Hiawatha Care Center

Based on observation, staff interviews, clinical record review, employee file review and facility policy review the facility failed to transfer one out of three residents reviewed according to their Care Plan resulting in one resident obtaining a laceration to her left leg that required sutures and a blood transfusion (Resident#1). The facility reported a census of 98 residents. Finding include:The Minimum Data Set (MDS) assessment for Resident#1 dated 9/2/25, listed diagnoses of Atrial Fibrillation (irregular heart beat), heart failure, and osteoporosis The Brief Interview for Mental Status (BIMS) score 4 out of 15 (severely cognitively impaired). The MDS reflected Resident#1 dependent on staff for chair to chair transfers. The Care Plan for Resident#1 dated 8/29/25, reflected interventions of Physical Therapy (PT), Speech Therapy (ST), and Occupational Therapy (OT) evaluation and treat, follow their recommendations Dated 8/29/25 and directed staff to transfers with assist of 1 staff with gait belt and a walker, date initiated 9/4/2025. The Medication Administration Record (MAR) dated 10/2015 directed the staff to administer Eliquis (blood thinning mediation) 2.5 milligrams (mg) two times a day for the pacemaker. The Progress Note dated 10/20/25 at 4:30 PM read a Certified Nurse Aid (CNA) called Staff D, Registered Nurse (RN) to the lounge area in the wing. Staff D found the Resident#1 in her wheelchair (w/c) with staff controlling the bleeding to her left lateral leg. The note reflected that Staff D applied a pressure dressing and wrapped it to control bleeding. Per Staff A, she was transferring Resident#1 and her left lateral leg caught the lever of the wheelchair causing the laceration. The Emergency Department (ED) Provider Note dated 10/20/25, identified staff transferred the resident into a wheelchair and accidentally cut the front aspect of her leg with significant bleeding per Emergency Medical Services (EMS). The ED note reflected a large left leg laceration with significant acute blood loss anemia requiring prolonged repair while in the ED (1.5 hours total), with patient required figure-of-eight sutures to tie off 2 different arteriolar bleeds (occurs when an artery is damaged, causing blood to flow rapidly and forcefully from the wound), multiple horizontal mattresses given that wound is under tension (stitch crosses under the wound horizontally), and wound approximated with otherwise standard simple suture. Bleeding completely resolved and was observed for over 2 hours with no development of a hematoma or any significant venous bleeding from the wound edges. No indication for anticoagulation reversal at this time. Hold Eliquis for at least 1 week. Admit to hospital, start 1 unit packed red blood cells (PRBC). Hemoglobin (Hgb) 5.9, baseline 9.1-10.6 grams per deciliter (g/dL) (a protein found in red blood cells that is responsible for transporting oxygen throughout the body). The Consult Note last updated 10/22/25, reflected Resident#1 presented to the ED on 10/20/25 with a leg laceration. The note reported staff transferred her into her w/c and accidently cut the front side of her leg with significant bleeding. The Note revealed Resident#1 required 4 figure-of-eight sutures to 2 arterial bleeders; 20 sutures total. The left anterior lateral lower leg laceration is approximated with sutures. The note included the wound painful for Resident#1 and included a photograph of the laceration post sutures. The wound approximately measured 7 centimeters (cm) long with another 2 cm curved around the top of the wound. On 10/27/25 at 2:51 PM Staff D reported as she passed medication on the wing when Staff A alerted her they needed help with a resident for a cut in the lounge. Staff D said she took her supplies, went to the lounge and when she saw the blood on the floor she knew she needed to send the resident to the hospital. She revealed Resident#1 took AC medication. Staff D reported Staff A told her, she just transferred Resident#1 from the recliner to the w/c and her upper left leg got a laceration. On 10/27/25 at 3:25 PM Resident #1 was in her room and sitting in her w/c. The w/c pedals were in place and able to move back freely. A pink bag sat in the seat of the w/c. The left w/c foot pedal metal above the release lever felt and looked sharp. On 10/28/25 at 2:01 pm Staff A reported on 10/20/25 around 4 PM Resident#1 needed to use the toilet. She said she placed the gait belt (G.B.) on Resident#1 and completed a stand pivot transfer (SPT) to the w/c that she placed right next to Resident#1. Staff A stated as she sat her in the chair Resident#1 said ouch. Staff A reported she saw Resident#1 left leg sat bent back at the knee under the w/c. Staff A revealed after she moved Resident#1's left leg she saw her knee high sock turned red from blood. Staff A reported she called for help, the Human Resource (HR) Director got to her first and applied pressure to the wound and Staff D got there next. Staff A reported the w/c pedal on the right side went back 180 degrees while the left foot pedal only went back 90 degrees. Staff A said a pink bag that held the phone hung on the left side of the w/c and prevented the foot rest from going back 180 degrees. On 10/28/25 at 12:52 PM the HR reported as she worked in her office on 10/20/25 she heard Staff A say Oh **** blood. HR said she immediately went to help. She said she saw a large puddle of blood on the floor. She told Staff A to get her a glove and she would apply pressure. She said the nurse lifted her pant leg, started to pull down her long sock and she saw a cut a few inches long and curved. HR said the nurse covered and applied pressure when she saw the blood poured out of the lower part of the cut. She said the nurse dressed the wound and she elevated her leg and she watched it as the nurse called people. On 10/28/25 at 3:40 PM Staff B, CNA reported she took the w/c pedals completely off when she transfers residents. She said she looked at the white board in their rooms to know how to transfer a resident. On 10/29/25 at 9:30 AM Staff C, Licensed Practical Nurse (LPN) reported when she transfers anyone she removes the w/c pedals so she doesn't trip on them, and sometimes flipping them back doesn't get them out of the way enough. On 10/29/25 at 10:48 AM Staff A reported she failed to use the walker with Resident#1 transfer that resulted in her leg laceration. On 10/29/25 at 11:12 AM, Physical Therapy Assistant (PTA) reported he expected the staff to use the walker for STP from the recliner to the w/c for Resident#1. He reported her discharge recommendation directed staff to transfer her with the assistance of 1 staff, G.B. and walker. On 10/29/25 at 11:30 AM Staff B, reported when she helped transfer Resident#1 she used the G.B. and the walker. On 10/29/25 between 12:15 and 12:30 PM the Director of Nursing, (DON) reported she identified a concern that Staff A failed to use the walker when she transferred R#1 and she received a laceration to her left leg. The DON reported Resident #1's pink bag hung on the left side of the w/c and stopped the w/c pedal from going all the way back. She said the w/c pedal that stuck out felt sharp and she thought that's what cut Resident #1s leg. The DON reported Staff A told her Resident #1 needed the bathroom. She put the gait belt on her and moved her to the w/c when she got the laceration. The DON reported she expected the staff to follow the white board in their rooms and the Care Plan. On 10/29/25 at 2:30 PM the PTA, reported he expected the staff to use the G.B and the walker with Resident#1 transfers for both the resident and staff safety. The facility provided a document titled Skills Fair dated 10/20/23 that reflected Staff A completed transfer training. The facility provided the Skills Fair Transfer training list that included one staff assist with gait belt and walker. The training included reminders to do all transfers slowly and follow the transfer direction on the white board in the residents room.

Based on observation, record review, resident and staff interviews, the facility failed to maintain a safe, palatable temperature of foods served at the noon meal on 3/11/25. The facility reported a census of 101 residents.
