Accura Healthcare Of Aurelia, Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, facility policy, and staff interviews, the facility failed to notify the physician when a resident with a history of cardiac and pulmonary conditions and oxygen dependence stopped using a Bilevel Positive Airway Pressure (BiPAP) machine at night for 1 of 12 residents reviewed. The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of congestive heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and centrilobular emphysema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Clinical Physician Orders dated 9/3/25 for Resident #2 showed the following:BiPAP on at bed time and off in the morningOxygen 3 liter per nasal cannula COPD and centrilobular emphysemaDuo Neb breathing treatments twice a day for COPDFluticase-Salmeterol inhaler twice a day for COPDPrednisone tablet daily for COPDTorsmide tablet daily for CHFEmpagliflozin tablet daily for CHFAlbuterol Sulfate inhaler every 6 hours as needed for shortness of breath and wheezing The Care Plan for Resident #2 revised on 8/15/25 showed the resident had a history of CHF, COPD, high blood pressure and arterial fibrillation (irregular heart rhythm). The goal for Resident #2 included the resident will not require hospitalization for her condition. The Care Plan lacked BiPAP usage and information.During an interview on 1/27/26 at 2:25 PM, Resident #2 reported the pulmonologist ordered her to wear a BiPAP at night related to CHF, COPD, and emphysema. When asked about the BiPAP location, the resident reported placing the device on a shelf due to personal preference not to use the machine because the mask fit poorly, despite trying several different masks. When asked about the duration it had been on the shelf, the resident stated at least three months. Upon clarification regarding nonuse during that period, the resident stated, No, I haven't worn it at all for about three months.During an interview on 1/28/26 at 1:27 PM, Staff A, Certified Nursing Assistant (CNA), reported working the night shift in October when the resident began inconsistent BiPAP use. Staff A reported the resident stated, I don't like it. Staff A further reported that in November the resident stopped using it altogether.Review of the December 2025 and January 2026 Treatment Administration Record (TAR) failed to accurately reflect BiPAP usage.During an interview on 1/27/26 at 2:47 PM, the Director of Nursing (DON) reported learning of Resident #2's nonuse of the BiPAP today. When asked if she knew the resident reported not using the BiPAP for the past three months, the DON stated, No. When asked whether staff inaccurately documented BiPAP use, the DON stated, I haven't looked at it. When asked if she felt physician notification was necessary, the DON reported yes. When asked why physician notification was necessary, the DON stated the resident could have breathing issues.During an interview on 1/28/25 at 9:45 AM, the DON stated, They need to document that the resident refused the treatment and notify the physician. The DON also indicated notification was necessary because, if needed, the resident wanted to be resuscitated, and staff recently had a code.During an interview on 1/28/26 at 12:15 AM, the DON reported the facility failed to have a policy regarding physician notification and that the facility followed the standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #27) reviewed for PASRR requirements. The facility reported a census of 35 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #27 documented diagnoses of dementia, Anxiety Disorder, adjustment disorder with depressed mood, depression and suicidal ideations. The MDS included a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The Medical Diagnosis list for Resident #27 revealed the following diagnoses:General Anxiety Disorder, dated 5/27/25Major depressive disorder, dated 6/12/2Suicidal ideation, dated 7/24/25Adjustment disorder with depressed mood, dated 8/6/25 The Clinical Orders for Resident #27 revealed the following medications:Memantine 2.5 mg tablet for dementia, dated 3/27/25Prozac 40 mg tablet daily for dementia, dated 6/25/25Zyprexa 5 milligram (mg) tablet daily for adjustment disorder with depressed mood, dated 9/7/25 The Telehealth Psych Progress Note dated 1/27/25 for Resident #27 showed the resident received psych services and is scheduled for a future appointment. During an interview on 1/27/25 at 2:47 PM with the Administrator, Director of Nursing (DON), and Social Worker (SW), the SW reported submission of a new PASRR earlier that morning for Resident #27. When asked whether a PASRR should be submitted when a new mental health disorder, mental health medications, and mental health services are present, the SW stated yes. During an interview on 1/28/25 at 9:45 AM, the DON reported asking whether responsibility for resubmission of the PASRR applied to her role. The Administrator instructed that responsibility rested with the Social Worker (SW). The DON further explained that future morning meetings will include team review of medications, new diagnoses, and services to identify the need for PASRR resubmission. During an interview on 1/28/26 at 12:15 AM, the DON reported the facility failed to have a policy regarding PASRRs and that the facility followed the standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility policy review the facility failed to accurately document Bilevel Positive Airway Pressure (BiPAP) machine usage for 1 of 12 residents (Residents #2). The facility reported a census of 34 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of congestive heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and centrilobular emphysema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Clinical Physician Orders dated 9/3/25 for Resident #2 showed an order for a BiPAP on at bedtime and off in the morning. During an interview on 1/27/26 at 2:25 PM, Resident #2 reported the pulmonologist ordered her to wear a BiPAP at night related to CHF, COPD, and emphysema. When asked about the BiPAP location, the resident reported placing the device on a shelf due to personal preference not to use the machine because the mask fit poorly, despite trying several different masks. When asked about the duration it had been on the shelf, the resident stated at least three months. Upon clarification regarding nonuse during that period, the resident stated, No, I haven't worn it at all for about three months.During an interview on 1/28/26 at 1:27 PM, Staff A, Certified Nursing Assistant (CNA), reported working the night shift in October when the resident began inconsistent BiPAP use. Staff A reported the resident stated, I don't like it. Staff A further reported that in November the resident stopped using it altogether.Review of the December 2025 Treatment Administration Record (TAR) for Resident #2 showed staff inaccurately documented the resident applied and/or removed the BiPAP every day of the month of December. Review of the January 2025 Treatment Administration Record (TAR) for Resident #2 showed staff inaccurately documented the resident either applied, and/or removed the BiPAP, or failed to document every day of the month of January.During an interview on 1/27/26 at 2:47 PM, the Director of Nursing (DON) reported learning of Resident #2's nonuse of the BiPAP today. When asked if she knew the resident reported not using the BiPAP for the past three months, the DON stated, No. When asked whether staff inaccurately documented BiPAP use, the DON stated, I haven't looked at it. During an interview on 1/28/25 at 9:45 AM, the DON reported reviewing BiPAP usage documentation for Resident #2 and identified inaccurate staff documentation indicating BiPAP use despite resident nonuse. The DON stated, We are going to have education to remind staff not to get in the habit of documenting things were done. They need to document the resident refused the treatment and notify the physician. During an interview on 1/28/26 at 12:15 AM, the DON reported the facility failed to have a policy regarding documentation and that the facility followed the standards of care.

Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene before and after catheter care for 1 of 2 residents reviewed (Resident #31). The facility reported a census of 34 residents.Findings include:During an observation on 1/28/26 at 1:08 PM, Staff A, Certified Nursing Assistant (CNA), failed to perform hand hygiene prior to donning personal protective equipment (PPE) and emptying urine from the catheter bag, per policy. Staff A then doffed PPE, failed to perform hand hygiene, and proceeded to arrange the catheter bag, privacy bag, and the resident's blanket before exiting the room.The Hand Hygiene Policy last updated on 11/13/24 identified hand hygiene is required immediately before donning and doffing gloves. During an interview on 1/27/26 at 2:47 PM, the Director of Nursing (DON), reported she expected staff to perform hand hygiene immediately before applying gloves and when staff removed gloves. During an interview on 1/27/26 at 3:31 PM, the Infection Preventionist indicated staff are expected to perform hand hygiene prior to putting on gloves, immediately after removing gloves, and when the staff leave the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and policy review the facility failed to report allegations of abuse in a timely manner for 1 of 1 residents reviewed. On 5/1/25, several staff members reported that Staff F was rude and verbally abusive to Resident #2. They did not have dates and times as to when these incidences occurred. The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff for toileting, dressing, rolling and transfers. She was always incontinent of urine and bowel, and was impaired on both sides of her upper and lower extremities. Diagnoses for Resident #2 included: heart failure, renal insufficiency and quadriplegia.The Care Plan for Resident #2 dated 4/15/25, showed that she was dependent on staff for activities of daily living related to unspecified intellectual disabilities. Staff were to converse while providing care. Resident #2 previously lived in a home for people with intellectual disabilities, unable to care of herself. She required the assistance of two staff with the Hoyer (mechanical lift) for all transfers. Resident #2 could be verbally aggressive, staff were to monitor behaviors when resident became agitated, intervene before agitation escalated. A facility self-report to the Department of Inspections and Appeals and Licensing (DIAL) showed that on 5/1/25, the Executive Director (ED) had been notified that Resident #2 was being verbally abused by Certified Nurse Aide (CNA) Staff F. Staff A, CNA reported that while she and Staff F were transferring Resident #2 with the Hoyer mechanical lift, Staff F said: I hope this hits you in the head and we're not friends, don't call me Buddy. The self-report lacked potential dates that the alleged incident occurred. On 10/20/25 at 2:04 PM Staff B said that Staff F was disrespectful and rough with Resident #2. She did not know the dates that this had occurred and said she knew she should have come forward sooner but she was afraid of retaliation. A written statement dated 5/1/25 at 7:34 PM from Staff H, CNA showed that Staff F was more mean to Resident #2 compared to other residents, more aggressive verbally. Staff H couldn't remember when it happened. On 10/21/25 at 11:00 AM, the Director of Nursing (DON) said that they were made aware of the concerns with Staff F, on 5/1/25 but they did not know the date or dates when the incidents occurred. She said the staff that had concerns were educated about the importance of reporting allegations of abuse immediately. 10/21/25 1:10 PM the administrator said that the staff had all been educated on the facility abuse prevention policy and the importance of reporting concerns immediately. A facility policy titled: Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy; Mental abuse was defined as use of verbal or nonverbal conduct which caused or potential to cause the resident to experience humiliation, intimidation fear shame agitation or degradation. All allegations of resident abuse, neglect exploitation mistreatment injuries of unknown origin and misappropriations would be reported immediately to the charge nurse. The charge nurse would be responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegation of resident abuse would be reported to Iowa Department of Inspections and Appeals no later than two hours after the allegations was made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all residents were free from verbal abuse for 1 of 5 residents reviewed (Resident #2.) Staff reported that on several occasions, a Certified Nurse Aide (CNA) addressed Resident #2 in a disrespectful and derogatory manner. The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff for toileting, dressing, rolling and transfers. She was always incontinent of urine and bowel, and was impaired on both sides of her upper and lower extremities. Diagnoses for Resident #2 included: heart failure, renal insufficiency and quadriplegia.The Care Plan for Resident #2, dated 4/15/25, showed that she was dependent on staff for activities of daily living related to unspecified intellectual disabilities. Staff were to converse while providing care. Resident #2 previously lived in a home for people with intellectual disabilities, and she was unable to care of herself. She required the assistance of two staff with the Hoyer (mechanical lift) for all transfers. Resident #2 could be verbally aggressive, staff were to monitor behaviors when resident became agitated, intervene before agitation escalated. A facility self-report to the Department of Inspections and Appeals and Licensing (DIAL) showed that on 5/1/25, the Executive Director (ED) had been notified that Resident #2 was being verbally abused by Certified Nurse Aide (CNA) Staff F. Staff A, CNA reported that while she and Staff F were transferring Resident #2 with the Hoyer mechanical lift, Staff F said: I hope this hits you in the head and we're not friends, don't call me Buddy. The self report lacked potential dates that the alleged incident occurred. On 10/20/25, Resident #2 was lying in bed as two CNA's prepared to change her brief and transfer her to the wheel chair. When addressed, the resident looked afraid and shook her head no. On 10/20/25 at 12:36 PM, Staff D, CNA said that she heard Staff F say to Resident #2 you need to be put on Hospice and this is why no one comes to visit you. She said that when Staff F would roll the resident over in bed, she would tug the bed pad quick and rough and the resident was afraid of falling. Staff F seemed annoyed by the resident and would just tell the resident to be quiet.On 10/20/25 at 2:04 PM, Staff B CNA, said that Resident #2 would always yell out when they provided incontinence care and transfers, but the resident was not able to swing her arms or hit them. Staff B said that when she and Staff F were transferring the resident with the Hoyer, Staff F threatened to put you down. Staff B interpreted that to mean that she was threatening to drop the resident out of the lift. Staff B said that Staff F said to the resident: You need to be put on hospice and you need to just go already, Staff B did not remember the date of these incidents and said she understood that she should have come forward sooner but she was afraid of retaliation. On 10/20/25 at 12:20 PM, Staff A, CNA, said that Staff F would tell Resident #2 that they weren't friends and she would pull hard on the resident when rolling her in bed. Staff A said that Resident #2 was afraid of falling out of bed and would say; please don't drop me. Staff F seemed annoyed by the resident. When transferring the resident with the mechanical lift into the wheel chair, the bars of the lift often came close to hitting the resident on the head. Staff A said that Staff F would pull back on the sling abruptly