PRINTED: 12/28/2022

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
165478 B. WING _____________________________
12/19/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

701 EAST MAPLELEAF DRIVE

ARBOR COURT
MOUNT PLEASANT, IA 52641

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 000 INITIAL COMMENTS F 000

Correction date: _____________________

The following deficiencies resulted from an

investigation of complaints #109546-C,
conducted on December 14, 2022 to December
19, 2022.

Complaints #109546-C was substantiated.

See code of Federal Regulations (42 CFR), Part

483, Subpart B-C.
F 757 Drug Regimen is Free from Unnecessary Drugs F 757
SS=J CFR(s): 483.45(d)(1)-(6)

§483.45(d) Unnecessary Drugs-General.

Each resident's drug regimen must be free from
unnecessary drugs. An unnecessary drug is any
drug when used-

§483.45(d)(1) In excessive dose (including

duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its

use; or

§483.45(d)(5) In the presence of adverse

consequences which indicate the dose should be
reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons

stated in paragraphs (d)(1) through (5) of this
section.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P60C11 Facility ID: IA0925 If continuation sheet Page 1 of 6
 PRINTED: 12/28/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
165478 B. WING _____________________________
12/19/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

701 EAST MAPLELEAF DRIVE

ARBOR COURT
MOUNT PLEASANT, IA 52641

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 757 Continued From page 1 F 757

This REQUIREMENT is not met as evidenced
by:
Based on clinical record review, physician
interview, staff interview and hospital record
review, the facility failed to respond to a warning
for possible interaction between an antibiotic and
anticoagulant medication and failed to intervene
appropriately once new bruising was observed in
multiple locations, which was an indicator of an
adverse side effect of an anticoagulation
medication for 1 of 2 (Resident #1) residents
reviewed on anticoagulant therapy. The facility
reported a census of 56 residents.

Findings include:

Resident #1's Admission Minimum Data Set

(MDS) dated 12/7/22 documented an admission
date of 11/30/22. The MDS documented a Brief
Interview for Mental Status (BIMS) of 15, which
indicated no cognitive impairment. The MDS
documented the resident received an
anticoagulation medication each of the last 7
days.

Progress Note written on 11/30/22 at 2:56 PM

documented a request sent out to the Primary
Care Provider (PCP) for the next INR (lab test to
measure anticoagulant) due date.

Progress Note written on 11/30/22 at 6:41 PM

documented the PCP ordered the INR to be
drawn in 2 weeks, on December 14, 2022.

Progress Note written on 12/5/22 at 6:30 PM

documented the PCP was notified of the resident
having an elevated temperature throughout the
PM shift, nausea and dizziness.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P60C11 Facility ID: IA0925 If continuation sheet Page 2 of 6
 PRINTED: 12/28/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
165478 B. WING _____________________________
12/19/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

701 EAST MAPLELEAF DRIVE

ARBOR COURT
MOUNT PLEASANT, IA 52641

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 757 Continued From page 2 F 757

Progress Note generated by the Electronic Health
Record (EHR) on 12/5/22 warned of a possible
drug interaction between Jantoven (warfarin,
Coumadin) 5 milligrams (mg) given daily for blood
thinning and the antibiotic Keflex. The EHR
identified the interaction as a moderate severity.
The use of the medications together had the
potential to increase the risk of bleeding
complications.

The Progress Notes lack documentation of the

nursing staff acknowledging the warning. The
Progress Notes lack notification to the PCP of the
warning. The Progress Notes lack
documentation of the PCPs decision and
rationale for using the medications together
despite the risk of interaction.

Progress Note written on 12/11/22 at 8:11 PM

documented turned resident to side, wound on
sacrum draining large amount of
foul smelling red and black substance. Appears
to be blood. Dressing changed, and resident
repositioned. New bruising on the resident's left
shin, left upper back, and on her ribs on the left
side. The bruises were purple on color. The
Advanced Registered Nurse Practioner (ARNP)
was made aware of bruising and other
assessment findings. The Progress Note
documented her response as if giving blood
thinners twice a day, decrease to once a day. It
was noted the resident would be having an INR
drawn in 3 days.

The resident's Care Plan alerted staff the resident

was on an anticoagulant and it required lab
monitoring. The resident was identified as not
needing terminal care.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P60C11 Facility ID: IA0925 If continuation sheet Page 3 of 6
 PRINTED: 12/28/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
165478 B. WING _____________________________
12/19/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

701 EAST MAPLELEAF DRIVE

ARBOR COURT
MOUNT PLEASANT, IA 52641

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 757 Continued From page 3 F 757

The Medication Administration Record (MAR) for
Resident #1 included warfarin 5 milligrams (mg)
daily. It was given daily from 12/1/22 thru
12/10/22. It was not given on 12/11/22 or
12/12/22.

