Every finding on record at Advena Living of Cherryvale

The facility reported a census of 26 residents and one main kitchen. Based on observation and interview, the facility failed to store and prepare food under sanitary conditions for the residents of the facility. This deficient practice put the residents of the facility at risk for illnesses related to food borne bacteria. Findings included:- On 09/02/25 at 09:17 AM, observations during the initial kitchen tour with Dietary Staff BB revealed the following concerns: The handwashing sinks had brown stains and grime buildup around the sink's inner and outer edges, surrounding the sink's bowl.The foot-operated trash can had a broken lid lying on the floor behind the trash can, in a pile of used coffee grounds. The open trash can was adjacent to the food preparation area, beside the steam table and a rack of clean dishes. Dietary Staff BB agreed that the food preparation area should have the trash contained to ensure food sanitation and contamination from bacteria.On 09/03/25 at 11:20 AM, during a kitchen follow-up tour with Dietary Staff BB, observations revealed the uncovered trash can at the handwashing sink in the food preparation area adjacent to the steam table. Dietary Staff BB confirmed the broken trash can was the same one from the day before and verified the uncovered trash.The facility did not provide a policy to address trash disposal and hand sanitation equipment in the kitchen.

The facility reported a census of 26 residents. Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility outside kitchen access hallway and laundry area. This created the risk for impaired safety and cleanliness. Findings included:- On 09/02/25 at 09:17 AM, a tour of the facility's kitchen area with Dietary Staff BB revealed a hallway leading from the kitchen to outside with multiple broken tiles and standing water on the floor, which was being tracked through the kitchen. Dietary Staff BB reported that when it rains, the water comes in the entrance hallway to the kitchen and must be mopped up to keep the water out of the kitchen. She confirmed the hallway was used by kitchen staff to take the trash out, and the broken tile prevented sanitation of the area. On 09/04/25 at 07:58 AM, Maintenance Staff U confirmed multiple broken tiles in the hallway outside the kitchen, which led to the outside. He stated he did not realize the broken and missing tiles existed. Maintenance Staff U agreed the area was unsanitizable due to broken and missing tiles in the hallway. On 09/03/25 at 03:30 PM, observation revealed missing linoleum flooring behind the nurse's desk, approximately 10 inches by four inches, and a second area approximately two inches by one inch.On 09/04/25 at 09:30 AM, a tour of the laundry with Maintenance Staff U revealed the following concerns:An exposed three-inch-tall sewage pipe between the washers was open and not capped. An unsanitizable, unsealed ceiling in the dryer room due to missing and flaking paint. Unsanitizable walls in the washing and drying area, along with the door frame and laundry storage cabinets, due to being heavily scuffed with exposed wood and chipped paint. A wall-mounted thermostat without a cover that had exposed electrical components. On 09/03/25 at 03:30 PM, Licensed Nurse (LN) G reported that she had not paid attention to or noticed the damaged floor. She stated that staff should report maintenance or repair concerns through a computer notification system.On 09/04/25 at 09:15 AM, Maintenance Staff U stated that he was unaware of the floor damage at the nurse's station until yesterday, when he received a work order through the facility's computerized reporting system.On 09/04/25 at 10:38 AM, Administrative Staff A reported that maintenance and/or environmental repair or concerns should be reported immediately into the facility's computerized program for maintenance and repair work orders.On 09/04/25 at 11:30 AM, Maintenance Staff U stated he was unaware of the chipped ceiling in the dryer room or the scuffed and chipped paint on the walls. He reported the exposed thermostat was not functional. Maintenance Staff U stated all environmental or maintenance concerns were to be placed as a work order through the computer program, so that tracking could be performed; all staff were regularly informed of this, but it did not always happen that way. Maintenance Staff U said he checked equipment monthly and kept a monthly tracking record.The facility policy Maintenance Service, dated 10/2021, documented that maintenance service would be provided to all areas of the building, grounds, and equipment. It further documented that the maintenance department would be responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner.

The facility reported a census of 26 residents; the sample included 14 residents. Based on interviews, record review and observation, the facility failed to ensure a safe, clean home-like environment in the resident's rooms and common areas. This deficient practice placed the residents at risk for tripping hazards, electrical accidents, respiratory hazards and decreased comfort. Findings included:- During an observation on 09/02/25 at 12:23 PM, there were multiple dark spots on the floor at the head of R15's bed, and molding was missing from the base of the wall next to the bathroom door, with exposed and broken drywall. There were damaged ceiling areas with exposed sheet rock, and the floor was dirty and stained.Observed on 09/02/25 at 11:22 AM, R30's had a large area of wall next to the resident's bed with exposed dry-wall, and paint was missing that was approximately a quarter of the wall; the floor was dirty and sticky.Observed on 09/02/25 at 11:25 AM, the north hallway floor and north hallway rooms had chipped and cracked floor tiles throughout. The north hallway tiles had bubbled areas and numerous areas that had risen, exposing the concrete floor underneath.Observed on 09/02/25 at 02:41 PM, R15 was moved to another room by staff.Observed on 09/04/25 at 11:28 AM, revealed a crack that went from the top door frame of R30's up and across the ceiling and down the wall on the other side to the top door frame of R17's room.Observed on 09/04/25 at 09:55 AM, there was a broken wall tile on the west wall of the resident dining room. Also observed were two open 220-volt plug outlets in the dining room and two open 220-volt plug outlets in the north resident hall; the outlets were approximately six inches off the ground. During an observation on 09/04/25 at 10:05 AM, Maintenance U tested the 220-volt outlets and then stated that all four were live with electricity, and originally thought they were not hooked up.During an interview on 09/02/25 at 02:10 PM, with Administrative Staff A and Maintenance U, Maintenance U reported that he was unaware of the damage in R15's room and was unaware of the dark-stained spots on the floor at the head of the bed. Administrative Staff A also reported that she had been unaware of the damage in R15's room. Administrative Staff A further reported that R15 would be moved to another room so that the room could be repaired.During an interview on 09/02/25 at 03:02 PM, Maintenance U reported that an electrician had been scheduled for 09/04/25 to evaluate what was needed to make electrical repairs in the facility. During an interview on 09/03/25 at 03:30 PM, Licensed Nurse (LN) G stated that maintenance or repair concerns were reported through a computer notification system called The Equipment Lifecycle System (TELS-a computerized Maintenance Management System used to streamline maintenance operations).During an interview on 09/04/25 at 10:30 AM, Maintenance U reported that all environmental or maintenance concerns were to be placed as a work order through the computer program TELS, so that tracking could be performed, and all staff were regularly informed of this, but this does not happen that way. Maintenance U further stated that he had been aware of the wall damage in room [ROOM NUMBER] and had planned to repair it with paneling that could not be chipped, and he had been waiting approximately two weeks for flooring quotes to replace the flooring throughout the building.During an interview on 09/04/25 at 10:38 AM, Administrative Staff A stated that maintenance and environmental repair notification had to be done through TELS, and not by word of mouth; and staff should have been vigilant and placed maintenance work orders immediately.During an interview on 09/04/25 at 11:30 AM, Maintenance U stated that he had not been made aware of the ceiling and wall crack in the north hall. The facility policy Environment-General Cleanliness and Maintenance, dated 08/24, documented that staff of the facility would provide a safe, clean, comfortable, and homelike environment, allowing each resident to use his/her personal belongings as much as possible. It further documented that the environment of care would support each resident's positive self-image and dignity.The facility policy Maintenance Service, dated 10/21, documented that maintenance service would be provided to all areas of the building, grounds, and equipment. It further documented that the maintenance department would be responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

The facility identified a census of 26 residents. Twenty-six medications were observed for medication administration accuracy. Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than five percent (%) when staff administered four medications in error resulting in a medication error rate of 17%. This placed the residents at risk of ineffective medication regimens. Findings included:- Resident (R) 12's Electronic Medical Record (EMR) included the following orders:Carafate oral tablet, 1.0-gram (gm) (Sucralfate- an anti-ulcer medication with potential to alter the absorption of some drugs), give 1.0 gm, by mouth before meals for GERD; dissolve tablet in liquid of choice, give 30 minutes before meals, ordered 0/15/25.Zofran oral tablet 4 MG/ (Ondansetron- medication to relieve nausea), give one tablet by mouth, before meals for nausea/vomiting (N/V) with meals, ordered 08/16/25.Lactulose (synthetic sugar used to treat constipation) oral solution, 20 grams/30 milliliters (ml). Give 30 ml by mouth every 24 hours as needed for constipation, AND give 30 ml by mouth in the morning for constipation. Give 30 ml daily until bowel movement (BM), ordered 08/07/25.Lactobacillus (probiotic to support gut health) oral capsule, give two capsules by mouth before meals for prevention of gastric upset, ordered 02/18/25.Protonix oral tablet, delayed release, 20 MG (Pantoprazole Sodium- a medication used to reduce gastric acid to prevent GERD), give 40 MG, by mouth, in the morning for gastrointestinal protection, ordered 04/02/25.Misoprostol oral tablet 200 micrograms (MCG): give one tablet, by mouth, two times a day, give with or after food ordered 06/19/25.Diclofenac sodium tablet delayed release 75 MG, give one tablet by mouth two times a day for leg pain associated with chronic pain syndrome. Take with or after food, ordered 06/19/25.Metformin HCl (medication used to lower blood glucose) tablet 500 MG, give one tablet by mouth, two times a day, for diabetes, give with /after meals to avoid gastrointestinal (GI) upset. Ordered 08/31/25.On 09/03/25 at 10:17 AM, observation revealed Certified Medication Aide (CMA) R obtained the R12's blood pressure (BP) and held the resident's propranolol (medication used to treat HTN). R12 refused the Lactulose when offered. CMA R administered the remaining medications to R12's altogether following her breakfast, including the Lactobacillus, Carafate, Zofran, and Protonix, which were ordered to be given before meals. CMA R confirmed the resident's medications were scheduled for the morning medication pass, which was from 08:00 AM to 11:30 AM, and stated the medications ordered to be administered before meals should not be given with meals or with other medications that were ordered to be given with food or meals. On 09/03/25 at 01:08 PM, Licensed Nurse (LN) G confirmed the resident had issues with vomiting after meals and lost weight. She stated R12 was on multiple medications prescribed to be given before meals to prevent her vomiting. LN G verified that those medications should be administered before meals and on an empty stomach to prevent gastric upset. LN G acknowledged that the medications the resident took, as noted during the observation, should not be given together. LN G said she should advise the physician of the medication administration error.On 09/03/25 at 03:02 PM, Administrative Nurse D confirmed medications should be administered as ordered by the physician. She reported she had contacted the physician regarding R12's medication, and the physician stated Carafate had to be given separately due to its interference with the absorption of other medications and to ensure the effectiveness of the medication. The facility's policy, Medication Administration Schedule, dated 12/2012, documented that medications shall be administered according to established schedules; a physician's order for specific times supersedes any routine schedule.

The facility reported a census of 26 residents. Based on observation, interview and record review the facility failed to provide a safe and functional handrails in one of two hallways. This placed the residents at risk of impaired safety. Findings included:- Observed on 09/04/25 at 10:20 AM, during the facility tour with Maintenance Staff U, numerous handrails in the north resident hallway were loose and easily moved by hand.During an interview on 09/04/25 at 10:30 AM, Maintenance Staff U stated that he was unaware that there were loose handrails.During an interview on 09/04/25 at 10:38 AM, Administrative Staff A stated that she was unaware that there were loose handrails anywhere in the facility. She further stated that she expected staff to be vigilant and place a work order whenever they noticed any damaged equipment or when environmental repairs were needed.The facility policy Environment-General Cleanliness and Maintenance, dated 08/2024, documented that staff of the facility would provide a safe, clean, comfortable, and homelike environment, allowing each resident to use his/her personal belongings as much as possible. It further documented that the environment of care would support each resident's positive self-image and dignity.The facility policy Maintenance Service, dated 10/2021, documented that maintenance service would be provided to all areas of the building, grounds, and equipment. It further documented that the maintenance department would be responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

The facility reported a census of 26 residents; the sample included 14 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 3, R4, R23 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These practices had the potential to lead to uninformed decisions regarding treatment. Findings included:- Review of the Electronic Health Record (EHR) for R3 included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), cerebral edema (abnormal buildup of fluid in the brain, causing it to swell and increasing pressure inside the skull), and adjustment disorder with anxiety (a mental health condition characterized by excessive worry, nervousness, and fear in response to a stressful life event). R3’s Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS indicated that R3 required the use of a walker and wheelchair for mobility, required supervision or touching assistance for personal hygiene and putting on his shoes, set-up or clean-up assistance for bathing and eating, and was independent for all other cares. The MDS also indicated that R3 took antianxiety (a class of medications that calm and relax people) and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications. The Falls Care Area Assessment (CAA), dated 02/26/25, documented that R3 had fallen at least one time since admission and was taking an antianxiety medication, a high-risk drug. The Psychotropic Drug Use CAA, dated 02/26/25, documented that R3 had been taking antipsychotic and antianxiety medications, high-risk drugs. R3's “Quarterly MDS,” dated 06/24/25, documented a BIMS score of 12, which indicated moderate cognitive impairment. The MDS indicated R3 required the use of a walker and wheelchair for mobility, required set-up or clean-up assistance for eating, oral hygiene, and bathing, was dependent on staff for putting on shoes, and was independent for all other cares. The MDS also indicated that R3 took antianxiety and antipsychotic medication. R3's Care Plan dated 06/20/24 documented R3 used psychotropic medications related to the disease process of schizophrenia. Interventions dated 04/11/24 included that staff were to administer psychotropic medications as ordered by the physician, monitor for side effects, and consult with the pharmacy and doctor to consider dosage reduction when clinically appropriate at least quarterly. R3’s EHR revealed a psychotropic informed consent, signed and dated 09/02/25, that listed psychotropic medication types with the side effects for Seroquel (an antipsychotic medication used to treat schizophrenia) 25 milligrams (MG) and Zyprexa (an antipsychotic medication used to treat schizophrenia) 15 MG at bedtime. R3’s EHR documented an order dated 08/08/25 for clonazepam 0.5 milligrams (MG) at bedtime for sleeplessness/anxiety and give 0.5 MG every eight hours as needed for sleeplessness/anxiety. An order, dated 04/01/25, for Seroquel (an antipsychotic medication used to treat schizophrenia) 25 MG at bedtime for schizophrenia; and an order, dated 03/28/25, for Zyprexa (an antipsychotic medication used to treat schizophrenia) 15 MG at bedtime for schizophrenia. R3’s EHR revealed a psychotropic informed consent, signed and dated 09/02/25, that listed psychotropic medication types with the side effects for Seroquel 25 MG and Zyprexa 15 MG at bedtime. R3’s EHR revealed a psychotropic informed consent signed and dated 08/08/25, for clonazepam (a medication used to treat anxiety) 0.5 MG at bedtime, but did not list the clonazepam 0.5 MG every eight hours as needed. Observed 09/03/25 at 09:37 AM, R3 sat in his wheelchair in his room staring at his bed. Observed on 09/03/25 at 12:10 PM, R3 was in the dining room, in his wheelchair, eating lunch with other residents. During an interview on 09/03/25 at 02:05 PM, Administrative Nurse D stated that psychotropic informed consents were to be completed prior to starting the psychotropic medication, increasing the dosage, or increasing the schedule. Administrative Nurse D also stated that the nurses were allowed to perform the informed consents. Administrative Nurse D verified that the start date for Seroquel was 04/01/25, and Zyprexa was 03/28/25, and the consent was not done until 09/02/25. During an interview on 09/03/25 at 03:30 PM, Licensed Nurse (LN) D stated that all nurses were responsible for ensuring that psychotropic informed consents were accurate and up to date. LN G said that if the consents were not completed or accurate, then the medication was to be put on hold until it was completed. During an interview on 09/04/25 at 10:03 AM, Administrative Staff A stated that psychotropic informed consents were to be performed anytime a psychotropic medication was changed or started, and before said changes. Administrative Staff A said that it included informing and getting signatures from the resident and/or the resident's legal guardian, and was to be obtained before giving the medication. The facility policy for Psychotropic Medication Monitoring, undated, included: The facility will obtain informed consent from the resident and/or resident representative before an antipsychotic medication is started. - R4's Electronic Medical Record (EMR) included the following diagnoses: anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R4's EMR documented the following physician's orders:Clonazepam (an antianxiety medication), 1 milligram (mg), by mouth (po), every (Q) 24 hours, as needed (PRN), for 90 days, for a diagnosis of anxiety, ordered 08/29/25.Clonazepam, 1 mg, po, at bedtime (HS), for a diagnosis of anxiety, ordered 08/08/25.Desvenlafaxine (an antidepressant medication), 100 mg, PO, every day (QD), for a diagnosis of bipolar disorder, ordered 08/08/25.Lamotrigine (a mood stabilizer medication), 100 mg, PO, twice daily (BID), for a diagnosis of bipolar disorder, ordered 08/08/25.Latuda (an antipsychotic medication), 120 mg, PO, QD, for a diagnosis of bipolar disorder, ordered 08/08/25. R4's EMR lacked documentation of informed consent for R4's psychotropic and antipsychotic medications. On 09/03/25 at 02:05 PM, Administrative Nurse D stated the informed consents for psychotropic drug use should be completed prior to the initiation of the medication. Administrative Nurse D confirmed the facility had not completed consents for R4's psychotropic medications. The facility policy for Psychotropic Medication Monitoring, undated, included: The facility will obtain informed consent from the resident and/or resident representative before an antipsychotic medication is started. - R23's Electronic Medical Record (EMR) included the following diagnoses: anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R23's EMR documented the following physician's orders:Lorazepam (an antianxiety medication), 0.5 milligrams (mg), by mouth (po), every (Q) 2 hours, as needed (PRN), for a diagnosis of anxiety, ordered 07/11/25.Mirtazapine (an antidepressant medication), 45 mg, PO, at bedtime (HS), PRN, for depression, ordered 05/09/25. R23's EMR lacked documentation of informed consent for R4's psychotropic medications. On 09/03/25 at 02:05 PM, Administrative Nurse D stated the informed consents for psychotropic drug use should be completed prior to the initiation of the medication. Administrative Nurse D confirmed the facility had not completed consents for R23's psychotropic medications. The facility policy for Psychotropic Medication Monitoring, undated, included: The facility will obtain informed consent from the resident and/or resident representative before an antipsychotic medication is started.

