Cedar Manor Nursing Home

1200 Mulberry Street, Tipton, IA 52772 (563) 886-2133
Non profit - Other 54 Beds Independent Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
28/100
#175 of 392 in IA
Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Cedar Manor Nursing Home has received a Trust Grade of F, which indicates significant concerns about the quality of care provided. It ranks #175 out of 392 facilities in Iowa, placing it in the top half, and #2 out of 4 in Cedar County, meaning there is only one local option that is better. The facility's trend is stable, with 6 issues reported in both 2023 and 2024. Staffing is a relative strength, with a 4 out of 5-star rating and a turnover rate of 44%, which is on par with the state average. However, the facility has accumulated $44,087 in fines, higher than 86% of Iowa facilities, suggesting ongoing compliance issues. Specific incidents include a serious case where a resident fell while being transferred by a CNA, resulting in three fractured ribs. Additionally, there was a failure to properly document wound assessments and seizure durations for other residents, which raises concerns about the quality of care and oversight. While Cedar Manor has some strengths in staffing, the overall poor Trust Grade and concerning incidents highlight significant weaknesses that families should consider carefully.

Trust Score
F
28/100
In Iowa
#175/392
Top 44%
Safety Record
High Risk
Review needed
Inspections
Holding Steady
6 → 6 violations
Staff Stability
○ Average
44% turnover. Near Iowa's 48% average. Typical for the industry.
Penalties
⚠ Watch
$44,087 in fines. Higher than 88% of Iowa facilities, suggesting repeated compliance issues.
Skilled Nurses
✓ Good
Each resident gets 46 minutes of Registered Nurse (RN) attention daily — more than average for Iowa. RNs are trained to catch health problems early.
Violations
⚠ Watch
18 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
Stable
2023: 6 issues
2024: 6 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (44%)

    4 points below Iowa average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

3-Star Overall Rating

Near Iowa average (3.1)

Meets federal standards, typical of most facilities

Staff Turnover: 44%

Near Iowa avg (46%)

Typical for the industry

Federal Fines: $44,087

Above median ($33,413)

Moderate penalties - review what triggered them

The Ugly 18 deficiencies on record

1 life-threatening 4 actual harm
Oct 2024 2 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on clinical record review, staff interview and facility policy review the facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) ...