when the resident was being lowered down into the wheel chair said; I hope you hit your head on the bar of the lift. A written statement, dated 5/1/25 at 7:34 PM, from Staff H, CNA showed that Staff F was more mean to Resident #2 compared to other residents, more verbally aggressive. Staff H couldn't remember the date it had happened. On 10/21/25 at 12:24 PM, Staff F denied having ever told a resident to shut up and she only suggested that maybe the resident should be on Hospice because it would be a good thing to help her with her anxiety. Staff F said that she had known Resident #2 for over 19 years, worked with her when she was in a group home for intellectual disabilities so she was familiar with how to interact with her. Staff F acknowledged that Resident #2 was afraid of falling when they rolled her in bed, mostly when her head would be down and looking at the floor. Staff F said she just tried to reassure her that we're not going to let you fall. Staff F said that after the allegations in May, she thought it would be best not to care for Resident #2 so there wouldn't be any more false allegations An Employee Corrective Action Form, Written Warning, dated 5/6/25, showed that there were allegations of abuse against Staff F. The expectations were that staff would speak to residents with dignity, respect and to provide great customer services. Staff F was re-educated on the facility abuse policy and she was assigned education on abuse prevention to be completed before returning to work. The written report showed that Staff F had been confronted about her treatment of Resident #2. Staff F responded that she had known the resident for a long time and I just know how she is. Management counseled her to consider her tone and how it may be perceived by other staff and visitors. Staff F and Management agreed that she would not to work with Resident #2 for the time being. On 10/21/25 at 8:30 AM, the ED and the Director of Nursing (DON) stated that they were first informed of the concerns with Staff F on 5/1/25 but did not have dates that the incidents had occurred. The ED said that a family member for Resident #2 reported that when the resident was in the group home, they had to treat her as if she was a 4-year-old. The ED responded that this was not acceptable in the nursing home environment. A facility policy titled: Freedom From Abuse Notice to Employees Resident/Patient Abuse, Neglect and Mistreatment of Belongings. Among the rights specified in the federal and state laws, each resident and patients had the right to a dignified existence and to be free form verbal, sexual, physical or mental abuse; Abuse included but not limited to: verbal abuse, oral, written, gestures language, including sarcastic remarks and derogatory statements, directed to residents' family members or significant others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to monitor and treat skin breakdown to prevent worsening of ulcers for 2 of 3 resident reviewed, (Resident #3 and #21). Resident #3 had an ulcer on his toe, staff failed to contact the doctor when treatment was ineffective. The toe was eventually amputated. Resident #21 had chronic pressure areas on her bottom and found to not have treatment in place. The facility reported a census of 32 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.
1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficit.) The resident had 1, unhealed, Stage 2 pressure ulcer. The MDS dated [DATE], showed that the resident had a diabetic foot ulcer. He was totally dependent on staff for transfers, toileting and hygiene, Diagnosis included type II diabetes mellitus, dysphagia following cerebrovascular disease, hemiplegia or hemiparesis, cerebrovascular accident.
The Care Plan for Resident #3, revised on 1/27/25, showed that he was non-ambulatory and non-weight bearing status and required the assist of 2 for mobility. The resident was at risk for skin impairment with a history of pressure to buttock, right toe, plantar aspect of the 5th toe. Staff were directed to follow the skin treatments as ordered by provider, check all of the body for breaks in skin and treat promptly as ordered by doctor.
In an observation on 3/4/25 at 6:44 AM, Staff A Certified Nurse Aide (CNA) and Staff B, CNA prepared to transfer Resident #3 from the wheel chair to the shower chair for a shower. The resident was wearing a shirt and brief. They transferred him to the bed with the use of the Hoyer Mechanical Lift. Once he was in bed, they removed the protective boots that covered his feet up to his knees. The resident had a callous on his right foot where the great toe had been. His right shin had three scabbed areas along the top of the bone. When asked about the scrapes, the CNA's said they didn't know if that was being documented or how long he had the skin breakdown.
The chart lacked documentation of the scrapes on his shin.
On 3/5/25 at 10:43 AM, Staff D, Registered Nurse (RN) acknowledged that she was responsible for documenting weekly skin issues. She said that she was not aware of any skin breakdown on the right shin for Resident #3. She went into the room and looked at the area and asked the resident what happened. He said that it was from crossing his feet in bed. Staff D said that she would start a skin sheet for him and a risk management because it is scabbed. She said she hadn't been told about it, the girls hadn't told her about those spots and that should have been documented.
A review of the chart revealed that on 5/6/24 at 11:50 AM, resident had been readmitted to the facility after a hospitalization with three new areas of skin breakdown. The readmission Assessment included:
Right foot big toe pressure area 0.3 centimeters (cm) x 0.3 cm open area.
Right foot little toe pressure area 0.8 cm x 0.5 cm.
Right foot second toe scattered scabs.
The following documentation was found in the Nursing Notes (NN) and on the paper documentation titled: Non-Ulcer Skin Assessment (SA) leading up to the amputation of the right great toe:
a. (NN) 5/8/24, Encounter note by NP; resident post hospitalization for pneumonia and returned to facility with antibiotic therapy. had scabs on left toes and dressing on right great toe, continue orders paint scabs on toes with betadine daily and right great toe remove old dressing, cleanse with saline, apply povidone-iodine to area, skin prep to surround kin and cover with polymen and meplex tape every 2 days, monitor for worsening signs/symptoms.
b. (SA) 6/4/24, 0.3 cm x 0.6 cm, wound bed is scabbed, surrounding skin color pink, surrounding tissue wound edges intact. Progress improved continue treatment plan.
c. (NN) 6/5/24 Encounter note by NP; skin on toes improved.
d. (SA) 6/11/24 size 0.3 cm x 0.6 cm scabbed, red and pink surrounding. improved
e. (SA) 6/18/24 size 0.5 cm x 1 cm. improved treatment continued.
f. (SA) 6/25/24 size 0.5 cm x 1 cm. improved treatment continued.
g. (SA) 7/2/24 0.8 cm x 1 cm. wound bed scab, pink surrounding skin intact wound edges. deteriorated. (chart lacked documentation of physician contact with change).
h. (SA) 7/9/24 0.6 cm x 1 cm scab, pink intact and improved
i. (SA) 7/16/24 0.5 cm x 1 cm wound bed yellow, surrounding skin pink surrounding tissue fragile progress is improved
j. (SA) 7/23/24 0.5 cm x 0.5 cm. surrounding tissue blanchable progress improved slough (dead tissue) yellow or white.
k. (NN) Encounter note from the NP, signed on 7/25/24 at 5:02 PM, did not address foot ulcers.
l. (SA) 7/30/24, 0.5 cm x 0.5 cm. yellow wound bed surrounding tissue fragile not changed
m. (SA) 8/6/24 0.5 cm x 0.5 cm slough 10%, improved
n. (NN) 8/13/24 at 10:59, the doctor was in the facility and antibiotic started related to cellulitis (bacterial skin infection) to right great toe.
o. (SA) 8/13/24 0.5 cm x 0.5 cm. yellow wound bed, pink surrounding skin, deteriorated, started on antibiotic.