Findings include:
1. An observation of the noon meal service in the [NAME] Dining Room on 3/11/25 revealed the
following:
a. At 11:45 AM Staff D, cook measured the temperature of the pork loin at 201.5 degrees Fahrenheit
and the turkey burgers at 155 degrees Fahrenheit.
b. At 12:40 PM, the Dietary Director measured the temperature of the pork loin at 180 Fahrenheit and
turkey burgers at 115 degrees Fahrenheit.
c. At 12:48 PM, the surveyor took temperatures and tasted the following:
Pork loin at 125 degrees Fahrenheit and tasted lukewarm.
Turkey burgers at 111.3 degrees Fahrenheit and tasted somewhat cool.
In an interview on 3/12/25 12:36 PM, the Dietary Director reported she would expect the temperature of the meat to be held at a temperature of at least 135 degrees after the meal service.
A review of the undated Facility Policy titled: Food Temperatures had documentation of the following:
All hot food items must be served 135 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to utilize the proper infection control techniques during an observation of a medication pass for 1 of 10 residents observed (Resident #57). The facility reported a census of 101 residents.
Findings include:
The Minimum Data Set (MDS) dated [DATE] identified Resident #57 as cognitively impaired with a BIMS (Brief Interview for Mental Status) of 08 and had the following diagnoses: Heart Failure, Non-Alzheimer's Dementia, and Cancer. The MDS also identified #57 required substantial/maximal assist with showers, dressing, and putting on and taking off footwear.
A review of the physician orders and the March 2025 Medication Administration Record had documentation of the order for Potassium Chloride ER (Extended Release) 40 meQ (milliequivalents) twice daily.
In an observation of medication pass on 3/11/25 at 9:00 AM, Staff A, RN removed 4 capsules of Potassium Chloride ER 10 meQ from the blister-packs and placed into a medication cup. Staff A then proceeded to pick up each capsule with her bare hands and empty out the contents into a medication cup. Staff A mixed the powder with pudding and spoon-fed to Resident #57.
In an interview on 3/12/25 at 3:30 PM, Staff A RN reported when emptying out the contents of a capsule, she would need to sanitize her hands and don gloves. She admitted she forgot to don gloves prior to opening up the capsules before she administered them to Resident #57.
In an interview on 3/13/25 at 9:46 AM, the Director of Nursing reported before a nurse would empty out the contents of a capsule into a med cup, she would expect the nurse to use hand sanitizer, put on gloves before emptying the contents of capsules into a med cup before giving to a resident.
A review of the undated Facility Policy titled: Medication Administration had documentation of the following: Staff follows established facility Infection Control procedures with medications as applicable, (ie: handwashing, antiseptic technique, gloves, isolation precautions, etc).

Based on observation, record review, and staff interview, the facility failed to ensure hair restraints were applied properly during a meal service. The facility reported a census of 101 residents.
Findings include:
An observation of the noon meal service in the [NAME] Dining Room on 3/11/25 revealed the following:
a. At 12:01 PM, both Staff B, Dietary Aide and Staff C, Dining Assistant did not have hair properly
tucked into their hair nets. Staff B had approximately 1.5 inches of hair exposed from the hair restraint. Staff C had approximately 3 inches exposed from the hair restraint.
b. At 12:29 PM, Staff B, Dietary Aide left the Dining Room remained with 1.5 inches of hair exposed
from the hair restraint.
c. At 12:33 PM Staff C remains with 3 inches of hair exposed from the hair restraint.
In an interview on 3/12/25 12:00 PM, Dietary Director reported she would expect her staff to check each other to make sure hair is properly tucked into the hair restraint before going out to serve food.
A review of the undated Facility Policy titled: Dietary Infection Control had documentation of the following: all staff are required to style their hair so it does not touch their collar. Hair restraints are required and should cover all hair.

Based on observation, clinical record review, policy review, and resident and staff interviews, the facility failed to ensure staff treated residents with dignity and allowed them to make their own choices and decisions for 3 of 11 residents reviewed for resident rights (Residents #4, #10, and #11). The facility reported a census of 66 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment tool, dated 12/30/24, listed diagnoses for Resident #4 which included fracture of the right pubis (the side of the hip bone), Alzheimer's disease, and anxiety. The MDS stated the resident required partial to moderate assistance for chair transfers and did not walk due to a medical condition or safety concerns. The MDS listed his Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition.
Care Plan entries, dated 12/30/24, stated the resident had a diagnosis of Alzheimer's and self-transferred. The Care Plan directed staff to explain the need for assistance with transfers to prevent injuries and to place the resident at the nursing station if (self-transfers) continued.
On 1/6/25 at 12:19 p.m., Resident #4 sat in his wheelchair near the nursing station and began to stand up. Staff A Licensed Practical Nurse (LPN) stated What are you doing? in a loud, harsh voice. The resident stated he intended to stand up after which Staff A stated No you're not, you broke your leg. The resident attempted to stand again and Staff A told him that he fell and broke his hip and now you are paying the price. Staff A stated this in a loud voice and multiple other residents and staff were in the area within earshot.
2. The MDS assessment tool, dated 11/23/24, listed diagnoses for Resident #10 which included cancer, pain in the right hip, and heart failure. The MDS stated the resident was dependent on staff for chair transfers and listed a BIMS score of 14 out of 15, indicating intact cognition.
Care Plan entries, revised 1/6/25, stated the resident was adjusting to the facility and required assistance with transfers. The entries directed staff to offer 1:1 support when anxious and allow her to express her feelings.
On 1/7/25 at 11:33 a.m., Resident #10 stated night shift staff told her she was not allowed to get up. She stated last night around 1:30 a.m., she asked to get up and staff told her she had to wait. She stated she woke up again at 3:30 a.m. and at that time staff agreed to get her up. She stated she mentioned this to the CNAs (Certified Nursing Assistants).
3. The MDS assessment tool, dated 1/2/24, listed diagnoses for Resident #11 which included adult failure to thrive, depression, and insomnia. The MDS stated the resident required supervision assistance with transfers and listed the resident's BIMS score as 15 out of 15, indicating intact cognition.
Care Plan entries, dated 1/2/25, stated the resident was new to the facility and would demonstrate satisfaction with her placement and cares.
On 1/7/25 at 3:53 p.m., Resident #11 stated Staff E CNA told her she could not sleep with her dentures in and did not return them to her for the night as the resident preferred. She stated another time, Staff E told her she had to go to bed even though she told her she was not tired.
The undated facility policy Dignity stated each resident shall be cared for in a manner which promoted and enhanced his sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy stated individual needs and preferences of residents were identified through the assessment process and residents were supported in exercising their rights.
An Employee Disciplinary Report, dated 1/2/25, stated Resident #10 complained that Staff E didn't have a lot of patience and told Resident #10 that if she could stand, she needed to do this. Resident #11 stated that Staff E told her she had to go to bed even though she didn't want to and would not allow her to sleep in her dentures after she stated she wanted to.
On 1/7/25 at 10:35 a.m., Staff A stated with regard to the comment she made to Resident #4 that she did not mean it strongly and it came out wrong.