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Based on clinical record review, staff interview and facility policy review the facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) to one out of three resident in a timely fashion (Resident#16). The facility reported a census of 50 residents. Findings include: The Clinical Census sheet for Resident #16 identified the start of the Skilled Nursing Facility (SNF) services on 5/10/24 and ended on 5/28/24. A Progress Note dated 5/28/24 at 10:59 AM revealed Resident#16 on SNF level of care until 5/29/24. The Progress Notes dated 5/27/24 and 5/26/24 did not include documentation regarding communication with the resident or her responsible party regarding the discharge from SnF services and the right to appeal. The CMS 10123 (Notice of Medicare Non-Coverage or NOMNC) form signed by Resident#16 responsible party reflected a dated of 5/29/24. The CMS 10055 (SNFABN) form signed by Resident#16 responsible party reflected a dated of 5/29/24. On 10/2/14 at 3:50 PM the Administrator reported she expected the Advanced Beneficiary Notice (ABN) provided to the resident or resident representative before the 48 hours notice requirement. 10/03/24 08:26 AM the Administrator reported the facility failed to have a policy for ABN.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure an indwelling catheter collection bag pla...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure an indwelling catheter collection bag placed in a dignity cover, with the bag and bag remained off the floor to prevent urinary tract infections for one of one resident (Resident #39) reviewed with an indwelling catheter. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], list of diagnoses included: congestive heart failure, dementia and sacral pressure ulcer. A Brief Interview for Mental Status score of 10 out of 15 indicated a moderate cognitive impairment. The MDS identified Resident #39 used an indwelling catheter (for urine collection). Review of admission Orders, dated 9/23/24, revealed an order admission for hospice. The orders also included an Indwelling Foley catheter for comfort. The Care Plan, dated 9/30/24, included a Focus area to address Indwelling Foley Catheter: 16F (French - catheter size) for comfort r/t Terminal condition. Interventions included: Check tubing for kinks each shift, and Monitor/record/report to MD (medical doctor) for s/sx (signs and symptoms) of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, Increased pulse, increased temp (temperature), Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. During an observation on 10/1/24 at 7:25 AM, Resident #39 in her room, asleep. The indwelling urinary collection bag and catheter tubing rested on the bedroom floor. The collection bag lacked a dignity cover. During an observation on 10/1/24 at 8:56 AM, Resident #39 awake and sitting up in recliner. The indwelling urinary collection bag and tubing rested on the bedroom floor. The collection bag lacked a dignity cover. A Health Status Note, dated 10/1/24 at 6:47 PM, documented, in part, Foley catheter present with blood tinged urine, order given to obtain urine with catheter change. A Health Status Note, dated 10/2/24 at 5:24 AM, documented, in part, change in cath (indwelling catheter) and UA (urinary analysis) taken. Waiting on results but no blood in foley bag on this shift. A laboratory provider document, dated 10/3/24, indicated the Urine Culture collected on 10/1/24 at 3:30 PM result: Culture 10,000-100,000 CFU/mL (colony-forming units per milliliter) Yeast. Further information to follow. During an interview on 10/2/24 at 10:20 AM, Staff A, Registered Nurse stated when a resident has a Foley catheter, to prevent a UTI (Urinary Tract Infection) staff should place the bag in a dignity bag and ensure both bag and tubing are kept off the floor. During an interview on 10/2/24 at 2:45 PM, the ADON (Assistant Director of Nursing) reported when a resident has a Foley catheter, she would expect staff place the bag in a dignity bag and ensure both bag and tubing are kept off the floor. A review of the undated policy titled: Catheter Care failed to direct staff to ensure the indwelling catheter bags are kept in a dignity bag and to keep both bag and tubing off the floor.
May 2024 4 deficiencies 2 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview and facility policy review, the facility failed to properly do...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview and facility policy review, the facility failed to properly document assessments for two of eight residents reviewed (Residents #2 and #3). The facility failed to document Resident #2's weekly wound assessments. In addition, the facility failed to document the time Resident #3's seizure lasted and failed to document follow-up assessments. The facility reported a census of 51 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2 required substantial/maximal staff assistance with toilet use and lower body dressing. Resident #2 required total staff assistance with putting on and removing footwear. The MDS included diagnoses of chronic congestive heart failure, renal insufficiency (kidney failure) and diabetes mellitus. The Incident Report dated 3/19/24 at 11:39 AM reflected while in the dining room, Resident #2 called out she spilled her coffee in her lap. The nurse went over to her and observed she spilled hot coffee on her left and right upper thigh. They removed Resident #2 from the dining room after applying a cool towel to her legs, then took her to her room. The Incident Report indicated she had a large red, blistered area on her upper left thigh, another area on her left thigh, and another area on the right upper thigh. The Non-Pressure Skin Condition Report paper document from 3/19/24 through 4/17/24 identified Resident #2 had burns to bilateral upper thighs that measured the following: a. Date first observed - 3/19/24: i. #1 right upper thigh - 1 cm (centimeter) by 1 cm blistered area ii. #2 left upper thigh - 9 cm by 2.5 cm blistered area iii. #3 left thigh above knee, reddened and tender, no measurements documented - The documentation of tissue type, surrounding skin color, wound edges, and pain, did not address which wound described. The form included all wounds on one sheet. The form lacked an assessment from 3/22/24 until 4/2/24. The Wound Clinic Notes dated 4/10/24 at 3:14 PM listed the following: a. Principal wound diagnosis: third degree burn left leg; second degree burn right leg. Comes from the care center with burns on her right and left leg. She reported she removed the lid to the coffee and spilled it on her jeans causing burns to her legs. Not sure when it occurred, but, it happened a few weeks ago. She has received appropriate treatment with Silvadene cream but the wound didn't improve. Resident #2 came in for debridement of her wounds as no one did this yet. b. Measurements of the burns: i. Right leg burns measurements = length 2.5 cm, width 1.1 cm - Wound base moist with fibrin, slough, biofilm, yellow small amount serosanguinous drainage - Peri wound clean and dry ii. Left leg medial thigh burns measurements = length 7.8 cm, width 2.4 cm - Wound base moist with fibrin, slough, biofilm, yellow/gray small amount serosanguinous drainage - Peri wound clean and dry - Multiple open areas on thigh from tape tears The Care Plan Focus revised 2/20/24 indicated Resident #2 had an activities of daily living (ADL) self-care performance deficit related to confusion, impaired balance, stroke, trauma caused by a fall with a subdural hematoma (bleeding on the brain). The Intervention revised 3/27/24 indicated Resident #2 could feed herself. She did require a lid on her coffee cup. The Care Plan did not identify Resident #2 with problems of the burns to both thighs after the incident on 3/19/24 until 4/23/24. On 4/18/24 at 8:28 AM observed Resident #2 sitting up in her wheelchair in the family room by the north dining room, wearing clean clothing with blanket on her lap covering both feet resting on the floor. She looked properly positioned and comfortable. On 4/18/24 at 11:10 AM Resident #2 continued sitting in the recliner in her room with both feet elevated. She still looked properly positioned and comfortable. When asked about the incident with the coffee spill, she reported being careless. When she took the lid off the coffee cup, she spilled the coffee on her lap, burning herself. She added she went to the wound clinic once a week. In an interview on 4/22/24 at 9:36 AM, Staff C, Registered Nurse (RN), reported Resident #2 spilled her coffee in March, while in the dining room. She pulled her pants away from her skin and placed cool towels on her upper thighs. When they took her to her room, she had red marks to both of her upper thighs. The ones on the left thigh appeared larger than the one on the right thigh. Staff C said they should have updated the Interventions on her Care Plan to keep the cups for hot liquids. As a result of the incident, she ended up with burns that needed treatment from the wound clinic for 2 or 3 weeks afterward as the burns didn't heal. In an interview on 4/22/24 at 1:47 PM, the Administrator reported she expected the nurses to document on wounds at least once a week and each wound have its own sheet with correlating wound assessments. Upon review of the facility form, she verified the documentation of the assessment didn't identify which wound the assessment reflected as the form included all 3 wounds on the left side of the form. This is the way they always documented when a resident had more than one wound. In an interview on 4/22/24 at 3:55 PM, Staff E, Certified Nurse Aide (CNA), reported after Resident #2 burned herself by spilling her coffee on her lap, she didn't know the new interventions added to her Care Plan. On 4/23/24 at 10:57 AM observed Staff C complete Resident #2's wound care. Staff C measured the wound to the left thigh as 5.2 cm long by 3.0 cm wide, before applying a dressing. Then Staff C measured wound to right thigh as 3.6 cm long by 1.3 cm wide, before applying a dressing. The wounds appeared to be healing with a small amount of serous (clear to yellow wound drainage) drainage. The wound had no signs of infection to wound bed or surrounding skin. In an interview on 4/22/24 at 11:07 AM, Staff A, CNA reported Resident #2 had an incident, but, she couldn't recall the exact date. The Care Plan should have received an Intervention added to the Care Plan to keep the lid on any hot liquids. In an interview on 4/22/24 at 11:36 AM, Staff D, CNA, reported after Resident #2 spilled her coffee on her lap. Staff D explained the facility should have updated her Care Plan to keep the lid on any cup of coffee she received. In an interview on 4/22/24 at 1:59 PM, the Assistant Director of Nursing (ADON) reported she expected the nurses to document wound assessments weekly on the skin sheet. In addition, she verified Resident #2 didn't have a documented assessment and she should have for the week of 3/22/24 to 4/1/24. Also, the ADON added each wound should have their own sheet for assessments. In an interview on 4/22/24 at 3:10 PM, the Director of Nursing (DON) reported she expected the nurses to document an assessment at least once a week and document it on the non-pressure skin forms. The DON added the nurses generally document all wounds on one sheet as they don't usually come across multiple burns very often. If a pressure ulcer, she expected one wound per sheet. She verified they didn't have any other assessments documented. They should have documented on Resident #2's wounds during the week of 3/24/24 through 3/30/24. The DON denied Resident #2 stayed in the hospital during that time. She is the facility wound nurse and couldn't explain the lack of documentation. After reviewing Resident #2's wound assessments, she verified the form didn't specify which wound it addressed. In an interview on 4/24/24 at 9:11 AM, Staff H, RN, reported when a resident has a wound, the nurse should document the assessments and measurements once a week, on paper form in the DON's office. Each wound should have its own sheet and would need to document measurements, color, drainage, odor or any granulation. The undated Skin Assessment policy directed the nurse to assess the resident's skin on day of admission and immediately implement a Care Plan for any resident at risk for pressure ulcers. Instruct nursing assistants to identify and report signs of breakdown such as a purple or dark area. Document the status of resident's skin weekly and PRN (as needed) 2. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #3 had an impairment to one side of their body. Resident #3 required substantial/maximal staff assist with showers/baths and repositioning, In addition, Resident #3 required total assistance from staff with toilet use, dressing, putting on and removing footwear, and personal hygiene. The MDS included diagnoses of cancer, hemiplegia (paralysis of one side of the body), and seizure disorder. The Health Status Note dated 12/2/23 at 1:21 PM indicated a CNA alerted the nurse of Resident #3 hunched over and jerking at the table. Resident #3 noted to be diaphoretic and pale, with stable vital signs. When assessed, Resident #3 didn't respond to verbal stimuli, but did respond to a sternal rub (rubbing on the chest bone to attempt arouse someone). The nurse spoke with the primary care physician (PCP) who gave an order for lorazepam (antianxiety medication) for seizure activity. The staff transferred Resident #3 into bed with the full-body mechanical lift and changed her brief. The Health Status Note dated 12/14/24 at 11:58 AM indicated the nurse went to Resident #3's room at 11:35 AM. Upon arrival, the nurse found Resident #3 sitting on the toilet unresponsive. The nurse noted Resident #3 with seizure-like activity for 10 seconds on the toilet and then became unresponsive again. The nurse called for another nurse for assistance. The Licensed Practical Nurse (LPN) assisted by administering 0.5 ml (milliliter) Ativan (lorazepam) as ordered at 11:37 AM. After ensuring Resident #3's safety they transferred her to the bed from the toilet. The staff placed Resident #3 lying down on her be with the head of the bed (HOB) elevated, call light within reach, and the bed in lowest position. The assessment revealed stable vital signs. The nurse notified the family and the nurse practitioner. The Incident Note dated 12/14/23 at 5:19 PM indicated the staff alerted the nurse of Resident #3 having seizure-like activity in the dining room at 5:07 PM. The staff took her to her room and gave her 0.5 ml of PRN Ativan at 5:09 PM. The nurse notified Resident #3's PCP about the seizure, who ordered to continue to monitor her and she would review her medications for any necessary adjustments. The nurses' notes included two assessments on 12/14/23 at 8:52 PM and 12/15/23 at 5:02 AM. Resident #3's clinical record lacked additional follow-up assessments. The Health Status Note dated 3/12/24 at 10:48 AM reflected upon arrival to Resident #3's room, she found her unresponsive on the bathroom toilet. She noted to have seizure like activity. The nurse administered her PRN lorazepam at 10:45 AM. The then safely transferred Resident #3 to bed from the toilet. They positioned her in bed lying down on her side with the HOB elevated. The nurse notified her PCP. The Health Status Note dated 3/13/24 at 8:10 PM indicated a CNA said Resident #3 didn't act normal, she turned herself sideways in the bed three times, she didn't appear to know the nurse. Due to the possible seizure activity, the nurse gave her PRN Ativan. Resident #3's clinical record lacked documentation from 3/13/24 at 8:10 PM until 3/21/24 at 2:21 PM. In an interview on 4/24/24 at 9:11 AM, Staff H reported after Resident #3 had a seizure, the nurse should document how long the seizure lasted, any vomiting, any incontinence, what led up to the seizure, and any signs of a possible infection. In an interview on 4/24/24 at 12:12 PM, the MDS Coordinator reported when a resident has a seizure, the nurse should she chart what they observed, how long the seizure lasted, level of consciousness, orientation, aura (visual or mental disturbances that signal a migraine or seizure), and if the resident could answer questions. In an interview on 4/24/24 at 1:26 PM, the Director of Nursing (DON) reported after a resident has a seizure, she expected the nurse to document the seizure activity, and follow the seizure policy. She didn't expect them to document the length of time the seizure occurred. Most of the time the nurse isn't always in the room when it starts, but she did expect them to document how long the seizure lasted while they were in the room. The Prolonged Seizure policy revised August 2022 instructed the nurse to assess the resident upon observation/notification of any seizure activity. If a nurse observes seizure lasting more than 2 minutes, give lorazepam 2 milligrams (mg) IM (shot into the muscles) unless contraindicated. A staff member will remain with the resident so nurse can notify the physician and family urgently. Repeat lorazepam 2 mg IM in 10 minutes after initial dose if resident continues to seize. The Nurse will notify the physician for further instructions and update the family. The policy failed to direct staff on what to document after seizure activity