A Physician Progress Note dated 8/13/24, showed that the visit diagnosis included; cellulitis and abscess (collection of pus surrounded by inflamed tissue) of toe of right foot. A breakdown to right big toe, area was wet, purulent (containing pus) with redness spreading up the foot. The patient was placed on antibiotic for 10 days. If no improvement, given his severe debility this likely could result in amputation. He had undergone amputation of previous toes due to similar circumstances. Next visit on 9/10/24 will follow closely
p. (NN) 8/18/24 at 10:09 AM, Encounter note by NP, follow up to cellulitis of right toe, erythema top of right foot.
q. (NN) 8/19/24 at 2:24 PM, less redness and swelling noted to right toe
r. (SA) 8/20/24 not changed granulation 90%, 80% red tissue.
s. (NN) 8/21/24 at 2:59 PM, no redness swelling odor or signs of infection.
(According to the Medication Administration Record, the last day of antibiotic was given on 8/22/24)
t. (NN) 8/23/24 at 5:49 PM, foot is slightly pink and warm, resident stated pain in ankle not foot.
u. (SA) 8/24/24 0.5 cm x 0.5 cm condition not changed continue with treatment
v. (SA) 9/3/24 size unchanged, wound bed white surrounding tissue pink 80% granulation, and white Progress improved
w. (SA) 9/10/24, size unchanged, progress was left blank, continue treatment.
x. (SA) 9/17/24, size same, progress not changed treatment continue
y. (NN) 9/19/24 Encounter by the NP indicated no acute concerns expressed from nursing the documentation lacked any reference to the foot ulcers.
z. (NN) 9/24/24 at 9:32 AM, call out to the Nurse Practitioner (NP) with update regards to right foot. Increased redness and drainage. May we have referral to wound nurse.
aa. (SA) 9/24/24 measured 0.5 cm x 0.5 cm yellow discharge, 100% slough. Progress deteriorated. Hand written note to be seen by wound care.
bb. (NN) 9/24/24 at 9:54 AM, orders for x-ray and referral to bone and joint surgeon.
cc. (NN) 9/26/24 at 2:45 PM, out of facility for appointment
dd. (NN) 9/26/24 at 4:17 PM resident admitted to hospital to amputate toe.
A note from the NP signed on 9/24/24, showed that she spoke with the nurse about concerns that the wound on the right great toe knuckle, had drainage and redness. The resident was unable to feel his toe when it was touched. Initiated orders for a wound culture, antibiotic, x-ray and referral to wound clinic and bone specialist.
According to the notes from the Bone, Joint and Sports Surgeons dated 9/26/24 at 4:32 PM, the X-rays of the right foot of Resident #3 showed erosive changes of the distal aspect of the medial proximal phalanx and proximal aspect (bone located on the bottom row) of the distal phalanx (bone at the end of toe) concerning for osteomyelitis. Sensation is diminished to the great toe, open ulceration noted to the dorsal medial aspect of right great toe at interphalangeal joint (joint between the phalanges of toe) It is covered in fibrotic slough, (yellow, tan or white, dead tissue) serous drainage (clear to yellow) present, full-thickness down to the bone measured 1.5 cm x 1.5 cm and there was visible and palpable bone (able to touch) within the wound bed. The toe was erythematous and edematous (red and swollen). Soupy, serous drainage present coming form the wound. Recommended admit to hospital tonight for Intravenous antibiotics, vascular workup and toe amputation within the next few days as long as vascular status was okay. Discussed risks with the patient, biggest risk included delayed wound healing, continued infections, possible need for further surgery and further loss of foot or limb.
According to the hospital History and Physical, dated 9/26/24 at 5:33 PM, the principal presenting problem included acute hematogenous osteomyelitis (inflammation of the bone due to infection) of right foot. Presented as an open ulceration to dorsal medial aspect of the right great toe at the interphalangeal joint of the hallux, covered with fibrotic slough, as well as healthy granular tissue. Some serous drainage present. It was full-thickness down to palpable and visible bone. Measured 1.5 cm x 1.5 cm the surrounding erythema to the right great toe. Soupy, serous drainage present.
On 3/5/25 at 10:26 AM, Staff D, Registered Nurse (RN) said that she was conducting skin assessments in May of 2024 and when Resident #3 came back from a hospitalization with pneumonia, he had scabs and other pressure injuries to his feet and legs. She said that they suspected that it had been caused by the foot devices that they were using at the hospital. She said that the doctors didn't ever change the treatments and the scabs kept getting moist. Staff D said that Resident #3 was always having some skin breakdown related to his diagnosis of diabetes. Staff D said that they would try a different treatment if the color, pain or discharge changed. The doctors and NP would visit monthly and they were always looking at the resident's feet but they didn't ever see a need to change the treatments.
On 3/5/25 at 11:30 AM, Staff D said that Resident #3 didn't get to the wound clinic on 9/24/24 because he was sent right to the bone specialist and then onto the hospital. Staff D reviewed the skin sheets and said that there hadn't been any changes in the toe that would have alerted them to call the doctor. Even if someone had seen a change, the doctor came in once a month and he or she would have looked at the resident's skin.
On 3/5/25 at 2:36 PM, Staff E, Licensed Practical Nurse (LPN) remembered when she called the NP on 9/24/24 with her concerns about Resident #3. She said that she thought it was getting worse and they hadn't changed treatment orders. It was about a week prior to the amputation that she noticed changes. She had been directed to report to the Director of Nursing, which she said she did. She said that as an LPN, she was told she was to report to an RN with skin issues. There were times when she would provide treatment and the residents dressing was not in place, or it was soiled and looked as if it hadn't been changed for a while.
On 3/5/25 at 12:10 PM, the NP said she remembered the ulcer on the toe of Resident #3 and that she contacted the primary care physician for culture and a wound care referral. She acknowledged that she saw the resident on 8/15/24 for a follow up after the primary care doctor had seen the resident on 8/13 and started an antibiotic for cellulitis on the right foot. The next visit she had with him was on 9/19 but did not make reference to the foot. When asked if she had looked at the foot on the 9/19 visit, she said that whatever she had in her notes was what she provided. The NP said that when she made monthly visits, she would consult with nursing before and after the visit about concerns and stated I can only address what I'm notified of. She stated that everything that she addressed was in her notes and could not say for sure if nursing should have contacted her sooner with changes in condition or what they may have seen leading up to the amputation that could have helped catch the deterioration sooner.