On 1/7/25 at 10:52 a.m., Staff B CNA stated Resident #10 informed her on 1/3/25 that she wanted to get up early and the night shift told her it was too early for her to get up. Staff B stated the resident told her staff treated her like a dog. Staff B stated she reported this to Staff D Licensed Practical Nurse (LPN).
On 1/7/25 at 11:08 a.m. Staff C CNA stated this morning Resident #10 told her she asked the night shift to get up and they told her she didn't need to get up. Staff C stated it was the resident's choice and she wanted to get up and was not allowed to do so. Staff C stated she did not report this to anyone yet.
On 1/7/25 at 11:17 a.m., via phone, Staff D stated no one reported to her any allegations of mistreatment by the night shift staff.
On 1/7/25 at 12:53 p.m., the Administrator stated he was not aware of any complaints Resident #10 had with the exception of what they had documented with Staff E. He stated he would provide documentation of this.
On 1/7/25 at 2:28 p.m. the Director of Nursing (DON) stated staff reported to her that Resident #10 stated Staff E's approach to her bothered her. She stated she spoke to Staff E regarding the fact that this is their home and residents were never an inconvenience. She stated she would want CNAs to report it if the night shift would not get residents up or if residents stated they were treated like a dog. She stated if this happened it would be addressed and they would complete an investigation. She stated the only complaints she was aware of were the complaints with Staff E and she was not aware of allegations the night shift would not get Resident #10 up. She stated residents could get up in their chairs when they wanted. When asked about the comment made by Staff A to Resident #4 regarding him paying the price, the DON stated this was terrible and she would want it stated in a different manner. She stated staff could offer to take him to the restroom (when he tried to get up).
On 1/8/25 at 11:30 a.m., the Administrator stated staff should treat residents with the utmost respect and dignity and they were allowed to get up when they wanted or sleep in. He stated he would want to know about allegations that residents reported being treated like a dog and not being allowed to get up during the night when they wanted. He stated if this was reported to him, the facility would carry out an investigation. He stated if it was determined to be anything which rose to the level of an allegation of abuse, they would suspend the staff member and report it. He stated he was not aware that Resident #10 made these allegations.

Based on clinical record review, policy review, and staff interview the facility failed to notify the ombudsman when a resident was transferred out of the facility for 3 of 4 residents observed (Residents #11, #15, and #65). The facility reported a census of 105 residents.
Findings include:
1. The Minimum Data Set (MDS) report dated 4/18/24 for Resident #11 documented a Brief Interview for Mental Status (BIMS) score of 8/15, indicating moderate cognitive impairment. The MDS documented diagnoses including: diabetes mellitus type 2 with diabetic neuropathy (nerve damage), cerebrovascular accident (stroke), and seizure disorder.
Clinical record review on 5/6/24 revealed no ombudsman notification was sent upon resident transfer to the hospital on 4/27/24.
2. The MDS report dated 4/11/24 for Resident #15 documented a BIMS score of 15/15, indicating no cognitive impairment. The MDS documented diagnoses including: cancer, anemia (lack of blood), and respiratory failure.
Clinical record review on 5/6/24 revealed no ombudsman notifications were sent upon resident transfers to the hospital on 8/3/23 and 4/3/24.
3. The MDS report dated 2/22/24 for Resident #65 documented a BIMS score of 8/15, indicating moderate cognitive impairment. The MDS documented diagnoses including: traumatic brain dysfunction, heart failure, and paraplegia (inability to voluntarily move lower parts of the body).
Clinical record review on 5/6/24 revealed no ombudsman notifications were sent upon resident transfer to the hospital on 1/3/24 and 1/24/24.
During an interview on 5/07/24 at 1:25 PM the Office Manager noted the Notice of Transfer form is sent to the ombudsman only if they resident discharges to the hospital. If they are transferred out and transferred back in they just mark that in the Electronic Health Record; they do not notify the ombudsman.
During an interview on 5/8/24 at 2:03 PM the Administrator noted the lack of notification to the ombudsman was his fault. He remarked he was not sending an ombudsman notification for transfers, only for discharges. He reported he will be changing this.
The facility lacked a policy on Long Term Care Ombudsman notification.

Based on observation, policy review, and staff interview the facility failed to keep bare hands off the drinking surface of glasses, and failed to bring food to the correct temperature and hold it at the correct temperature to prevent food-borne illness. The facility reported a census of 105 residents.
Findings include:
During an observation of the noon meal service on 5/6/24 from 11:52 AM to 12:42 PM Staff A, Dietary Aide served 12 glasses to 12 residents with bare fingers touching the drinking rim surface of the glasses.
In an observation of the noon meal preparation and service on 5/7/24 from 11:43 AM to 1:14 PM the following was identified:
1. The following items were not heated to the appropriate temperature of 165° Fahrenheit (F) or cooled to the appropriate temperature of 41° F before serving:
a. Pureed ham- 161.3° F
b. Pureed mixed vegetables- 155.7° F
c. Chicken noodle soup- 132.0° F
d. Tartar sauce- 58.9° F
2. The following items were not held at the appropriate temperature of 135° F or higher, or held at the appropriate temperature of 41° F or lower throughout meal service:
a. Ham- 132.6° F
b. Ground ham- 133.3° F
c. Pureed ham- 130.3° F
d. Pureed mixed vegetables- 124.0° F
e. Lettuce Salad- 50.8° F
f. Tartar sauce- 61.0° F
During an interview on 5/8/24 at 2:21 PM Staff B, Dietary Supervisor explained she expected staff to keep thumbs off the edge of plates, keep hands off the top of glasses, and use handles of silverware. Staff are to handle glasses by the bottom. She noted the facility has skills fairs yearly on how to serve correctly. She further expected food temperatures to be checked prior to meal service and to be up to the correct temperature. She explained the facility investigates any complaints of food not being hot enough. She noted she expected staff to follow facility policies and they will begin working on a Plan of Correction immediately.
The facility policy titled Employee Sanitary Practices, undated, instructed staff to pick up silverware and cups by their handles, and to pick up glasses by their base. It further instructed staff to follow all federal, state, and local requirements.
The facility policy titled Food Temperatures, undated, instructed staff:
1) All hot food items must be served at a temperature of at least 135 degrees F.
2) All cold items must be served at a temperature of at least 41 degrees F.
3) Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking.

Based on observation, staff interview, record review, review of the facility's policy and review of the Food and Drug Administration (FDA) Food Code, the facility failed to monitor the dish machine's chemical and temperature levels to ensure the dish machine was providing the correct amount of chemicals needed to sanitize dishware. These failures had the potential to increase the risk of food borne illnesses and affect 105 residents living at the facility who received food from dietary services.
Findings Include:
During an observation on 01/23/23 at 9:28 AM in the kitchen, the Dietary Manager (DM) tested the temperature and sanitation levels of the dishwasher (low-temp model). The dishwasher temperature read 130 degrees Fahrenheit. The chemical levels were at 200 parts per million (ppm) concentration. At 9:28 AM, the DM stated the staff was supposed to check the temperature and sanitation levels of the dishwasher three times a day (i.e., after every meal), but in most cases, they try to check every day.
Review of a facility document titled, Sanitizer and Temperature Recording Chart, dated 11/2022 through 01/2023 revealed there were 30 missing entries on this document which would register the sanitation and temperature in degrees Fahrenheit of the dishwasher.