The facility identified a census of 26 residents; the sample included 14 residents. Based on observation, record review, and interviews, the facility failed to include Resident (R) 1 or her representative in the development and planning of the resident's care plan. This deficient practice placed R1 at risk of impaired care and decreased autonomy. Findings included:- R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychotic disturbance (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, thoughts, and behaviors), mood disturbance (psychiatric conditions characterized by persistent and intense changes in emotional state, such as prolonged sadness, irritability, or mania, leading to a decreased quality of life and potential functional impairment), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R1's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS indicated that R1 required the use of a walker and wheelchair for mobility, required supervision or touching assistance for oral hygiene and upper body dressing, partial to moderate assistance for toileting and personal hygiene and lower body dressing, set-up or clean-up assistance for eating, and was dependent on staff for putting on footwear. The MDS also indicated that R1 took an antidepressant (a class of medications used to treat mood disorders) and opioid (a class of controlled drugs used to treat pain) medication.The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 01/29/25, documented that R1 had a BIMS summary score less than 13.The Functional Abilities (Self-Care and Mobility) CAA, dated 01/29/25, documented that R1 required set-up or clean-up assistance for eating, supervision or touching for oral hygiene, and partial or moderate assistance for toileting hygiene.R1's Quarterly MDS, dated [DATE], documented a BIMS score of 15, which indicated intact cognition. The MDS indicated that R1 required the use of a walker and wheelchair for mobility, required partial to moderate assistance for bathing, and set-up or clean-up assistance for all other cares. The MDS also indicated that R1 took opioid medication.R1's Care Plan, dated 06/03/24, documented that R1 had dementia with an intervention for staff to communicate with the resident, the resident's family, and caregivers regarding R1's capabilities and needs.R1's EMR revealed an admission date of 11/02/22 with care plan signature pages of attendance for 07/09/24 and 12/18/24 that showed R1 had attended and participated in the care plan meeting. R1's EMR lacked evidence that the resident was invited and/or included in any further care plan meetings.During an interview on 09/02/25 at 10:44 AM, R1 reported she had not been informed or invited to her care plan meetings.During an interview on 09/03/25 at 08:42 AM, Social Services X stated that she was unable to provide documentation of R1's care plan meetings or documentation that R1 was invited and/or attended her care plan meetings. Social Services X further stated that she was responsible for notifying the residents of the meetings along with the provider, the resident's legal guardian, and anyone else the resident wanted in attendance.During an interview on 09/03/25 at 09:38 AM, Administrative Nurse E verified there was no documentation available for care plan meetings. Administrative Nurse E also stated that the Social Services Designee (SSD) was responsible for providing the resident notification about the care plan meetings and that they are held every 90-days, and included the resident, resident's legal guardian, provider, Director of Nursing (DON) or Assistant Director of Nursing (ADON), Dietary Manager (DM) and anyone else the resident wanted in attendance.During an interview on 09/04/25 at 10:03 AM, Administrative Staff A stated that the resident should be notified of their care plan meeting times and that it should be scheduled around their time availability; the SSD was responsible for coordinating the care plan meetings, and documentation of the care plan meeting should have been filed in the paper chart and EHR. Administrative Staff A further stated that the facility was in the process of performing chart audits, and was aware there had been a records lapse. The facility policy Care Planning-Interdisciplinary Team, dated 10/21, documented that the resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. The policy further documented that every effort would be made to schedule care plan meetings at the best time of the day for the resident and family.

The facility reported a census of 26 residents; the sample included 14 residents, with five sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure a14-day stop date or justification for the continuation of an as needed (PRN) psychotropic medication (alters mood or thought) including a specified duration for Resident (R)3. This deficient practice placed R3 at risk of unnecessary psychotropic medication and related adverse effects. Findings included:- Review of the Electronic Health Record (EHR) for R3 included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), cerebral edema (abnormal buildup of fluid in the brain, causing it to swell and increasing pressure inside the skull), and adjustment disorder with anxiety (a mental health condition characterized by excessive worry, nervousness, and fear in response to a stressful life event).R3's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS indicated that R3 required the use of a walker and wheelchair for mobility, required supervision or touching assistance for personal hygiene and putting on his shoes, set-up or clean-up assistance for bathing and eating, and was independent for all other cares. The MDS also indicated that R3 took antianxiety (a class of medications that calm and relax people) and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications.The Falls Care Area Assessment (CAA), dated 02/26/25, documented the R3 had fallen at least one time since admission and was taking an antianxiety medication, a high-risk drug.The Psychotropic Drug Use CAA, dated 02/26/25, documented the R3 had been taking antipsychotic and antianxiety medications, as high-risk drugs.R3's Quarterly MDS, dated 06/24/25, documented a BIMS score of 12, which indicated moderate cognitive impairment. The MDS indicated R3 required the use of a walker and wheelchair for mobility, required set-up or clean-up assistance for eating, oral hygiene, and bathing, was dependent on staff for putting on shoes, and was independent for all other cares. The MDS also indicated that R3 took antianxiety and antipsychotic medication. R3's Care Plan dated 06/20/24 documented R3 used psychotropic medications related to the disease process of schizophrenia. Interventions dated 04/11/24 included that staff were to administer psychotropic medications as ordered by the physician, monitor for side effects, and consult with the pharmacy and doctor to consider dosage reduction when clinically appropriate at least quarterly.R3's EHR documented an order dated 08/08/25 for clonazepam (a medication used to treat anxiety) 0.5 milligrams (MG) at bedtime for sleeplessness/anxiety and give 0.5 MG every eight hours as needed for sleeplessness/anxiety. The order lacked a stop date.Review of R3's MAR/TAR for the month of August 2025 revealed that R3 had not received the PRN 0.5 MG of clonazepam for the dates 08/08/25 through 08/31/25.R3's EHR lacked a specific duration with a physician justification to continue the PRN clonazepam.Observed 09/03/25 at 09:37 AM, R3 sat in his wheelchair in his room staring at his bed.Observed on 09/03/25 at 12:10 PM, R3was in the dining room, in his wheelchair, eating lunch with other residents.During an interview on 09/03/25 at 02:05 PM, Administrative Nurse D stated that psychotropic medications were to have a stop date after 14 days, or a rationale for the continuation beyond 14 days must have been included for any non-antipsychotic psychotropic medications. Administrative Nurse D verified there was no stop date or rationale for continuation of the as-needed clonazepam beyond the 14 days for R3. During an interview on 09/03/25 at 03:30 PM, Licensed Nurse (LN) D stated that as-needed psychotropic medication should have had a 14-day stop date. During an interview on 09/04/25 at 10:03 AM, Administrative Staff A stated that as-needed psychotropic medication should have had a start and end date not to exceed 14 days.The facility did not provide a policy related to 14-day stop dates for psychotropic medications.

The facility reported a census of 26 residents. The sample included 14 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to notify the Ombudsman of Resident (R)23's admission to the hospital, placing the resident at risk of impaired rights related to transfers and discharge. Findings included:- R23's Electronic Medical Record (EMR) included the following diagnoses: Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R23's EMR documented in the progress notes that the resident transferred to the hospital on [DATE]. R23's EMR lacked documentation of the Ombudsman being notified of the transfer to the hospital. The facility was unable to provide evidence that the Ombudsman was notified of the transfer. On 09/04/25 at 10:21 AM, Administrative Nurse D confirmed the Ombudsman had not been notified of the resident's discharge to the hospital on [DATE]. The facility policy for Transfer or Discharge Notice, revised December 2016, included: The facility shall provide the Ombudsman with notification of residents who transfer or discharge from the facility.

The facility reported a census of 26 residents. The sample of 14 residents included three residents reviewed for nutrition. Based on observation, interview, and record review, the facility failed to provide ongoing assessment by the Registered Dietician (RD) for the effectiveness of interventions and impact of nausea and vomiting on nutritional status for Resident (R)12, who had experienced a significant weight loss and continued with insidious loss. This deficient practice placed the resident at risk for continued weight loss and malnutrition. Findings included:- R12's Electronic Health Records (EHR) Physician Orders (POS), dated 08/04/ 25 documented: diagnoses which included multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), spastic hemiplegia (paralysis of one side of the body) affecting right dominant side, cerebral infarct (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), neuroleptic induced Parkinsonism (drug induced parkinsonism), Schmorl's Nodes of the thoracic region (herniation of the disc through the weak cart cartilage of the adjacent vertebral body of the mid chest region), diabetes (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), seizures, chronic pain syndrome, major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), leg pain, altered mental status, insomnia (inability to sleep), unsteadiness, gastroesophageal reflux (GERD- digestive disease in which stomach acid or bile irritated the food pipe lining), hypertension (HTN- high blood pressure), constipation, and migraines.R12's 11/07/24 Annual Minimum Data Set (MDS) documented a Brief interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS noted she received high-risk medications, which included antipsychotic (medication to treat major mental health disorders), antidepressant (medication to treat mood disorders), and opioid (narcotic pain medication). The MDS documented R12 felt snacks between meals were very important. The MDS noted R12 had functional limitations in her range of motion for both sides of her upper and lower extremities. Her height was 64 inches, and her weight was 161 pounds (lbs.).The Nutritional Status Care Area Assessment (CAA), dated 11/14/25, documented R12's body mass index (BMI) was 27.7%. Her diet order was a regular diet with sugar-free condiments, regular texture, and regular, thin liquids. The CAA noted R12 weighed 164 lbs. She fed herself without difficulty and had decreased her snacking. She had maintained her weight over the previous two months, and staff encouraged her to follow her diet restrictions. Staff would continue to monitor and report changes as needed to the charge nurse and/or appropriate staff.R12's Quarterly MDS, dated 07/16/25, documented changes from the Annual MDS that included a BIMS score of 14, indicating intact cognition. Her weight was 132 lbs. R12's Care Plan dated 07/30/24, directed staff R12 had a desire to maintain her weight, and had experienced recent weight loss, initiated 03/28/18. Staff were to provide a dietary consult for nutritional regimen and ongoing monitoring, initiated 03/28/18. Staff were to monitor, document, and report as needed any signs or symptoms, which included weight loss, initiated on 03/28/18.R12's EHR, under the Physician Orders, included the following orders:Weekly weight in the morning every Sunday for weight loss initiated 08/17/25.No added salt, sugar-free diet, regular texture, with regular, thin liquids, order 08/14/25Protein supplement with medication passes three times a day for supplement ordered 07/28/25.R12's EHR recorded an RD Dietary/Nutrition Progress Note dated 07/05/25 at 04:41 PM that noted R12 had nausea and vomiting for more than two days. The note documented R12's weight fluctuated and noted the RD would check in R12 at the upcoming visit regarding nausea and vomiting per the dietary manager (DM) and RD observations.\Review of R12's Vital Sign/Weight documentation, dated 07/13/25 through 09/03/25, revealed the following weights, which indicated a loss:07/13/25 132.0 lbs.07/23/25 128.5 lbs.07/25/25 127.0 lbs.07/27/25 127.0 lbs.08/03/25 129.4 lbs.08/17/25 119.3 lbs.08/24/25 120.5 lbs.08/31/25 119.0 lbs.The RD visit information provided by the facility for 08/11/25 lacked evidence that the RD assessed R12 for the continued weight loss and to evaluate the effectiveness of nutritional interventions.On 09/03/25 at 08:50 AM, R12 fed herself sausage, eggs, and cheese and stated her breakfast was very good.On 09/03/25 at 01:03 PM, R12 sat in her wheelchair at the reception desk, drinking clear liquid through a straw. She reported she only ate a small amount of her lunch of spaghetti and green beans, but said she threw up after lunch. Certified Nurse Aide (CNA) N walked by, and R12 said she could not drink anymore, or she would vomit. CNA N took the cup and asked if R12 wanted something else, and suggested water. R12 agreed, and CNA N provided her with some water and offered to help R12 get cleaned up. Further observation revealed lumpy yellow vomit in R12's chair. CNA N stated the vomitus looked like undigested eggs and then asked the resident if she had eggs for lunch. R12 replied that she had eggs for breakfast. On 09/03/25 at 10:17 AM, Certified Medication Aide (CMA) R administered R12's medications following her breakfast. CMA R confirmed the resident vomited frequently and had lost weight. On 09/03/25 at 01:08 PM, Licensed Nurse (LN) G confirmed R12 had issues with vomiting after meals and had lost weight.On 09/03/25 at 02:50 PM, Dietary Staff BB and Administrative Nurse D confirmed the RD should evaluate identified high-risk residents during her monthly visits. Dietary Staff BB and Administrative Nurse D verified R12 was at high nutritional risk due to her significant weight loss and should have been assessed on the RD's monthly visit on 08/11/25.The facility did not provide a policy to address RD assessments and review of the effectiveness of dietary interventions for high-risk residents with significant weight loss.