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, family and staff interview and review of facility policies, the facility failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, family and staff interview and review of facility policies, the facility failed to ensure the safety of 2 of 8 residents reviewed (Resident #1 and #5). Resident #5 fell while transferring with a Certified Nurse Aide (CNA). The fall resulted in 3 fractured ribs and a hemothorax (a condition where blood collects in the pleural space, the hollow area between lungs and rib cage). In addition, the facility failed to determine the cause of Resident #1's a facial bruise. The facility reported a census of 51 residents. Findings included: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #5 required substantial/maximal staff assistance with showers and walking up to 50 feet. In addition, Resident #5 required total assistance from staff for toilet use, lower body dressing, and putting on and taking off footwear. The MDS included diagnoses of chronic congestive heart failure (impaired heart function that results in a fluid imbalance), renal insufficiency (impaired kidney function), urinary tract infection (UTI), diabetes mellitus, other fracture and chronic obstructive pulmonary disease (COPD). The Incident Report dated 2/1/24 at 3:40 PM reflected Resident #5 fell in her room while transferring with a CNA from her wheelchair to her recliner. The CNA lowered Resident #5 flat on the ground. The nurse assisted Resident #5 with the laceration on her lower left back. The area measured 5x1 (unknown measurement units). The nurse cleansed, applied steri strips, and covered the wound with bordered gauze. The Health Status Note dated 2/1/24 at 6:23 PM identified as Resident #5 transferred from her wheelchair to her recliner, she fell. The CNA lowered Resident #5 to lay flat on the ground. The nurse assessed Resident #5 and found a laceration on her lower left back, measuring 5x1 (unknown measurement units). The nurse cleaned, steri-stripped, and covered the area with a bordered gauze. Two staff members assisted Resident #5 up and transferred her to the recliner. The nurse notified her primary care provider (PCP) and family. The Health Status Note dated 2/2/24 at 9:14 AM described the assessment as a fall assessment due to her fall on 2/1/24 at 3:40 PM. The note indicated while assisting Resident #5 from the wheelchair to her recliner, the CNA noticed her beginning to fall and promptly lowered her to the floor. Resident #5 sustained a laceration on her lower back. Her last fall occurred on 6/9/23, and she saw her PCP on 1/23/24 with no new orders issued. Resident #5 experienced hallucinations and had a scheduled appointment with psychiatry for 2/9/24. She required the assistance of two staff members for pivot transfers and enrolled in a restorative program. The details are available in the progress notes. Resident #5 last received acetaminophen (mild pain reliever) as needed (PRN) dose medication on 2/1/24 at 2:12 AM. The pharmacy reviewed her chart on 1/2/24 and requested psychiatry notes. Psychiatry services evaluated Resident #5 on 1/12/24. She wore gripper socks with a blood glucose level of 118. Her BIMS score was 15 on 12/10/23, which remained unchanged from her previous score on 9/26/23, indicating intact cognition. The facility implemented a fall intervention plan to ensure to properly position the wheelchair next to the recliner during transfers. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. Resident #5 required substantial/maximal staff assistance with showers and walking up to 50 feet. In addition, Resident #5 required total assistance from staff for toilet use, lower body dressing, and putting on and taking off footwear. The MDS included diagnoses of chronic congestive heart failure, renal insufficiency (kidney failure), and diabetes mellitus. The Incident Report dated 2/29/24 at 6:15 AM identified Resident #5 fell. Upon enter Resident #5's room, she found her lying on the floor on her left side. Resident #5 complained of left rib pain and had a laceration on left cheek that measured 4x0.5 (unknown measurement units). The staff transferred Resident #5 with an assist of two and a full-body mechanical lift. Resident #5 stated both her legs gave out while transferring with the staff to wheelchair. The Health Status Note dated 2/29/24 at 10:36 AM reflected a CNA called the nurse to Resident #5's room. Upon entering, the nurse found Resident #5 lying on her left side on the floor. Resident #5 complained of left rib pain and had a laceration on left cheek that measured 4x0.5 (unknown measurement units). The staff transferred Resident #5 to bed with an assist of 2 staff and a full-body mechanical lift. She said as she transferred with a staff member to her wheelchair, her legs gave out. Resident #5's vital signs reflected abnormal results for her blood pressure of 86/51 (average 120/80) and oxygen saturation of 76% (average greater than 90%) on room air (RA). The Nurse contacted Resident #5's PCP who gave the following orders: 1) X-ray of left rib with posterior chest and left facial bone 3 views. 2) Hold Bumex (diuretic to remove excess fluids) that day. 3) Push fluids that day. The facility contacted the portable x-ray company who completed the ordered x-rays. The Health Status Note dated 2/29/24 at 5:11 PM identified Resident #5's X ray results. The results reflected a mildly displaced left eighth rib fracture. The facial bones x ray results revealed no displaced maxillofacial fracture. The facility faxed a copy of the results her PCP. 3/11/24 at 3:19 PM the staff called the nurse to Resident #5's room due to her complaints of left-sided chest pain. Resident #5 said her pain went from her left breast and radiated up to her neck. The staff called the PCP, who gave orders to send to the emergency department (ED) for further evaluation. The facility notified her son and transferred Resident #5 by ambulance at 3:33 PM to the ED. The Hospital History and Physical dated 3/11/24 indicated Resident #5 presented to the ED with complaints of severe left chest pain radiating to her left jaw. She fell at the nursing home approximately one week before. She reported hitting her head. She explained she had 3 falls in February where the nursing assistants didn't properly hold her wheelchair in place when she went to sit down. The workup in the ED showed a CT angiogram revealing fractures to her left 7th through 10th ribs with associated large pleural effusion that appeared as a mixture of blood and fluid. The ED contacted the Cardiothoracic surgery for a consult, who inserted a chest tube (tube inserted into the chest to drain air, fluid, or blood that could cause the lung to collapse or affect the heart or esophagus) on 3/12/24. The hospital removed the chest tube on 3/21/24. The admission summary dated [DATE] at 12:50 PM reflected Resident #5 arrived from the hospital after she had a fall resulting in multiple rib fractures on her left side which caused a hemothorax on the left. Resident #5 required a chest tube while in the hospital. The Incident Report dated 3/25/24 at 6:15 PM directed to read the attached progress note dated 3/25/24 labeled Incident Note. Upon entering the room, the nurse observed Resident #5 lying on her left side in front of recliner with her head partially under the bed, on top of the tray table (broken during fall). The nurse noted the recliner completely elevated, which caused her fall. Resident reported she had the controller under her. When it started going up, she couldn't reach it to stop it. The recliner went all the way up, causing her to fall out of the recliner on to her left side, landing on the tray table and falling to the ground. When she fell she hit the left side of her face on the table. The Health Status Note dated 3/26/24 at 2:26 PM reflected the facility called the ambulance at 1:52 PM. Resident #5 went to the hospital at 2:24 PM by ambulance. The Health Status Note dated 3/26/24 at 9:17 PM indicated Resident #5 returned from the hospital by ambulance. She complained of shoulder pain of 7, indicating moderate pain. The nurse gave her Dilaudid. The Incident Note dated 3/29/24 at 6:23 PM documented a CNA called the nurse to Resident #5's room at 6:03 PM because they found her on the floor. Upon entering the room, the nurse found Resident #5 on the floor in front of the recliner. When asked how she got on the floor, she replied while looking for her lift chair remote, she pushed her tray table away from her, and she slid out of the chair. She denied pain or injury. The staff assisted back to her chair. On 4/17/24 at 2:00 PM observed Resident #5 sitting in her recliner in her room. She wore an oxygen (O2) nasal cannula with continuous oxygen flow maintained at 3 liters per concentrator. She had even and unlabored respirations. Resident #5 reported the staff used the lift lately to transfer her from the bed to her recliner. When they transfer her with the lift, her knees will hit the lift and this is where she has a lot of pain. This happens every time they used the lift on her. In addition, she reported other times they forgot to lock the wheelchair when they transferred her, resulting in her falling before she sits down. On 4/22/24 at 10:30 AM witnessed Resident #5 sitting in her recliner with eyes closed, feet elevated, wearing continuous O2 maintained at 2.5 liters per nasal cannula per concentrator. She had even and unlabored respirations. She looked properly positioned and appeared comfortable. In an interview on 4/24/24 at 11:22 AM Staff F, CNA, reported she transferred Resident #5 from her bed to her wheelchair when she fell on 2/29/24. She couldn't recall if she had a gait belt on Resident #5 or not. Staff F thought Resident #5 needed to have a gait belt on with transfers. As Resident #5 tried to sit in her wheelchair, she didn't catch the wheelchair and fell forward. Resident #5's face hit the oxygen concentrator first then the trash can. Staff F explained she couldn't stop her from falling. She went to the hospital, but not that same day. After she went to the hospital, she had a few rib fractures. The day Resident #5 fell, Staff F didn't know she had a history of falls. Staff F was not sure, if it would've been on the Care Plan with all the falls she had, however, someone should have written it in the communication book on each shift. In an interview on 4/24/24 at 9:36 AM, Staff G, CNA, reported when she arrived to work on 2/29/24, she heard over the two-way radio that there was a resident on the floor. She went to Resident #5's room and Staff F, CNA was in the room with her. Resident #5 was laying on the floor by her recliner, bleeding from a laceration to her left cheek. She said you need to kick Staff F's a__ because she felt it was her fault that she fell to the floor. Staff F said she went to pivot Resident #5 to her wheelchair when Resident #5 leaned forward and hit her face on the trash can. Staff G explained Staff F didn't have the gait belt around Resident #5 as the Care Plan directed to transfer her using a gait belt. When asked if Resident #5 had a history of falls prior to that fall, Staff G responded she had one on 2nd shift. Resident #5 told her, she only fell because the staff person didn't pay attention and didn't lock her wheelchair. In an interview on 4/24/24 at 9:11 AM, Staff H, RN reported on 2/29/24, the aides reported that Resident #5's legs got weak and she fell. One aide transferred her with a gait belt from her recliner to the wheelchair when her legs buckled. Staff H wasn't in the room when Resident #5 fell and when she arrived to the room, she witnessed Resident #5 lying face down next to the bed. She hit her face on the trash can. She did have some bleeding from a laceration to her cheek it measured about 4 cm (centimeters) by 1 cm. She had good range of motion to both arms and legs. She complained of left rib pain. Resident #5 appeared pretty upset with a facial grimace of pain The Care Plan directed to transfer her with an assist of one using a gait belt. She now required two to assist, using the gait belt, and a pivot transfer. Staff H reported Resident #5 had more falls after that fall. She would accidentally hit the wrong button on her recliner (mechanical lift chair) and dump herself out of the chair. They would take the remote and put it in the side pocket so she can't use it without the staff there. Resident #5 did not go to the hospital that day as the portable x-ray company did x rays and they found a fracture to her eighth left rib. A couple of weeks later, Resident #5 complained of chest pain. She does have a cardiac history, so they sent her to the hospital. She was gone for a couple of weeks with a hemothorax and required a chest tube. In an interview on 4/24/24 at 1:26 PM, the DON (Director of Nursing) reported the cause of Resident #5's falls, one of them was because she had a UTI. Resident #5 recently had a fall when Biotech found an 8th rib fracture and a laceration to her face. She went to the hospital a few weeks later when she complained of an onset of acute chest pain that radiated to her neck, she does have a cardiac history. On 4/25/24 at 8:12 AM, Resident #5 reported the following as she sat up in bed without oxygen on, respirations even and unlabored, properly positioned and appeared comfortable. In an interview on 4/29/24 at 9:51 AM, Staff F, CNA, reported when she came to work on 2/29/24, she worked as the only aide in the South hall and took care of 16 residents from 6:00 AM to 6:30 AM. As she got Resident #5 out of bed and into the wheelchair, she put a gait belt around her. When she went to fall forward, I went to grab her and she just had a hospital gown on. If she didn't have a gait belt on, Staff F wouldn't have had anything to grab. When she fell, Staff F explained she called the nurse on the 2-way radio and said she had a resident on the floor. Staff F removed the gait belt because she knew Resident #5 needed transferred with the full-body mechanical lift. In a follow-up interview on 4/29/24 at 11:01 AM, Staff H reported when Resident #5 fell on 2/29/24, she had Staff F in the room with her. Staff H added Staff F did have a gait belt around Resident #5. In a follow-up interview on 4/29/24 at 12:07 PM, Staff G reported after Resident #5 fell, and she arrived to the room, Resident #5 did not have a gait belt on her. In an interview on 5/1/24 at 10:20 AM, the Administrator reported the facility did not have a policy on fall prevention. 2. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety disorder and unspecified atrial fibrillation (an abnormal heart rhythm). Resident #1 required substantial/maximal assistance with oral hygiene, toilet use, and showers. Resident #1 required total assistance from staff for lower body dressing, putting on and taking off footwear. The Care Plan Focus revised 4/16/24 identified Resident #1 had a problem of impaired cognitive function related to dementia and forgetfulness. The Interventions directed the following: a. Monitor for safety and gait stability. b. Monitor for safety as she may need redirection. The Health Status Note dated 4/15/24 at 9:38 PM reflected the CNA notified the nurse of a raised bruise to left side of forehead. Upon assessment, the nurse noted a 3 cm (centimeter) by 3 cm raised yellowish purple bruise. The Incident Report dated 4/15/24 at 9:40 PM identified Resident #1 with a yellowish purple raised bruise that measured 3 cm (centimeters) by 3 cm to the left side of her forehead. Resident #1 didn't show signs/symptoms of pain. On 4/17/24 at 1:48 PM witnessed Resident #1 asleep in her recliner with feet elevated, wearing eyeglasses, clean clothing, and nonskid shoes. She looked properly positioned and appeared comfortable. She had a bruise to the left side of forehead above her eyebrow which appeared approximately 2 inches in diameter, yellowish and purple in color. Resident did not respond when asked how she bruised her forehead. On 4/18/24 at 8:40 AM observed Resident #1 sitting in her wheelchair in her room, wearing eyeglasses, clean clothing and nonskid shoes. She looked properly positioned and comfortable with both feet on the foot pedals. Her forehead still had a fading bruise above her left eyebrow, yellowish purple in color and approximately 1½ inches in diameter. In an interview on 4/18/24 at 2:10 PM, Staff B, CNA reported she thought Resident #1 got the bruise last weekend which was my weekend off (April 13 and 14). When Staff B saw her before her weekend off on Friday the 12th, she did not have a bruise. The Health Status Note dated 4/19/24 at 4:23 PM indicated Resident #1's 3 cm by 3 cm bruise remained on her forehead. She had no pain. The bruise looked yellow and light blue. On 4/22/24 at 10:36 AM watched Resident #1 sit in her wheelchair in the South Hall Family Room. She wore clean clothing, eyeglasses, and gripper socks. Both feet sat on foot pedals of wheelchair and she sat on a pressure reducing cushion. The bruise remained above her left eyebrow but appeared as a fading yellowish and light purple in color. The Health Status Note dated 4/22/24 at 1:39 PM described Resident #1's bruise on the left side of her forehead as yellow in color with no drainage noted. The area measured 3 cm by 3 cm. In an interview on 4/22/24 at 1:59 PM, the Assistant Director of Nursing (ADON) denied knowing about Resident #1's bruise until the previous week. She expected the staff to report it as soon as they saw it. By the time she learned of the bruise, it already turned yellow. When she interviewed the staff, no one seemed to know how or when it happened. In an interview on 4/22/24 at 3:10 PM, the DON reported she expected her staff to report bruises such as Resident #1's as soon as they first see it. By the time they reported it on 4/15/24 the bruise already turned yellow and purple. She reported the nurse who cared for Resident #1 over the weekend didn't report it to her. In an interview on 4/24/24 at 9:36 AM, Staff G reported when she came in that Monday, 4/15/24 she noticed the bruise on top of Resident #1's left forehead. The bruise's size looked a little bigger than a half dollar coin and purple. No one seemed to know what caused the bruise. Resident #1 didn't talk much and didn't respond when staff asked her what happened. The Health Status Note dated 4/26/24 at 2:22 PM bruise to left side of Resident #1's forehead healed. The Care Plan review completed on 4/25/24 revealed it failed to address the bruise of unknown origin identified on 4/15/24. The undated Skin Assessment policy directed the nurse to assess the resident's skin on day of admission and immediately implement a Care Plan for any resident at risk for pressure ulcers. Instruct nursing assistants to identify and report signs of breakdown such as a purple or dark area. Document the status of resident's skin weekly and PRN (as needed)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, resident, family, and staff interview, the facility failed to treat two ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, resident, family, and staff interview, the facility failed to treat two of eight residents reviewed with dignity and respect (Residents #1 and #5). The facility reported a census of 51 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety disorder and unspecified atrial fibrillation (an abnormal heart rhythm). Resident #1 required substantial/maximal assistance with oral hygiene, toilet use, and showers. Resident #1 required total assistance from staff for lower body dressing, putting on and taking off footwear. The Care Plan Focus revised 4/16/24 identified Resident #1 had a problem of impaired cognitive function related to dementia and forgetfulness. The Health Status Note dated 4/15/24 at 9:38 PM indicated a certified nurse aide (CNA) notified the nurse Resident #1 had a raised bruise to the left side of her forehead. Upon assessment, the nurse noted Resident #1 had a 3-centimeter (cm) x 3 cm raised yellowish-purple bruise. Resident #1 appeared alert per baseline and showed no signs or symptoms of discomfort. The Health Status Note dated 4/15/24 at 9:47 PM reflected the staff reported Resident #1 often laid in bed on her left side against the wall. The nurse put an intervention in place to place a pillow against the wall. On 4/17/24 at 1:48 PM observed Resident #1 asleep in her recliner with her feet elevated, properly positioned, and appeared comfortable. When she woke up, observed a bruise on the left side of her forehead (above her eyebrow). The bruise appeared yellowish-purple in color and approximately 2 inches in diameter. When asked how she bruised her forehead, Resident #1 did not answer. On 4/18/24 at 8:40 AM, witnessed Resident #1 sitting in her wheelchair in her room, properly positioned and appeared comfortable with both feet on the foot pedals. She had a fading bruise above her left eyebrow, that appeared yellowish-purple in color and looked approximately 1 ½ inches in diameter. In an interview on 4/17/24 at 1:48 PM, Resident #7 reported she lived at the facility for over a year as Resident #1's roommate. She overheard staff talking to her and treating her roughly for as long as she lived there. Resident #7 overheard Resident #1 yelling ow, ow, ow! After Resident #1 yelled, the aides said don't hit me and I won't hit you The other day when they got her up, Resident #7 told the aide she needed to comb Resident #1's hair and the aide replied Why? No one will care. 2. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #5 required substantial/maximal staff assistance with showers and walking up to 50 feet. In addition, Resident #5 required total assistance from staff for toilet use, lower body dressing, and putting on and taking off footwear. The MDS included diagnoses of chronic congestive heart failure (impaired heart function that results in a fluid imbalance), renal insufficiency (impaired kidney function), urinary tract infection (UTI), diabetes mellitus, other fracture and chronic obstructive pulmonary disease (COPD). In an interview on 4/17/24 at 2:00 PM, Resident #5 reported some of the staff (she was afraid to mention names and feared retaliation) felt she wet her pants on purpose. She said she couldn't help it because she took Bumex. They have told her there are other people that take that and they don't wet as much as you do. Resident #5 explained the aides complained about her urinating a lot. She told them 3 days ago that she had a UTI, as they didn't clean her very well. The Care Plan Focus revised 12/10/23 identified Resident #5 used diuretic therapy (medication to help remove excess fluid) related to hypertension (high blood pressure) and heart failure. The Interventions directed the staff to: a. Administer diuretic medications as ordered by physician. b. Monitor for side effects and effectiveness. c. Monitor/document/report PRN (as needed) adverse reactions to diuretic therapy: dizziness, postural hypotension, fatigue, and an increased risk for falls. Resident #5's Urine Culture Test Results from 12/12/23 to 4/20/24 reflected the following results: a. 12/12/23: 100,000 cFu (colony forming units) of Escherichia Coli (E. Coli bacteria normally found in stool). b. 3/2/24: 100,000 cFu of E. Coli c. 4/20/24: 10,000 to 50,000 cFu E. Coli In an interview on 4/22/24 10:15 AM, Resident #7 reported she overheard Staff J, Certified Nurse Aide (CNA), tell a resident across the hall about Resident #5 being lazy, fat and disgusting. She added Resident #5 pushed her button all the time to use the bathroom. She called Resident #5 a b_ch. She heard the aides yelling at Resident #5 God damn it, you're wet all the time. You're a f___g b__ch for hitting my daughter. Resident #7 reported this to the Administrator and the Director of Nursing (DON), who reported they already knew about it. Their solution was to remove the three CNAs from working the hallway and make them work on the other 2 halls. In an interview on 4/24/24 at 11:06 AM, Resident #5's family member reported he didn't like the way they let Resident #5 urinate in her pants instead of taking her to the bathroom. They make her sit in her pants, telling her it wasn't time to take her to the bathroom. She takes a pill that makes her urinate a lot. She said they do not clean her very well down there and she always has a UTI (Urinary Tract Infection). She said that it is degrading to her and it's very embarrassing. She'll call to say she went in her pants again and had her call light on for at least half an hour. This happens several times a week. In an interview on 4/24/24 at 1:26 PM, the DON reported she expected staff to toilet residents after meals, before bed, and as needed (PRN). If a resident called to have their incontinent briefs changed, she expected staff to change the briefs as soon as possible. When informed what Resident #5 reported the staff said to her earlier and what Resident #7 had reported, the DON reported that is absolutely unacceptable for staff to speak to residents in that manner. The Administrator reported the facility didn't have a policy on dignity, however, they provided the Resident's [NAME] of Rights which indicated: the resident has the right to dignified existence and the facility must treat the resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to update Care Plans for th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to update Care Plans for three of eight residents reviewed. (Residents #1, #2, and #4). The facility failed to update the residents Care Plans after the staff discovered Resident #1 had an injury of unknown origin. After Resident #2 sustained burns to her thighs after she spilled coffee on her lap. Then after Resident #4 had a choking episode which required the Heimlich maneuver (first-aid treatment used to try to remove a blockage from someone's airway). The facility reported a census of 51 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. Resident #1 required substantial/maximal assistance with oral hygiene, toilet use, and showers. Resident #1 required total assistance from staff for lower body dressing, putting on and taking off footwear. The MDS included diagnoses of Alzheimer's disease, anxiety disorder and unspecified atrial fibrillation (an abnormal heart rhythm). The Health Status Note dated 4/15/24 at 9:38 PM indicated a certified nurse aide (CNA) notified the nurse Resident #1 had a raised bruise to the left side of her forehead. Upon assessment, the nurse noted Resident #1 had a 3-centimeter (cm) x 3 cm raised yellowish-purple bruise. Resident #1 appeared alert per baseline and showed no signs or symptoms of discomfort. The Incident Report dated 4/15/24 at 9:40 PM indicated Resident #1 had a yellowish purple bruise that measured 3 cm by 3 cm to the left side of her forehead. Resident #1 didn't show signs or symptoms of pain. The Health Status Note dated 4/15/24 at 9:47 PM reflected the staff reported Resident #1 often laid in bed on her left side against the wall. The nurse put an intervention in place to place a pillow against the wall. On 4/17/24 at 1:48 PM observed Resident #1 asleep in her recliner with her feet elevated, properly positioned, and appeared comfortable. When she woke up, observed a bruise on the left side of her forehead (above her eyebrow). The bruise appeared yellowish-purple in color and approximately 2 inches in diameter. When asked how she bruised her forehead, Resident #1 did not answer. On 4/18/24 at 8:40 AM, witnessed Resident #1 sitting in her wheelchair in her room, properly positioned and appeared comfortable with both feet on the foot pedals. She had a fading bruise above her left eyebrow, that appeared yellowish-purple in color and looked approximately 1 ½ inches in diameter. The linked Health Status Note dated 4/19/24 at 4:23 PM indicated Resident #1 continued to have a 3 by 3 cm bruise on her forehead, that looked yellow and light blue. On 4/22/24 at 10:36 AM witnessed Resident #1 sitting in her wheelchair in the South Hall Family Room. She wore clean clothing, eyeglasses, and gripper socks. She had both of her feet on the foot pedals of wheelchair. The wheelchair contained a pressure reducing cushion on the seat. The bruise above her left eyebrow remained and looked faded yellow and light purple in color. The Health Status Note dated 4/22/24 at 1:39 PM identified Resident #1's bruise on the left side of her forehead looked yellow in color with no drainage noted. The area measured 3 cm by 3 cm and she didn't show signs of pain at the time. The Health Status Note dated 4/26/24 at 2:22 PM reflected Resident #1's bruise healed on the left side of her forehead. Resident #1's Care Plan reviewed on 4/30/24 lacked injury of unknown origin (bruise to her forehead) identified on 4/15/24. 2. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. Resident #2 required substantial/maximal staff assistance with toilet use and lower body dressing. Resident #2 required total staff assistance with putting on and removing footwear. The MDS included diagnoses of chronic congestive heart failure, renal insufficiency (kidney failure) and diabetes mellitus. On 4/18/24 at 8:28 AM observed Resident #2 sitting up in wheelchair in the family room by the north dining room, wearing clean clothing with blanket on her lap covering both feet resting on the floor. She looked properly positioned and comfortable. On 4/18/24 at 11:10 AM Resident #2 continued sitting in the recliner in her room with both feet elevated. She still looked properly positioned and comfortable. When asked about the incident with the coffee spill, she reported being careless. When she took the lid off the coffee cup, she spilled the coffee on her lap, burning herself. She added she went to the wound clinic once a week. In an interview on 4/22/24 at 1:59 PM, the Assistant Director of Nursing (ADON) reported after Resident #2's accident with the coffee, she expected the Care Plan updated within 24 hours to 48 hours. The ADON reported the MDS coordinator is responsible for updating the Care Plans. In an interview on 4/22/24 at 3:10 PM, the Director of Nursing (DON) reported she expected the Care Plan updated as soon as possible after the incident occurred, within 48 hours. She described the MDS coordinator as the person responsible for updating the Care Plans. She added Staff K, Licensed Practical Nurse (LPN) could also assist with Care Plans. In an interview on 4/22/24 at 3:55 PM, Staff E, CNA, reported after Resident #2 burned herself by spilling her coffee on her lap, she didn't know the new interventions added to her Care Plan. On 4/23/24 at 10:57 AM observed Staff C, Registered Nurse (RN), complete Resident #2's wound care. Staff C measured the wound to the left thigh as 5.2 cm long by 3.0 cm wide, before applying a dressing. Then Staff C measured wound to right thigh as 3.6 cm long by 1.3 cm wide, before applying a dressing. The wounds appeared to be healing with a small amount of serous (clear to yellow wound drainage) drainage. The wound had no signs of infection to wound bed or surrounding skin. In an interview on 4/24/24 at 12:12 PM, the MDS Coordinator reported she receives information on changes on the residents' conditions on a daily basis in the morning meetings and when she makes observations on the residents. The administrative staff participate in Medicare meetings every Thursday to discuss changes on the residents. When a resident has a change, such as a new burn to the skin, she explained the Care Plan should address it within 24 to 48 hours. She also reported she was not informed of Resident #2's burns until 3/28/24 and she added the intervention of keeping the lid on coffee cups that day. She admitted she forgot to address the burns on the Care Plan until 4/23/24, after the surveyor's inquiry. In an interview on 4/24/24 at 1:26 PM, the DON remarked the floor nurses didn't usually update the Care Plan. The MDS Coordinator did it, but the DON could also update the Care Plan. They review the Care plans as needed, such as, when therapy makes updates. They review the long-term care residents quarterly. 3. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 2, indicating severely impaired cognition. Resident #4 required total assistance from staff for all activities of daily living (ADLs). The MDS included diagnoses of renal insufficiency (kidney failure), non-Alzheimer's dementia and anxiety disorder. Resident #4 received a mechanically altered diet. The Incident Note dated 1/2/24 at 8:11 AM identified a CNA informed the nurse they did the Heimlich on Resident #4 after she choked on a banana. The CNA told the nurse no CNAs on that hall had a 2-way radio to call the nurse. The assessment revealed clear lungs bilaterally with stable vital signs. On 4/18/24 at 11:51 AM watched Staff L, CNA, sit beside Resident #4 in the North dining room and assisted her with her meal. No episodes of Resident #4 choking occurred. An additional observation on 4/23/24 at 5:15 PM witnessed Staff I, CNA, help Resident #4 eat without any choking episodes. The Care Plan Focus revised 2/6/24 identified Resident #4 had a potential altered nutritional status due to her poor cognition as she required assistance with intake. The Care Plan directed the staff to serve her diet as ordered (pureed). Then offer substitutes for foods she didn't like or eat. The Care Plan lacked her choking episode from 1/2/24 which required the Heimlich maneuver. The undated Care Plans policy described the facility's policy as to initiate and update Care Plans as needed for each resident. The policy directed to update Care Plans within 72 hours of a significant change in condition.
Dec 2023 1 deficiency 1 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0760 (Tag F0760)