During an interview on 01/26/23 at 12:08 PM, the DM stated that the potential issue that can arise from not properly testing temperatures and checking the sanitation levels is dirty dishes. She stated, Ideally we take temperatures and check the sanitization levels after every meal service, but if we do it every day that is good. At least monthly, we know that is getting taken care of through [name of vendor]. They do a monthly routine maintenance on the dishwasher and make sure the dishes are being properly cleaned and the tubing is cleaned.
During a subsequent interview on 01/26/23 at 1:45 PM, the DM acknowledged the missing entries in the temperature and sanitation logs and stated, It happens; we get busy. I don't know what more I can say, we get busy.
During an interview on 01/26/23 at 1:46 PM, the Dietary Aide stated that the staff should check the temperature and sanitization of the dishwasher daily to ensure it is functioning properly. Staff then document the results on the temperature and sanitation logs. The DA further stated, We document the temperature and sanitation levels every shift and if we can't, we make time.
Review of the FDA Food Code 2022 revealed, Adequate cleaning and sanitization of dishes and utensils using a ware-washing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize. If the exposure time during any of the cycles is not met, the surface of the items may not reach the time-temperature parameter required for sanitization. Contact time is also important in ware-washing machines that use a chemical sanitizer since the sanitizer must contact the items long enough for sanitization to occur. In addition, a chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.
Review of the facility's policy titled, Dish Machine Temperature Log, indicated Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The Food Service Director will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. The Food Service Director will spot check the log to assure temperatures are appropriate, and staff is monitoring dish machine temperatures. Dishwashing staff will be trained to report any problem with the dish machine to the Food Service Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and review of the facility's policy, the facility's failed to ensure: a. Staff performed proper hand hygiene in between glove changes during resident care for two of two residents (Resident #28 and #94); b. Staff wore the required Personal Protective Equipment (PPE) when providing care to a COVID-19 positive resident for one of one residents (Resident #255); and c. The development and implementation of an adequate water management program to prevent exposure and potential infection by Legionella for 106 facility residents, who were over the age of 65, or other residents, remained in the facility over 24 hours.
Findings Include:
1. Review of Resident #28's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, blindness, sacral pressure ulcer, right heel pressure ulcer, and muscle weakness.
Review of Resident #28's Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/15/22, located in the EMR under the MDS Tab, revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognitively intact. Continued review of the MDS revealed Resident #28 had one unstageable and three-stage three pressure ulcers present upon admission.
Review of Resident #28's Physician's Orders dated 01/2023, located in the EMR under the Orders Tab, revealed an order for daily wound care to resident's sacral and right heel pressure ulcers.
During an observation on 01/25/23 at 10:30 AM, Licensed Practical Nurse (LPN) 5 provided wound care to Resident #28's sacral wound; during wound care, LPN 5 changed her gloves fifteen times without performing hand hygiene (i.e., washing hands with soap and water or using alcohol-based hand sanitizer). Also, Resident #28 had two loose bowel movements during wound care. LPN 5 did not perform hand hygiene after cleaning the resident, changing her gloves, and continuing wound care.
During an interview on 01/25/23 at 11:52 AM, LPN 5 stated, I did not use sanitizer during the dressing change. I left my sanitizer at the Nursing Station. Normally, I would sanitize my hands at every glove change.
During an interview on 01/25/23 at 3:18 PM, the Infection Preventionist (IP) stated, The Wound Care Nurse should use standard precautions. The nurse told me that she had left her sanitizer at the Nursing Station. I would expect the nurse to wash her hands before the dressing change, and after removing the soiled dressing, the nurse should remove gloves, sanitize her hands, and don (apply) a new set of gloves. If the resident had a bowel movement during the dressing change, I would expect the nurse to wash her hands with soap and water.
During an interview on 01/26/23 at 1:00 PM, the Director of Nursing (DON) stated it was her expectation LPN 5 would have used hand sanitizer after every glove change and washed her hands after providing peri-care.
2. Review of Resident #94's undated admission Record, located in her EMR under the Profile Tab revealed she was admitted to the facility on [DATE] with diagnoses which included anorexia nervosa, dysphasia, and gastrostomy status.
Review of Resident #94's Quarterly MDS with an ARD of 12/02/22 and located in her EMR under the MDS tab, revealed a BIMS score of eight out of 15 indicating she moderately cognitively impaired.
Review of Resident #94's Physician's Orders, dated 01/2023 located in her EMR under the Orders Tab directed Nursing Staff to cleanse skin area surrounding G-Tube insertion site with soap and water and rinse well (or wound wash). Pat dry. Apply Vitamin A&D Ointment. Cover w/split 4 x 4 gauze, secure with paper tape one time a day for Skin Care.
Review of Resident #94's Treatment Administration Record (TAR), dated 01/2023 located in her EMR under the Orders Tab directed Nursing Staff to cleanse skin area surrounding G-Tube insertion site with soap and water and rinse well (or wound wash). Pat dry. Apply Vitamin A&D Ointment. Cover w/split 4 x 4 gauze, secure with paper tape one time a day for Skin Care. Registered Nurse (RN 4's) initials entered for 01/23/23 which indicated the nurse completed the treatment.
Review of Resident #94's Comprehensive Care Plan, dated 10/03/22, and located in the resident's EMR under the Care Plan Tab documented - Potential for impaired skin integrity due to presence of g-tube. Perform skin treatment to g-tube site per physician's orders. Provide preventative skin treatments per Physician's Orders.
During an observation on 01/23/23 at 2:47 PM of RN 4 performing wound care to Resident #94's gastric tube insertion site. RN 4 cleaned Resident #94's insertion site and doffed (removed) dirty gloves and donned (apply) clean gloves; however, RN 4 did not perform hand hygiene in between glove changes.
During an interview on 01/25/23 at 3:37 AM, the Infection Preventionist (IP) confirmed it was her expectation that the facility staff would have performed hand hygiene either washing their hands or use of hand sanitizer, between donning and doffing of gloves during wound care.
During an interview on 01/26/23 at 10:15 AM, RN 4 stated she should have performed hand hygiene in between doffing and donning gloves when she removed the dirty dressing and cleaned Resident #94's gastric tube.
During an interview on 01/26/23 at 1:00 PM, the Director of Nursing (DON) stated during the observation of wound care provided by RN 4 to Resident #94's gastric tube insertion site, RN 4 did not perform hand hygiene and should have performed hand hygiene when she doffed her dirty gloves and prior to donning clean gloves.
Review of the facility's undated policy titled, Handwashing documented - Use an alcohol-based hand rub or, soap (antimicrobial or non-antimicrobial) and water for the following situations:
a. Before handling clean or soiled dressings.
b. After handling used dressings or contaminated equipment.
c. After removing gloves.
3. Review of Resident #255's undated admission Record located in his EMR under the Profile Tab revealed he was admitted to the facility on [DATE] with multiple diagnoses to include chronic obstructive pulmonary disease (COPD), Alzheimer's Disease, pneumonia, and cardiac murmur.
Review of Resident #255's Progress Note, dated 01/23/22, located on his EMR under the Progress Notes Tab documented the resident remains in isolation due to being Covid Positive.
Review of Resident #255's Physician's Orders, dated 01/2023, located in the resident's EMR under the Orders Tab revealed - Budesonide [belongs to class of medications called Corticosteroids-decreases the swelling and irrigation in the airways and had potential for serious side effects including difficulty breathing, swelling of the face, throat, tongue, lips eyes hands feet ankles and lower legs, chest pain, vomiting,] Inhalation Suspension 0.5 mg /2 ml give 2 ml orally two times a day. Continued review of the order revealed no order for Transmission Based Precaution (TBP).