The facility reported a census of 26 residents. The sample of 14 residents included one resident reviewed for pain management. Based on observation, interview, and record review the facility failed to provide adequate pain management for Resident (R) 12 when staff failed to administer scheduled pain medication separate from medication that interfered with the absorption and therapeutic effectiveness of her pain medication. This placed the resident at risk for uncontrolled pain and decreased quality of life. Findings included:- R12's Electronic Health Records (EHR) Physician Orders (POS), dated 08/04/ 25 documented: diagnoses which included multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), spastic hemiplegia (paralysis of one side of the body) affecting right dominant side, cerebral infarct (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), neuroleptic induced Parkinsonism (drug induced parkinsonism), Schmorl's Nodes of the thoracic region (herniation of the disc through the weak cart cartilage of the adjacent vertebral body of the mid chest region), diabetes (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), seizures, chronic pain syndrome, major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), leg pain, altered mental status, insomnia (inability to sleep), unsteadiness, gastroesophageal reflux (GERD- digestive disease in which stomach acid or bile irritated the food pipe lining), hypertension (HTN- high blood pressure), constipation, and migraines.R12's 11/07/24 Annual Minimum Data Set (MDS) documented a Brief interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS documented R12 received scheduled pain medication and reported frequent pain, which occasionally interfered with sleep and activities of daily living (ADL). The MDS noted R12 received scheduled pain medication and reported frequent pain rated at a seven out of 10 on a 0-10 scale (scale where zero represents no pain and 10 the worst pain imaginable), which occasionally interfered with sleep and ADL. The MDS noted she received high-risk medications, which included antipsychotic (medication to treat major mental health disorders), antidepressant (medication to treat mood disorders), and opioid (narcotic pain medication).R12's 07/16/25 Quarterly MDS, documented changes from the Annual MDS, which included a BIMS score of 14, indicating cognitively intact. The MDS noted R12 reported very severe, almost constant pain.The Pain Care Area Assessment (CAA), dated 11/04/25, documented R12 rated her pain at a six out of 10, and reported generalized pain. She currently received tramadol (narcotic pain medication) and meloxicam (non-steroidal anti-inflammatory), scheduled for pain and Tylenol as needed (PRN). Staff should monitor the effectiveness of pain medications. Nursing staff were assessing and monitoring the resident for effectiveness and medication side effects.R12's Care Plan dated 07/30/24 documented the resident had chronic pain related to migraines, MS, arthritis, and Schmorl's Nodes of the thoracic (mid-back) region. Staff should anticipate her need for pain relief and respond to any complaints of pain. The plan directed staff to evaluate the effectiveness of pain interventions, dosing schedules, and resident's satisfaction with the results. The plan directed staff to discuss the number and type of medications the resident was taking and the potential for drug interactions and side effects from overmedication. The plan documented R12 had more than one prescribing physician, so staff should ensure that each physician had the full list of medications, including over-the-counter and as-needed medications. The plan directed staff to monitor for possible side effects, which include depression, agitation, poor appetite, and gastric upset. The plan directed staff to review medications with physicians and a consulting pharmacist for duplication of medications, proper dosing, and timing.R12's EHR, under the Physician Orders, dated 8/04/25, included the following medications:Tramadol HCl Tablet, 50 milligrams (MG); give by mouth three times a day for pain, ordered 07/25/25.Tylenol oral tablet; give 325 MG, by mouth, every six hours as needed for pain management, not to exceed (NTE ) 3 grams in 24 hours, ordered 07/25/25.Misoprostol (medication used to treat pain by reducing swelling and inflammation) oral tablet 200 micrograms (MCG), give one tablet, by mouth two times a day, for pain, give with or after food ordered 06/19/25.Diclofenac sodium tablet delayed release (non-steroidal anti-inflammatory used to treat pain) 75 MG, give one tablet by mouth two times a day for leg pain associated with chronic pain syndrome. Take with or after food, ordered 06/19/25.Carafate oral tablet, 1.0-gram (gm) (Sucralfate- an anti-ulcer medication with potential to alter the absorption of some drugs), give 1.0 gm, by mouth before meals for GERD; dissolve tablet in liquid of choice, give 30 minutes before meals, ordered 0/15/25.Zofran oral tablet 4 MG/ (Ondansetron- medication to relieve nausea), give one tablet by mouth, before meals for nausea/vomiting (N/V) with meals, ordered 08/16/25.Lactobacillus (probiotic to support gut health) oral capsule, give two capsules by mouth before meals for prevention of gastric upset, ordered 02/18/25.Protonix oral tablet, delayed release, 20 MG (Pantoprazole Sodium- a medication used to reduce gastric acid to prevent GERD), give 40 MG, by mouth, in the morning for gastrointestinal (GI) protection, ordered 04/02/25.On 09/03/2025 at 08:50 AM, R 12 observed feeding herself sausage, egg, and cheese and stated her breakfast was very good.Observation on 09/03/25 at 10:17 AM revealed R12 reported to Certified Medication Aide (CMA) R that she had pain all over and rated her pain a 10 out of 10. CMA R administered all of R12's medications together, including the tramadol, misoprostol, and diclofenac, following breakfast without regard for the physician's orders to administer four medications (Carafate, Zofran, Lactobacillus, and Protonix) before meals to prevent GI upset. CMA R confirmed the resident vomited frequently. She confirmed the four medications were ordered before meals, and the medications that were ordered with food or after meals should not be given together with those to be given before meals. CMA R verified that the scheduled pain medications were scheduled and administered at the same time as the four GI medications, even though the GI meds were ordered before meals to prevent nausea and vomiting at meals, which could interfere with the effectiveness of the pain medications. On 09/03/25 at 01:03 PM, R12 sat in her wheelchair at the reception desk, drinking clear liquid through a straw. She reported she only ate a small amount of her lunch of spaghetti and green beans, but said she threw up after lunch. She stated she had pain in her back. Certified Nurse Aide (CNA) N walked by, and R12 told the CNA she could not drink anymore, or she would vomit. R12 told CNA N she was hurting all over, and CNA N asked the resident when she last had her pain medication. R12 stated she had been given pain medication earlier, but she had thrown it up, and she did not get any relief from her pain.On 09/03/25 at 01:08 PM, Licensed Nurse (LN) G confirmed the resident had issues with vomiting after meals. She stated R12 was on multiple medications prescribed to be given before meals to prevent her from vomiting, and verified that those medications should be administered before meals and on an empty stomach to prevent gastric upset. LN G acknowledged that the medications the resident took for pain and to prevent GI upset should not be given together. She stated she should advise the physician of the medication administration error and the resident's vomiting after the meal and medication administration. LN G said staff should change the administration times of the medications to ensure they were given at appropriate times to prevent adverse reactions and maximize the effectiveness of the pain medications. On 09/03/25 at 03:02 PM, Administrative Nurse D confirmed medications should be administered as ordered by the physician. She reported she had contacted the physician regarding the medication errors, and the physician had stated Carafate should be given separately from other medications due to its interference with the absorption of other medications to ensure the effectiveness of the medications. The facility did not provide a policy on pain management.

The facility reported a census of 26 residents. The sample included 14 residents which included six residents for unnecessary medications. Based on observation, interviews, and record review, the facility failed to acknowledge and/or act on the consultant pharmacist's (CP) recommendation to resolve identified irregularities for Resident (R)10, related to anticoagulant (inhibits the blood from clotting) medication. This placed R10 at risk for unnecessary medications and related complications. Findings included:- R10's Physician Orders, dated 08/06/25, revealed diagnoses which included hypertension (HTN-high blood pressure), chronic kidney disease, hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).R10's Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. He received high-risk medications, which included an anticoagulant.R10's Quarterly MDS, dated 06/25/25, documented the resident received an anticoagulant high-risk medication.R10's Care Plan, dated 07/17/25, directed staff to administer anticoagulant therapy medication as ordered by the physician and monitor for side effects and effectiveness every shift.R10's Physician Orders (POS) dated 08/06/25, included the following orders:Xarelto (anticoagulant) oral tablet; give 2.5 milligrams (MG), by mouth, two times a day for a history of stroke; ordered 12/28/24.Monitor for side effects of anticoagulant medication to include discolored urine, black tarry stools, sudden severe headache, diarrhea, muscle or joint pain, lethargy, bruising, sudden changes in mental status, vital signs, shortness of breath, nose bleeds, nausea and/or vomiting, ordered 4/26/24.R10's CP Pharmacy Medication Review, dated 07/23/25, documented a pharmacy recommendation that Xarelto was added to the 2019 Beers Criteria due to increased risk of serious bleeding compared to other anticoagulants when used long-term in adults older than 75 years. In order to avoid the potential for adverse events, please consider discontinuing or replacing this resident's Xarelto with Eliquis (an anticoagulant) 5 MG, two times a day. The recommendation was sent to the physician for follow-up by the facility on 07/28/25.Review of R10's Pharmacy Medication Review, and subsequent physician follow-up and clinical record, dated 07/23/25 through 09/03/25, lacked evidence that the facility obtained a response from the physician to follow up to the 07/23/25 pharmacist recommendation (42 days after the initial recommendation).On 09/02/25 at 11:00 AM, R10 sat in his wheelchair. He wore a foam splint on his left hand.On 09/03/25 at 11:16 AM, Administrative Nurse D confirmed the above findings. She stated she had overlooked that the physician had not responded to the CP's recommendation in a timely manner. The facility did not provide a policy to address follow-up on CP recommendations.

The facility census totaled 26 residents on two halls. Based on observation, interview, and record review, the facility failed to ensure the staff had properly secured storage of resident medications. This deficient practice placed the residents at risk of missing medications and ineffective medication regimens. Findings included:- Observed on 09/04/25 at 10:13 AM, in the Environmental Services closet, delivery boxes sat on the floor. One box contained the following stock medications: A&D Ointment (a moisturizing cream for skin), two bottles of 81 milligram (MG) aspirin (ASA- a nonsteroidal anti-inflammatory drug [NSAID] used to treat pain, fever, and inflammation, and also used at low doses to prevent heart attacks and strokes), folic acid 1000 micrograms (MCG) (a B-vitamin that helps the body make new cells), probiotic (stimulates the growth of gut normal flora), Voltaren Gel (type of NSAID that treats joint pain caused by arthritis), Allegra 180 MG 24 hour (a medication that treats and prevents symptoms of allergies), Niacin 500 MG (vitamin B3, a water-soluble vitamin that is essential for bodily functions and energy metabolism), and Senna-Plus (a stool softener and laxative).During an interview on 09/04/25 at 10:20 AM, Administrative Nurse D stated that when medications were delivered, they were to go straight to the medication room, then get sorted and placed where they were intended to go. During an interview on 09/04/25 at 10:40 AM, Administrative Staff A stated that medication should not have been stored anywhere other than the medication cart or medication room.The facility policy Storage of Medication, dated 11/20, documented that the facility would store all drugs and biologicals in a safe, secure, and orderly manner.

The facility reported a census of 32 residents with 12 residents sampled, including one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to the one sampled Resident (R)14, while staff provided cares in his room. Findings included: - Review of Resident (R)14's Physician Order Sheet (POS), dated 12/12/23, documented the following diagnoses: morbid obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions) and benign prostatic hyperplasia (BPH-a condition in which the flow of urine is blocked due to the enlargement of prostate gland causing an increase in frequency of urination at night and difficulty in urinating). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had an indwelling urinary catheter (thin tubing inserted into the bladder to drain urine into a bag). The Urinary Incontinence/Indwelling Urinary Catheter Care Area Assessment (CAA), dated 12/27/23, documented the resident had an indwelling catheter but required staff assistance with getting onto and off the bedpan for bowel movements (BM). The Annual MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He had an indwelling urinary catheter. The care plan for urinary, revised 11/15/23, instructed staff the resident had an indwelling urinary catheter. Staff were to monitor for signs and symptoms of pain or discomfort due to the catheter. Review of the resident's electronic medical record (EMR) included the following physician's order: Cleanse the suprapubic area with normal saline (NS), apply a split gauze 4 X 4 gauze pad and tape to secure, every day for preventative, ordered 12/02/23. On 01/03/24 at 11:12 AM, Licensed Nurse (LN) G entered the resident's room to clean the suprapubic catheter area and apply a new split gauze pad. While cares were being provided, Certified Nurse Aide) M knocked on the resident's room door and entered immediately without waiting for a response from anyone in the room. The resident was on his back on the bed with his pants lowered down past his groin while the LN provided cares. When the room door opened, the staff exposed the resident to anyone in the hallway outside of his door. On 01/03/24 at 11:12 AM, LN G stated she would expect the staff to await a response after knocking before opening the door to a resident's room. On 01/04/24 at 09:11 AM, CNA M confirmed she had not waited for a response from the resident's room after knocking because she did not know that LN G was doing cares with the resident at that time. On 01/14/24 at 12:50 PM, Administrative Nurse D stated she expected staff to wait for a response from a resident before walking into their room. The facility policy for Resident Rights, revised December 2016, included: Staff shall treat all residents with kindness, respect, and dignity. The facility failed to show respect and dignity to this exposed resident while staff provided cares.

The facility reported a census of 32 residents with 12 selected for review which included one resident reviewed for Advance Directives (legal documents that provide instructions for medical care). Based on interview and record review, the facility failed to ensure one Resident (R)6's request for full resuscitative measures in case of cardiac or respiratory arrest was communicated in the care plan and to the hospice provider. Findings included: - Review of Resident (R)6's medical record, revealed diagnosis included chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set(MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The resident received hospice services. The Cognitive Loss Care Area Assessment (CAA), dated 09/27/23, assessed the resident was able to answer questions readily with a BIMS score of 11. The resident was able to make his needs known. The Care Plan, reviewed 12/13/23, instructed staff the resident was not at nor approaching end of life at this time. The resident was on hospice services and had a Do Not Resuscitate (DNR) order. The medical record contained a Do Not Resuscitate document signed by the resident dated 07/24/19. The medical record contained an Advance Directive Statement, dated 07/23/21 signed by the resident which indicated he did want cardiopulmonary resuscitation. Interview, on 01/02/24 at 03:01 PM, with Social Service Staff X, confirmed the Advance Directive dated 07/29/19 requested DNR and the Advance Directive Statement dated 07/23/21 requested full code measures. Social Service Staff X stated the resident had a designated power of attorney now and the facility staff would need to contact them to clarify the resident's desires. Interview, on 01/02/24 at 03:06 PM with Administrative Nurse D revealed the medical record should reflect the resident's most up to date code status and the Advance Directive Statement dated 07/23/21, would revoke the DNR signed 07/24/19. Interview, on 01/03/24 at 11:07 AM, with Hospice Nurse GG, revealed she knew of the DNR signed by the resident on 07/24/19 but did not know about the full code request Advance Directive Statement dated 07/23/21, and would need to contact the hospice social worker for clarification. The facility policy Resident Rights revised 2016, instructed staff the resident has the right to self-determination and to be informed of and participate in his or her care planning and treatment. The facility failed to clarify the Advance Directive Statement to ensure the resident's choice for accurate resuscitation/DNR were honored.

The facility reported a census of 32 residents with 12 residents sampled, including two residents reviewed for hospitalization . Based on interview and record review, the facility failed to provide the two Residents (R)14 and R 20 and/or their representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the residents' transfer to the hospital. Findings included: - Review of Resident (R)14's Physician's Order Sheet (POS), dated 12/12/23, documented a diagnosis of constipation (inability to pass stool). The Significant Change Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had no impairment in functional range of motion (ROM) and was always continent of bowel. The Urinary Incontinence/Indwelling Urinary Catheter Care Area Assessment (CAA), dated 12/27/23, documented the resident required staff assistance with toileting due to requiring assistance to get him onto and off the bedpan for bowel movements (BM)s. The Discharge Return Anticipated MDS, dated [DATE], documented the resident had an unplanned discharge to an acute hospital. The care plan lacked staff instruction regarding the need for a bed hold should the resident discharge to an acute hospital setting. Review of the resident's electronic medical record (EMR) revealed it lacked a signed bed hold for the hospitalization on [DATE]. On 01/04/24 at 09:15 AM, Administrative Staff A stated the facility lacked a bed hold for this resident upon his discharge to the hospital. The facility lacked a policy regarding bed holds. The facility failed to provide this resident and/or their representative with a written notice specifying the duration and cost of the bed hold policy at the time of the resident's transfer to the hospital. 28560 - Review of Resident (R)20's Physician Order Sheet, dated 12/07/23, revealed diagnoses included hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), chronic renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Significant Change Minimum Data Set, dated dated dated [DATE] assessed the resident with a Brief Interview for Mental Status) BIMS score of 13 which indicated normal cognition. The Care plan reviewed 10/18/23, instructed staff the resident was able to make his own decisions, but staff to educate the resident to ensure decisions are safe regarding health and safety. The resident transferred and admitted to acute care on 10/05/23 for bradycardia (slow heart rate) and returned to the facility on [DATE]. The medical record lacked a bed hold. The resident transferred and admitted to acute care on 10/20/23 for pneumonia (inflammation of the lungs) and returned to the facility on [DATE]. The medical record lacked a bed hold. Interview, on 01/04/24 at 10:30 AM, with Administrative Staff A, revealed staff did not issue bed holds for the transfers and the facility lacked a policy for issuing a bed hold. The facility lacked a policy for bed hold. The facility failed to issue a bed hold to this resident/responsible party for this resident's two transfers/admissions to acute care as required.