On 3/6/25 at 12:35 PM, the DON said that she was not working at the facility in August of 2024 but she did look at the record on the progression of the toe wound for Resident #3 and acknowledged that it was concerning the nurses hadn't noticed the deterioration sooner. The DON read the report from the bone specialist and said that there would have been some warning signs before the wound was down to the bone. She would have directed the nurses to address and reassess the treatments if there wasn't improvement in healing after two weeks of a treatment. The DON said that they have two different skin sheets, one for non-ulcer and one for when an ulcer had developed. The form to be used after ulcer development, had more detailed documentation to include odor, coloring, size etc.
2) The MDS dated [DATE], showed that Resident #21 had a BIMS score of 14 (intact cognitive ability). She required partial assistance with toileting hygiene, dressing and toilet transfers. Resident #21 was at risk for pressure ulcer, and treatments included application of nonsurgical dressing. Her diagnoses included malnutrition, depression, weakness and pressure ulcer of sacral region, Stage 2.
On 3/4/25 at 10:04 AM, Staff L, CNA assisted Resident #21 in the bathroom. When asked if she had any skin breakdown, Staff L said that she didn't know of any. The resident said she did, and when she got up from the toilet the CNA acknowledged that she had some protective cream on her buttocks. Staff L wiped her bottom with a cloth and noted some redness and a small slit near the coccyx. The resident said that it did hurt and she asked the CNA for a patch. Staff L said that she could not do that, that would have to be done by the nurse, so the resident asked for a lot of cream.
A review of the Orders tab in the electronic chart revealed an order dated 2/5/25 at 2:58 PM, for Mepilex (foam dressing for acute and chronic wounds) to coccyx to be changed every 3 days and as needed (PRN) until healed.
A Nursing Note dated 2/3/25 at 1:33 PM, showed that the resident had an area on the inner buttocks below coccyx measured 2 cm x 0.5 cm.
Review of the skin sheets found a new sheet titled: Non-ulcer Skin Assessment, started on 2/3/25, that documented an open area to inner buttock, left. The document lacked any follow up measurements or descriptions of the ulcer.
On 3/5/25 at 2:48 PM, Staff E said that she applied the dressing for Resident #21 and at times, the dressing has not been on as ordered.
On 3/6/25 at 12:33 PM, the DON said that at times, the wound nurse would get pulled to the floor and it may be difficult for her to get all of the assessments completed. She did not know why there wouldn't have been a follow up to measurements or documentation and staff are directed to complete treatments as ordered.
On 3/6/25 at 11:11 AM, the Administrator said that they did not have a specific policy for skin assessments, but staff were directed to refer to the DIMES protocol for skin issues.
Debridement Infection, Moisture Balance, Edge and Supportive Products. (DIMES)
The Wound Care Guidelines included description of wounds and supportive products, but lacked information on when nursing should contact the doctor and recognize the current treatment regimen consider changing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure safe transfer techniques with the use of a Gait Belt (GB) for 1 of 3 residents reviewed, (Resident #17). The facility reported a census of 32 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intake cognitive ability). He required partial assistance with toileting hygiene, showering, dressing and transfers. Resident #17 had diagnoses that included: atrial fibrillation, heart failure, anxiety and depression.
The Care Plan updated on 2/23/25 showed that Resident #17 was at risk for falls and staff were to have the Gait Belt in place for all transfers and to ensure the resident was wearing the appropriate footwear. Limited physical mobility related to morbid obesity.
On 3/3/25 at 1:01 PM, Resident #17 was sitting in a wheel chair that did not fit well and he seemed to be sliding down. The resident said that he could stand and pivot with transfers, but he needed assistance with walking. He said that he had a fall in the shower room when he slipped to the floor. Resident #17 said that he didn't want to get the staff in trouble, but the Certified Nurse Aide (CNA) that was transferring him from the shower chair to the wheel chair hadn't used a GB.
A Nursing Note dated 2/21/2025 at 11:23 PM, showed that at approximately 6:55 PM that evening, the nurse was alerted to the shower room by a CNA after Resident #17 fell after his shower. The CNA reported to the nurse that Resident #17 had been sitting on the shower chair when he went to stand up onto a dry towel in front of him, he slid out of the chair onto the floor. Upon entering shower room, the nurse noted that the resident was naked, on the floor with his legs extended in front of him. He did not have a GB around him. The intervention initiated at the time of the fall was for the CNA staff to use gait belt with all transfers.
On 3/5/25 at 11:03 AM, Staff G, Registered Nurse (RN) said that she remembered when Resident #17 had the fall in the shower and that he did not have a GB applied. She said it was the expectation that staff would always use gait belt with assisted transfers.
On 3/6/25 at 12:31 PM, the Director of Nursing (DON) said that the CNA should have dried the upper part of body of the resident after his shower, then put on his shirt before applying the GB. She thought that agency staff were required to complete a competency checklist before working on the floor independently.
A checklist form titled: Competency for Ambulation with a Gait Belt updated on 5/11/21, showed that staff were expected to apply GB over clothing and not on bare skin and tighten so it was snug. Stand facing resident, grasp belt on each side brace knees against the resident knees, block resident feet with your feet, assist to standing position. Stand at resident's side while they gain balance and do not let go of the GB. If the learning did not meet the requirements for the competency, training must be given and competency repeated within 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that staff interacted with residents with dignity and respect for 1 of 13 residents reviewed, (Resident#9). The facility reported a census of 32 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability.) She was dependent on staff for toileting, showering and lower body dressing and required substantial assistance with toilet and sit to stand transferring. Diagnoses for Resident #9 included; anemia, hypertension, peripheral vascular disease, diabetes mellitus, osteoporosis, bipolar disorder, and fracture of the right pubis
A Care Plan revised on 2/12/25, showed that Resident #9 was occasionally dependent on staff and others for meeting her emotional, intellectual, physical and social needs, and staff were to converse with the resident while providing care. Staff were to provide resident with cues, reorientation, reassurance and supervision as needed. The resident required assistance of one staff with a Wheeled [NAME] (FWW) and gait belt.
On 3/4/25 at 1:35 PM, Resident #9 was sitting in her recliner. When asked about an interaction with Staff I, Certified Nurse Aide (CNA) that morning, she became fidgety and teary eyed, and said I don't want to get anyone in trouble. Resident #9 said that it was about 4:00 AM that morning when she woke up with abdominal pressure and needed to use the bathroom. The resident turned on her call light and Staff I came into the room, and with a rough tone she snapped what do you want? The resident told the CNA that she needed to use the toilet and the CNA told her that the morning staff could do it later. Resident #9 told Staff I that she was having pressure and really needed to go, so the CNA helped her out of bed into the wheel chair. Resident #9 asked her if she was going to use the gait belt and she said that's not necessary. The resident told her that the other CNA always used it, and that therapy told her they needed to use it every time, but Staff I just responded but that ain't me and proceeded to transfer her to the wheel chair then onto the toilet. She said that she prayed she wouldn't fall. Resident #9 said that once she was on the toilet Staff I yelled at her push! you need to push harder! The resident told her she was trying but she was afraid that her catheter would come out. The CNA stayed in the room for about 10 minutes while the resident was on the toilet then checked on her and said you didn't do anything, I knew you wouldn't. Resident #9 said she felt that the CNA didn't want to help her at all and the resident apologized to the CNA several times. Resident #9 said that she felt afraid when this CNA came into her room because she felt that Staff I really didn't want to take care of her and she didn't feel safe with her.