Review of Resident #255's Medication Administration Record (MAR), dated 01/2023, located in the resident's EMR under the Orders Tab revealed - Budesonide Inhalation suspension 0.5 mg /2 ml .2 ml inhale orally two times a day. Continued review revealed RN2 had initialed the MAR for the date of 01/23/23 for his morning dose which indicated she administered the medication. Further review revealed no order for TBPs.
Review of Resident #255's Comprehensive Care Plan, dated 01/17/23, located in the resident's EMR under the Care Plan Tab documented the resident had tested positive for COVID-19. Maintain isolation precautions.
During a Medication Administration observation on 01/24/23 at 9:22 AM (with the DON supervising the medication preparation and beside Resident #255's door entry for medication administration), RN2 entered Resident #255's room wearing regular glasses (no side shields, no goggles or face shield), no gown, a procedure mask (no N95 mask), and gloves. RN 2 administered Resident #255's inhalation (aerosol treatment) to the resident, by depositing medication into the reservoir on his oxygen mask tubing, attached to his nebulizer machine and placed his oxygen mask on his face. RN 2 stated she wore regular glasses and a procedure mask into Resident #255's room.
During a brief interview on 01/26/23 12:16 PM, the IP stated the facility required a procedure mask for entry into COVID positive rooms unless the resident was receiving aerosol treatments and a N95 mask was required to be worn by the staff.
During an interview on 01/26/23 at 12:57 PM, the DON stated it was her expectation the Nursing Staff would have worn an N95 mask, goggles, gloves, and no gown while providing care for Resident #255 (COVID positive) with aerosol (nebulizer) treatment.
Review of facility-provided undated policy titled COVID-19 Response Plan documented - To provide an outline for staff when working with residents that are suspected or confirmed to have COVID-19 and are participating in aerosol-generating procedures should wear the following appropriate PPE including:
a. N95 or higher-level respirator mask.
b. Gloves.
c. Gown (if needed).
d. Face Shield/Goggles.
4. Review of website for ASHRAE titled Risk Management for Legionellosis dated 10/15 indicated - The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors:
a. Health-care facility with patient stays over 24 hours.
b. Facilities designated for housing occupants over age [AGE].
c. The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system.
Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for Legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system.
Review of the Centers for Disease Control and Prevention (CDC) website titled Legionella.Prevention and Control, dated 03/25/21 indicated - The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Seven Key Elements of a Legionella water management program are:
a. Establish a water management program team.
b. Describe the building water systems using text and flow diagrams.
c. Identify areas where Legionella could grow and spread.
d. Decide where control measures should be applied and how to monitor them.
e. Establish ways to intervene when control limits are not met.
f. Make sure the program is running as designed (verification) and is effective (validation).
g. Document and communicate all the activities.
The principles of effective water management include:
a. Maintaining water temperatures outside the ideal range for Legionella growth.
b. Preventing water stagnation.
c. Ensuring adequate disinfection.
d. Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella.
e. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met.
Review of a document provided by the facility titled Water Management Policy undated indicated the following:
a. Purpose: Developing a Water Management Program to Reduce Microbial Growth and Prevent the Spread of Legionella.
b. Policy: Facility will maintain a Water Management Team that meets annually to develop systems consistent with ASHRAE and CDC guidelines. Each facility will have a program specific to the building and water system. Water Management Team will actively identify and manage hazardous conditions that could lead to spread of Legionella.
During an interview on 01/24/23 at 8:37 AM, the Administrator confirmed the facility has not started a process for water management, which would address water pathogens such as Legionnaires.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and review of the facility's policy, the facility failed to ensure one of one residents sampled with an indwelling urinary catheter, had the catheter tubing secured by a leg strap to prevent dislodgement (Resident #254). The facility's deficient practice increased Resident #254's risk of urethral injury.
Findings include:
Review of Resident #254's undated admission Record located in the resident's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral and nicotine dependence.
Review of Resident # 254's Physician's Orders, dated 01/2023 located in the resident's EMR under the Orders Tab revealed no order for an indwelling catheter tubing leg strap.
Review of Resident #254's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 01/2023 located in the resident's EMR under the Orders Tab revealed no order for an indwelling catheter tubing leg strap.
Review of Resident #254's Baseline and Comprehensive Care Plan located in the resident's EMR under the Care Plan tab revealed no intervention for catheter care including indwelling catheter tubing leg strap.
During an observation on 01/25/23 at 12:05 PM, Resident #254 with an indwelling catheter with a drainage bag on the bedframe in a dignity bag. Resident #254 stated she did not have a device on her upper leg to secure her indwelling catheter tubing. Resident #254 showed the surveyor she did not have a leg strap to her upper leg to secure her indwelling catheter tubing.
During a brief interview on 01/25/23 at 4:12 PM, Licensed Practical Nurse (LPN) 1 stated the facility utilized a soft material leg strap to ensure indwelling catheters tubing stayed in place.
During a brief interview on 01/26/23 at 8:36 AM, Certified Nursing Assistant (CNA) 1 (was in the room with Resident #254) stated Resident #254 did not have a leg strap to secure her urinary catheter tubing and should have one on to stabilize her tubing.
During an interview on 01/26/23 at 9:51 AM, Registered Nurse (RN) 4 confirmed the facility utilized leg straps to stabilize a resident's indwelling catheter's tubing. RN 4 stated stabilization of the resident's indwelling catheter tubing with leg straps was important. RN 4 also stated securing the indwelling catheter was provided to prevent the tubing from being pulled out of the resident's body and injuring the resident's urethra.
During an interview on 01/26/23 at 1:07 PM, The Director of Nursing (DON) stated Resident #254 did not have a leg strap to secure her indwelling catheter tubing and should have. The DON stated she would ensure the information was included on the resident's MAR going forward to ensure the nursing staff checked if the resident had her leg strap. The DON also stated leg straps were important to ensure Resident #254's indwelling catheter was not accidentally pulled out and caused the resident injury.
Review of facility-provided undated policy titled Catheter Care, Urinary, directed on the following:
a. Educate and train on catheter care and prevent catheter-associated urinary tract infections.
b. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site(Catheter tubing should be strapped to the resident's inner thigh).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policy review, the facility failed to complete a thorough investigation for three residents of four residents reviewed for potential abuse/neglect (Resident #13, #35 and #153). There was no evidence the facility investigated an allegation of potential verbal abuse between Resident #13 and Resident #31. There was no evidence the facility interviewed other current residents or staff regarding the allegation of an injury of unknown origin for Resident #153. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect.
Findings Include:
1. Review of Resident #13's undated admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile Tab indicated the resident was admitted to the facility on [DATE].
Review of Resident #13's EMR indicated the resident was involved in a potential verbal abuse incident with Resident #31.
2. Review of Resident #31's admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE].
Review of Resident #31's EMR indicated the resident was involved in a potential verbal abuse incident with Resident #13. Resident #31 voiced he was scared.
A request was made for the facility's investigation which involved Resident #13 and Resident #31. The facility failed to provide documentation to support an investigation occurred, by the end of the survey.