The facility reported a census of 32 residents with 12 selected for review. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for two of the 12 residents reviewed. Resident (R)7 for non-pharmaceutical interventions for pain, and R6 for revision of resuscitation preferences. Findings included: - Review of Resident (R)6's medical record, revealed diagnosis included chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set(MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The resident received hospice services. The Cognitive Loss Care Area Assessment (CAA), dated 09/27/23, assessed the resident was able to answer questions readily with a BIMS score of 11. The resident was able to make his needs known. The Care Plan, reviewed 12/13/23, instructed staff the resident was not at nor approaching end of life at this time. The resident was on hospice services and had a Do Not Resuscitate (DNR) order. The medical record contained a Do Not Resuscitate document signed by the resident dated 07/24/19. The medical record contained an Advance Directive Statement, dated 07/23/21 signed by the resident which indicated he did want cardiopulmonary resuscitation. Interview, on 01/02/24 at 03:01 PM, with Social Service Staff X, confirmed the Advance Directive dated 07/29/19 requested DNR and the Advance Directive Statement dated 07/23/21 requested full code measures. Social Service Staff X stated the resident had a designated power of attorney now and the facility staff would need to contact them to clarify the resident's desires. Interview, on 01/02/24 at 03:06 PM with Administrative Nurse D revealed the medical record should reflect the resident's most up to date code status and the Advance Directive Statement dated 07/23/21, would revoke the DNR signed 07/24/19. Interview, on 01/03/24 at 11:07 AM, with Hospice Nurse GG, revealed she knew of the DNR signed by the resident on 07/24/19 but did not know about the full code request Advance Directive Statement dated 07/23/21, and would need to contact the hospice social worker for clarification. The facility policy Resident Rights revised 2016, instructed staff the resident has the right to self-determination and to be informed of and participate in his or her care planning and treatment. The facility failed to review and revise this resident's care plan to reflect his determination of preference for resuscitation/DNR. 34056 - Review of Resident (R)14's Physicians Order Sheet (POS), dated 12/12/23, documented the following diagnoses: constipation (the inability to pass stool) and pain (physical suffering or discomfort caused by illness or injury). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received scheduled and as needed (PRN) pain medications. No non-pharmaceutical pain interventions for pain were attempted. The resident reported regular pain which affected his sleep, day to day activities and the pain interfered with his therapy activities. The resident reported the worse pain in the past five days was ten out on a one to ten pain scale. He received opioid medication (a compound resembling opium in addictive properties or physiological effects) during the seven-day lookback assessment period. The Pain Care Area Assessment (CAA), dated 12/27/23, documented the resident was non-compliant with reporting pain to the nursing staff. The Annual MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He received scheduled pain medications. No non-pharmaceutical pain interventions for pain were attempted. The resident reported frequent pain which affected his sleep and interfered with his therapy activities and occasionally affected his day-to-day activities. The resident reported the worse pain in the past five days was ten out on a one to ten pain scale. He received opioid medication during the seven-day lookback assessment period. The care plan for pain, revised 11/15/23, lacked instructions regarding non-pharmaceutical interventions for the resident's pain. Review of the resident's electronic medical record (EMR), included the following physician orders: Oxycodone (an opioid pain medication) 5-325 milligrams (mg), by mouth (po), in the afternoon for pain, ordered 01/07/23. Oxycodone (an opioid pain medication) 5-325 mg, po, in the morning for chronic pain, ordered 01/07/23. Oxycodone (an opioid pain medication) 5-325 mg, po, at 06:00 PM, for chronic pain, ordered 01/06/23. On 01/03/24 at 11:12 AM, the resident stated he had a lot of pain from diabetic neuropathy (a type of nerve damage that can occur if you have diabetes) for which he received opioid pain medications. The resident stated he was unaware of any non-pharmaceutical interventions for his pain. On 01/04/24 at 12:50 PM, Administrative Nurse D confirmed the resident had no non-pharmaceutical pain interventions and should have some type of non-pharmaceutical interventions for his chronic pain. The facility policy for Care Plans, Comprehensive Person-Centered, revised December 2016, included: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs will be developed and implemented for each resident. The facility failed to complete a comprehensive care plan, to include non-pharmaceutical interventions for pain, for this resident who has pain.

The facility reported a census of 32 residents with 12 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plan for two sampled Residents (R)14, regarding failure to revise the care plan to include constipation and R7 regarding failure to revise the care plan to include aphasia communication. Findings included: - Review of Resident (R)14's Physician Order Sheet (POS), dated 12/12/23, documented a diagnosis of constipation (the inability to pass stool). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He was always continent of bowel and had constipation present during the assessment lookback period. The Urinary Incontinence/Indwelling Urinary Catheter Care Area Assessment (CAA), dated 12/27/23, documented the resident required staff assistance with getting onto and off from the bed pan for bowel movements (BM)s. The Annual MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He was always content of bowel and had constipation present during the assessment lookback period. The care plan, revised 11/15/23, lacked staff instruction regarding interventions to relieve the resident's constipation. Review of the resident's electronic medical record (EMR) revealed the following physician's orders: 1. MiraLAX (a laxative) 17 grams (gm), by mouth (po) in the morning for constipation, ordered 12/24/23. Review of the resident's Medication Administration Record (MAR) from 12/24/23 through 01/04/24, revealed the medication was given, as ordered. 2. Senna Plus Oral Tablet (a laxative) 8.6-go mg, two tablets po at bedtime (HS) for constipation, ordered 12/23/23. Review of the resident's Medication Administration Record (MAR) from 12/24/23 through 01/04/24, revealed the medication was given, as ordered. 3. Milk of Magnesia (MOM), 400 milligrams (mg) per five milliliters (ml), po every (Q) 24 hours, PRN for no BM in three days, ordered, 12/30/23. Review of the resident's Medication Administration Record (MAR) from 12/24/23 through 01/04/24, revealed the medication was not given. Review of the resident's EMR from 12/24/23 through 01/03/24 revealed the resident did not have a BM from 12/27/23 through 01/03/24, a total of six days. No PRN medication for constipation was given by staff. On 01/03/24 at 11:12 AM, the resident stated staff had not offered a PRN medication for his constipation. If staff offered him a medication, he would take it. He does not refuse medications. On 01/04/24 at 10:56 AM, Licensed Nurse (LN) G stated she would pull the BM list every morning which showed which residents had not had a BM and needed a PRN medication. LN G stated she would give the BM list to the CMA to know which residents required a PRN medication on that shift. On 01/03/24 at 10:41 AM, Certified Medication Aide (CMA) R stated the LN would give her a bowel sheet each morning which showed which residents required a PRN medication for bowels. CMA R stated she would wait until later in the morning to give the PRN medications to allow the residents an opportunity to have a bowel movement on their own without the use of a medication. On 01/04/24 at 12:50 PM, Administrative Nurse D stated it was the expectation for staff to review and revise the care plan to include the resident problems, like constipation. The facility policy for Care Plans, Comprehensive Person-Centered, revised December 2016, included: Assessments of residents are ongoing and care plans shall be revised as information about the residents and the residents conditions change. The facility failed to review and revise the care plan to include constipation. 28560 Review of Resident (R)7's Physician Order Sheet, dated 12/12/23, revealed diagnoses that included hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness on one side of the body) due to cerebral vascular accident (stroke), and aphasia (a condition of disordered or absent language function). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13 (13-15 normal cognitive function) and the resident had clear speech. The Quarterly MDS, dated [DATE], assessed the resident had unclear speech and was usually able to make himself understood with difficulty communicating some words or finishing thoughts but was able if prompted or given time, and ad clear comprehension. The resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The Communication Care Area Assessment (CAA) dated 02/17/23, did not trigger. The Care Plan, reviewed 11/07/23, lacked revision to include the resident's unclear speech. Interview, on 01/02/24 at 12:01 PM, with the resident, revealed he was not trying to grow a beard and he communicated that staff needed to assist him with set up. The resident had difficulty finding words and expressed frustration with communications. Interview, on 01/03/24 at 10:10 AM, with Certified Nurse Aide (CNA) O, revealed the resident did have some communication issues and can become frustrated when trying to make his needs known. Interview, on 01/03/24 at 03:28 PM, with CNA Q, revealed staff need to listen closely to the resident to determine what he needs. CNA Q stated the resident did point to things to communicate. Interview, on 01/02/24 at 02:46 PM, with Social Service Staff X revealed the resident can speak but staff need to be patient and listen closely to what he is trying to say. Social Service Staff X stated she did not know if the resident received therapy. Interview, on 01/04/24 at 10:21 AM, with Administrative Nurse D, confirmed the lack of the resident's speech difficulty on the care plan and would expect the Care Plan include goals and interventions. The facility policy for Care Plans, Comprehensive Person-Centered, revised December 2016, included: assessments of residents are ongoing, and Care Plans shall be revised as information about the residents and the resident's conditions change. The facility failed to review and revise this resident's Care Plan to include goals and interventions for the resident's aphasia to improve communication and decrease frustration.

The facility reported a census of 32 residents with 12 selected for review which included two residents reviewed for hygiene needs. Based on observation, interview and record review, the facility failed to ensure one Resident (R)7 of the two residents received assistance for grooming. Findings included: - Review of Resident (R)7's Physician Order Sheet, dated 12/12/23, revealed diagnoses that included hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness on one side of the body) due to cerebral vascular accident (stroke), and aphasia (a condition of disordered or absent language function). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13 (13-15 normal cognitive function. The resident had impairment in functional range of motion on one side of the upper and lower extremities and required maximal assistance for bathing. The Quarterly MDS, dated [DATE], assessed the resident had unclear speech and was usually able to make himself understood with difficulty communicating some words or finishing thoughts but was able if prompted or given time, and had clear comprehension. The resident had a BIMS score of 14, which indicated normal cognitive function. The resident had impairment in functional range of motion on one side of the upper and lower extremities and required partial assistance for bathing. The resident received an anticoagulant (a medication used to prevent blood clots by interfering with the process of making clots). The ADL (Activity of Daily Living) Care Area Assessment (CAA), dated 02/17/23, assessed the resident required limited to extensive assistance of staff to perform most activities of daily living. The Care Plan, reviewed 11/07/23, instructed staff the resident was independent with most ADL's but may need assistance with set-up. The resident received showers on Tuesday and Friday evenings. Observation on 01/02/24 at 12:01 PM, revealed the resident had several days hair growth on his face. The resident indicated he did not want to grow a beard and needed staff assistance to shave. Interview, on 01/03/24 at 03:28 PM, with Certified Nurse Aide (CNA) Q, revealed the resident received showers in the evenings and was cooperative. The resident required staff assistance with shaving. Observations on 01/03/24 and 01/04/24, revealed the resident continued unshaven. Interview on 01/04/24 at 10:16 AM, with Certified Medication Aide (CMA) R, revealed the resident had frequent thick hair growth and sometimes declined shaving opportunity. Interview, on 01/04/24 at 10:00 AM, with CNA P, revealed staff needed to supervise the resident with shaving to ensure he did not cut himself. Interview on 01/04/24 at 10:19 AM, with Administrative Staff B, revealed she would expect staff to assist the resident with shaving on shower days or as needed. Interview, on 01/04/24 at 10:21 AM, with Administrative Nurse D revealed she would expect staff to assist the resident with shaving with showers and as needed. Administrative Nurse D stated sometimes the resident refused. The facility policy Activities of Daily Living (ADL), Supporting, revised March 2018, instructed staff to provide the resident with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The facility failed to ensure staff provided shaving assistance for this resident who preferred a clean shaven appearance.

The facility identified a census of 32 residents, with 12 residents sampled, including two residents reviewed for constipation. Based on record review, interview and observation, the facility failed to ensure one Resident (R)14 received as needed (PRN) medications to treat constipation (the inability to pass stool), when needed in a timely manner. Findings included: - Review of Resident (R)14's Physician Order Sheet (POS), dated 12/12/23, documented a diagnosis of constipation (the inability to pass stool). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He was always continent of bowel and had constipation present during the assessment lookback period. The Urinary Incontinence/Indwelling Urinary Catheter Care Area Assessment (CAA), dated 12/27/23, documented the resident required staff assistance with getting onto and off from the bed pan for bowel movements (BM)s. The Annual MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He was always content of bowel and had constipation present during the assessment lookback period. The care plan, revised 11/15/23, lacked staff instruction regarding constipation. Review of the resident's electronic medical record (EMR) revealed the following physician's orders: 1. MiraLAX (a laxative) 17 grams (gm), by mouth (po) in the morning for constipation, ordered 12/24/23. Review of the resident's Medication Administration Record (MAR) from 12/24/23 through 01/04/24, revealed the medication was given, as ordered. 2. Senna Plus Oral Tablet (a laxative) 8.6-go mg, two tablets po at bedtime (HS) for constipation, ordered 12/23/23. Review of the resident's Medication Administration Record (MAR) from 12/24/23 through 01/04/24, revealed the medication was given, as ordered. 3. Milk of Magnesia (MOM), 400 milligrams (mg) per five milliliters (ml), po every (Q) 24 hours, PRN for no BM in three days, ordered, 12/30/23. Review of the resident's Medication Administration Record (MAR) from 12/24/23 through 01/04/24, revealed the medication was not given. Review of the resident's EMR from 12/24/23 through 01/03/24 revealed the resident did not have a BM from 12/27/23 through 01/03/24, a total of six days. No PRN medication for constipation was given by staff. On 01/03/24 at 11:12 AM, the resident stated staff had not offered a PRN medication for his constipation. If staff offered him a medication, he would take it. He does not refuse medications. On 01/04/24 at 10:56 AM, Licensed Nurse (LN) G stated she would pull the BM list every morning which showed which residents had not had a BM and needed a PRN medication. LN G stated she would give the BM list to the CMA to know which residents required a PRN medication on that shift. On 01/03/24 at 10:41 AM, Certified Medication Aide (CMA) R stated the LN would give her a bowel sheet each morning which showed which residents required a PRN medication for bowels. CMA R stated she would wait until later in the morning to give the PRN medications to allow the residents an opportunity to have a bowel movement on their own without the use of a medication. On 01/04/24 at 12:50 PM, Administrative Nurse D stated Certified Nurse Aides (CNA) were to document all BMs on the computer. The night LN was to run the bowel report and pass it on to the LN on the day shift. The LN would then decide of giving the resident the PRN medication for bowels. Administrative Nurse D confirmed the resident had gone six days without a PRN bowel medication. The facility policy for Bowel Protocol for Constipation, undated, included: All residents of the facility will be assessed each shift for bowel patterns per CNA reporting in the charting system. The licensed nurse on each shift will generate a bowel report from the system at the beginning of the shift and initiate the bowel protocol as appropriate. The facility failed to ensure this resident received a PRN medication for constipation when needed in a timely manner.