A resident was harmed · This affected 1 resident

Based on clinical record review, staff, resident, and Advanced Registered Nurse Practitioner (ARNP) interviews, and facility policy review, the facility failed to administer the correct medication to ...

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Based on clinical record review, staff, resident, and Advanced Registered Nurse Practitioner (ARNP) interviews, and facility policy review, the facility failed to administer the correct medication to 1 out of 7 residents reviewed, when a resident received another resident's medication in error (Resident #1). The facility reported a census of 48 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident #1, dated 10/25/23, listed diagnoses of Atrial Fibrillation (Afib), coronary artery disease (CAD), heart failure, and hypertension (high blood pressure). The MDS reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The Care Plan for Resident # 1 dated 11/2/2023, identified altered cardiovascular status related to congestive heart failure and Atrial fibrillation. The Care Plan reflected interventions to include: a. Monitor for shortness of breath (SOB) and report if needed. b. Monitor vital signs per facility protocol. Notify Physician of significant abnormalities. c. Monitor/document/report needed any signs or symptoms of CAD: chest pain or pressure especially with activity, heartburn, nausea, vomiting, SOB, excessive sweating, dependent edema, changes in capillary refill, color/warmth of extremities. The Care Plan further identified Resident #1 took a blood thinning medication to treat the Afib. The Care Plan directed the staff to administer the anticoagulant as ordered by the physician, monitor for signs and symptoms of bleeding. The Progress Note dated 11/28/23 at 12:29 p.m., revealed the nurse gave the wrong to medication to Resident #1 at breakfast. The note identified the medications of Resident #2 were given to Resident #1 instead of his own medication. The Progress note reflected the error immediately reported to the Assistant Director of Nursing (ADON) who revealed the Advanced Registered Nurse Practitioner (ARNP) planned an onsite visit. The note described the ADON directed the nurse to obtain baseline vitals. Resident #1's vitals obtained at 7:15 a.m., blood pressure (BP)145/79, heart rate (Hr)111, temperature (T) 98, respirations (R) 16, oxygen saturation (O2 Sat) 95%. The note identified Resident #1 vomited and complained of chest pain at five out of 10 on pain scale and then denied any pain. The Progress note included vitals of BP 81/51, Hr 69, O2 Sat 92% the ARNP and the family of resident in the resident room decided to send him to the hospital for the low BP. The staff alerted 911 at 9:39 a.m., the note revealed the ambulance staff directed the facility to call poison control. The list of Resident #2's medications Staff A, Registered Nurse (RN), administered to Resident #1 included: a. Cymbalta 90 milligrams (mg), for depression. b. Eliquis 2.5 mg, blood thinner. c. Famotidine 40 mg, prevent heartburn. d. Hydrocodone/acetaminophen 5-325 mg 2 tablets narcotic for pain. e. Lidocaine patch 4% topical to back right and left hip, for pain. f. Lisinopril 10 mg, for high BP. g. Metoprolol 12.5 mg, for high BP. h. Prilosec 40 mg, treats heartburn. i. Miralax 17 Grams, for constipation. j. Senna-plus 8.6-50 mg, for constipation. k. Solifenacin 5 mg, for bladder spasm. l. Tizandine 4 mg, muscle relaxer. m. Valacyclovir 500 mg, for antiviral. n. Buspirone 1 mg for anxiety. Review of Resident #1's November 2023 Medication Administration Record (MAR) showed the resident identified with further diagnoses including constipation, chronic pain, Benign Prostatic Hypertrophy (BPH which affects bladder function) and prescribed similar medications as Resident #2 for high blood pressure, blood thinner, pain, constipation, and bladder control. The Nurse Practitioner's note dated 11/28/23, confirmed Resident #1 hypotensive (low BP) as a result that he received another resident's medication that were not prescribed to him that included Hydrocodone, Cymbalta, Lisinopril, Eliquis among others she thought it best the resident went to the emergency room (ER) for evaluation and management. On 12/5/23 at 12:20 p.m., the ARNP stated clinically Resident # 1 looked well, alert and at his baseline at the time of her visit on 11/28/23. She confirmed the reason she sent him to the hospital due to the low BP. On 12/6/23 at 11:41 a.m., Staff A, Registered Nurse (RN) reported she passed Resident #2's medications to Resident #1. Staff A reported she knew the first name of resident #1, but both residents had the same first name. She stated as she explained the inhalation medication she planned to administer next, Resident #1 told her that's not one of his medications. She realized at that moment she made a mistake and immediately went and reported the incident to the ADON. On 12/6/23 at 10:19 a.m., the ADON stated on 11/28/23 the same day the ARNP scheduled here. The Staff A, went to her and reported she gave Resident #1 Resident #2's medications. The ADON stated she told her to take baseline set of vitals and repeat every 30-45 minutes. The ADON said the ARNP planned to visit the facility that day and she could tell her about the medication error. The ADON revealed at 8:50 a.m., Resident #1's BP dropped and she called the ARNP the ARNP was there in 10 minutes. The ADON said the family sat with Resident #1. The ADON stated the Medication Administration Records held pictures of each resident and the dining room seating chart were current. On 12/7/23 at 11:12 a.m., Resident #1 reported he failed to remember the nurse or the morning he got the wrong medications. He knew they sent him to the hospital because of low blood pressure. He reported he felt worse the next day light headed and dizzy. The undated Medication Error Procedure directed Nursing Staff, upon recognition of the error the following to be done: a. Obtain a full set of Vitals and start an Incident Report (IR). b. Contact the Doctor (Dr), the Director of Nursing (DON), or ADON, and Resident Representative. c. Monitor condition and notify the DON or ADON & Dr if any noted changes. d. Follow the Doctor Orders. The facility provided an undated Nurses Annual Competencies included a Procedure Routine Medication, noted to ensure to use the 5 RIGHTS when administering all medications: 1. Right route. 2. Right dose. 3. Right time. 4. Right Resident. 5. Right medication.
Jun 2023 5 deficiencies 1 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Based on clinical record review, observation, staff interviews and facility policy review the facility failed to implement interventions to prevent the development of a pressure ulcer for a resident i...

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Based on clinical record review, observation, staff interviews and facility policy review the facility failed to implement interventions to prevent the development of a pressure ulcer for a resident identified at risk for the development of pressure ulcers and failed to perform hand hygiene during wound care for one out of one resident reviewed for pressure ulcers (Resident #8). The facility reported a census of 44 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - An intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II - A Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Minimum Data Set (MDS) Assessment for Resident #8, Dated 4/13/23, included diagnoses of non- Alzheimer's dementia, malnutrition, and altered mental status. The MDS documented Resident #8 required extensive assist of 2 staff for bed mobility, transfers and toileting. The MDS revealed Resident #8 lacked pressure ulcers/wounds at the time of the MDS, and identified her at risk for pressure ulcers. The MDS included a list of options for skin and ulcer/injury treatments to include: a. Pressure reducing device for chair. b. Pressure reducing device for the bed. c. Turing/repositioning program. d. Nutrition or hydration intervention. e. Pressure ulcer/injury care. f. Surgical wound care. g. Application of non-surgical dressings. h. Application of ointments/medication. i. Application of dressing to feet. z. None of the above. The MDS identified None of the above marked. The MDS reflected Resident #8's weight as 138 pounds. The MDS showed a Brief Interview for Mental Status (BIMS) score of 00, (sever impaired cognition). The Care Plan (CP) for Resident #8 dated 5/6/2023, identified a goal for skin will be free of breakdown related to incontinence. The CP listed intervention that failed to include pressure reducing devices. The Care Area Assessment (CAA) dated 4/14/23, identified Pressure Ulcer/Injury triggered related to the extensive assist needed for bed mobility, frequent urinary incontinence and Resident #8 at risk for developing pressure ulcers. The CAA revealed the facility failed to address the risk of pressure wounds in the Care Plan. The Braden Scale (a tool utilized to assess potential to develop pressure ulcers) dated 4/3/23, reflected a score of 17 (15-18 Mild Risk). The Matrix 802 provided by the facility on 6/26/23, identified Resident #8 developed a facility acquired (FA) Stage (St) II pressure ulcer. The facility failed to complete addition Braden's Scales with the condition change. The Skin/Wound Note dated 6/6/2023 at 4:21 PM, identified Resident #8 presented with a Stage II open area on buttocks 2.3 Centimeters (cm) by 0.9 cm by 0.1 cm deep. No drainage from the wound. The surrounding skin appeared pink. The wound bed contained granulation tissue (collagen rich tissue forming at the site of an injury) and slough (combination of leucocytes, bacteria, dead and living cells). The Physician's Ordered fax dated 6/6/23, showed a Stage II open area on buttock 2.3 cm by 0.9 cm by 0.1 cm, alternation pressure mattress on bed, Roho cushion, significant weight loss. Treatment: Alginate calcium cover with proximal 4 inch by 4 inch bordered dressing every day until healed. The Treatment Administration Record dated 6/6/2023, directed: apply Melgisorb calcium alginate (AG) (highly absorbent antimicrobial) to wound and cover with 4 inch by 4 inch silicone bordered dressing daily until healed. The Weights Summary dated 6/29/23, showed an admission weight of 137.8 pounds on 4/3/23. The weight recorded on 04/20/2023, the resident weighed 137.4 lbs. On 05/16/2023, the resident weighed 123.2 pounds which is a -10.33 % Loss. On 6/28/23 at 8:19 AM, Staff B, Licensed Practical Nurse (LPN) and Staff C, LPN preformed hand hygiene and applied gloves. Staff C, assisted Staff B to position Resident #8 for wound care. At 8:26 AM, Staff B, removed the old dressing from Resident #8's left buttock. The dressing appeared 25 % covered in dark colored drainage. Staff B, put the dressing in the trash. The wound bed appeared 100% yellow slough. Staff B, sprayed the wound with wound cleaner and used 4 inch (in) by 4 in gauze pad to wipe the wound. Staff B, removed her gloves and failed to perform hand hygiene before she put on another pair. At 8:27 AM, Staff B placed the ordered treatment on the pressure wound. On 6/27/23 at 5:15 PM, Staff D, Certified Nurses Aid, (CNA) stated Resident #8 complains of some pain to her bottom after we get her in bed at night. On 6/28/23 at 8:14 AM, Staff B, LPN, reported the wound on Resident #8's buttock is from pressure. Staff B, revealed the facility failed to reposition Resident #8 frequently and failed to utilize pressure reducing devices. On 6/29/23 at 8:29 AM, the Administrator revealed Resident #8 entered the facility on Hospice Care and then went on Skilled Level of Care. On 6/29/23 at 12:23 PM, the Director of Nursing, (DON) reported Resident #8's significant weight loss contributed to the development of her pressure area. The DON stated the resident wasn't much for going to bed. On 6/29/23 at 12:42 PM, the MDS Coordinator, confirmed the accuracy of the admission MDS. She stated if the facility placed pressure reducing devices for Resident #8 it would be on the MDS. The facility provided a policy tiled Wound Care dated 8/2022, directed at the following points: Point #9: Remove gloves and discard after the old dressing is removed. Point #10: Directed to wash hands and put on clean gloves. Point # 11: Provide wound care as ordered by the Physician. Point # 12: Remove gloves and wash hands. The facility provided an undated policy titled Pressure Ulcers which revealed it is the policy of the facility to ensure that residents who enter the facility without pressure ulcers do not develop pressure ulcers unless the resident's clinical condition indicates that they were unavoidable and to treat existing pressure ulcers to heal them and prevent complications. Under the Procedure Section of the policy the following documented: a. Residents are monitored for pressure ulcers and pressure risk upon admission. b. Braden score is completed at admission as well as quarterly and as needed. c. If resident is determined to be a pressure risk based on Braden Score or Clinical Assessment, interventions are put into place as appropriate such as but not limited to: a. Alternating pressure mattress. b. Roho cushion. c. Frequent repositioning. d. Heel elevating boots. f. Treatments as ordered by Provider. g. Dietary interventions as appropriate.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on clinical record review, observations, resident and staff interviews and facility policy review the facility failed to report one out of one allegation of abuse to the state agency (Resident #...

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Based on clinical record review, observations, resident and staff interviews and facility policy review the facility failed to report one out of one allegation of abuse to the state agency (Resident # 96). The faculty reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #96 dated 10/20/22, listed diagnoses of congestive heart failure, and respiratory failure. The Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating intact cognition. The Incident Report dated 12/12/22 at 9:00 PM, reflected Resident #96 reported a Certified Nurses Aid (CNA) hit her in the face with a closed fist. The Incident Report revealed the Administrator signed the document on 12/13/22. On 06/26/23 at 2:30 PM, Resident #96 stated, Staff F, Certified Nurses Aid, (CNA) punched her in the face. Resident #96 revealed that hurt her pride, hurt her face, and she felt disrespected. On 6/26/23 at 2:30 PM, Resident #96 hands shook and she appeared upset as she described the incident On 06/28/23 at 11:14 AM, Staff G, CNA stated she knew Resident #96 reported Staff F hit her in the face. On 06/28/23 02:55 PM, Staff E, Licensed Practical Nurse (LPN) confirmed Resident #96 reported Staff F hit her the face. Staff E stated she called the Administrator about the incident. On 6/26/23 at 10:15 AM, the Administrator reported the facility had no pending self-reports to the State Agency (SA). On 6/29/23 at 12:30 PM, the Administrator confirmed, she failed to report Resident #96's allegation of abuse to the SA. The facility provided a policy titled Abuse Prevention, Identification, Investigation, and Reporting Policy dated 11/11/22, and documented all allegations of abuse shall be reported to the State Agency.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

Based on clinical record review, observations, staff interviews and facility manual review the facility staff failed to complete a Significant Change Minimum Data Set (MDS) Assessment when a resident ...

