Based on employee file review, staff interview, and policy review, the facility failed to complete a criminal record check and dependent adult/child abuse registry check prior to an employee's hire date for 1 of 5 employee. The facility reported a census of 43. Findings include: Employee record review of Staff A, dietary aide, showed a hire date of 3/6/24. A Parental Consent for a Minor was signed by Staff A's mother on 3/7/24, which gave the facility permission to complete a criminal and abuse background check. Staff A's Single Contact License and Background Check was completed on 3/19/24 at 3:38 PM. Review of Staff A's time card revealed a total of five shifts worked prior to the completion of the background check (3/6/24, 3/10/24, 3/11/24, 3/13/24, and 3/16/24). The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy states that the facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code § 58.11(3). During an interview on 8/13/24 at 3:00 PM, the Administrator acknowledged that the criminal and dependent adult/child abuse registry check was not completed prior to Staff A's hire date nor prior to working shifts.

Based on clinical record, facility policy, and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for 1 of 13 residents reviewed (Resident #24). The facility reported a census of 38 residents. Findings include: The MDS for Resident #24 dated 4/29/23 revealed a Brief Interview of Mental Status score of 7 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of stroke, diabetes mellitus, dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and anarthria (inability to speak). The MDS revealed the resident required the extensive assistance of 1 person with eating. The MDS revealed the resident did not have have a feeding tube or a mechanically altered diet. The Medication Review Report signed by a physician on 3/28/23 revealed orders for: 1. Honey thick liquids. No solid diet at this time. Must be fully upright for all intake, liquids via spoon or cup. If resident is having trouble initiating swallowing or expressing pain with swallow, please stop intake for that meal. Start date 3/16/23. 2. Nutren 2.0 Oral Liquid (Nutritional Supplements) give 250 milliliters (mL) via g-tube (gastrostomy tube) 3 times a day for tube feedings. Water flush with 60 mL before and after feedings and/medications. The Rehab Communication on 3/20/23 revealed ST (speech therapist) recommends pureed solids and honey thick liquids. In an interview on 5/17/23 at 4:13 PM, the Director of Nursing (DON) reported that the Registered Dietician (RD) completed the section of the MDS in which the feeding tube or a mechanically altered diet were not correctly assessed. When asked if it is the responsibility of the nurse that signs the MDS assessment to ensure the MDS assessment was completely accurately, the DON reported it was. In the same interview, the DON reported the facility does not a policy regarding MDS assessments and that she would do a modification to the 4/29/23 MDS submission.

**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 1 residents reviewed for PASRR requirements, (Resident #18). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 documented diagnoses of major depressive disorder, anxiety disorder and posttraumatic stress disorder.The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 1/25/23 revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level 1 screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed question #1- Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past listed depression or depression disorder. Review of the MDS dated [DATE] revealed an active diagnosis of major depressive disorder, anxiety disorder and posttraumatic stress disorder. Review of the Medication Review Report signed 3/28/23 revealed the following diagnosis of major depressive disorder, anxiety disorder and posttraumatic stress disorder. Review of Resident #18 ' s chart lacked a follow-up and resubmission of a PASRR with the diagnosis of major depressive disorder, anxiety disorder and posttraumatic stress disorder. The facility revealed there is no policy on PASRR and they follow the PASRR recommendations. Interview on 5/17/23 at 2:34 p.m., wth the Social Worker revealed Resident #18 ' s PASRR will be redone to include the diagnosis.

Based on clinical record, facility policy, and staff interview, the facility failed to develop a care plan to include side effects of high risk medications for 1 of 5 residents reviewed (Resident #28). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) for Resident #28 dated 4/18/23 revealed a Brief Interview of Mental Status (BIMS) score of 4 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of hip and knee replacement, hypertension (high blood pressure), arthritis, asphasia (inability to speak), and low back pain. The MDS revealed the resident diuretic and opioid medications. The Medication Review Report signed by a physician on 4/13/23 revealed orders for: 1. Furosemide oral 20 milligrams (mg) give 20 mg by mouth one time a day related to essential (primary) hypertension with a start date of 4/12/23. 2. Hydrocodone-acetaminophen oral tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain related to displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing with a start date of 4/11/23. 3. Hydrocodone-acetaminophen oral tablet 7.5-325 mg give 2 tablets by mouth every 6 hours as needed for pain related to displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing with a start date of 4/11/23. The Care Plan with an initiated date of 4/11/23 lacked side effects of furosemide and hydrocodone-acetaminophen. In an interview on 5/16/23 at 2:26 PM, the Director of Nursing (DON) reported that she would expect side effects of high risk medications to be on resident's care plans. In an interview on 5/17/23 at 12:27 PM, the DON reported the facility does not have a policy regarding care plans, they follow regulations.