On 3/5/25 at 9:50 AM, Staff I, said that around 4:00 AM Resident #9 had her call light on so she went to check on her. The resident said she needed to go to bathroom so she transferred her to the bathroom with the use of the gait belt. She continued to complain of stomach pressure and Staff I said why don't you try pushing? The resident responded nothing comes out so she waited in the room for about 10 minutes. The resident did not have a bowel movement so she told her to make sure to tell the morning girls so they could try again. She said that she put the resident back to bed with no incident and reminded her to pull her call light if she needed anything else. Staff I said that the resident thanked her several times and they had gotten along great. Staff I maintained that she did everything the resident wanted, when she was on the toilet and said she was having trouble going, she suggested that she push harder. The resident had responded; I am, I'm trying. so Staff I said she didn't think she going to go so she wiped her and assisted her back to bed. Staff I said that she suggested that the resident make sure that the morning girls knew she hadn't had a bowel movement. Staff I maintained that she always used a gait belt with transfers, she suggested that told the resident try to push harder but did not yell at her. Staff I maintained that she treated the resident with respect
On 3/5/25 at 2:31 PM, Staff E, Licensed Practical Nurse (LPN) said she administered medication to Resident #9 that morning and asked the resident how she was doing. The resident told her she was still upset about an interaction that happened with Staff I earlier that morning. The resident reported that she needed to use the bathroom and the CNA didn't use the belt when she transferred her and was rude and snapped you said you gotta go, now go!
On 3/5/25 at 3:05 PM, Staff K, Activities Director, said that Resident #9 told her that she put on her call light that morning because her stomach was hurting she needed to use the bathroom. When the CNA came in, she told her that it could wait till morning but the resident told her again, that she needed to go to the bathroom so she assisted her to the toilet. The aide said to her Now go! and push! She had small results, and the aide told her she didn't go much, and brought her back into bed. Staff K said that the resident was visibly upset.
On 3/6/25 at 12:39 PM, The Director of Nursing (DON) said that Staff I tended to have a loud voice and she could soften her tone around residents because some were more sensitive than others.
Facility policy titled: Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, mental abuse was the use of verbal or nonverbal conduct which causes or had the potential to cause the resident to experience humiliation, intimidation, fear, shame agitation or degradation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure staff followed physicians' orders for 2 of 13 residents reviewed, (Resident #17 and #9). Resident #17 had an order for International Normalized Ratio (INR) blood test to be conducted on 2/13/25, staff failed to complete the blood draw. Staff were directed to report to the doctor if/when the Blood Glucose (BG) levels were out of parameters for Resident #9. The facility failed to follow through according to physician's orders. The facility reported a census of 32 residents.
Findings include:
1) According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) He required partial assistance with toileting hygiene, showering, dressing and transfers. Resident #17 was using anticoagulant medications and his diagnoses included: atrial fibrillation, heart failure, anxiety and depression.
The Care Plan updated on 2/23/25, showed that Resident #17 was at risk for falls and staff were to have gait belt in place for all transfers and ensure the resident was wearing the appropriate footwear. He had limited physical mobility related to morbid obesity and was at risk for abnormal bleeding related to routine use of anticoagulants.
On 3/3/25 at 1:01 PM, Resident #17 was sitting in a wheel chair in his room, he did not have any visible bruising on his arms or legs. The resident said that in February, he had a high INR (measures the clotting time of blood.) The resident said that he had been getting regular labs but they missed one and by the time they checked it, the INR was very high. He did not have any bleeding concerns.
A review of the file revealed a Nursing Note dated 2/6/25 at 3:15 PM, for a verbal order to hold warfarin and restart 3 milligrams (mg) on Saturday, recheck INR on Thursday, 2/13/25.
The chart lacked documentation that the order for a recheck of the INR had been entered into the electronic chart, or that the blood test had been taken on 2/13/25.
According to the Lab Administration report dated 2/24/25 at 8:56 PM high value INR of 8.5 with reference range of 0.86 - 1.18.
A document titled: PT/INR Tracking spreadsheet showed the last date that the testing had been documented was on 2/5/25 with no follow up dated for the next INR.
On 3/5/25 at 7:30 AM Staff F, Licensed Practical Nurse (LPN) acknowledged that she was the nurse that entered the nursing note and had taken the verbal order on 2/13/25. She remembered the resident and his unstable INRs and they were drawing labs about once a week and were making many medication changes. Staff F had only worked at the facility a few times and did not remember the process for lab draws and if they were entering them directly to the Medication Administration Record (MAR) or if they were just passing on in report to the next shift. Staff F said that she works in many different facilities and they had different processes.
On 3/6/25 at 12:30 PM, the Director of Nursing (DON) said that she did a chart audit and found that the INR lab for Resident #17 had been missed on 2/13/25. She said that the nurses didn't always use the INR tracking sheet and there maybe another way to keep closer tabs on the testing and next blood draw using the Electronic Health Record.
2) According to the MDS dated [DATE], Resident #9 had a BIMS score of 14 (intact cognitive ability.) She was dependent on staff for toileting, showering and lower body dressing and required substantial assistance with toilet and sit to stand transferring. Diagnoses for Resident #9 included; anemia, hypertension, peripheral vascular disease, diabetes mellitus, osteoporosis, bipolar disorder, and fracture of the right pubis.
A Care Plan revised on 2/12/25, showed that Resident #9 had diabetes and staff were directed to follow doctors' parameters for low/high blood sugars and report as directed. The resident was occasionally dependent on staff and others for meeting her emotional, intellectual, physical and social needs, and staff were to converse with the resident while providing care. Provide resident with cues, reorientation, reassurance and supervision as needed.
An Order Audit Report from the electronic chart showed an order on 2/5/25 at 12:24 PM, for Accu-Chek (measures blood glucose levels) to report to the physician if/when the BG levels were greater than 350 mg/dl (milligrams per deciliters) or lower than 70 mg/dl.