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Based on clinical record review, observations, staff interviews and facility manual review the facility staff failed to complete a Significant Change Minimum Data Set (MDS) Assessment when a resident developed a pressure area for 1 out of 1 residents reviewed with pressure sores (Resident #8) and when the same resident had a significant weight loss for 1 out of 12 residents reviewed for weight loss (Resident #8). The facility reported a census of 44 residents. Findings Include: The MDS Assessment for Resident #8 Dated 4/13/23, included diagnoses of non- Alzheimer's dementia, malnutrition, and altered mental status. The MDS revealed Resident #8 lacked pressure ulcers/wounds at the time of the MDS, and identified her risk for pressure ulcers. The MDS reflected Resident #8's weight at 137.8 pounds. The Skin/Wound Note dated 6/6/2023 at 4:21 PM, identified Resident #8 presented with Stage 2 Pressure Ulcer open area on buttocks 2.3 centimeters (cm) by 0.9 cm by 0.1 cm deep. No drainage from the wound. The surrounding skin appeared pink. The wound bed contained granulation tissue (collagen rich tissue forming at the site of an injury) and slough (combination of leucocytes, bacteria, dead and living cells). The Weights Summary dated 6/29/23, showed an admission weight of 137.8 pounds on 4/3/23. The weight recorded on 4/20/2023 listed Resident #8's weighed 137.4 lbs. On 05/16/2023, Resident #8 weighed 123.2 pounds which is a -10.33 % loss in just over 4 weeks. On 6/28/23 at 8:19 AM, Staff B, Licensed Practical Nurse (LPN) and Staff C, LPN preformed hand hygiene and applied gloves. Staff C, assisted Staff B to position Resident #8 for wound care. At 8:26 AM, the dressing appeared 25 % covered in dark colored drainage. The wound bed appeared with 100% yellow slough. On 6/29/23 at 12:42 PM, the MDS Coordinator stated she would normally do a Significant Change MDS with the pressure ulcer and weight loss, but she does allow some time for the weight loss to improve and pressure wound to heal. She continued that she followed he Resident Assessment Instrument (RAI) Manual. The Resident Assessment Instrument (RAI) Manual dated 10/2019, included some Guidelines to Assist in Deciding If a Change Is Significant or Not: a. Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days). b. Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected multiple residents

Based on observations and staff interview the facility failed to transport leftover food items from the East Kitchenette down the hallway to the Main Kitchen in accordance with professional standards ...

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Based on observations and staff interview the facility failed to transport leftover food items from the East Kitchenette down the hallway to the Main Kitchen in accordance with professional standards of practice for infection control and food safety, by not properly covering the food transported. The facility reported a census of 44 residents. Findings Include: 1. On 6/26/23 at 12:09 PM, the Dietary Staff observed transferring leftover food from the East Kitchenette down the facility hallway to the Main Kitchen on a three shelf wheeled cart. The leftover food containers noted to be uncovered with kitchen utensils still in the containers. Once inside the Main Kitchen the Dietary Staff discussed with the [NAME] about the leftover food. 2. On 6/27/23 at 12:11 PM, the East Kitchenette leftover food observed being returned to the kitchen by Staff A, Dietary Staff. The leftover food noted uncovered on a cart and transferred down the facility hallway to the Main Kitchen. Outside of the Main Kitchen, Staff A asked about the leftover food and what the process was when the leftovers were returned to the Main Kitchen. Staff A stated the leftover food would be thrown away. Staff A further stated the empty containers and dirty utensils would be cleaned. The bottom shelf of the cart noted to contain two uncovered individual desserts. Observation of the Main Kitchen continued from the Community Dining Room window, and Staff A observed taking the two individual uncovered desserts from the leftover cart and transported them into the Main Kitchen refrigerator for storage. Staff A noted to loudly verbalize to ask the [NAME] if any leftovers were to be kept. On 06/27/23 02:25 PM, Staff A interviewed about the leftover food from the East Kitchenette dining room. Staff A stated the [NAME] lets staff know if any leftover food is to be saved from the East Kitchenette dining room . Staff A then gave an example of chili being leftover can be combined with new chili made if the cook wanted to. When asked if the leftover food is for the residents or facility staff, Staff A stated for either. Staff A acknowledged saving two leftover transported uncovered desserts from lunch today. On 6/28/23 at 11:35 AM, an interview completed with the Dietary Manager (DM). The DM stated after meeting with staff, she was made aware the Main Kitchen [NAME] decided if transported uncovered leftovers were being kept from the East Kitchenette. The DM learned uncovered transported leftover food was being kept in the Main Kitchen walk in refrigerator for both staff and residents.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, staff interview and Dietary documentation review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safe...

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Based on observation, staff interview and Dietary documentation review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced during the brief Initial Tour of the kitchen and follow up visits to the kitchen. The facility reported a census of 44 residents. Findings Include: 1. On 6/26/23 at 9:53 AM, a brief Initial Tour of the Main Kitchen revealed the following concerns: a. A Vulcan gas stove with build up grim within the six burners of the stove. The back wall ledge of the stove approximately 3 inches in height noted with visible grime and grease across the length of wall. b. A Vulcan oven next to the stove had a build up of grime vertically streaked down the right side panel of the oven. The temperature dial, all oven door crevices observed to have grime and dust build up. c. The Vulcan oven and an adjoining table with a small steam oven had an open bottom that showed visible pieces of food and dirt on the floor that had not been swept up. d. Across from the Vulcan range and ovens, a food prep area with a red commercial mat on the floor, noted covered with a sticky substance, several black marks and dirt in the circular cut out areas of the mat. e. A ceiling vent located to the right of the food prep table had debris and dust dangling. f. The left side of the food prep table had a white ceiling tile with several brown stains visible. g. The left side of the food prep table placed next to a cement wall with visible brown food build up. h. Review of the Main Kitchen Refrigerator Temperature Check Log showed eight dates of twenty-six with missing temperature checks documented. 2. During a check on 6/27/23 at 9:21 AM, the East Kitchenette Refrigerator bottom freezer observed with large amounts of spilled ice cream pink and white in color stuck to the surface of the freezer. 3. On 6/27/23 at 10:45 AM, a follow-up visit to the kitchens revealed none of the above mentioned equipment or floors cleaned of debris or grime. On 6/27/23 at 2:25 PM, an interview completed with Staff A, Dietary Staff. When asked about kitchen cleaning and how often cleaning is completed, Staff A stated the 'jobs' were completed as assigned to sweep and mop, wipe off counters and stove. Staff A stated the stove needed cleaned every time it was used. When asked about deep cleaning, Staff A reported deep cleaning had not been an issue. When asked how often the floor was to get mopped, Staff A stated at least once a week. Staff A further explained wiping the walls completed whenever staff had a chance to do it. Staff A stated duties included occasional cooking for breakfast also. On 6/27/23 at 2:35 PM, during an interview with the Dietary Manager (DM), she acknowledged the above mentioned equipment of concern, floors and ceiling being dirty of grime and dust and the deep cleaning not being completed. When asked if the Dietary Staff had flowsheets to check off when cleaning completed, the DM provided check sheet forms the staff complete when assigned cleaning is completed.
Nov 2022 3 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Based on personnel file review, document review, policy review and staff interviews, the facility failed to ensure 1 of 1 new employees selected for review, with a criminal background, received an Iow...

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Based on personnel file review, document review, policy review and staff interviews, the facility failed to ensure 1 of 1 new employees selected for review, with a criminal background, received an Iowa Department of Human Services (DHS) clearance to work, according to State law. The facility reported a census of 51. Findings Include: Review of the facility's New Employee Report revealed a hire date of 2/26/20 for Staff A, Registered Nurse (RN). A document titled Single Contact License and Background Check (SING), dated 2/17/20, revealed the Iowa Division of Criminal Investigation (DCI) needed to perform additional research on criminal background. A document titled Iowa Criminal History Non Conviction, dated 2/20/20, revealed the DCI identified a criminal record for Staff A and provided a report which contained further details. The personnel file lacked evidence the facility contacted the Department of Human Services (DHS) to obtain clearance for Staff A to work at the facility. Review of a facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy, 4/1/17, revealed in part . It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation and misappropriation of resident property . These procedures shall include the screening . The facility will conduct an Iowa criminal record check . on all prospective employees .in the manner prescribed under 481 Iowa Administrative Code . During an interview on 10/27/22 at 10:45 a.m., the Business Office Manager (BOM), confirmed they do not have documentation to show Staff A received a DHS clearance to work at the facility. She reported the Department of Criminal Investigation (DCI) criminal history report had not prompted the facility to have Staff A write an explanation and submit to DHS. The BOM confirmed Staff A, RN worked at the facility from 2/26/20 until 10/15/22 provided care and treatment to the residents of the facility. During an interview on 11/1/22, at 4:15 p.m., the Administrator, confirmed Staff A was employed as a full-time Night Nurse since hired and was terminated after her last shift on 10/15/22. The Administrator stated that the DCI report had not prompted the facility to submit to DHS for approval to hire.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and provider interviews, and facility policy review the facility failed to follow professional sta...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and provider interviews, and facility policy review the facility failed to follow professional standards for medication administration by failing to discontinue (D/C) cardiac medications (amlodipine 10 mg daily and metoprolol 50 mg daily) as ordered by the Cardiologist on 7/26/22 which resulted in Resident # 3 receiving the discontinued medications as well as the newly ordered cardiac medication (carvedilol 12.5 mg twice daily) on 7/27, 7/28, and 7/29/22. The facility additionally failed to notify the provider and report the error. The facility reported a census of 51 residents. Findings Include: 1. According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderately impaired cognitive ability. The MDS documented medical diagnoses that included: hypertension, permanent atrial fibrillation, sick sinus syndrome (abnormal heart rhythms), cardiac pacemaker, and chronic lung disease. A Nursing Progress Note dated 7/26/22 at 11:22 a.m. by Staff C, Licensed Practical Nurse (LPN), documented that Resident #3 had returned from a cardiology appointment at around 10:45 a.m. with the following new orders: a. D/C amlodipine, metoprolol, and furosemide. b. Start carvedilol 12.5 milligrams (mg) by mouth (PO) twice daily (BID). c. Start torsemide 40 mg every day. d. Noted the Cardiologist would also like to let the Primary Care Provider (PCP) know not to change the medications he just started and to call with questions and concerns. e. The Cardiologist would also like blood pressure (BP) to stay around 130/75, contact if raised significantly. A Physician Orders Form dated 7/26/22 documented the following new orders: a. D/C amlodipine. b. D/C metoprolol. c. D/C furosemide. d. Carvedilol 12.5 mg PO BID. e. Torsemide 40 mg every day PO. Review of the Electronic Medication Administration Record (EMAR) for 7/1/22-7/31/22 for Resident #3 included: a. An order dated as initiated on 2/22/22 for amlodipine tab 10 mg daily, scheduled in the a.m. b. The order was dated as discontinued on 7/31/22 at 9:06 a.m. c. The medication was signed as administered on 7/27, 7/28, and 7/29/22 after the order was received to discontinue use. An order dated as initiated on 1/20/22 for metoprolol 50 mg Extended Release (ER) daily, scheduled in the a.m. The order was dated as discontinued on 7/31/22 at 9:06 a.m. The medication was signed as administered on 7/27, 28, and 7/29/22 after the order was received to discontinue. An order dated as initiated on 7/26/22 for carvedilol 12.5 mg twice daily, scheduled in the a.m. and p.m. The medication was signed as administered on 7/27, 7/28, and 7/29/22 in addition to the medications that were ordered to discontinue. In an interview on 11/1/22 at 10:05 a.m., Staff C, Licensed Practical Nurse (LPN) confirmed that she had received the written orders from Resident #3's Cardiologist on 7/26/22. Staff C stated she had noted in the Electronic Progress Note and faxed to the Pharmacy. Staff C recalled that she had not sent the fax until the end of her shift and failed to confirm that the fax had been received by the Pharmacy. Staff C further stated that she had failed to pull the Medication Card from the medication cart for the discontinued medications. Staff C Responded that the Director of Nursing (DON) had since clarified the expectation that the discontinued cards should have been pulled. Staff C added that new protocols have been put in place. Staff C returned to work on 7/30/22, realized the medications had not been discontinued and had continued to be administered to Resident #3 in addition to the newly ordered medication. Staff C admitted that she had not notified the provider of the error, and additionally had not notified the DON or filled out a Medication Error Report. Staff C clarified that she wasn't clear about the process and the expectations. In an interview on 10/31/22 at 4:30 p.m., the DON stated that facility staff had failed to remove the discontinued medications from the medication cart when the order was received and faxed to the Pharmacy. Additionally, the DON would have expected staff to confirm the fax was received. The DON revealed that a new process was initiated on 8/15/22 following identification of the medication error which included: a. Manually discontinue the medications in the EMAR. b. Go to the appropriate cart and remove discontinued or changed Medication Cards. c. Keep confirmation sheet from fax and discard after changes are approved in EMAR. The changes were incorporated into facility policy titled Implementing New and Discontinued Physician Orders dated as revised on 8/2022. In an interview on 11/1/22 at 11:25 a.m., the Administrator stated she would have expected the provider to be notified of the medication error and would also have expected the DON to be notified. The Administrator confirmed the provider and the DON were not notified and a Medication Error Report was not initiated. In an interview on 11/1/22 at 11:45 a.m., Resident #3's Primary Care Provider stated she would have expected to be called as soon as the medication error was discovered. Confirmed she would have requested closer monitoring of vitals signs and would have referred facility to contact the cardiologist for further direction. The Provider confirmed that she had not been notified of the error at the time was discovered. In an interview on 11/1/22 at 1:50 p.m., a Pharmacist from the local pharmacy confirmed they had not received a fax from the facility on 7/26/22. Review of undated facility protocol identified by the facility as found in the Nurse Competency Book identified the following steps are expected when a medication error occurs: a. Obtain a full set of vitals. b. Contact Physician and DON. c. Monitor resident and notify DON and Physician if changes are noted. d. Follow physician orders. e. Fill out an Incident Report.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, clinical record review, policy review and staff interviews the facility failed to ensure lorazepam intensol concentrated liquid (anti-anxiety medication), a level 4 controlled dr...