The facility reported a census of 29 residents, with 12 residents selected for review including four residents reviewed for accidents, with two of those reviewed for falls. Based on observation, record review, and interview the facility failed to [MEDICATION(S)] to prevent Resident (R)32 from potentially causing harm to himself or others due to inappropriate use of a cigarette lighter by setting a cereal box on fire in the smoking area, falling asleep with a lit cigarette in his hand in the smoking area, extinguishing a cigarette butt in a towel in the smoking area, smoking inside the facility and placing cigarette butt on a cover, and spraying a flammable substance towards a lighter. This deficient practice placed the residents of the facility in immediate jeopardy. The facility also failed to implement interventions following falls to prevent future falls for R18 and R30. Findings included: - The Order Summary Report, for Resident (R)32 dated 05/05/21, included diagnoses of disorder of the brain, attention-deficit [CONDITION(S)] disorder-predominantly [CONDITION(S)] type (a chronic condition including attention difficulty, [CONDITION(S)], and impulsiveness), and major depressive disorder (major mood disorder) with severe with psychotic abnormal thinking and perceptions) features. The Annual Minimum Data Set (MDS), dated [DATE], assessed R32 with a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. R32's mood score was zero, which indicated minimal to no depression. He had no physical or verbal behaviors towards others, no other behaviors not directed towards others, no rejection of care, and no change in behaviors compared to the last assessment. R32 was independent with setup help for transfers and locomotion on and off the unit, could walk independently without setup help for walking in his room, walked in the corridor once or twice, and used a wheelchair for mobility. He had current tobacco use, received seven days of antipsychotic medication, and did not receive psychological therapy. The Quarterly MDS, dated [DATE], assessed R32 with the same BIMS score, and a mood score of nine, which indicated mild depression. He had verbal behaviors directed towards others one to three days, and no change to the other behaviors. There was no change in his transfers or locomotion on/off unit, he required supervision and limited assist of one staff for walking in his room, limited assist of one for walking in the corridor, and used a wheelchair and walker for mobility. He continued to receive an antipsychotic medication for seven days and did not receive psychological therapy. The [CONDITION(S)] Drug Use Care Area Assessment (CAA), dated 03/03/31, revealed R32 currently took [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)] and other mental emotional conditions) for diagnosis of [CONDITION(S)] disorder (major mental illness that caused people to have episodes of severe high and low moods). R32 often stated how difficult it was to be a man of his age living in a nursing home, he missed his dog, and he missed his ability to live on his own. The staff allowed him time to discuss his feelings about his current living situation, and recent loss of independence, were to monitor him for worsening depression or risk of harming himself, and report to the charge nurse, primary care physician, and social service designee immediately should he show worsening depression. The Care Plan, dated 05/11/21, revealed R32 was a smoker and the goal stated he would not suffer injury from unsafe smoking practices. He could smoke outside, unsupervised. On 05/09/19, the staff were to instruct him about the facility policy on smoking locations, times, and safety concerns, and notify the charge nurse immediately if they suspected the violated the facility smoking policy. On 11/26/20, a smoking assessment was to be done per policy. On 05/09/19, the staff were to observe his clothing and skin for signs of cigarette [CONDITION(S)]. The Smoking-Safety Screen, located under the assessment tab in the electronic medical record (EMR), dated 12/21/20, indicated R32 could light his own cigarette, the facility had difficulty with him following the rules to keep six feet apart, he did not need the facility to store his cigarettes and lighter, and he was safe to smoke without supervision. The Progress Note, located in the EMR, dated 12/28/20 at 10:42 PM, revealed R32 was drowsy throughout the day and was not his baseline status, around mid-day he was considerably more drowsy, and found outside asleep with a lit cigarette in his hand. R32 denied any use of alcohol or taking any medications that were not his scheduled medications and Licensed Nurse (LN) K reviewed with him that his primary care physician (PCP) would be contacted to review the concerns. R32 then went to his room and slammed the door, after a brief period the staff went to the room and found his closet open with everything disheveled. LN K reviewed the PCP orders for a urinary drug screen and R32 became angry and agitated that staff contacted the PCP, refused the drug screen, and cursed at LN K. R32 then went to his room and came out with two glass syrup bottles and sat in the hallway in the wheelchair. LN K had been told R32 planned on throwing them at her and the staff redirected him not to do so. R32 then went outside to smoke and was waiting to talk to Administrative Staff A. He complied with the urine drug sample and continued to curse and argue with the staff. The facility failed to provide supervision at that time to ensure R32 was smoking safely. The Smoking-Safety Screen, located under the assessment tab in the electronic medical record (EMR), dated 01/20/21, under the safety section of the assessment, lacked answers to the question if he could light his own cigarette and if the facility needed to store the lighter and cigarettes. The facility failed to complete all questions on the assessment. The Progress Note, located in the EMR, dated 02/16/21 at 09:58 AM, revealed staff passed on in report that R32 might have been smoking in the facility last night on 02/15/21 around 09:00 PM, as the staff smelled smoke and cologne. The staff notified the department heads when they came into the facility and they reviewed the cameras. R32 went into a room in the hallway for a couple of minutes, came back out, went to his room, then sprayed cologne in the living area and in the room he had been in. The room had ashes and a cigarette was found tossed in a corner of the room on top of the cover. The staff notified Administrative Staff. A Review of the EMR following this event lacked any action the facility took to prevent R32 from repeating this action. The Progress Notes, dated 03/01/21 at 01:22 AM, revealed R32 was outside smoking and he lit an empty cereal box on fire on the patio table. The fire was put out with water and no injury or damage noted. R32 stated he had to do it for psychological well-being. The Progress Notes, contained a late entry on 05/26/21 at 06:08 PM, for the date of 03/01/21 at 05:03 AM, revealed the staff educated R32 on how dangerous it was to start a fire and it could cause him to get burned or catch the facility on fire. R32 argued stating that a little fire would not hurt anything and refused to give LN L his lighter and went to his room for the rest of the night. R32 stayed in his room, went to sleep, and had no further behaviors on that shift. The facility failed to provide supervision to R32 following the education and refusal to give the facility staff his lighter after lighting the cereal box on fire, The Progress Note, dated 03/14/21 at 01:43 PM, revealed Social Services Staff X was in the dining room area and happened to glance up, looked through the window, and saw R32 put out his cigarette in a towel that sat the table outside in the smoking area of the patio. R32 moved his wheelchair away, then Social Service staff X went outside to check the towel as it was starting to smoke. R32 turned and went back over to the towel where it was smoking and smashed it out before Social Service staff X could reach it. R32 stated that the rain could put it out if it caught fire. Social Service Staff X removed the towel and R32 told her to get back inside and leave him alone. Review of the EMR following this event lacked any action the facility took to prevent R32 from repeating this action. The Progress Note, dated 04/24/21 at 02:13 PM, revealed that R32 wheeled himself to the nurses station and stated he would just tell on himself, he had Bod body spray and wanted to see what would happen if someone sprayed it into a fire (R32 was flickering his lighter). LN J questioned R32 it if flamed up and he said yes and that R7 was holding it and said it burned her, but it did not. R32 gave LN J the spray and then went outside. LN J then went to talk to R7 who stated that R32 had both the spray and the lighter, and the flame burnt her hand. LN J assessed R7's hand and no redness or [CONDITION(S)] were found. LN J notified Administrative Nurse D who instructed to take his lighters away and Administrative Staff A would talk to him on Monday. LN J went to R32 and requested his lighters and he responded no, not happening. LN J told R32 that she would report that and a few minutes later he brought her two lighters. He was sitting close to a red lighter but did not turn that one in stating that is all of mine and I will use others to light my cigarettes until Monday then. Review of the EMR following this event lacked any action the facility took to prevent R32 from repeating this action. The Smoking-Safety Screen, located under the assessment tab in the electronic medical record (EMR), dated 05/24/21, indicated that R32 smoked more than 10 cigarettes a day, could light his own cigarette, did not need the facility to store his lighter and cigarettes, and chooses to keep his cigarettes and lighter in his room for storage. He did not need supervision while smoking. On 05/25/21 at 11:58 AM, R32 was outside on the patio holding a cigarette, closed his eyes for a few seconds, then opened them up to smoke the cigarette. The resident smoked without staff supervision. On 05/25/21 at 09:59 AM, Administrative Staff A stated that she received guidance that R32 had a right to keep items purchased with his own money in his possession. On 05/25/21 at 03:30 PM, LN H stated that R32 can smoke on his own and kept his lighter and cigarettes on him. Staff completed smoking assessments on admission and as needed, but was not sure how often they required an update. On 05/26/21 at 03:35 PM, Administrative Nurse D stated at one point the facility tried to keep cigarettes and lighters away from everyone, then it was put into place that the residents purchased these items, so they have the right to have the items in their possession Administrative Nurse D stated that it was exceptionally difficult when it came to following the rules for R32, he knew a lot of people and he had a cell phone. The therapist encouraged him to have burning ceremonies and so R32 thinks it is okay to do that no matter what we say. The smoking assessment was based off of what the staff observed. The facility policy Smoking Policy-Residents, dated 07/2017, indicated that smoking is only permitted in designated resident smoking areas, smoking is not allowed inside the facility under any circumstances. The resident will be evaluated on admission, quarterly, a significant change and as determined by staff for their ability to smoke safely with or without supervision per a completed Safe Smoking Evaluation. Any smoking related privileges, restrictions, concerns shall be noted on the care plan. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident can not smoke safely with the available levels of support and supervision. This facility maintains the right to confiscate smoking articles found in violation of our smoking policies. The facility failed to [MEDICATION(S)] to prevent R32 from potentially causing harm to himself or others due to inappropriate use of a cigarette lighter. The facility failed to [MEDICATION(S)] or provide supervision to prevent re-occurrence of the actions. This deficient practice placed the residents of the facility in immediate jeopardy. On 05/26/21 at 06:17 PM, Administrative Staff A was informed that the residents were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to [MEDICATION(S)] to prevent a resident from potentially causing harm to himself or others due to inappropriate use of a cigarette lighter. The facility provided an acceptable plan of removal of the immediate jeopardy on 05/27/21 at 11:10 AM. The plan included: 1. The facility met with R32 on 05/26/21 at 07:00 PM and educated him on the violations and all smokable tobacco products and lighters were removed from his room and person. 2. R32 was placed on 1:1 staff supervision beginning on 05/26/21 at 07:15 PM until 05/27/21 AM at which time staff on the current shift and on-coming morning shift would be in-serviced. 3. R32's visitation at the community with any outside individuals will be supervised by staff to prevent him from obtaining lighters or other fire sources. In the even he goes out of the community to an appointment or event, he will be supervised by staff to prevent him from obtaining lighters or other fire sources. 4. The staff will supervise R32 while smoking and he will not be permitted to have lighters, matches, or other sources of actual flame in his possession. 5. Supervising staff will light smokable tobacco products for R32. 6. All lighters were confiscated from all smoking residents and smoking times established, every two hours on the even hour. 7. The staff will utilize the residents most recent smoking assessments to determine if a resident meets the criteria for supervised smoking during the designated smoking times. 8. The smoking policy was updated to reflect the smoking schedule and control of all lighters, matches, or other fire sources. 9. All staff will be in-serviced on the new smoking policy and the individual need of residents by direct education from Administrative Nurse D or designee at the start of their shift on 05/27/21, or at any time they can come in if they are not on the schedule for this day. All staff were to be in-serviced by midnight on 05/27/21. The survey team validated the immediate jeopardy was removed on 05/27/21 at 05:50 PM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was lowered to an G following the removal of the immediate jeopardy. - The Order Summary Report, dated 04/05/21, for Resident (R)18, included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbances, metabolic [CONDITION(S)] (a chemical imbalance of the blood that affects the brain that can lead to personality changes), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbance. The Annual Minimum Data Set (MDS), dated [DATE], assessed R18 with short and long-term memory problems and moderately impaired decision making. She required extensive assistance of two or more staff for bed mobility and toilet use, supervision and setup for transfers and walking in room and corridor, and supervision and one staff assistance for locomotion on/off the unit. She had steady balance at all times except when moving on and off of the toilet, no impairment to her range of motion, and did not require mobility devices. She had two or more non-injury falls and two or more minor injury falls since the last assessment. The Quarterly MDS, dated [DATE], assessed R18 with short and long-term memory problems and severely impaired decision making. She required extensive assistance of two or more staff for bed mobility, transfers, toilet use and locomotion on unit, walking did not occur, and she was totally dependent on one staff for locomotion off the unit. Her balance was not steady and required staff assistance for surface to surface transfers and moving on and off of the toilet. She had impaired range of motion to one side of her lower extremities and used a wheelchair for mobility. She had one major injury fall since the last assessment. The Falls Care Area Assessment (CAA), dated 02/18/21, indicated R18 had a high risk for falls. She required limited to extensive assistance with most cares, was steady on her feet, occasionally incontinent of urine, and had dementia. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential CAA, dated 02/18/21, indicated R18 had an ADL deficit due to increased incontinence and dementia, required two staff to assist with toileting, dressing, and bed mobility. R18 did not recall how to use a call light to ask for assistance, but occasionally would ask where the bathroom was or to be taken to the bathroom. The Cognitive Loss CAA, dated 02/18/21, indicated she did not usually ask for help, but if staff asked her what she needed, she often was able to answer short, direct questions at times. Staff should offer assistance often. The Care Plan, revised 05/04/21, included R18 was a high risk for falling related to confusion, gait and balance problems, unawareness of safety needs, and wandering. The ADL portion of her care plan indicated she could move in bed independently but may require some assistance at times to enter or exit the bed. Staff were to assist her to the toilet every two hours. She had been identified as a fall risk on the care plan on 02/21/20, 05/19/20, and 02/17/21. Interventions included: 1. On 02/17/21, the staff were to ensure nonskid footwear was worn. 2. On 02/21/20, the staff were to follow facility fall protocol, keep bed at height appropriate to allow for easy entry and exit, and review information on past falls and attempt to determine cause of falls. The staff were to record the possible root causes, alter or remove any potential causes if possible, and educate the resident/family/caregivers/interdisciplinary team as to causes. The Fall Risk Assessment, under the assessment tab in the electronic medical record (EMR), dated 07/04/20 and 04/16/21 assessed R18 as a high risk for falling. The Progress Note, dated 10/20/20 at 04:10 AM indicated around 03:20 AM a staff heard a thud and crying, and R18 was on the floor. Staff noted a laceration above her right eyebrow measuring 0.7 centimeters (cm) and the resident complained of pain to the right hip when staff assisted her to change her clothing. The charge nurse treated the area above R18's right eyebrow, sent R18 to the emergency room for X-rays, and later R18 returned to the facility with no new orders. She could ambulate at that time without difficulty. The IDT [interdisciplinary team] Post Fall Assessment, located under the assessment tab in the EMR, dated 10/20/20, indicated the staff updated the care plan. The assessment lacked a root cause analysis of the fall or a new intervention to prevent further falls. The care plan lacked an intervention to prevent future falls. The Progress Notes, dated 10/27/20 at 02:56 PM, revealed R18 sat in a recliner in the TV area resting her head on her hand on top of her right knee, fell asleep, then fell forward out of the recliner hitting her knees to the ground, then her head, causing an abrasion and bruising to her right temple. A fax was sent to the primary care physician to review medication due to her not sleeping well at all. The IDT Post Fall assessment, located under the assessment tab in the EMR, dated 10/27/20, lacked an immediate intervention to prevent further falls. The care plan lacked a new intervention. The Progress Note, dated 03/03/21 at 04:59 AM, revealed a Certified Nurse Aide (CNA) notified the nurse that R18 was on the floor in the beauty shop sitting on her bottom holding her head close to the wall and the trash can was close and turned over. R18 had her pants down and she had a bowel movement on the floor. A purple raised area was noted to the top/back of her head. The IDT Post Fall Assessment, located under the assessment tab in the EMR, dated 03/03/21, lacked a root cause analysis and a new intervention to prevent further falls. The care plan lacked a new intervention. The facility Witnessed Fall report, dated 04/04/21 at 04:51 AM, revealed that R18 was sitting on her bottom in another resident's room, the other resident reported that R18 entered her room and shut the door and proceeded to take the blankets off of her bed, so she got out of bed to stop R18 when she fell to the floor. R18 had just been assisted by CNA O to the toilet before the fall occurred. The Progress Note, dated 04/04/21 at 05:01 AM, revealed that R18 had a reddened right knee and no further injuries noted. The Progress Note, dated 04/04/21 at 05:11 AM, revealed that R18 screamed in pain when touching her right knee and the staff called the emergency medical service to send her to the emergency room . The Progress Note, dated 04/04/21 at 08:51 AM, revealed R18 returned to the facility with a knee immobilizer, a new order for Tylenol (medication use to treat mild pain) until her appointment with orthopedics. The Progress Note, dated 04/4/2021 at 11:00 PM, revealed new orders to keep the knee immobilizer in place, non-weight bearing until orthopedics sees her, call in the morning for an appointment, and ice pack for 20 minutes on and 20 minutes off to her knee. The Progress Note, dated 04/06/21 at 12:23 AM, revealed R18 had a fall on Sunday, and had a fracture (broken bone) of the patella (kneecap) on her right leg. The Progress Note, dated 04/06/21 at 12:26 PM, revealed that R18 continued on fall follow-up and a fracture to her patella of the right leg, and required two to three staff to assist with transfers due to her being non-weight bearing to the right leg. The Progress Note, dated 04/06/21 at 03:40 PM, indicated the staff contacted the other resident via phone of the room that R18 fell in on 04/04/21. The other resident stated R18 entered the room, staff tried to get her out, then the door shut, so she got up tried and help R18, who tossed a blanket from the bed and it landed on top of the other resident's head. When the other resident removed the blanket, their legs got tangled and they both fell to the ground and then R18 landed on top of her. The Progress Note, dated 04/06/21 at 04:45 PM, revealed R18 returned from her orthopedic appointment with a hyperextension knee brace to her right lower extremity, locked extension, weight bearing to be as tolerated with the hinged knee brace in place to locked extension, no range of motion to her knee for three weeks, and her next appointment would be on 04/27/21. The EMR lacked an IDT Post Fall Assessment for the fall on 04/04/21, and the care plan lacked an immediate intervention to prevent further falls. On 05/20/21 at 10:06 AM, observation revealed the unlocked beauty shop door and a sign in place next to the door to keep the door locked at all times when not in use. The beauty shop was not in use at that time. On 05/24/21 at 10:20 AM, R18 was sitting up in her wheelchair in the dining room eating breakfast, a brace was in place to her right leg under her pants. On 05/24/21 at 10:52 AM, R18 stood up at the dining room table from her wheelchair and the nursing staff responded immediately. R18 sat down and the staff applied a gait belt, R18 repositioned herself farther back in the wheelchair, and then the staff propelled her to her room in the wheelchair to assist her to the bathroom. On 05/24/21 at 01:40 PM, CNA N stated that R18 was not a fall risk that she was aware of, she used to walk everywhere, but now she wore a brace on her leg. R18 usually stayed in her chair and did not try to get up by herself. She tried to take R18 to the bathroom everyone to two hours. CNA N stated when a resident had a fall, the nurse let her know what the new intervention would be. On 05/24/21 at 03:22 PM, Administrative Nurse D revealed the nursing staff communicate the fall interventions to the nursing staff, not all of the nurses felt comfortable updating the care plan, and they put their new intervention on their fall assessment. The nurses would put fall information on the pass along report sheets. The electronic documentation system had a message board used for various communication, but not all fall interventions appeared on the alert system. On 05/25/21 at 10:42 AM, Administrative Nurse D stated there was not a new intervention for the fall on 10/20/20, the intervention for the fall on 10/27/20 was for a medication review, and that it was not an immediate intervention to prevent further falls. Additionally, Administrative Nurse D stated the intervention for the fall on 03/03/21 was to keep the beauty shop door locked and it did not get put on the care plan. When R18 fell on [DATE], the thought process was that her mobility level changed, she was immobile with non-weight bearing status, and when that changed, they put her on therapy. Administrative Nurse D stated the charge nurse should put an immediate intervention in place following a fall. The facility policy Accident and Incidents-Investigating and Reporting, revised 07/2017, lacked information about determining a root cause and implementing a new intervention post falls to prevent further falls. The facility failed to determine a root cause analysis and implement immediate interventions following falls for R18, with one of those falls resulting in a fracture of her right patella. - Review of Resident (R) 30's Physician Orders, dated 05/04/21, revealed diagnoses which included dementia (a progressive mental disorder characterized by failing memory, confusion) with behavioral disturbances, [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (major mood disorder), anxiety disorder, cerebral infarction (stroke- occlusion or stenosis in the brain, and [CONDITION(S)] (inability to sleep). The Significant Change Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. The resident experienced signs and symptoms of [CONDITION(S)]. The resident was totally dependent on staff for locomotion and required extensive assistance of staff with transfers and activities of daily living (ALDs). The resident did not walk, his balance with transition was not steady, and was only able to stabilize with staff assistance. The resident had two or more falls without injury and one fall with minor injury since the previous assessment. He was frequently incontinent of bowel and bladder. The Quarterly MDS, dated [DATE], documentation revealed the resident had severely impaired cognition and had two or more falls without injury since the prior assessment. The Care Area Assessments (CAA), for Cognitive Loss/Dementia, Urinary Incontinence, Falls, and [CONDITION(S)] Drug Use, dated 3/10/2021, documentation included the resident had severely impaired cognition and staff should continue to monitor for wandering, as well as decline or improvement in cognitive status and report changes to the charge nurse. Currently he was incontinent of urine and required extensive assistance of staff for locomotion, ambulation, transfers, and toileting. The staff should offer to assist the resident to the toilet every two to three hours as tolerated and report further episodes of incontinence to the charge nurse. He was identified as high risk for falls with a fall risk assessment score of 33. He was recently admitted to the facility and had an additional room change following a wandering episode. Fall prevention interventions included staff should ensure the resident had appropriately fitting non-skid footwear in place, his assistive devices were nearby, and his bed should be maintained in a position that allowed him to easily enter/exit the bed as desired. The Care Plan (CP), initiated on 08/12/2020, directed staff as follows: 1. Monitor for possible signs and symptoms of adverse drug reaction such as falls, fatigue, incontinence, agitation, lethargy, confusion, and agitation, initiated 8/12/2020 2. The resident has an ADL self-care performance deficit related to confusion, fatigue, limited mobility, [CONDITION(S)], and history of a stroke. He was able to use the toilet, transfer and ambulate with staff assistance. 3. Physical Therapy (PT) and/or Occupational Therapy, (OT) referrals as ordered and as needed (PRN). 4. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. He needs prompt response to all requests for assistance. 5. The resident will be assisted to toilet/bathroom within 30 minutes after completing meals. 6. Encourage the resident to keep room free from clutter, initiated on 11/17/2020. 7. Encourage the resident to call for assistance, initiated on 11/17/2020. 8. Ensure the resident wears appropriate, well-fitting nonskid footwear when ambulating or mobilizing in wheelchair. 9. Physician to perform medication review to see if dose reductions or discontinuation is feasible for medications that place him at increased risk for falls. 10. Ensure the resident has unobstructed path to the bathroom. 11. Re-evaluate the resident's toileting plan. Initiated 02/17/21. Review of the facility fall log documentation, dated 10/11/2020 through 04/24/2021, revealed the resident experienced falls on the following dates: 10/11/20, 10/29/20, 11/14/20, 11/17/20, 11/21/20, 11/21/20, 12/09/20, 12/27/20, 01/16/21 (two falls), 02/04/21 (two falls), 02/07/21, 02/11/21, 2/17/21, 03/02/21, 03/16/21, 03/17/21, 03/29/21, and 04/24/21. Review of the resident's medical record and the facilities' Fall investigations revealed the facility failed to implement an appropriate revised or new immediate intervention timely to prevent further falls for the resident following falls, on 10/29/20, 11/14/20, 11/17/20, 01/16/20 (one fall), 02/04/21, 02/07/21, and 03/16/21. The facility also failed to implement an immediate care planned intervention to re-evaluate the resident's toileting program following a fall on 02/17/21, related to toileting. On 05/20/21 at 01:13 PM, the resident sat in his reclining chair, restlessly moving his legs for short intervals. He talked slow but distinctly and could answer some questions. On 05/24/21 at 12:22 PM, the resident sat in a reclining chair quietly no fidgeting or restlessness noted. On 05/24/21 at 02:12 PM, Certified Medication Aide (CMA) S stated the resident did not walk anymore. He was not at as high a risk of falls now as before when he walked. He continued to be at risk for falls. Sometimes the resident would just start shaking. He had a fall out of the bed a few weeks ago. CMA S reported he made sure the resident sat all the way back in the chair seat. He rolled out of the bed. Staff use a pillow to position him from away the edge. When a resident falls the staff notify the nurse. The nurse should complete a fall assessment and start a new intervention to prevent further falls immediately. The staff meet to discuss the new intervention and pass the new intervention on in report at the change of shift. The care plan should have new interventions added to direct the staff in what to do to prevent further falls. The staff meet to discuss the new intervention and it is passed along in report. The nurse informs the staff. The staff use the care plan and new alerts will identify any new interventions. On 05/25/21 at 08:37 AM, Certified Nurse Aide (CNA) M stated the resi [TRUNCATED]

