1/13 documented [DIAGNOSES REDACTED]. Resident #8's MDS dated [DATE] documented the resident had a BIMS score of 3 meaning the resident was severely cognitively impaired. The MDS also documented the resident was frequently incontinent of bowel and bladder with no toileting program in place to manage the resident's bowel continence. The resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 2 staff to transfer, extensive assistance of 2 staff to toilet, extensive assistance of 1 staff for personal hygiene, and total assistance of 2 staff for bathing. POS dated 7/1/13, documented an order for [REDACTED]. Resident #8's June 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 4 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #8's July 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 2 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #8's August 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 2 occasions between the hours of 10:00 p.m. and 6:00 a.m. 4. Resident #1's MDS dated [DATE] documented [DIAGNOSES REDACTED]. incontinent of bowel and bladder. Resident #1's nursing care plan dated 3/20/13 revealed a problem identified as Alzheimer's dementia, resident requires assistance for all needs, and interventions that included check and change before and after meals, at bedtime and as needed. POS dated 7/2013, documented an order dated 4/24/13, for [MEDICATION NAME] 10 mg insert 1 suppository rectally every day as needed for constipation. Resident #1's April 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 3 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #1's May 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 6 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #1's June 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 5 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #1's July 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 5 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #1's August 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 3 occasions between the hours of 10:00 p.m. and 6:00 a.m. 5. Resident #9's MDS dated [DATE] documented [DIAGNOSES REDACTED]. The resident required extensive assistance by 2 or more staff members for transfers to and from the bed and chair, bathing, dressing, toileting and personal hygiene, the resident was non-ambulatory, frequently incontinent of urine and occasionally incontinent of bowels. Resident #9's nursing care plan dated 5/14/13 revealed a problem identified as declined mobility, with interventions that included assist to toilet/commode before and after meals, at bedtime and as needed. POS dated 7/2013 documented an order dated 3/8/11, for [MEDICATION NAME] 10 mg insert 1 suppository rectally every day as needed for constipation. Resident #9's May 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 6 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #9's June 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 6 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #9's July 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 4 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #9's August 2013 Medication Administration Records (MAR) documented the resident received a [MEDICATION NAME] suppository on 1 occasion between the hours of 10:00 p.m. and 6:00 a.m. 6. Resident #10's MDS dated [DATE] documented [DIAGNOSES REDACTED]. Resident #10's nursing care plan dated 5/1/13 revealed a problem identified as severe dementia with assist required for all activities of daily living and interventions that included check and change for incontinence and provide incontinence care as needed. POS dated 7/2013 documented an order dated 3/9/12, for [MEDICATION NAME] 10 mg insert 1 suppository rectally every day as needed for constipation. Resident #10's May 2013 Medication Administration Records (MAR) documented the resident received a [MEDICATION NAME] suppository on 1 occasion between the hours of 10:00 p.m. and 6:00 a.m. Resident #10's June 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 7 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #10's July 2013 Medication Administration Records (MAR) documented the resident received [MEDICATION NAME] suppositories on 3 occasions between the hours of 10:00 p.m. and 6:00 a.m. Resident #10's August 2013 Medication Administration Records (MAR) documented the resident received a [MEDICATION NAME] suppository on 1 occasion between the hours of 10:00 p.m. and 6:00 a.m. During an interview on 8/8/13 at 10:10 a.m., the Director of Nursing (DON) reported the facility did not have a policy or procedure for bowel regimen protocols. The DON expected nursing staff to review resident bowel records daily and administer medications such as Milk of Magnesia or [MEDICATION NAME] suppositories if ordered, to obtain physician orders [REDACTED]. When asked, what time the medications should be administered, the DON stated that the Milk of Magnesia could be administered in the evening, and the [MEDICATION NAME] could be administered anytime during the day or evening. When questioned about the administration of [MEDICATION NAME] suppositories between 10 p.m. and 6 a.m., the DON was not aware that staff administered the medication on the night shift.