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Based on observation, clinical record review, policy review and staff interviews the facility failed to ensure lorazepam intensol concentrated liquid (anti-anxiety medication), a level 4 controlled drug that required refrigeration was secured in a separately locked compartment within the medication refrigerator for 2/2 residents with liquid lorazepam observed during shift count (Resident #4 and #5). Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence. Additionally, the facility failed to complete a Control Shift Count as directed by facility policy. The facility reported a census of 51 residents. Findings Include: 1. Review of the October 2022 electronic Medication Administration Record (MAR) for Resident #4 documented an order dated as received on 9/23/22 for lorazepam concentrate 2 milligrams/milliliter (mg/ml), administer 0.5 ml by mouth every 4 hours as needed for anxiety and an order dated 9/30/22 for ABH compound cream (lorazepam/diphenhydramine/Haldol) apply 1 ml (4 clicks) to the volar aspect (wrist) of the resident every 6 hours. 2. Review the October 2022 electronic Medication Administration Record (MAR) for Resident #5 documented an order dated as received on 9/13/22 for lorazepam concentrate 2 mg/ml, administer 0.25 ml by mouth every 2 hours as needed for restlessness/anxiety/nausea. Observation and interview on 10/27/22 at 12 Noon, Staff B, Licensed Practical Nurse (LPN) revealed the liquid Lorazepam 2 mg/ml for Resident #4 and Resident #5 was located in the medication refrigerator located in the locked medication room. The medication refrigerator was not locked and the medication was not stored in a locked compartment of the refrigerator. Resident #4 also had a container of ABH compound cream stored in the unlocked refrigerator in a dispenser that delivered the required dose (1 ml) by twisting the bottom of the container 4 clicks. The container was not marked. Staff B confirmed there was not a way to determine how much remained. Staff B, LPN verified that the liquid lorazepam was not stored in a separately locked compartment and that the medication refrigerator was not locked. Staff B further revealed the narcotic counts are completed at 6:00 a.m., 2:00 p.m., at 10:00 p.m., but not completed when 12-hour shift staff change occurred at 6:00 p.m. In an interview on 10/27/22 at 12:15 p.m., the Director of Nursing (DON) confirmed that liquid lorazepam was not double locked, she had contacted maintenance and will be securing in the refrigerator with a separate lock. The DON further confirmed that shift count was not completed with the change to some nurse's working 12-hour shifts. The DON stated that the facility policy for narcotic count directed narcotic count at with each shift change and added that they just hadn't adapted with the change in schedules. The DON informed the facility planned adjust their counts for every shift change. Review of undated facility policy titled Narcotic Medication Usage and Recording included the following: Every shift change two nurses will count to verify the count sheets are accurate to supply on hand.
Mar 2022 3 deficiencies 1 IJ
CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0760 (Tag F0760)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The 5 Day MDS assessment dated [DATE] revealed Resident #53 scored 12 out of 15 on a BIMS exam, which indicated the resident ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The 5 Day MDS assessment dated [DATE] revealed Resident #53 scored 12 out of 15 on a BIMS exam, which indicated the resident was cognitively intact. The assessment identified the resident took an anticoagulant medication 3 out of the 7 days of the reference period. Diagnoses for Resident #53 included heart failure, stroke and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The Care Plan, most recent revision date 3/15/22, documented, anticoagulant therapy related to (r/t) atrial flutter. Interventions per the Care Plan, all dated 9/15/17, included the following: a. Administer Anticoagulant medications as ordered by Physician. b. Monitor for side effects. c. Labs as ordered. d. Report abnormal lab results to the MD (physician) e. Monitor/document/report as needed (PRN) adverse reactions of Anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs (v/s). Review of the clinical record for Resident #53 revealed the following in February 2022: The admission Orders sheet dated 2/14/22, crossed off with the new date of 2/15/22, had been signed on the Physician signature line on 2/15/22. The admission Orders documented the following Warfarin orders: a. Warfarin 2 milligram (mg) PO (oral) Q (every) Sunday, Monday, Wednesday, Friday and Saturday. *start on 2/17/22* b. Warfarin 1 mg PO Q Tuesday, and Thursday. *start on 2/17/22* The Health Status Note dated 2/15/2022 at 1:12 PM revealed the resident had returned to the facility from the hospital. The Fax Cover Sheet dated 2/15/22 documented the following comments regarding Warfarin: Warfarin on hold till 2/17/22. The MAR dated February 2022 revealed Warfarin 1 mg had been administered on 2/15/22. On 3/24/22 at 11:12 AM, Staff I, Registered Nurse (RN)/Admissions/Discharge Coordinator was queried about the process followed after a PT/INR had been drawn. Staff I explained there was a form that was filled out that had PT/INR and current Warfarin doses. The Physician would be faxed, and if the INR result was greater than 3 the doctor was called right away and the medication was on hold. Then, they would wait for a fax that day for any new orders. Orders were faxed to the Pharmacy, the medication was pulled from the [NAME] (Unit Dose System), a note was put on [NAME] for how long Coumadin (Warfarin) was on hold, and the Pharmacy would send a new package if there were new doses. Staff I was queried if any of the process steps were new, and Staff I acknowledged putting the label on [NAME] and pulling the drug were new steps. Staff I was queried when the results would be faxed to the doctor, and explained they would be faxed right away. Staff I acknowledged the lab would be drawn in the morning. Staff I was queried about response from the Physician, and responded the doctor would fax back or if they had been called they could give orders then. Per Staff I, the medication was not given until the PM, so during the day when waiting it would not affect the patient because they had all day for the doctor to get back to the facility. Staff I further explained that if they did not hear back from the doctor, then usually later in the day they would call. Per Staff I, Staff J, Assistant Director of Nursing (ADON) usually did the PT/INR's. Staff I explained if they did not hear back from the doctor that day, they would have to call them, and they had to hear back from them. If greater than 3 (INR), the medication was on hold until they heard back. Staff I was queried about PT/INR frequency, and explained it was completely up to the Physician, and the Physician would usually tell them when it was due again. Staff I was queried as to the process if they did not hear back about results that day or that week, and explained the DON would be contacted, and hopefully the Medical Director would be called as it was not acceptable to not respond to the PT/INR and they needed to respond to all faxes. Staff I was queried if the medication would continue to be given, and responded no. On 3/24/22 at 1:28 PM, ADON J was queried about PT/INR's at the facility, and explained she normally would draw them. If she was not at the facility, then a Charge Nurse would do so. ADON J explained the lab would be obtained, a form was filled out, and if over 3 a note would be made so the Doctor caught it and a cover sheet would be sent with the same information. ADON J was queried about a time frame from when the result was obtained to when it was sent, and explained she normally she tried to draw them in the morning, and if she had not heard back by 3:00 PM or 4:00 PM in the afternoon the same day then they would call the office. When queried as to the process if the Doctor had not responded, ADON J explained they would typically give them a phone call. If the result was above 3, the Warfarin would be pulled and they would tell the Charge Nurse. When queried about continuing to administer the medication if the Doctor had not responded, ADON J explained they would do so unless it was out of range. On 3/24/22 at 3:27 PM, the Director of Nursing (DON) explained once the INR was obtained, it would be immediately faxed to the doctor's office. If the number was greater than 3 (INR) it was pulled and held. If the doctor did not respond before 5, then they would be called to figure out if they had received the fax. The DON explained usually if they were not in the office that day, then she would call them the next day, and usually INR's were ordered to land on days when they were in the office. Per the DON, the turnaround time for the Physician should be the next day, and they would refax or call if it had been a day or more and they had not heard from the Doctor. The DON acknowledged the medication would continue to be given until they heard back unless it was greater than 3 (INR), and 24 hours was an adequate amount of time to wait for a response. The Facility Policy for Anticoagulants/Coumadin active at the start of the survey was requested. The facility provided an undated policy titled INR Pro-time Policy, which documented the following: Policy: It is the policy of [Facility Name] to hold the medication, Coumadin, or other anticoagulant, until a Physician has been notified if INR lab result is greater than 3.0: a. INR/Prothrombin lab test will be drawn on a resident as ordered by Attending Physician. b. Courtesy copy of results is sent to Attending Physician in addition to the facility. c. Licensed nurse will check printer for INR/PT test results Monday through Friday. d. Log will be kept on INR PT's drawn. e. INR greater than 3.0 will be called to the Physician. f. Anticoagulation medication will be held until Physician returns our call. g. Physician will be contacted again before 5:00 PM on the day the dose is held if new orders have not been received by that time. The undated Facility Policy titled Implementing Physician Orders, documented, Policy: It is the policy of [Facility Name] to accurately implement physician's orders for our residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 3/23/22 at 3:30 PM. An IJ situation determined on 3/23/22 that started on 2/1/22 when the Nursing Staff failed to hold a Coumadin dose as Physician ordered. The Facility removed the Immediate Jeopardy on March 24, 2022, after the start of the Survey through the following actions: a. Staff education regarding the new policy for PT/INR. b. Created a new policy for Implementing Physicians orders. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their Policy and Procedure. Based on observation, clinical record review, staff interview, and hospital record review, the facility failed to hold a Coumadin (Warfarin) medication (blood thinner) according to the Physician's order for 2 out of 2 residents reviewed (Resident # 34 and # 53). Resident #34 identified with an International Normalized Ratio (INR) lab value on 1/31/22 of 8.0 (therapeutic level 2-3). The facility failed to hold the Coumadin dose 2/1/22 and the recheck of the INR on 2/2/22 revealed a critical INR of 10.8. Resident #34 required transportation to the hospital. This failure resulted in Immediate Jeopardy to the health, and safety of the residents. The facility reported a census of 51 residents. Findings Include: 1. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #34, reflected diagnoses of heart failure, and cancer. The MDS listed the resident with Brief Interview for Mental Status score of 11 out of 15 indicating moderate cognitive impairment. The MDS documented 7 out of 7 days of the reference period the resident received anticoagulant medication. A Health Status Note dated 1/31/2022 at 1:10 PM, read: blood taken from third and fourth finger right hand for the facility Pro-Time machine. Both results read no clot detected for blood drawn from right hand for International Normalized Ratio (INR) and Prothrombin Time Test (PT) and now to be sent to hospital lab outreach. Tolerated procedure without incident. No visible signs of bleeding. Will hold Coumadin until lab results return. The Health Status Note dated 1/31/2022 at 4:13 PM, read: the lab stated the specimen sent for the INR and PT was under filled and are unable to run test. Blood drawn from right hand for the INR and PT to be sent to Mercy Lab Outreach. Tolerated procedure without incident. The Health Status Note dated 1/31/2022 at 7:50 PM, revealed at 7:36 PM, this Nurse got a call from Mercy Lab that Resident #34's INR level is 8.0. At 7:41 PM, called the Physician, and the Physician ordered Hold Coumadin the 2/1/22 dose and recheck INR. Read back via telephone. Review of the Physician's Order reflected to hold the Coumadin on 2/1/22 and recheck INR on 2/2/22. The Health Status Note dated 2/1/2022 at 1:42 PM, stated the resident complained of just not feeling good. Has not been eating. Pallor poor. Daughter concerned. Overall assessment done: Temperature -98.4, Blood pressure -93/61, Pulse - 104, Oxygen Saturation (O2 Sat) - 94%, and respirations - 16. Physician notified. New order to repeat chest x-ray, complete blood count (CBC) and basic metabolic panel (BMP) and urinalysis (UA) culture and sensitivity (C&S) if positive. X-ray notified The Medication Administration Record (MAR) directed Coumadin 6 milligrams (mg) 1 tablet by mouth every evening on Monday, Tuesday, Wednesday, Friday and Saturday. The MAR documented the medication as a hazardous drug. The MAR dated 2/1/22, revealed staff administered Coumadin 6 milligrams on 2/1/22. The MAR failed to reflect the new order to hold the Coumadin on 2/1/22. The Health Status Note dated 2/2/2022 at 11:42 AM, Physician aware of INR retested today and stating no clot detected this is out of range which is greater than 8. No evidence of bleeding noted and Hemoglobin was 11.5. Discussed situation with resident about treatment here at facility or going to hospital. Resident chose hospitalization. New order to send to Hospital emergency room (ER) to evaluate and treat. Physician changed Coumadin to hold today and tomorrow with recheck of INR on the 2/4/2022 if here. Daughter updated. 911 called at 11:20 AM and ambulance arrived at 11:30 AM. Review of the PT/INR drawn on 2/2/22, listed a critical INR at 10.8 (general range is 2.0 to 3.0). The Health Status Note dated 2/3/22, reflected Resident #34 in the hospital. The Hospital Discharge Summary Note dated 2/7/22 reflected Resident #34's goal INR at 2-3. The Summary documented Resident #34's INR on admission greater than 10 and the hospital provided fresh frozen platelets and 10 milligrams (mg) intravenous (IV) vitamin K. Review of Resident #34 admission ordered to the facility on 2/7/22 reflected a diagnoses of sub-therapeutic INR. The Care Plan for Resident #34 dated 3/1/22, read anticoagulant therapy related to history of myocardial infarct, aortic valve replacement, cardiomyopathy, and heart valve transplant. The Care Plan listed the following interventions: a. I will not be hospitalized for signs and symptoms of excessive bleeding. b. Administer anticoagulant medications as ordered by physician. c. Monitor for side effects and effectiveness. d. Complete Labs as ordered. e. Report abnormal lab results to the MD. On 3/23/22 at 3:21 PM, Staff C, Registered Nurse (RN), reported Staff D, Licensed Practical Nurse (LPN) completes the finger stick INR or Staff J, Assistant Director of Nursing (ADON). Staff C reported giving the next dose of Coumadin depends on results of the INR. After we get the results of the PT/INR we notify the doctor and get any new orders. If the coagulation (CoAg) does not register then we take a better sample, run that to the lab, and send those results to the doctor for an order. Staff C stated she would clarify with the doctor before she gave Coumadin, to make sure the resident got the correct dose. On 3/23/22 at 1:54 PM, Staff D, LPN, reported new orders from the Physician are faxed to the Pharmacy and the Pharmacy updated the MAR, and the order goes in the DON box for double checking. Over the weekend the nurses will check each other's orders. On 3/23/22 at 1:56 PM, Staff E, RN, stated the orders are sent to the Pharmacy and the Pharmacy adds them to the MAR. She reported the Pharmacy gets the new orders on the MAR in about 10-15 min. Staff E continued to explain over the weekend and during after-hours we add new orders. On 3/24/22 at 10:10 AM, Staff K, Certified Pharmacy Technician, reported the Facility is expected to fax orders to them, the Pharmacy adds orders to the MAR. Staff K, said if the facility obtained an order to hold a medication like Coumadin, the Pharmacy wants to see the order so they don't send the medication. Staff K revealed it is the facility's responsibility to go into Accu flo (program utilized between the facility and Pharmacy to communicate) and mark held on the doses. On 3/24/22 at 3:10 PM, the Director of Nursing (DON), reported her expectation is the nurses follow the Physician Orders. The DON confirmed staff failed to hold Resident #34's Coumadin on 2/1/22 as the Physician ordered.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interviews the facility failed to document and assess 1 out of 1 resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interviews the facility failed to document and assess 1 out of 1 resident reviewed for oxygen (O2) use (Resident # 34). The facility reported a census of 51 residents. Finding Include: The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of chronic obstructive pulmonary disease (COPD). The MDS documented the resident's Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognition. The Care Plan for Resident #34 dated 3/1/22, directed the Nursing Staff to monitor the resident for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance and failed to address the oxygen use. On 3/22/22 at 11:21 AM, observed Resident #34 sat in his recliner with O2 in place, and failed to show a date on the oxygen tubing to show when last changed. The Physician's Telephone Order dated 3/9/22, directed to administer Oxygen at 2 litters per hour for comfort as needed. The Medication Administration Record (MAR) and the Treatment Administration Record (TAR) both dated 3/2022, failed to reflect Resident #34's use of oxygen. On 3/23/22 at 1:59 PM, the Director of Nursing (DON) reported the O2 company comes every week, and changes out the O2 tubing and the O2 Company documents that. On 3/24/22 at 8:52 AM, Staff D, Licensed Practical Nurse (LPN), reported the Nursing Staff sign off the O2 use on the MAR, she confirmed Resident #34 being on O2 failed to be on the MAR or TAR. On 3/24/22 at 10:10 AM, Staff K, Certified Pharmacy Technician, reported the Facility is expected to fax orders to them, and the Pharmacy then adds orders to the MAR, except things they don't provide. O2 is something the facility adds independently. On 3/24/22 at 3:25 PM, the DON reported her expectation is Oxygen (O2) orders are placed on the MAR & TAR for the Nursing Staff to sign off as the resident needed the Oxygen, and the Nursing Staff are expected to assess the resident's need for the O2. The facility provided an undated policy titled Oxygen Usage, which directed at point #3, place order on Accuflo, and at point # 6 directed monitor O2 saturations as ordered.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow proper infection control techniques durin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow proper infection control techniques during catheter care and incontinence care (of bowel movement) for one of one residents reviewed with an indwelling urinary catheter. (Resident #8). The facility reported a census of 51 residents. Findings Include: 1. The Minimum Data Set, dated [DATE] identified Resident #8 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 11 out of 15. The MDS documented the following diagnoses: benign prostatic hyperplasia, renal insufficiency and urinary tract infection. The MDS also identified the resident with an indwelling catheter and always incontinent of bowel. A review of the Physician Orders revealed the following orders: a. On 1/20/22, for an indwelling catheter and to change the catheter monthly on the 11th of the month b. On 1/27/22, place a 16 french Foley catheter if resident unable to void with 10 cc (cubic centimeters), diagnosis of urinary retention. The Care Plan with the Goal Target Date of 5/1/22 identified the resident with the problem of Activities of Daily Living (ADL) self-care performance deficit and failed to direct staff to remove any soiled items from underneath the resident after providing incontinence care. A review of the Hospital Discharge summary dated [DATE], identified the resident with the principal diagnoses of COVID-19 virus infection and urinary tract infection. In an observation of incontinence care on 3/23/22 1:52 PM, Staff A, Certified Nursing Assistant (CNA) washed hands, donned gloves, and unfastened the resident's incontinent brief which had a moderate amount of stool in it. After Staff A cleansed the resident's right gluteal fold and part of the rectal crease, a small amount of stool now noted on the soaker pad underneath the resident. Staff A failed to remove the soaker pad before she asked the resident to turn on his back where his bare skin had come into contact with the stool on the pad. In an interview on 3/24/22 at 8:22 AM, Staff A, CNA reported when providing incontinence care on a resident after a bowel movement, she would remove the soiled soaker pad and place a new one underneath the resident. She admitted she forgot to do this the other day as the surveyor made her nervous. In an interview on 3/24/22 at 8:49 AM, Staff G, CNA reported when providing incontinence care on a resident after a bowel movement, she would change the soiled soaker pad immediately and place a new one underneath the resident. In an interview on 3/24/22 at 9:21 AM, the Director of Nursing reported she would expect the aides to change the soaker pad after the resident has been incontinent of stool Also replace the pad immediately after they clean the resident, by tucking the soiled soaker pad underneath and then place a new one on top. A review of the undated facility policy titled: Peri-Care Policy documented the following procedure: a. Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area (front to back using clean side of washcloth with each stroke and working from the inside/out). b. Remove the wet incontinent pad. c. Place a clean and dry incontinent pad under the resident.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What changes have you made since the serious inspection findings?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • 44% turnover. Below Iowa's 48% average. Good staff retention means consistent care.
Concerns
  • • Multiple safety concerns identified: 1 life-threatening violation(s), 4 harm violation(s), $44,087 in fines. Review inspection reports carefully.
  • • 18 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • $44,087 in fines. Higher than 94% of Iowa facilities, suggesting repeated compliance issues.
  • • Grade F (28/100). Below average facility with significant concerns.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Cedar Manor Nursing Home's CMS Rating?