The facility reported a census of 37 residents with six residents selected for review, which included three residents with changes in condition. Based on observation, interview, and record review, the facility failed to assess neurological changes in Resident (R)1, which resulted in progression of a stroke over a period of approximately 15 hours which excluded the resident from the three hour window of opportunity for medical therapy (to dissolve the blood clot) to reverse the progression of the stroke. This lack of neurological assessment and transfer to acute care placed the resident in immediate jeopardy as the resident developed dysphagia (swallowing difficulty), right sided facial drooping, right sided extremity weakness, and dysarthria (difficulty to form and pronounce words). Findings included: - Review of R1's History and Physical dated 12/22/20 included [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed the resident had clear speech and a Brief Interview for Mental Status score (BIMS) of seven which indicated severe cognitive impairment. The resident was independent with bed mobility, transfers, dressing, toilet use, ambulation, and the resident had no impairment in upper or lower extremities. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA,) dated 02/05/20, assessed the resident was mostly independent with all ADLs, but may require supervision to limited assist at times. The resident ambulated with a walker. The resident was able to eat independently. The Care Plan, revised 10/26/20, instructed staff the resident had a self-care deficit due to confusion, impaired balance, and occasional weakness. The resident toileted independently and may require limited assistance at times. The resident transferred independently. The resident fed herself a mechanical soft diet independently. The Baseline Care Plan dated 12/25/20 (after the stroke) instructed staff that the resident required one-person assistance with eating, personal hygiene and bed mobility. The resident required two-person assistance with toilet use, dressing, bathing, and transfers. The resident was on a pureed diet with nectar thickened liquids. Review of the Electronic Medical Record (EMR), revealed a COVID-19 Resident Progress Note Form, dated 12/22/20 at 03:07 AM, which documented the resident as alert with no signs or symptoms of distress or discomfort. The resident's temperature was 97.7 degrees Fahrenheit, and Oxygen saturation as 94% (percent) on room air. A Nurses' Note, by Licensed Nurse (LN) H, dated 12/22/20 at 08:30 AM , (approximately 14 hours after Certified Nurse Aide (CNA) N notified LN G the resident had facial drooping, difficulty swallowing, and right arm weakness, and approximately 12 hours after CNA N notified LN G of the resident's difficulty speaking and noticeable weakness in her right arm and right leg when transferring into bed. LN H assessed the resident could not move her right arm and right leg, and was nonverbal. LN H notified the PCP (primary care provider) and responsible party, and staff transferred the resident to acute care. Review of the History and Physical from acute care, dated 12/22/20, revealed the resident's CT scan (computerized tomography) indicated a subacute middle cerebral artery infarction (stroke is an interruption of blood flow to the areas of the brain that receive blood through the middle cerebral artery). The physician noted the resident had right sided facial drooping, dysarthria, and right sided weakness. The physician indicated the facility failed to transport the resident to an acute care setting at the onset of her symptoms, and the resident missed the window of opportunity for stroke reversing interventions. Observation on 12/30/20 at 08:30 AM revealed CNA M fed the resident pureed hot cereal and nectar thickened water. The resident had weakness in her right arm and was unable to feed herself. The resident had right sided facial drooping and answered yes and no questions by shaking her head. Observation on 12/30/20 at 01:30 PM revealed the resident was in bed with her head leaned onto the left side rail. Administrative Nurse E assisted the resident to reposition in bed. The resident had weakness in her right arm and leg, and attempted to move them upon command, however, she was unable to move her right extremities. The resident continued with right facial drooping and inability to speak words. Interview on 12/30/20 at 11:10 AM, with CNA M revealed she provided care to the resident during the day on 12/21/20. CNA M stated at 04:30 PM, the resident was alert and oriented. She fed herself breakfast and lunch and she ambulated to the bathroom. CNA M stated she checked the resident between 05:30 and 06:00 PM and noted the resident was drowsy and she had difficulty awakening her. CNA M reported the resident's drowsiness to LN G. CNA M attempted to feed the resident her mechanical soft diet and the resident chewed, but she started coughing and choking. CNA M noticed the resident could not get her words out and mumbled when she asked the resident if she was alright. CNA M again reported the change in the resident's status to LN G. CNA M's shift ended at approximately 06:00 PM, and she made one last check on the resident and noted the resident was not fully opening her right eye. CNA M again reported this change in status to LN G. Interview on 12/30/20 at 01:45 PM with LN M revealed she did not remember CNA M reporting to her the resident's change of condition related to the resident's facial droop and swallowing difficulty on 12/21/20. LN M stated she did not visualize the resident until approximately 08:30 PM on 12/21/20 after CNA N reported the resident's weakness to LN M stated she attributed the resident's weakness to the resident's recovering status from COVID and did not assess the resident's neurological status. LN M stated she did a COVID-19 Resident Progress Note Form on 12/22/20 at approximately 03:07 AM, but did not awaken the resident to assess her neurological status. Interview on 12/30/20 at 02:30 PM with Administrative Staff A and Administrative Nurse D revealed they expected licensed nurses to assess residents when CNA's notified them of a change in status. Administrative Staff A stated the facility provided staff education on stroke signs and symptoms to the nursing staff and reviewed the Change in a Resident's Condition or Status Policy after the resident transferred to an acute care. Interview on 01/04/21 at 10:53 AM with LN H revealed the resident exhibit a change in status when she assessed her in the morning of 12/22/20. Interview on 01/04/21 at 11:00 AM with Physician Extender GG revealed she expected licensed staff to neurologically assess a resident for stroke symptoms immediately and transfer the resident to acute care for medical care to attempt to reverse the stroke deficits. Interview, on 01/05/21 at 3:44 PM with CNA N, revealed she noted the resident had right sided facial drooping, and lacked movement in her right arm and could not bear weight while she transferred the resident into her bed around 08:00 PM. CNA N stated she notified LN G at that time. The Change in a Resident's Condition or Status Policy, revised May 2017, instructed staff upon being notified of a potential or actual change in condition, the nurse would assess the resident and notify the attending physician when there had been a significant change in the resident's physical, emotional, or mental condition. The facility failed to neurologically assess this resident for stroke symptoms when CNA M reported the change in the resident's status to LN G three times on 12/21/20. LN G failed to neurologically assess this resident throughout the 12- hour shift, placing the resident in immediate jeopardy with progression of stroke deficits and lack of acute medical care outside of the window of opportunity (three hours) for stroke reversing medication administration. This deficient practice was cited as past non-compliance as the facility completed the following prior to the surveyor entering the facility on 12/30/2020 at 08:45 AM: A focused Quality Assurance Performance Improvement (QAPI) meeting initiated on 12/22/2020 at 5:00 PM, with the Administrator, Assistant Director of Nursing, Executive Vice President, and the Medical Director. All staff in-serviced on abuse, neglect and exploitation policy- completed on 12/23/20 at 09:00 PM All staff in-serviced on resident change in condition policy- completed on 12/23/20 at 09:00 PM All staff in-serviced on identifying signs of a stroke via handout and video - completed on 12/23/20 at 09:00 PM.