A review of the electronic record showed that from 2/5/25 - 3/2/25, the BG levels were outside parameters and the chart lacked documentation that the doctor had been contacted on the following dates:
a. 2/6/25 at 6:40 AM BG; 367
b. 2/6/25 at 11:23 AM BG: 366
c. 2/6/25 at 7:29 PM BG; 374
d. 2/7/25 at 8:37 AM BG; 386
e. 2/7/25 at 3:14 PM BG; 370
f. 2/8/25 at 7:34 PM BG; 436
g. 2/9/25 at 6:37 AM BG; 371
h. 2/12/25 at 7:26 PM BG; 353
i. 2/13/25 at 12:46 PM BG; 365
j. 2/14/25 at 6:20 AM BG; 358
k. 2/15/25 at 7:30 PM BG; 458
l. 2/16/25 at 4:37 PM BG; 352
m. 3/1/25 at 11:35 AM BG; 351
n. 3/2/25 at 7:35 PM BG; 359
On 3/6/25 at 12:39 PM, the Director of Nursing (DON) said that she was looking through the file for Resident #9 and did see that the high blood glucose levels were not being reported to the physician. She would expect the nurses to follow the doctors' orders on the parameters. The DON said that they did not have a specific policy on reporting blood glucose to the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to update the resident's care plan to accurately reflect interventions ordered by the physician and accurately list residents current assistance level for 2 of 12 residents reviewed (Residents #23 and #32). The facility reported a census of 36 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 documented diagnoses of myositis (a group of rare conditions that can cause muscles to become weak, tired and painful), generalized muscle weakness and radiculopathy (pinched nerve or injury or damage to nerve roots in the area where they leave the spine). The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS revealed Resident #32 has a pressure ulcer or injury and has one or more unhealed pressure ulcers or injuries. The MDS revealed resident was dependent on staff for bed mobility and transfers to and from bed to chair, and chair to bed.
Review of the Care Plan with a revision date of 1/25/24 revealed the following information:
Resident #32 required assistance of 2 staff to turn and reposition in bed, required assistance of 2 staff with dressing, required assistance of 2 staff with mechanical lift for transfers, required assistance of 1 staff with all personal hygiene and was independently able to move/ wheel self in wheelchair.
Review of Treatment Plan signed 2/1/24 revealed the following information:
a. Continue to use ROHO cushion.
b. Sit upright in wheelchair or other chair with the cushion, do not recline.
c. Sit no more than 1.5 hours at a time for meals, then reposition. Other times should be in bed, on his side.
d. Protein supplement per dietician.
e. Heel protectors.
Review of the Order Summary Report signed by the physician dated 2/2/24 revealed the following orders:
a. Cleanse and dress right heel three times a week and as needed with an order date of 1/15/24.
b. Head of Bed no higher than 30 degrees for skin impairment with an order date of 11/16/23.
c. Magic cup for wound healing with an order date of 12/4/23.
d. [NAME] hose on during the day and off at night for skin impairment with an order date of 11/16/23.
e. Use of better pressure redistribution cushion, sit for no more than one two hours for meals, and reposition on side in bed, turning frequently with an order date of 1/15/24.
f. Use Prevalon boots 24 hours a day, remove each shift to check for skin impairment with an order date of 1/15/24.
h. When up in wheelchair pressure relief every 15 minutes for skin impairment.
i. Arginaid packet daily with an order date of 12/29/23.
Review of the February Treatment Administration Record (TAR) revealed the following orders:
a. Cleanse and dress right heel three times a week and as needed with a start date of 1/16/24.
b. Head of Bed no higher than 30 degrees for skin impairment with a start date of 11/16/23.
c. Magic cup for wound healing with a start date of 12/5/23.
d. [NAME] hose on during the day and off at night for skin impairment with a start date of 11/16/23.
e. Use of better pressure redistribution cushion, sit for no more than one two hours for meals, and reposition on side in bed, turning frequently with a start date of 1/15/24.
f. Use Prevalon boots 24 hours a day, remove each shift to check for skin impairment with an start date of 1/15/24.
h. When up in wheelchair pressure relief every 15 minutes for skin impairment with a start date of 11/17/23.
i. Arginaid packet daily with a start date of 12/29/23.
Review of the Care Plan with a revision date of 1/25/24 revealed a focus area the resident has potential or actual impairment to skin integrity. The focus area lacked current interventions ordered by the physician.
Interview on 2/06/24 at 1:55 p.m., with the DON revealed she would expect all current interventions to be listed on the care plan and would expect the interventions to be updated as they are changed.
2. The MDS dated [DATE] for Resident #23 revealed a BIMS of 14 which indicated intact cognition. The MDS revealed the resident had diagnoses of diabetes mellitus, insomnia, and generalized muscle weakness. The resident had 2 falls since the last comprehensive MDS assessment.
The Care Plan revealed in pertinent part:
a. ADL (Activities of Daily Living) Focus Area intervention initiated 2/27/23 and revised on 2/5/24 revealed that for transfers, the resident was independent with 4WW (4 wheeled walker), assist of one as needed.
b. Fall Focus Area intervention initiated 1/19/24 revealed that the therapy department changed the resident to assist of 1 with transfers.
In an interview on 2/07/24 at 8:45 AM, Staff A, Certified Nurse Assistant (CNA) reported the resident was an assist of 1 with personal cares, but that the resident reported that she performs cares independently instead of putting her call light on for assistance. When Staff A assisted the resident, she charted the task performed as provided with assistance, when the resident reported she performed a task independently, Staff A charts this as independently performed. Staff A reported she was not sure what level of assistance the resident required with care as she has observed the resident walking independently in the hall with only the assistance of her walker since she has required the assistance of 1 with personal cares.
In an interview on 2/7/24 at 1:50 PM, the Director of Nursing (DON), reported that the resident was independent, she had required assistance of 1 for ADLs when she received physical therapy (PT) services. The DON reported that we need to update the resident's care plan now because it's not relevant any more.
In an interview on 2/6/24 at 3:10 PM, the Director of Nursing (DON) reported that the facility does not have a policy for Care Plans.

Based on observations, facility policy, 2022 Food Code, and staff interview, the facility failed to store kitchenware and utensils in a manner to prevent contamination; failed to store a measuring scoop in a clean manner; bulk foods did not have an open date labeled; provide covered trash cans; cover food stored in a freezer. The facility reported a census of 36 residents.
Findings include:
Observation on 2/05/24 at 9:13 AM of dry storage room revealed:
1. Two muffin baking pans turned right side up.
2. A powdered drink mix canister with scoop inside.
Observation on 2/05/24 at 9:13 AM of main area of kitchen revealed:
1. Two boxes of disposable silverware not closed.
2. Two containers of silverware without eating end of the utensil covered.
3. Shelf storing cutting boards not laying vertically.
4. Reusable and disposable dishware stored right side up and not covered.
5. Two uncovered trash cans.
6. No open date on bulk storage of sugar, flour, and breadcrumbs.
7. Utensils for food preparation and serving stored uncovered on hooks on the wall.
Observation on 2/05/24 at 9:16 AM of 2 door freezer revealed a tray of individual dishes of ice cream with no cover.