Based on observation, clinical record, facility policy, resident interview, and staff interview, the facility failed to obtain a physician order for a medication and permitted a resident to self administer a medication without assessment or physician order for 1 of 13 residents reviewed (Resident #140). The facility failed to obtain a physician order for a mechanically altered diet for 1 of 1 resident reviewed (Resident #24). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #140 dated 5/9/23 revealed the resident had a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. The MDS revealed the resident's primary medical condition was aftercare following explantation of shoulder joint prosthesis and had upper extremity impairment on 1 side. Observation on 5/15/23 at 12:25 PM of 2 bottles of over the counter eye drops in clearly visible on the resident's bedside table. In an interview on 5/15/23 at 12:25 PM, the resident reported that he brought the eyedrops into the facility and they (facility staff) know about it. The Clinical Record lacked an order for the eye drops and an order that the resident could self administer the eye drops. In an interview on 5/16/23 at 2:26 PM, the Director of Nursing (DON) reported that the eye drops were not in the resident's possession when he was admitted to the facility, if the resident's family brought them into the facility, they did not report it and the facility would have no way of knowing the resident had eye drops in his room. When asked if the resident told staff about the eye drops, the DON reported that she did not know anything about it. In an interview on 5/17/23 at 12:27 PM, the DON reported that the facility does not have a policy regarding self administration of medication, that they follow regulations. 2. The MDS for Resident #24 dated 4/29/23 revealed a Brief Interview of Mental Status score of 7 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of stroke, diabetes mellitus, dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and anarthria (inability to speak). The MDS revealed the resident required the extensive assistance of 1 person with eating. The Medication Review Report signed by a physician on 3/28/23 revealed orders for honey thick liquids. No solid diet at this time. Must be fully upright for all intake, liquids via spoon or cup. If resident is having trouble initiating swallowing or expressing pain with swallow, please stop intake for that meal. Start date 3/16/23. The Rehab Communication on 3/20/23 revealed ST (speech therapist) recommends pureed solids and honey thick liquids. This Rehab Communication did not have a physician signature. The Clinical Record lacked a physician signed order for a pureed diet after 3/20/23. In an interview on 5/17/23 at 4:13 PM, when asked what the definition of a no solid foods order was, the Director of Nursing (DON) reported that it would mean the resident was to have a pureed diet and that puree food was not considered solid food. In the same interview, the DON reported that the process she had in place to ensure a resident's diet order was correct failed and that the facility did not have a policy regarding what different diet orders were defined as to know for sure what the definition of a no solid food diet was. In an interview on 5/17/23 at 4:19 PM, the Registered Dietician (RD) reported that in her time practicing as an RD, she has never seen an order for no solid foods, that if she saw an order written that way she would assume it meant the resident was to have a mechanically soft diet.