Based on observation, interview, and record review, the facility failed to implement CMS and CDC recommended infection control practices in order to control and prevent the potential spread of COVID-19 amongst residents and staff. The facility failed to ensure that facility staff appropriately wore facial masks, including when entering the room of a resident under observation for COVID-19; failed to thoroughly screen staff for COVID-19 prior to caring for residents in the facility, and failed to ensure staff providing care to residents under observation for developing signs or symptoms of COVID-19 wore appropriate PPE. These same staff then provided care to other residents of the facility, who were not under observation for COVID-19. Additionally, the facility failed to ensure that the residents of the facility practiced social distancing during mealtimes. A determination was made that the facility's noncompliance with one or more requirements of participation placed all residents in the facility in immediate jeopardy, which began on 3/18/20. On 7/1/20 at 3:34pm, the Administrator was notified of the immediate jeopardy at F880, Infection Prevention and Control. The immediate jeopardy was removed on 7/1/20 after the surveyor verified implementation of the facility's removal plan. The scope and severity was lowered to an F. Findings include: - Review of CDC recommendations for the use of facemasks, located in guidance titled Preparing for COVID-19 in Nursing Homes, documented the following: Implement Source Control Measures. HCP (healthcare providers) should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE (personal protective equipment) is required. Further review of CDC recommendations for new admissions and readmissions of residents documented the following: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. On 7/1/20 at 9:35am, a sign on resident (R1)'s door documented: Isolation 6/19/20-7/3/20. No PPE supplies were available outside of R1's room. On 7/1/20 at 9:43am, Nurse Aide (NA1) indicated that R1 was on isolation following her admission to the facility. NA1 further indicated that R1's neighbor, R2, was not on isolation. NA1 indicated that when staff entered R1's room, they must wear a facemask and gloves, but no further PPE. NA1 indicated that facility staff were expected to only wear a facemask and gloves when entering isolation residents' rooms as regular practice. NA1 indicated that facility staff would only don further PPE if a resident tested positive for COVID-19. NA1 indicated that residents would sit across the table from each other at activities and at meals, but that facility staff would attempt to keep them six feet apart. On 7/1/20 at 10:07am, NA1, wearing only a cloth facemask, assisted R1 with her pillow. NA1 stood at R1's bedside, within three feet of R1. NA1 finished assisting R1, exited the room, used alcohol-based hand rub, and immediately entered R2's room. R2 indicated to NA1 that she would like to lay down in bed, and NA1 assisted R2 with transferring. On 7/1/20 at 11:25am, a facility staff person stood in R3's room, with a cloth facemask on. The mask failed to be applied correctly, and hung beneath the staff person's nose, exposing the nostrils. On 7/1/20 at 11:27am, dietary staff (D1) entered R1's room to deliver R1's noon meal. D1 wore only a cloth facemask, which was applied inappropriately, leaving D1's nose exposed. D1 stood within six feet of R1 while providing her with her noon meal. D1 then left R1's room, performed hand hygiene, picked up another meal tray, and entered R2's room to deliver her noon meal. R2 was not on isolation. D1's facemask continued to be worn inappropriately. After exiting R2's room, D1 performed hand hygiene, picked up another lunch tray, and entered the room of R4, another resident who was not on isolation. D1 continued to wear the facemask inappropriately. On 7/1/20 at 11:36am, D1 indicated that the cloth facemasks were ill-fitting, and often slipped down beneath the nose. D1 indicated that when facility staff entered R1's room, they were expected to wear only a facemask and gloves. Facility staff would only wear further PPE if a resident was positive for COVID-19. D1 then indicated that facility staff were provided with two cloth facemasks at the beginning of the COVID-19 pandemic. D1 then indicated that facility staff received a text message on Monday, which documented that if facility staff needed a mask for their shift, they must pay $1.00 to the facility to get one. On 7/1/20 at 11:55am, a facility staff person, wearing only a disposable surgical mask (no other PPE was utilized by this staff member), entered R1's room carrying a full-body mechanical lift sling. On 7/1/20 at 12:18pm, Registered Nurse (RN1) indicated that facility staff were expected to wear only a facemask and gloves when entering R1's room. RN1 indicated that this practice seemed wrong, as R1 was under observation for COVID-19 symptoms, and that some people could be sick with COVID-19 but yet be free of symptoms of the disease. RN1 indicated that the facility recently tested a different resident for COVID-19, and while the facility awaited test results, facility staff were instructed by administration to wear only a facemask and gloves. RN1 indicated this was done because facility administration didn't feel like the resident had COVID-19. RN1 indicated that staff would only wear full PPE if a resident tested positive for COVID-19. RN1 indicated that facility staff were unaware of where the PPE supplies were, thusly inaccessible, but that facemasks were available in the Director of Nursing's (DON's) office. RN1 indicated that facility staff were supplied with two cloth facemasks by the facility, but that administration had sent a text message indicating that if facility staff needed a different mask, they must pay $1.00 to receive one. RN1 indicated that the facility attempted to practice social distancing with the residents, and tried to keep them six feet apart. RN1 indicated that facility staff did not focus on that any longer, and that low staffing played a part. RN1 indicated that at times, other facility staff wore facemasks beneath their noses, or would pull them down after leaving a resident room. RN1 indicated that on-the-spot education would be provided to the staff. RN1 indicated that it would be a struggle to keep a case of COVID-19 contained in the facility. On 7/1/20 at 12:34pm, NA2 exited a resident room, with their facemask beneath their nose, leaving the nostrils exposed. On 7/1/20 at 12:36pm, NA2 indicated that R1 was on isolation because she recently admitted to the facility. NA2 indicated that when staff entered R1's room, they were expected to wear only a facemask and gloves. NA2 indicated that they would only wear additional PPE if a resident became symptomatic, or tested positive for COVID-19. NA2 indicated that at mealtimes, facility staff would seat residents two to a table, and would attempt to keep them socially distanced, but could not always do that. NA2 indicated that the facility was often short-staffed, and that this was why they could not ensure residents were kept socially distanced. NA2 indicated that facility staff were provided with two cloth facemasks by the facility, but that if they needed a new one, they would have to pay $1.00. NA2 further indicated that the facility had surgical masks available, but that staff were told they could not wear them. NA2 indicated that the cloth masks were ill-fitting, and often fell down. During a confidential interview, a staff person provided the Federal surveyor with the text message, which read: Alert: MASK!! Nothing has changed, they are required and you MUST wear them correctly when out with residents! There has been a lot of staff forgetting their mask. If you have to get a another mask from facility, it will cost you $1.00 thanks! On 7/1/20 at 12:54pm, the DON indicated that the facility had a good supply of PPE, and was not short. The DON indicated that new admissions or readmissions were required to be on isolation for 14 days following entrance to the facility. The DON indicated that facility staff were expected to only wear a facemask and gloves to provide care for residents under observation for signs or symptoms of COVID-19. The DON indicated that facility staff attempted to enforce social distancing, but some residents preferred to sit next to each other. The DON indicated that she was not aware of any issues with social distancing during mealtimes on the secured memory care unit. The DON indicated that some facility staff were forgetting their cloth masks at home, and so the administration sent a mass text message stating that extra masks would cost $1.00. On 7/1/20 at 1:00pm, the Administrator indicated that the mass text message was sent as a joke, and was not meant to be taken seriously. On 7/1/20 at 3:28pm, the DON indicated that the facility practice for new admissions and PPE since the onset of the pandemic was for staff to wear only a facemask and gloves when entering their rooms. - Review of CMS guidance, titled Guidance for Limiting the Transmission of COVID-19 for Nursing Homes, dated 3/4/20, documented the following: How should facilities monitor or limit visitors? Facilities should screen visitors for the following: 1. International travel within the last 14 days to restricted countries. For updated information on restricted countries visit: https://www.cdc.gov/coronavirus/2019- ncov/[MEDICATION NAME]/index.html 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. Has had contact with someone with or under investigation for COVID-19 . How should facilities monitor or restrict health care facility staff? The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above). Review of the Staff Screening Form COVID-19 documented that facility staff were to write their names, then document answers to the following questions: temperature, if shortness of breath was present, if cough was present, if so, was the cough new or changed; if sore throat was present, if so, was the sore throat new or changed; if redness was present around the eyes, and if the staff was sent home. Staff were to document the date and time of the screening. Review of the Staff Screening Form COVID-19 logs revealed the following: On 3/18/20, 3/21/20, 3/29/20, 3/30/20, 3/31/20, 4/2/20, 4/11/20, 4/13/20, 4/15/20, 4/16/20, 4/26/20, 5/22/20, 5/30/20, 6/24/20, and 6/28/20, facility staff failed to answer all screening questions prior to facility entry. On 3/23/20, 3/29/20, 4/3/20, 4/8/20, 4/26/20, 4/29/20, 5/14/20, 5/19/20, 5/21/20, 5/30/20, 6/3/20, 6/19/20, and 6/29/20, facility staff failed to have their temperature taken prior to facility entry. None of the facility staff indicated on the forms that they were sent home, indicating that they were permitted to begin their shifts. Review of Medical Personnel Only screening logs documented that medical personnel visitors were expected to document the date, their name, a telephone number, and their temperature. The visitors were expected to answer the following questions: if they experienced shortness of breath, a cough, if so, was the cough new or changed; a sore throat, if they traveled outside of the United States, and if they had redness around the eyes. Review of the Medical Personnel Only logs revealed the following: On 3/18/20, a visitor failed to answer any of the screening questions. On 4/10/20, a visitor failed to answer all of the screening questions. On 4/20/20, two visitors failed to answer any of the screening questions. On 5/8/20, a visitor failed to document a temperature. On 5/19/20, two visitors failed to document temperatures, or answer any of the screening questions. On 5/27/20, a visitor failed to document a temperature, or answer any of the screening questions. On 6/9/20, two visitors failed to document temperatures or answer any of the screening questions. On 6/21/20, two visitors failed to answer any screening questions. On 6/22/20, a visitor failed to document a temperature or answer any of the screening questions. On 6/23/20, two visitors failed to document temperatures or answer any screening questions. On 6/24/20, two visitors failed to answer any screening questions. On 6/25/20, two visitors failed to answer any screening questions, and an additional visitor failed to document a temperature or answer any questions. Review of the Visitors Only screening logs documented that resident's visitors were expected to document the date, their name, a telephone number, and their temperature. The visitors were expected to answer the following questions: if they experienced shortness of breath, a cough, if so, was the cough new or changed; a sore throat, if they traveled outside of the United States, the name of the resident they were visiting, and the time of entry to the facility. Review of the Visitors Only screening logs revealed the following: On 6/24/20, a visitor failed to answer any of the screening questions, and documented a temperature of 99.3F (Fahrenheit). On 7/1/20 at 10:45am, the Administrator indicated that the screening logs got mixed up, and that staff and resident visitors sometimes signed in on the Medical Personnel Only forms. On 7/1/20 at 12:54pm, the DON indicated that the facility administration reviewed the logs regularly to check if there were any blanks on the logs. The DON indicated that facility staff screened themselves into the facility, and were expected to complete the screening log themselves.The DON indicated that she was not aware of any issues with facility staff, visiting medical personnel, or resident visitors failing to complete the screening logs. - Review of CDC recommendations, located in Preparing for COVID-19 in Nursing Homes, under the section Additional Strategies Depending on the Facility's Reopening Status, documented the following: Implement Social Distancing Measures Implement aggressive social distancing measures (remaining at least 6 feet apart from others): Cancel communal dining and group activities, such as internal and external activities. Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene. Further review of CDC recommendations, located in Infection Prevention and Control (IPC) Guidance for Memory Care Units, documented the following: Continue to provide structured activities, which may need to occur in the resident's room or be scheduled at staggered times throughout the day to maintain social distancing . Limit the number of residents or space residents at least 6 feet apart as much as feasible when in a common area, and gently redirect residents who are ambulatory and are in close proximity to other residents or personnel. On 7/1/20 at 9:10am, two residents sat in their wheelchairs in the main dining room, at the same table. The residents were approximately three feet apart. Neither of the residents wore facemasks. At 9:41pm, the residents continued to sit in the same manner. Intermittent observations between 9:10am and 9:41am revealed that no staff attempted to educate the residents about social distancing, or made attempts to separate the two residents. On 7/1/20 at 11:56am, two residents sat in the main dining room for the noon meal. The residents sat within six feet of each other, and did not wear masks. On 7/1/20 at 11:58am, on the facility's secured memory care unit, an unsampled male resident and an unsampled female resident sat at the same table, eating their meals. The residents sat within six feet of each other. At 12:00pm, approximately two minutes after the Federal surveyor entered the unit, a staff person picked up the male resident's meal and placed it at a different table. The staff person then assisted the male resident to sit at the different table. On 7/1/20 at 12:54pm, the DON indicated that the facility attempted to enforce social distancing among the residents of the facility. The DON indicated that she was not aware of any issues regarding social distancing in the secured memory care unit.