3. Review of Resident #153's undated admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE].
Review of Resident #153's EMR indicated the resident was found with misaligned hips on 11/08/22 and the facility ordered an x-ray. The results of the x-ray determined the resident had a fracture of her left hip and was sent to the local hospital for evaluation and treatment.
A request was made for the facility's investigation. The facility did not provide documentation to support an investigation occurred after the discovery of Resident #153's injury of unknown origin, by the end of the survey.
During an interview 01/23/23 at 4:42 PM, the Administrator stated he has not had any abuse allegations in the past six years. The Administrator stated if a resident had a concern, the facility would deal with it immediately.
During an interview on 01/26/23 at 10:11 AM, the Administrator stated the facility did investigate Resident #153's left hip fracture and the facility determined the resident sustained the left hip fracture when she had a fall prior to her admission to the facility. As for the resident-to-resident potential verbal abuse, the Administrator stated Resident #13 and Resident #31 both sundown as part of their dementia and at no part did it rise to abuse.
Review of the facility provided undated policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy, indicated should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the following will occur:
a. The Administrator or his/her designee will designate a member of management to investigate the alleged incident.
b. The Administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident.
c. Review documentation in the Resident Record (including review of assessment if resident injury).
d. Assess the resident for injury if the allegation involves physical or sexual abuse.
e. Provide proper notifications to primary care provider, responsible party, etc.
f. Attempt to obtain Witness Statements (oral and/or written) from all known witnesses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility policy review, the facility failed to report an allegation of abuse to the State Survey Agency and failed to report an injury of unknown origin for three residents of 49 sampled residents reviewed for abuse (Resident #13, #31 and #153). These failures had the potential to contribute to continued potential abuse in the facility for these three residents.
Findings include:
1. Review of Resident #13's undated admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included cognitive social or emotional deficit following a nontraumatic subarachnoid hemorrhage.
Review of Resident #13's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/20/22, located in the resident's EMR under MDS Tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated the resident was moderately cognitively impaired. The MDS also revealed the resident had no physical or verbal behavioral symptoms directed to others.
Review of a document provided by the facility titled Care Plan, failed to address Resident #13 had difficulties, such as verbally/physically encounters with his roommate or with other residents.
Review of Resident #13's Behavior Progress Note, located in the resident's EMR under the Progress Notes dated 12/15/22 indicated the resident was verbally aggressive with his roommate (Resident #31). Licensed Practical Nurse (LPN 3) indicated in the resident's Progress Notes that Resident #13 accused Resident #31 of committing inappropriate sexual acts while in the bathroom. LPN 3 noted this was not a truthful statement. LPN 3 indicated in the resident's Progress Notes Resident #31 was so afraid of Resident #13 that Resident #31 refused to sleep in his bed. It was noted in the Progress Note Resident #31 had to leave the room and the Power of Attorney, Physician, and Social Services were notified about the incident.
During an interview on 01/24/23 at 2:31 PM, LPN 3 stated she notified Social Services (SS) of the incident for follow up. LPN 3 stated the staff removed Resident #31 from his room. LPN 3 stated she did not report this resident to resident incident since this was an on-going issue between the two residents. LPN 3 stated if there was an allegation of potential verbal/physical abuse she would report it to the Director of Nursing (DON).
2. Review of Resident #31's admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia.
Review of Resident #31's Quarterly MDS with an ARD of 12/04/22, located in the resident's EMR under MDS Tab indicated the resident had a BIMS score of four out of 15 which revealed the resident was severely cognitively impaired. The MDS also revealed the resident had no physical or verbal behavioral symptoms directed to others.
Review of a document provided by the facility titled Care Plan, failed to address that Resident #31 had difficulties with his roommate or with other residents.
Review of Resident #31's Social Service Progress Note dated 12/16/22, located in the resident's EMR under the Progress Notes Tab indicated the SS documented she went to see the resident since staff communicated to her Resident #31 was scared of his roommate (Resident #13). SS noted Resident #31 did not remember the incident and asked him if he wanted to change rooms. Resident #31 refused a room change.
Review of Resident #31's Progress Note, dated 12/17/22, located in the resident's EMR under the Progress Notes Tab indicated Resident #31 found sitting on the side of his bed while his roommate Resident #13 was speaking loudly to him. Resident #31 reported to LPN 5 that Resident #13 threatened to beat him up and he was scared. Resident #31 reported that Resident #13 was racist. LPN 5 indicated staff would check on him throughout the night and Resident #31 rested and watched TV.
During an interview on 01/24/23, LPN 5 stated Resident #13 was hallucinating and believed he was pulled over by the police. LPN 5 confirmed she did not report the resident-to-resident incident to the DON as an allegation of potential verbal abuse.
During an interview on 01/25/23 at 9:38 AM, SS stated both Resident #13 and Resident #31 would forget the previous day's incident. SS confirmed LPN 5 notified her, and we took the resident-to-resident to Quality Assurance (QA) and the two residents were separated and we continue to monitor them. SS stated the decision to call the State Survey Agency (SSA) was up to the Administrator.
During an interview on 01/26/23 at 10:34 AM, the Administrator stated he did not report the resident-to-resident which involved Resident #31 and Resident #13 to the SSA since it did not rise to the level of potential abuse. The Administrator stated this was an on-going issue between the two residents and both were offered a room change.
3. Review of a document provided by the facility (referred to as Hospital Records) titled H&P and dated 10/15/22 indicated Resident #153 sustained a fall while at a Memory Care Unit. The H&P revealed the resident sustained a lumbar transverse process fracture.
Review of Resident #153's undated admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and a fracture of the lumbar vertebrae.
Review of Resident #153's Clinical Summary Progress Notes, located in the resident's EMR under the Progress Notes Tab dated 10/20/22 indicated the resident was admitted to the facility for Skilled Services related to a lumbar fracture. The Clinical Notes revealed the resident was able to follow direction and no complaints of pain. The Clinical Notes indicated the resident was able to ambulate with assistance of one, with the use of a gait belt and a front wheeled walker (FWW) with a wheelchair following.
Review of Resident #153's MDS with an ARD of 10/25/22 located in the resident's EMR under the MDS Tab indicated the resident had a BIMS score of seven out of 15 which revealed the resident was severely cognitively impaired. The MDS also indicated the resident required extensive assistance of one person for bed mobility and extensive assistance of two persons for transfers. The MDS further revealed the resident sustained a fall and a fracture prior to her admission.
Review of Resident #153's Clinical Summary Progress Notes located in the resident's EMR under the Progress Notes tab dated 11/04/22, revealed the resident continued with skilled therapy due to a lumbar vertebrae fracture. The Progress Notes revealed the resident was unable to indicate pain location. The Progress Note indicated in Skilled Therapy the resident complained of left hip pain in the past. The nurse documented the resident had no current pain during this assessment.
Review of Resident #153's Clinical Summary Progress Notes, located in the resident's EMR under the Progress Note tab dated 11/07/22, indicated the resident's left lower extremity was weaker than the right side. The resident expressed no non-verbal expressions of pain. On 11/08/22, LPN2 indicated the resident had expressions of non-verbal pain and had uneven hip alignment. LPN2 notified the Nurse Practitioner (NP) and obtained a portable x-ray to the resident's left hip.