Based on observation, clinical record, and staff interview, the facility failed to serve the correct consistency of food for 1 of 1 resident reviewed (Resident #24). The MDS for Resident #24 dated 4/29/23 revealed a Brief Interview of Mental Status score of 7 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of stroke, diabetes mellitus, dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and anarthria (inability to speak). The MDS revealed the resident required the extensive assistance of 1 person with eating. Observation on 5/17/23 at 12:24 PM revealed the resident ate pureed food for lunch with visible pieces of corn in the puree. The Week 5 Wednesday puree menu for the noon meal revealed pureed cream corn was served. In an interview on 5/17/23 at 5:06 PM the Registered Dietician reported that pureed foods should be applesauce to mashed potato consistency with no pieces of food recognizable from its original form. She provided education to the Certified Dietary Manager (CDM) last week on the consistency food should be in for puree.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The MDS for Resident #32 dated 3/10/23 revealed a BIMS score of 4 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of depression, anxiety, and dementia. The MDS revealed the resident took medications for depression and an anti-psychotic. The LTC (Long Term Care) Progress Note signed by a physician on 4/5/23 revealed orders for the following medications: a. Citalopram 20 mg PO (by mouth) daily. b. Lorazepam 0.5 mg PO BID (twice daily) PRN (as needed). c. Quetiapine 25 rng tablet PO bedtime. d. Trazodone 50 mg tablet PO bedtime. The Care Plan with an initiated date of 6/9/22 lacked side effects of the resident's high risk medications. In an interview on 5/16/23 at 2:26 PM, the Director of Nursing (DON) reported that she would expect side effects of high risk medications to be on resident's care plans. In an interview on 5/17/23 at 12:27 PM, the DON reported the facility does not have a policy regarding care plans, they follow regulations. Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in 4 out of 13 sampled residents reviewed for comprehensive care plans (Resident #9, #18, #25 and #32). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of anxiety disorder, depression and Alzheimer ' s Disease.The MDS showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of the May 2023 Medication Administration Record (MAR) revealed the following orders: Remeron (antidepressant medication) daily with an order date of 10/25/22. Risperidone (antipsychotic medication) daily with an order date of 12/26/22. Review of the MDS dated [DATE] revealed antipsychotic and antidepressant medication taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/28/23 revealed the following orders: Remeron daily with an start date of 10/25/22. Risperidone daily with an start date of 12/26/22. Review of the current care plan undated lacked information regarding the usage and side effects of antipsychotic and antidepressant medication. 2. The MDS assessment dated [DATE] for Resident #18 documented diagnoses of major depressive disorder, anxiety disorder and posttraumatic stress disorder.The MDS showed a BIMS score of 13 indicating no cognitive impairment. Review of the May 2023 Medication Administration Record (MAR) revealed the following orders: Duloxetine (antidepressant medication) daily with an order date of 1/26/23. Bupropion (antidepressant medication) daily with an order date of 1/26/23. Lantus (insulin) daily with an order date of 3/4/23. Review of the MDS dated [DATE] revealed antidepressant medication and insulin injections taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/28/23 revealed the following orders: Duloxetine daily with a start date of 1/26/23. Bupropion daily with a start date of 1/26/23. Lantus daily with a start date of 3/4/23. Review of the current care plan undated lacked information regarding the usage and side effects of antidepressant medication and insulin. 3. The MDS assessment dated [DATE] for Resident #25 documented diagnoses of major depressive disorder, anxiety disorder and hypertension.The MDS showed a BIMS score of 0 indicating severe cognitive impairment. Review of the May 2023 Medication Administration Record (MAR) revealed the following orders: Furosemide (diuretic medication) daily with an order date of 10/26/19. Sertraline (antidepressant medication) daily with an order date of 11/2/22. Tramadol (pain medication) twice a day with an order date of 2/21/23. Morphine Sulfate (pain medication) every 2 hours as needed with an order date of 5/3/23 with a discontinuation date of 5/12/23. Morphine Sulfate (pain medication) every 2 hours as needed with an order date of 5/12/23. Review of the MDS dated [DATE] revealed antidepressant medication and diuretics taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/28/23 revealed the following orders: Furosemide daily with a start date of 10/26/19. Sertraline daily with an order date of 11/2/22. Tramadol 2 times a day with a start date of 2/21/23. Review of the current care plan undated lacked information regarding the usage and side effects to watch for with antidepressant medication, diuretic medication and pain medication.

Based on observation, facility policy, and staff interview, the facility failed to transport linen in a manner to prevent contamination. The facility reported a census of 38 residents. Findings include: Observation on 5/17/23 at 11:53 AM of a cart in the 100 hall with resident clothing hanging on it, a staff person was delivering clothing from this cart into resident rooms. There was no cover on the cart or near the cart. Observation on 5/17/23 at 12:16 PM of a cart in the 200 hall with resident clothing hanging on it, a staff person was delivering clothing from this cart into resident rooms. There was no cover on the cart or near the cart. Observation on 5/17/23 at 1:47 PM of towels on an uncovered cart in the 200 hall. In an interview on 5/17/23 at 12:36 PM, the Environmental Services Supervisor (ESS) reported that she has had this position at the facility for 1 month, she had previously worked at the facility for the past 2 years in a different position and has never been told or observed laundry be covered while transported within the facility. In the same interview, the ESS reported that the only cart that is covered to transport clean laundry within the facility is used to deliver washcloths and hand towels to resident rooms. The Laundry Department policy with a revision date of 6/21/21 lacked direction on the transportation of clean laundry. In an interview on 5/18/23 at 11:19 AM, the facility's Infectoin Preventionist reported that the facility has never covered their clean laundry carts and agreed that they should be covered.