Review of the hospital records for Resident #1

(Clinical Report dated 12/12/22 under History of
Present Illness) documented that her INR was
therapeutic on 11/29/22 at 2.9 (normal for this
resident's use of the medication is 2.0 to 3.0).

Review of the hospital records, Clinical Report

dated 12/12/22 documented that when the
resident arrived in the emergency room her INR
was greater than 17.3 (the lab analyzer could not
actually determine a level as it did not read that
high). The lab results document an INR of over
10 is considered critical for a resident on warfarin
therapy.

During an interview on 12/14/22 at 3:29 PM the

Emergency Department (ED) physician stated
when the resident was admitted to the ED on
12/12/22 she had bruising on her arms, legs and
trunk. Her hemoglobin (hgb- protein that carries
oxygen to the tissues and organs) was low. The
physician reported that the resident was found to
have a gastrointestinal bleed (GI Bleed) and had
lost about 4 units of blood presumably through
her stools. The hospital was setting up a unit of
blood to give to the resident but she passed
before it was ready.

During an interview on 12/15/22 at 11:52 AM the

PCP stated he was notified on 12/5/22 that the
resident was not feeling well. She had an
elevated temperature and nausea. He stated he
ordered Keflex for the elevated temperature and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P60C11 Facility ID: IA0925 If continuation sheet Page 4 of 6
 PRINTED: 12/28/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
165478 B. WING _____________________________
12/19/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

701 EAST MAPLELEAF DRIVE

ARBOR COURT
MOUNT PLEASANT, IA 52641

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 757 Continued From page 4 F 757

because she had a pressure ulcer on her sacrum.
Stated he was concerned she may be developing
an infection in that and so the antibiotic was for
skin bacteria. He stated he requested and
received a status update on 12/7/22. He ordered
some blood tests. The bloodwork came back with
her hgb at 11.6, "she was a little anemic." He
stated he did not receive notification about the
possible interaction between the warfarin and the
Keflex. He stated she had previously used
warfarin and Keflex together successfully many
times. He stated if her intakes decreased that
could cause her warfarin to be more potent but
did not feel the Keflex was the cause. He stated
he was not notified of the resident's decreased
intakes and he was not notified prior to sending
her to the ED on 12/12/22.

During an interview on 12/15/22 at 10:28 AM Staff

A stated if she had a question about a medication
dosage or interaction there was a drug book
available for reference. She was unable to locate
the book. She entered the Director of Nursing's
(DON) office to ask about the book. After a few
minutes, the surveyor entered the DON's office to
see if they had found the book. The DON was on
her computer and stated she was looking for it. A
minute later Staff A and the DON entered the
medication room to look for the book. Staff A
came out of the medication room and stated
there was not a book in there. The Clinical Nurse
Consultant entered the nurses station and stated
the medication information was in the EHR. He
was unable to locate it or show staff where to find
it. The DON stated there is a single desktop
computer at the nurses station that has full
Internet access. She stated they could either use
that or their personal cell phones to Google
medications if they had a question about dosages
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P60C11 Facility ID: IA0925 If continuation sheet Page 5 of 6
 PRINTED: 12/28/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________

C
165478 B. WING _____________________________
12/19/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

701 EAST MAPLELEAF DRIVE

ARBOR COURT
MOUNT PLEASANT, IA 52641

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 757 Continued From page 5 F 757

or interactions. She stated they do not issue
facility phones to use for references.

An Immediate Jeopardy (IJ) was identified on

12/15/22 (with the start date being noted as
12/5/22), and the facility was notified of the IJ on
12/15/22. The IJ was removed on 12/15/22 when
the facility developed and implemented the
following corrective action plan:

-Facility Nurses were educated by the

DON/Admin on 12/15/22 policies
PCU56-Medication Monitoring,
PCU-58Medication Discrepancies and Adverse
Medication Reactions
-Facility Nursing staff were educated on policy
NursA.9 Notification of Change in Resident
Condition by DON/Admin.
-Staff educated on 12/15/22 on monitoring PCC
for alerts for potential drug/drug interactions by
DON
-Staff educated on the importance of monitoring
bruising on residents with Anticoagulant therapy
on 12/15/22 for Dr. Notification by DON
-Facility did a 100% audit on all residents on
Coumadin to ensure appropriate routine lab in
place for PT/INR. Don completed this audit

The scope and severity level of the IJ deficiency

was lowered from a "J" to an "G" at the time of
the survey after the facility completed the above
removal plan.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P60C11 Facility ID: IA0925 If continuation sheet Page 6 of 6