Review of a document provided by the facility titled X-Ray Left Minimum Two Views, dated 11/08/22 indicated Resident #153 had a comminuted, angulated, foreshortened intertrochanteric fracture of the left hip.
During an interview on 01/24/23 at 2:23 PM, LPN2 confirmed she was the nurse who identified misalignment of Resident #153's hips. LPN2 stated the medical provider was notified an X-Ray obtained. LPN2 stated she either reported the incident to the on-coming nurse or to the Director of Nursing (DON).
During an interview on 01/26/23 at 10:11 AM, the Administrator stated he did not report Resident #153's hip fracture to the SSA as an injury of unknown origin. The Administrator stated there was no incident and stated the facility determined the left hip fracture was a result of the resident's fall prior to her admission. When asked if the hospital records reflected his analysis of a prior left hip fracture, the Administrator stated the hospital records did not.
Review of the facility's undated policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy, indicated the following:
a. All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion or chemical restraint not required to treat the resident's medical symptoms. b. Verbally aggressive behavior such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating.
c. Examples of injuries that could indicate abuse include, but are not limited to - Injuries that are non-accidental or unexplained, fractures, sprains or dislocations.
d. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative.
e. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made.
f. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than twenty-four (24) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility's policy review, the facility failed to ensure two of twenty-seven sampled residents had a Physician's Order and was screened/assessed for the self-administration of medications prior to self-administration of medications (Resident #203 and #255). The facility's deficient practice increased the residents risk for adverse medication reactions.
Findings Include:
1. Review of Resident #203's undated admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile Tab revealed the resident admitted to the facility on [DATE] with diagnoses which included morbid obesity, diabetes mellitus, peripheral vascular disease, major depressive disorder, and chronic pain.
Review of Resident #203's Minimum Data Set (MDS) assessment dated [DATE], located in the EMR under the MDS Tab, revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #203 cognitively intact.
Review of the resident's revised Care Plan dated 01/06/23, located in the EMR under the Care Plan tab, documented Resident #203 did not have a Care Plan related to the self-administration of medication.
During an observation and an interview on 01/25/23 at 8:34 AM, Resident #203 had a full medication cup of pills sitting on the overbed table. At 8:45 AM, the medication cup was empty. When asked, the resident said, I took the pills.
Review of Resident #203's Physician's Orders, dated 01/2023, located in the EMR under the Orders Tab, revealed the resident did not have a Physician Order to self-administer medications.
Review of Resident #203's EMR under the Assessments Tab and Miscellaneous Tab revealed the resident did not have a documented assessment to self-administer medications.
During an interview on 01/25/23 at 10:25 AM, Licensed Practical Nurse (LPN) 2 stated, I left the medications at the bedside this morning. I thought there was a Care Plan to do so. I talked to the MDS Coordinator, who confirmed Resident #203 did not have a Care Plan to self-administer medications, and the medication should not have been left them at her bedside.
During a follow-up interview on 01/26/23 at 9:09 AM, Resident #203 stated that LPN2 left the medications at her bedside yesterday because she (LPN2) was going to be behind in her schedule.
During an interview on 01/26/23 at 12:53 PM, the Director of Nursing (DON) stated, that should not have happened. The nurse thought it was Care Planned. I already talked to the nurse. We do not have self-administration of medications here.
2. Review of Resident #255's undated admission Record located in the resident's EMR under the Profile Tab revealed he was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), Alzheimer's, pneumonia, and cardiac murmur.
Review of the resident's Physician's Orders dated 01/2023 located in the resident's EMR under the Orders Tab revealed - Budesonide (belongs to class of medications called Corticosteroids-decreases the swelling and irrigation in the airways and had potential for serious side effects including difficulty breathing, swelling of the face, throat, tongue, lips eyes hands feet ankles and lower legs, chest pain, vomiting). Inhalation Suspension 0.5 mg (milligrams)/2 ml (milliliters) give 2 ml orally two times a day. Continued review of the order revealed Resident #255 did not have an order to self-administer his medication.
Review of Resident #255's Medication Administration Record (MAR) dated 01/2023, located in the resident's EMR under the Orders Tab documented - Budesonide Inhalation suspension 0.5 mg /2 ml, inhale 2 ml orally two times a day. Noted Registered Nurse (RN) 2's initials entered on 01/23/23 for his morning dose (indicating she administered his medication) and the resident did not have an order to self-administer his medication.
Review of Resident #255's Comprehensive Care Plan located in the resident's EMR under the Care Plan Tab revealed no intervention for self-administration of medication.
During a medication administration observation on 01/24/23 at 9:22 AM, the Director of Nursing (DON) supervised the medication preparation beside Resident #255's door entry for medication administration. RN2 administered the inhalation medication by depositing it into the reservoir of his oxygen mask tubing, attached to his nebulizer machine and placed his oxygen mask on his face. RN2 exited the resident's room and did not remain with him for the completion of his medication administration.
During an observation on 01/24/23 at 9:44 AM, RN2 entered Resident #255's room and stated she was returning to remove his nebulizer treatment. The resident noted sitting on his chair with his oxygen mask off.
During a brief interview on 01/25/23 at 11:19 AM, (with the DON present) RN2 stated she was not assigned to provide care for any residents who performed self-administration of their medications. RN2 confirmed the residents who self-administered medications included an order on their MAR. The DON stated the facility did not have any residents who performed self-administration of medications. The DON stated for a facility resident to perform medication self-administration, the facility performed a medication self-administration assessment to ensure the facility's resident was safe to administer their own medication and had a Physician's Order to self-administer medications. The DON also stated an intervention on their Care Plan would be developed to reflect self-administration of medications.
During an interview on 01/25/23 at 2:15 PM, RN2 confirmed all medication administration should be monitored by the Nursing Staff until consumed by the residents, including inhalation medications. RN2 stated she was unsure what complications could occur with steroid nebulizer treatments. RN2 confirmed Nursing Staff should remain with residents until the nebulizer treatments completed. RN2 confirmed she did not remain with Resident #255 for completion of his nebulizer administration and should have remained with him until the completion of his nebulizer treatment. RN2 also stated she did not remain with Resident #255 because his wife was at his bedside, and he had done treatments at home. RN2 confirmed the facility did not ensure the resident's wife was educated regarding complications of nebulizer treatments. RN2 confirmed the standard of practice was for nurses to remain with residents until the administration of their medications were complete.
During an interview on 01/26/23 at 12:57 PM, the DON stated it was her expectation for the facility Nursing Staff administering inhalation medication was to initiate nebulizer treatment in the room and check on the resident periodically. The DON stated she did not expect the Nursing Staff to remain with the residents for completion of their nebulizer/inhalation medication administration. The DON confirmed nebulizer treatments were usually steroid medications and Resident #255 was administered a steroid by inhalation. The DON also stated the Professional Standard of Practice was for Nursing to remain with residents, until their medication was consumed.
Review of facility-provided policy titled Self-Administration of Medication, revealed - Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Assess each resident's cognitive and physical abilities to determine whether self-administrating medications is safe and clinically appropriate for the resident.
Review of facility-provided policy titled Nebulizer Administration documented - Providing guidelines for safe nebulizer administration to review the Physician's Order for nebulizer administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and facility policy review, the facility failed to conduct behavior tracking and monitor the side effects of antidepressant medications for five of five sampled residents reviewed for unnecessary medications (Residents #20, #69, #74, #204 and #205). These failures place the residents at risk for not obtaining the intended therapeutic goal of the antidepressant medication and the potential for serious adverse effects from the antidepressant medications.