The 2022 Food Code directed, in pertinent part, that receptacles and waste handling units for refuse shall be kept covered inside the food establishment if the receptacle contained food resident and was not in continuous use.
The Food Storage Policy dated 2021 directed in pertinent part:
1. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination.
2. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.
3. Scoops must be provided for bulk foods (such as sugar, flour, and spices). Scoops should be kept covered in a protected area near the containers rather than in the containers. Scoops should be washed and sanitized on a regular basis.
4. All (frozen) foods should be covered, labeled, and dated.
In an interview on 2/05/24 at 9:26 AM, the Dietary Manager (DM) reported she hadn't thought to date opened bulk sugar, flour, or breadcrumbs.
In an interview on 2/07/24 at 1:09 PM, the Dietary Manager reported that a new dietary employee left the scoop in the container of drink mix, that she had lids to the trash cans but the lids did not have pieces to cover the trash cans, that she was the staff member that did not cover the individual portions of ice cream found in the freezer, and that she was aware that utensils and kitchenware needed to be covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] for Resident #32 documented diagnoses of diabetes mellitus, hypertension and anemia. The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed Resident #32 had taken insulin injections the last 7 out of 7 days in the review period.
Review of the Order Summary Report signed by the physician dated 2/2/24 revealed the following orders:
a. Humalog injection solution sliding scale three times a day for diabetes with a start date of 11/16/23
b. Humalog kwikpen solution one time a day for diabetes with a start date of 12/5/23
c. Humalog kwikpen solution 2 times a day for diabetes with a start date of 12/4/23
d. Lantus solostar solution one time a day for diabetes with a start date of 11/16/23
Review of the February Medication Administration Record (MAR) revealed the following orders:
a. Humalog injection solution sliding scale three times a day with a start date of 11/16/23
b. Humalog kwikpen solution one time a day with a start date of 12/5/23
c. Humalog kwikpen solution 2 times a day with a start date of 12/4/23
d. Lantus solostar solution one time a day with a start date of 11/16/23
Review of the Care Plan with a revision date of 1/25/24 lacked information regarding usage of insulin and signs and symptoms to watch for.
Interview on 2/06/24 at 1:56 p.m., with the DON revealed she would expect the care plan to have insulin usage listed and side effects of the medication on the care plan.
Interview on 2/06/24 at 3:11 p.m., with the Director of Nursing (DON) revealed the facility does not have a policy on care plans.
Based on clinical record, facility policy, and staff interview, the facility failed to develop care plans to reflect side effects of high risk medications insulin and melatonin or an Urinary Tract Infection (UTI) for 2 of 12 residents reviewed (Residents #23 and #32). The facility reported a census of 36 residents.
Findings include:
1. The MDS dated [DATE] for Resident #23 revealed a BIMS of 14 which indicated intact cognition. The MDS revealed the resident had diagnoses of diabetes mellitus, insomnia, and generalized muscle weakness.
The Order Summary Report signed by a physician on 1/16/24 revealed an order for melatonin, 3 milligrams (mg) given one time per day.
In a Nurses Note on 1/11/24 at 8:00 PM, Staff E, Licensed Practical Nurse (LPN) reported, in pertinent part, new order for ATB (antibiotic) for UTI.
The Doctor's Orders and Progress Notes signed by an Advanced Practice Registered Nurse (ARNP on 1/11/24 revealed an order for nitrofurantoin (antibiotic) 100 mg BID (twice per day) for 5 days.
The Care Plan with an initiated date of 2/7/23 did not contain information related to:
a. Melatonin, including side effects.
b. UTI diagnosis.
The document, What's a care plan in a nursing home?, accessed on 2/07/24 at 10:48 AM from medicare.gov directed, in pertinent part, that the basic care plan include ongoing, regular assessments of a condition to see if health status has changed, with changes to the care plan as needed.
In an interview on 2/07/24 at 1:50 PM, the DON reported that she will look into why the resident's infection wasn't on her care plan. When asked why melatonin was not on the resident's care plan, the DON responded by asking what should be on the resident's care plan since she had orders for melatonin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, facility policy, and staff interview, the facility failed to provide a restorative exercise program for 1 of 1 resident reviewed (Resident #20). The facility reported a census of 36 residents.
Findings include:
The Minimum Data Set (MDS) dated [DATE] for Resident #20 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of osteoarthritis to his left knee, osteoporosis (loss of bone strength), and muscle weakness.
In an interview on 2/05/24 at 10:40 AM, the resident reported that his physical therapy (PT) ended last week and that he was waiting for someone to come to his room this week to show him the exercises he is supposed to do on his own. The resident reported that he goes to a group exercise held in the facility, but that he would like individual assistance with an exercise program to maintain the progress he made in PT.
The PT Discharge Summary signed by a PT on 2/1/24 directed, in pertinent part, that the resident:
1. Will continue with ambulation 5-7 times per week with 4 wheeled walker with assist of 1.
2. Will continue to do seated and standing exercises on a modified independent basis.
The Care Plan intervention initiated 8/18/22 and revised 12/7/22 directed the following with ambulation: please assist to breakfast with my 4 wheeled walker, with bilateral AFO's (Ankle Foot Orthosis, medical device) on lower extremity.
The Task List revealed, in pertinent part, walk to one meal a day with 4 wheeled walker, with bilateral AFO's on lower extremity.
In a concurrent record review and interview on 2/07/24 at 9:42 AM, Staff A, Certified Nurse Assistant (CNA), demonstrated where she charts the tasks the resident receives. The task to walk to one meal a day was not present on Staff 's electronic charting device. Staff A reported no other place existed to chart against the task to walk the resident to one meal per day.
The Clinical Record lacked documentation that the resident had assistance with seated and standing exercises on a modified independent basis after his PT discharge on [DATE].
In an interview on 2/07/24 at 1:50 PM, the Director of Nursing (DON) reported that when a resident discharged from therapy services with a restorative exercise program, she adds those to the task list for the CNAs to chart against. The DON reported that the resident was discharged from PT with only a walk to dine program. The DON reported that the electronic health record (EHR) has had some recent glitches, that may be the reason the charting for the resident's walk to dine program was not visible. When the DON was made aware that the walk to dine task started in December 2022, she responded by saying she would make sure to find the documentation and that the only location documentation existed was in the EHR.
In an interview on 2/7/24 at 2:20 PM, the DON reported that the walk to dine task was entered into the EHR incorrectly and she could not produce documentation that the task occurred. The facility did not have a policy for restorative therapy.