Based on personnel record and staff interview, the facility failed to comply with state regulations (Iowa Code 135C.33(2) and Iowa Administrative Code -58.11(3)b) regarding pre-employment screening. The facility failed to obtain the required Department of Human Service (DHS) evaluation prior to employment for one of five employees reviewed (Staff A). The facility reported a census of forty-three (43) residents. Findings Include: Review of personnel files revealed the facility hired Staff A on 11/22/11. Staff A's abuse registry background check and criminal history checks were completed on 11/3/11. The criminal history background check identified further research was required and directed the facility to await DCI's (Division of Criminal Investigation) final response. The results dated 11/9/11 established Staff A with a criminal record. The employee's file lacked any indication the facility requested DHS evaluate Staff A's history prior to her hire date (11/22/11). During an interview on 6/12/12 at 4:20 p.m., the Administrator stated that he completed the background checks for all potential hires. The Administrator stated Staff A's report from DCI indicated "Waiver on File", and did not direct any further action was necessary. During an interview on 6/13/12 at 9:10 a.m., the Administrator stated that he had completed the required documents and sent via facsimile (fax) and left phone messages with personnel Iowa DHS about the matter, and that Staff A would not return to work until the required authorization was received. During an interview on 6/14/12 at 10:25 a.m., the Administrator stated Iowa DHS would not evaluate a criminal record search more than 30 days old; and a new criminal record search had been requested for Staff A. At the time of survey exit on 6/15/12, the facility had not received Iowa DHS's authorization for Staff A to work at the licensed health care facility. The facility's undated Dependent Adult Abuse Policy revealed the following: 1. The facility shall screen all potential employees for a history of abuse, neglect or mistreating residents. 2. The facility will conduct a criminal record check and dependent adult/child abuse registry check on all prospective employees prior to hire, in the manner prescribed un 58.11(3).

Based on observation, staff interview, and review of facility employee handbook, the facility failed to safeguard clinical record information against possible unauthorized use. The facility census was 43 residents. Findings include: On 6/12/12 at approximately 9:25 a.m. observation during the initial dietary tour of the kitchen and storage area of the facility basement with Staff B, dietary supervisor, revealed 6 - 4 drawer file cabinets unlocked and resident records accessible immediately inside the room. Staff B said keys to unlock the basement storage area were available to all dietary employees and the nurse. 2. During environmental tour on 6/14/12 between 12:00 p.m. and 1:15 p.m.,the file cabinets containing resident records remained unlocked. The Administrator stated the cabinets contained resident financial records. During the final exit conference on 6/15/12 at 11:00 a.m., the Administrator stated that the file cabinets that contained the resident financial files were now locked. Review of the facility employee handbook revealed in part in paragraph one under CONFIDENTIAL INFORMATION the following: The resident's charts must be guarded and held as confidential information.

Based on clinical record review and staff interview, the facility failed to provide documentation of physician visits completed every 30 days for the first 90 days after admission and every 60 days thereafter for four of ten residents reviewed. The facility census was 34 residents. (Resident #1, #2, #3 & #9 ) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The Admission Record documented the resident as admitted to the facility on [DATE]. The resident had physician visits completed on 1/12/11, 3/2/11 and 4/13/11, indicating 30 day visits were not completed as required in February 2011. 2. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The Admission record documented the resident as admitted to the facility on [DATE]. The resident had physician visits completed on 10/15/10, 12/1/10, 3/2/11 and 4/19/11, indicating 30 day visits were not completed as required after admission. 3. The MDS assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. The Admission record documented the resident as admitted to the facility on [DATE]. The resident had physician visits completed on 12/18/10, 3/5/11 and 5/26/11, indicating a 30 days visit and a 60 day visit was missed. 4. The May 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Admission record documented the resident as admitted to the facility on [DATE]. Review of physician visits revealed the resident as seen on 9/18/10 and not again until 12/16/10 or for three months when the resident should of been seen every 30 days. During interview on 5/27/11 at 8:55 a.m., the Director of Nursing (DON) indicated no further physician visits could be found for the residents. During interview on 5/27/11 at 11:00 a.m., the DON indicated the facility had no formal policy in regards to physician visit frequency. The facility followed the regulations and had all doctors sign the admission form requiring them to visit the resident every 30 days the first 90 days and every 60 days thereafter.