Findings Include:
1. Review of Resident #20's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile Tab, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder.
Review of Resident #20's Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/08/23, located in the EMR under the MDS tab, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognitively intact. The resident received antidepressant medication for seven of seven days during the lookback review period.
Review of Resident #20's Comprehensive Care Plan, updated 01/08/23, located in the EMR under the Care Plan Tab, documented - Monitor for changes with mood/behavior and inform the physician.
Review of Resident #20's Physician's Orders, dated 01/2023, located in the EMR under the Orders Tab, revealed the resident received citalopram (an antidepressant) 40 milligrams (mg) daily. Further review failed to reveal orders for behavior tracking and to monitor the side effects of antidepressant medications.
Review of Resident #20's Medication Administration Records (MARs) and Treatment Administration Records (TAR), dated 11/2022 through 01/2023, located in the EMR under the Orders Tab, failed to reveal orders for behavior tracking or medication side effects monitoring for antidepressant medications.
2. Review of Resident #69's undated admission Record located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, single episode.
Review of Resident #69's Quarterly MDS with an ARD of 12/05/22, located in the resident's EMR under the MDS Tab indicated the resident's BIMS score was six out of 15 which indicated the resident was severely cognitively impaired. The MDS also indicated the resident had no depressive symptoms and the resident took an antidepressant for seven of seven days of the MDS lookback period.
Review of a document provided by the facility titled Care Plan, dated 06/11/21 indicated Resident #69 had issues with mood and behavior which were related to his diagnosis of dementia. The intervention was to monitor for changes in depression.
Review of Resident #69's Clinical Physician Orders, located in the resident's EMR under the Orders Tab dated 05/02/22, indicated the medical provider ordered Lexapro (an antidepressant) 10 mg to be administered by mouth daily for the resident's diagnosis of depression.
Review of Resident #69's MAR located in the resident's EMR under the Orders Tab for the months of 10/2022 through 01/2023 failed to indicate the resident's depression was being monitored.
Review of Resident #69's Progress Notes, located in the resident's EMR under the Progress Notes Tab failed to address monitoring for depressive behaviors.
3. Review of Resident #74's undated admission Record located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included unspecified mood disorder.
Review of Resident #74's Annual MDS with an ARD of 11/13/22, located in the resident's EMR under the MDS Tab indicated the resident had a BIMS score of three out of 15 which revealed the resident was severely cognitively impaired. The resident had minimal depression. The MDS also revealed the resident took an antidepressant for seven of seven days of the assessment lookback period.
Review of a document provided by the facility titled Care Plan, dated 11/16/21 indicated Resident #74 was on an antidepressant. The interventions were to monitor for changes in depression.
Review of Resident #74's Clinical Physician Orders located in the resident's EMR under the Orders Tab dated 04/11/22 indicated the medical provider ordered bupropion (an antidepressant) 50 mg to be administered by mouth two times a day related to the resident's diagnosis of major depressive disorder.
Review of Resident #74's Clinical Physician Orders located in the resident's EMR under the Orders Tab dated 06/13/22 indicated the medical provider ordered mirtazapine (an antidepressant) 3.75 mg to be administered by mouth two times a day related to the resident's diagnosis of major depressive disorder.
Review of Resident #74's MAR located in the resident's EMR under the Orders Tab for the months of 10/2022 through 01/2023 failed to indicate the resident's depression was being monitored.
Review of Resident #74's Progress Notes, located in the resident's EMR under the Progress Notes tab failed to address monitoring for depressive behaviors.
4. Review of Resident #204's undated admission Record located in the EMR under the Profile Tab, revealed Resident #204 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder and major depressive disorder.
Review of Resident #204's EMR revealed the admission MDS Assessment was not available for review. The facility was in the process of completing the admission MDS Assessment.
Review of Resident #204's BIMS assessment dated [DATE], located in the EMR under the Assessment Tab, revealed the resident with a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
Review of Resident #204's Comprehensive Care Plan, dated 01/18/23, located in the EMR under the Care Plan Tab, documented - Monitor for changes with mood/behavior and inform the physician.
Review of Resident #204's Physician's Orders, dated 01/2023, located in the EMR under the Orders Tab revealed the resident received mirtazapine (an antidepressant)15 mg daily and fluoxetine HCL (an antidepressant) 20 mg daily. Further review failed to reveal orders for behavior tracking and to monitor the side effects of antidepressant medications.
Review of Resident #204's MAR's and TAR's, dated 01/2023, located in the EMR under the Orders Tab, failed to reveal orders for behavior tracking or medication side effect monitoring for antidepressant medications.
5. Review of Resident #205's undated admission Record, located in the EMR under the Profile Tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included major depressive disorder.
Review of Resident #205's MDS with an ARD of 01/19/23, located in the EMR, under the MDS Tab, revealed the resident with a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
Review of Resident #205's Comprehensive Care Plan located in the EMR under the Care Plan Tab, documented, Monitor for changes with mood/behavior and inform the physician.
Review of Resident #205's Physician's Orders, dated 01/19/23, located in the EMR under the Orders Tab, revealed the resident received mirtazapine (an antidepressant) 15 mg daily and sertraline HCL (an antidepressant)100 mg daily. Further review failed to reveal orders for behavior tracking and to monitor the side effects of antidepressant medications.
Review of Resident #205's MAR's and TAR's dated 01/19/23, located in the EMR under the Orders Tab, failed to reveal orders for behavior tracking or medication side effects monitoring for antidepressant medications.
During an interview on 01/25/23 at 9:38 AM, the MDS Coordinator stated, I am unable to provide you with a policy and procedure; we do not monitor for behaviors or side effects of antidepressant medications like we do with more serious medications.
During an interview on 01/25/23 at 11:39 AM, Licensed Practical Nurse (LPN) 1 stated if a resident was on an antidepressant the Clinical Staff only monitored for depressive symptoms for a certain amount of time after the medication had been started. LPN1 also stated the use of antipsychotics were the medications only monitored by the Clinical Staff.
During an interview on 01/26/23 at 11:17 AM, Registered Nurse (RN) 1 stated the staff did not conduct behavior tracking or monitor the side effects of antidepressant medications, document resident behaviors, or side effect monitoring for antidepressants.
During an interview on 01/26/23 at 12:38 PM, the Director of Nursing (DON) confirmed that staff do not conduct behavior tracking or monitor residents for the side effects of antidepressant medications.
During an interview on 01/26/23 at 12:38 PM, the DON stated going forward the facility would be monitoring residents on an antidepressant, for signs of depression.
During an interview on 01/26/23 at 2:29 PM, the MDS Coordinator, who was also the Quality Assurance (QA) Nurse, confirmed the facility was not monitoring residents who were on an antidepressant.
Review of a facility document titled, Summary of Unnecessary and Psychotropic Medications, dated 08/11/21, documented - Monitoring of Psychotropic Medications: When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences. After initiating or increasing the dose of a psychotropic medication, the behavioral symptoms must be reevaluated periodically (at least during quarterly care plan review, if not more often) to determine the potential for reducing or discontinuing the dose based on therapeutic goals and any adverse effects or functional impairment.