CMS assigns Cedar Manor Nursing Home an overall rating of 3 out of 5 stars, which is considered average nationally. Within Iowa, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Cedar Manor Nursing Home Staffed?

CMS rates Cedar Manor Nursing Home's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 44%, compared to the Iowa average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Cedar Manor Nursing Home?

State health inspectors documented 18 deficiencies at Cedar Manor Nursing Home during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 13 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Cedar Manor Nursing Home?

Cedar Manor Nursing Home is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 54 certified beds and approximately 51 residents (about 94% occupancy), it is a smaller facility located in Tipton, Iowa.

How Does Cedar Manor Nursing Home Compare to Other Iowa Nursing Homes?

Compared to the 100 nursing homes in Iowa, Cedar Manor Nursing Home's overall rating (3 stars) is below the state average of 3.1, staff turnover (44%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Cedar Manor Nursing Home?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Cedar Manor Nursing Home Safe?

Based on CMS inspection data, Cedar Manor Nursing Home has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Iowa. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Cedar Manor Nursing Home Stick Around?

Cedar Manor Nursing Home has a staff turnover rate of 44%, which is about average for Iowa nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Cedar Manor Nursing Home Ever Fined?

Cedar Manor Nursing Home has been fined $44,087 across 3 penalty actions. The Iowa average is $33,520. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Cedar Manor Nursing Home on Any Federal Watch List?

Cedar Manor Nursing Home is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.