The facility reported a census of 31 residents, with 4 residents sampled for accidents. Based on observation, interview and record review the facility failed to provide an environment that kept 2 of the 4 sampled residents (#1 and #3) safe from falls and failed to ensure 1 sampled resident (#3), was safe from unlocked chemicals. Resident #1 fell on [DATE] from his/her recliner and sustained a laceration to the head that required sutures. Also the facility reported 17 of the residents resided in the special care unit of the facility, and identified 10 as confused and self-mobile. Based on observation, interview and record review, the facility failed to ensure a safe environment for the 10 confused and self-mobile residents, when staff left a bottle of sanitizer/cleaner on the dining room table in the special care unit, and 1 (#2) of the 10 residents, opened the bottle and started drinking the chemical before staff noticed this and took the bottle away. Findings included: - Resident #1 admitted to the facility with a [DIAGNOSES REDACTED]. The 11/3/17 annual MDS (minimum data set) identified the resident with a BIMS (brief interview for mental status) score of 7 (0-7 indicated cognition severely impaired), independent with walking, used a walker for mobility and had no falls since the last MDS. The 11/13/17 ADL (activities of daily living) CAA (care area assessment) documented he/she required assistance with ADLs related to weakness and a [DIAGNOSES REDACTED]. The 11/13/17 fall CAA, failed to trigger for further assessment. The 2/3/18 quarterly MDS documented he/she experienced one fall with minor injury since the last MDS. The 2/6/18 care plan instructed staff as follows: The resident was a high risk for falls, related to confusion and gait/balance problems. Be sure his/her call light remained within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A revision to the care plan on 3/5/18, documented an actual minor injury fall on 3/5/18, with a laceration (wound to the skin) and skin tear (tear in the top layer of skin) noted, room re-arranged (with permission of resident), staff educated not to leave the resident in the recliner with his/her feet up without supervision. Review of the resident's prior care plan dated 2/6/2018, revealed he/she fell on [DATE], and the facility educated the staff to ensure the resident wore non-skid footwear. Further review revealed on 11/26/17, the resident slid out of the recliner and staff were to offer assistance with cares and double check that the resident's non-skid footwear was in place. The 2/6/18 fall risk assessment documented the resident scored 13, a score over 10 indicated he/she was a high risk for falls. Review of the nurses' notes in the electronic record revealed, on 3/5/18 the resident fell in his/her room, resulting in an open wound to the back of the head that measured 3.5 centimeters by 0.5 centimeters, and a skin tear to the right elbow that measured 1.5 by 0.5 centimeters, and staff sent the resident to the hospital. The nurses' notes, on 3/5/18 at 7:06 PM, documented the resident returned to the facility with an order to follow-up with his/her healthcare provider in 24-48 hours, to keep the wound clean and dry, and the staples intact to the back of his/her head. On 4/4/18 at 8:45 AM, observation revealed the resident sat in the recliner in his/her room wearing regular slippers without socks. At 9:40 AM, observation revealed he/she pulled his/her feet in and out of the slippers, and commented the shoes were okay but too big. The resident wore the same shoes at 12:10 PM, when eating lunch in the dining room. On 4/4/18 at 12:55 PM, direct care staff E walked with the resident to his/her room, with the walker and assisted him/her to sit in the recliner. The staff ensured the call light was in reach, asked the resident if he/she needed anything else, and left. On 4/4/18 at 9:45 AM, direct care staff D reported the resident used a front wheeled walker with ambulation and would get up in his/her room and walk without the walker at times. Direct care staff D reported the resident could put his/her own socks and shoes on, would change them at times, and rarely wore gripper socks. Direct care staff D reported he/she was never instructed to put gripper socks on the resident, and reported he/she was not working when the resident fell , and hurt his/her head. Direct care staff D reported the intervention was staff were to check on the resident every 1 to 2 hours. He/she reported the intervention was in the intervention notebook , kept at the nurses' desk in the unit. On 4/4/18 at 12:55 PM, direct care staff E reported not working when the resident fell , and was unsure what intervention was put into place. Direct care staff E reported he/she thought the staff were to check on the resident every hour or so. The staff reported the resident as able to put shoes and socks on him/herself. Direct care staff E reported he/she was never instructed to make sure the resident wore gripper socks, and reported the unit had a care plan/intervention book with interventions and teachable moments when licensed staff added new interventions, but the staff were so busy he/she did not often have time to review the book. On 4/4/18 at 1:00 PM, direct care staff F reported he/she came to the unit at mealtimes to assist, and would check the book to see if staff added any new interventions after the resident fell . Direct care staff F reported the intervention was to check on the resident often and staff rearranged the room. On 4/4/18 at 2:35 PM, administrative nursing staff C reported the intervention added to the care plan was to rearrange the room, and educate the staff to not leave the resident in the recliner with his/her feet elevated without supervision. Staff C checked the resident's slippers, and reported they seemed fine. The resident then slipped one foot out of the slipper and stated, They are too big. Staff C obtained a pair of gripper socks and asked the resident to try on the socks. The resident said, Ok. Administrative nursing staff C reported staff added the intervention to the care plan and the care plan/intervention book kept at the nurse's desk on the unit. Staff C retrieved the book, and after flipping through several pages, found the resident. Administrative staff C verified the book required the staff to take a lot of time to find the information and verified the resident's prior care plan, dated 2/6/18 documented non-skid footwear for all transfers/ambulation and added the staff should know the resident should wear the non-skid footwear. On 4/6/18 at 8:35 AM, administrative nursing staff B reported the 3/7/18 investigation for the fall revealed the staff put the footrest up on the recliner, and was unaware the resident was unable to lower it. Administrative nursing staff B reported the 2/6/18 care plan documented the resident should wear non-skid footwear, but was able to remove them and was not wearing them when the fall occurred, and added further this was not included in the 2/6/18 care plan, or on the 3/7/18 fall investigation that he/she saw. On 4/6/18 at 10:16 AM, licensed nursing staff G reported he/she was at the facility on 3/5/18, when the resident fell . Licensed nursing staff G reported he/she went to the room, and saw the resident was on the floor with his/her legs out in front of him/her, with one shoe off. The staff did not remember if the resident wore socks. Licensed nursing staff G reported the resident was usually pleasantly confused, able to dress him/her self, and used a walker for ambulation. The staff reported the resident sometimes would get up without the walker in the room, to change the record on the record player. Licensed nursing staff G reported he/she did not know what the intervention was for the fall, and added he/she did not remember if the resident wore gripper socks. The facility policy for fall documentation, dated 12/2010, documented the post fall review includes new or revised preventive interventions determined to be appropriate to prevent further falls. The facility failed to ensure this cognitively impaired, high risk for falls resident, received adequate supervision and assistive devices to prevent repeated accidents. The facility failed to ensure the resident wore the planned gripper socks to assist the resident with stability, while ambulating. The resident fell , was sent to the hospital, where he/she required staples to close a [MEDICAL CONDITION]. - Resident #2 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 12/1/17 MDS (minimum data set) documented he/she had severely impaired cognition and required extensive assistance with most ADLs (activities of daily living), and used a walker and wheelchair for mobility. The 12/1/17 cognitive CAA (care area assessment) documented he/she had severely impaired cognition related to a [DIAGNOSES REDACTED]. The 3/1/18 quarterly MDS documented no changes with the resident's cognition or ADLs from the 12/1/17 MDS. The 3/6/18 care plan instructed staff as follows: admitted to memory care unit on 3/27/17. He/she is totally dependent on one staff for eating. He/she is on a fluid restriction, of 1500-2500 milliliters, and needs assistance with his/her fluids. The resident's 1/23/18 at 6:59 PM, nurses' notes revealed, on 1/23/18 around 9:10 AM, staff observed the resident drinking a cleaner (hazardous chemical) from a bottle. Staff sent the resident to his/her primary care physician, and the resident's guardian was notified. Notarized statements by facility staff documented as follows: On 1/23/18, direct care staff H documented, that he/she worked the night shift, the night before the incident, on 1/22/18. Staff H noticed a housekeeper in the memory care unit around 5:30 AM. He /she noticed the sanitizer bottler at that time (on a dining room table) but assumed the housekeeper was using it. On 1/23/18, housekeeping staff I documented, as he/she entered the dining area at 9:10 AM, after cleaning the living room. Staff I noted the resident in the corner by the popcorn machine, with what appeared to be a bottle of cleaner, tipped up to his/her mouth. The resident was drinking it, as if it were a pop. Housekeeping staff I, hollered to the direct care staff that the resident was drinking the cleaner. A direct care staff took the bottle of cleaner away from the resident. It apparently was the sanitizer they used. The direct care staff got the bottle away from the resident and called the charge nurse. On 1/23/18, direct care staff J documented, on he/she heard the housekeeper yell Hey as the resident grabbed a bottle of sanitizer and began to drink it. Direct care staff J took the bottle away from the resident, and got some water for him/her to drink. The staff then notified the charge nurse. On 1/23/18, licensed nursing staff K documented, he/she was the charge nurse on 1/23/18, when staff called him/her to the unit, related to a resident drinking a chemical. Licensed nursing staff K documented the resident was in a wheelchair drinking water, when he/she got to the unit. Staff stated the resident got ahold of a bottle of cleaning spray and drank some. Staff K took the resident's vital signs and took the resident to see his/her primary care physician. The staff called the emergency line for the local chemical company and the poison control center with a number given. The staff notified the resident's guardian by phone at 10:00, AM. The poison control hot line advised the staff to watch the resident for nausea, vomiting, diarrhea, skin and throat irritation, and to give fluids. Interview, on 1/26/18, with direct care staff L, revealed he/she used the sanitation spray to clean the dining room tables on Saturday the 20th, before the shift ended around 9:15 to 9:30 PM. Staff L remembered he/she locked the spray up, close to 9:30 PM. The facility's 1/29/18 investigation, documented on 1/23/18 around 9:10 AM, the resident was in the dining room and drank sanitizer/cleaner from a bottle left on the table. The staff took the resident to see his/her primary care physician, after drinking a glass of water, given to him/her by a a direct care staff. The charge nurse called the poison control, told them the resident was given water to drink immediately. The poison control instructed the nurse to watch the resident closely. The administrative staff educated the staff that all chemicals were to be locked immediately after use. The resident returned from the doctor, with instructions to monitor the resident for throat irritation, nausea, vomiting, and diarrhea. The facility investigation further documented, on 1/22/18, per the camera video at approximately 9:30 PM, direct care staff L used the chemical on the table and set the bottle on the same table where the resident grabbed it on 1/23/18, per the video camera. Direct care staff reported, in the notarized statement he/she locked it up. The investigation documented the day staff reported they had not removed any sprays from the cabinet. On 4/4/18 at 3:45 PM, administrative nursing staff B reported the facility did the investigation related to the incident of the resident drinking the chemical, and only noted it in the nurse's notes. Staff B reported he/she reviewed the videos of the unit and saw when/where direct care staff L, left the chemical out on the evening of 1/22/18. Staff L worked that evening from 2:00 PM -10:00 PM. Administrative nursing staff B reported the direct care staff received no disciplinary action, but did receive education on the chemicals. The facility's undated policy for hazardous chemicals documented: All hazardous chemicals are to be locked at all times to avoid accessibility of any elder in the facility. Staff will replace all supplies after use. The facility failed to ensure a safe environment, for the 10 confused and self-mobile residents of the memory care unit, without accessible hazardous chemicals. Resident #2 who was cognitively impaired, found the bottle of hazardous sanitizer/cleaner on the dining room table, and began drinking the chemical from the bottle before staff noticed and took the chemical away from the resident.

The facility reported a census of 30 residents, with 15 residents residing within the special care unit. Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure protection of all the residents of the SCU (special care unit) from physical abuse, when 1 resident (#1) of 3 reviewed for abusive behaviors, attacked another resident (#2) on 3 different occasions, twice on 12/29/17 and once on 12/30/17, which resulted in resident #2 receiving a [MEDICAL CONDITION] (wound to the skin) requiring steri-strips, an ear laceration, a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the forehead, and a scrape to the bridge of the resident's nose. The facility failed to provide adequate supervision to prevent the abuse, which placed all 14 residents of the SCU in immediate jeopardy for abuse from resident #1. Findings included: - Resident #1's physician's orders [REDACTED]. what may normally be felt from time to time)), [MEDICAL CONDITION] type (major mental illness that caused people to have episodes of severe high and low moods) and [MEDICAL CONDITION] (any major mental disorder characterized by a gross impairment in reality testing). The admission Minimum Data Set, dated dated [DATE], recorded staff assessed the resident with long and short term memory loss and moderate impairment of daily decision making. The assessment evidenced the resident experienced inattention, had little interest in doing things, had trouble concentrating and displayed actions indicative of being short tempered, easily annoyed, and had physical behavioral symptoms directed toward others (1-3 days of the lookback period), however, indicated this did not occur toward other residents or disrupt the environment. The 3/7/17 Care Area Assessment for behaviors documented the resident displayed some inappropriate behaviors since admission towards nursing staff. Staff educated the resident that treating staff this way was not appropriate and no further incidents occurred. Staff assessed the resident as an elopement risk and placed a wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) related to the resident's history of eloping from a previous facility. A Care Area Assessment for [MEDICAL CONDITION] medications, dated 3/7/17, included the physician prescribed [MEDICATION NAME] related to a [DIAGNOSES REDACTED]. The resident's care plan, dated 12/7/17, directed staff to: Provide resident education on inappropriate behaviors. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document. Assess and address for contributing sensory deficits Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Behavioral health to evaluate and treat via inpatient services. Provide physical and verbal cues to alleviate anxiety. Give positive feedback. Assist verbalization of the source of agitation, and assist to set goals for more pleasant behaviors. Encourage seeking out of staff members, when agitated. Give the resident as many choices as possible about care and activities. Monitor/document/report PRN (as needed) any sign/symptom of the resident posing a danger to self and others. Psychiatric/Psychogeriatric consults, as indicated. Every 15 minute checks discontinued on 8-2-17 related to no recent behaviors. Attempt to find a way to meet the resident's needs, without telling the resident, No. Staff to approach the resident calmly, in order to attempt not to agitate the resident. Re-approach later. When the resident became agitated intervene before agitation escalated; guide the resident away from the source of the distress; engage calmly in conversation; if response was aggressive, staff walk calmly away, and approach later. Review of a facility investigation recorded on 12/29/17 at approximately 7:45 PM, staff observed resident #2 walking towards the table where resident #1 sat for meals. Staff observed resident #1 was not at the table as resident #2 approached and reached out to touch the fluid filled glasses on the table, resident #1 rushed to the table, and pushed the table into resident #2 which shoved resident #2 onto the floor. Licensed nursing staff D notified the DON (director of nursing) who then instructed the facility staff to keep the residents away from each other. At 7:50 PM resident #1 sat in a recliner in the lobby area (without supervision), jumped up and ran to nearby resident #2 and hit resident #2 in the face with a closed fist. Again, staff separated the residents. Staff called the DON, EMS (emergency medical services) and the police. Upon the DON's arrival to the facility, resident #2 walked about the facility, with blood noted on his/her forehead. Resident #1 slept in his/her room. The DON instructed a CNA (certified nurse aide) to stand outside of resident #1's room, until resident #1 transferred from the facility to the ER (emergency room ) for evaluation by the local mental health clinic. The resident was taken to the ER for evaluation and then returned to the facility around 1:30 AM, with no new orders. On 12/30/17 at 7:30 AM staff noted resident #1 awakened and went to the television area, and sat, unsupervised. After a few minutes, staff observed resident #2 standing near the tables in the dining area, heard resident #1 running from the television area to the dining area and staff yelled out to stop. Staff were unable to reach either resident, before resident #1, again attacked resident #2, hitting the resident in the back which knocked the resident to the floor. The staff called EMS and the police. Staff found placement for the resident in a BHU (behavioral health unit). Review of the investigation documents indicated the staff documented one-on-one supervision on 12/30/17 from 2:30 AM to 5:45 AM then from 8 AM to 1:30 PM. The remainder of the one-on-one supervision documentation was incomplete. The facility lacked documentation of one-on-one supervision for 12/29/17. The facility report indicated that at shift change on 12/30/17 at 6:00 AM, off-going CNAs instructed oncoming CNA staff to keep an eye on the resident. Staff reported they checked the resident a couple of times that morning and the resident slept in his/her room. At 7:30 AM, staff observed the resident in the lobby, seated in the recliner. At 7:45 AM resident #1 observed resident #2 in the dining room, walked up to him/her, hit the resident and caused resident #2 to fall down. After the incident resident #1 again returned to his/her room. At 8:00 AM administrative staff A arrived at the building and instructed all staff in the unit on the understanding that staff were to monitor resident #1 one on one at all times. The staff reported finding a BHU to accept the resident, transportation arrangements were made and the resident exited the building with 3 staff members at 2:00 PM on 12/30/17. On 1/11/18 at 1:34 PM, direct care staff E reported the resident seemed in a good mood on 12/30/17. Staff E indicated he/she assisted another resident with a cup of coffee, when he/she heard a noise and turned around to see resident #1 run out of the television area into the dining room, headed straight toward resident #2, hit the resident in the back and knocked the resident to the floor. Staff immediately intervened to protect resident #2. The staff member reported that another CNA that morning indicated he/she was to provide one on one supervision with resident #1, when he/she got out of bed. On 1/11/18 at 1:40 PM, licensed nursing staff C reported the morning of 12/30/17 the nurse received report from the off-going nurse that resident #1 was on one to one observation. Staff further indicated that due to the unit coordinator being on the unit, he/she did not immediately go to the unit to check on anything. At about 7:30 AM the staff requested the nurse to come to the unit. Upon arrival, staff C checked resident #2 for injury, made notifications and checked on resident #1, who seemed his/her normal self. On 1/11/18 at 1:55 PM, administrative nursing staff B reported that around 7:35 PM, (on 12/29/17), the facility called him/her and reported that resident #1 pushed the table into resident #2, causing resident #2 to fall. At that time, staff B reported he/she instructed staff to monitor resident #1, one on one. A short time later the facility called again to report resident #1 had again attacked resident #2, punching the resident in the face. Staff B instructed the staff to call EMS and the police. Again, staff were instructed to monitor resident #1, one on one. Resident #1 went to the ER prior to staff B leaving the facility that night. Staff B reported that during shift change the staff were instructed to provide one on one supervision. In the morning resident #1 got out of bed, went to the living area, where he/she sat until seeing resident #2 up and about, and then attacked resident #2, hitting the resident in the back and knocking the resident to the floor. On 1/11/18 at 2:08 PM, administrative staff A reported staff failed to handle the incidents as he/she expected. Staff were to provide one on one observation, as instructed, and that did not occur. The facility policy, dated 11/16, regarding Abuse Prevention, documented the definition of abuse included hitting, slapping, pinching and kicking. If abuse is suspected the DON or the designee would separate the residents to ensure no access to each other occurs until the circumstances of the alleged incident can be determined. The facility policy, dated 11/16, regarding Abuse Prevention, documented the definition of abuse included hitting, slapping, pinching and kicking. If abuse is suspected the DON or the designee would separate the residents to ensure no access to each other occurs until the circumstances of the alleged incident can be determined. The facility failed to protect all residents of the SCU from physical abuse, when the facility failed to provide continuous, adequate supervision for resident #1, from 12/29/17 at 7:45 PM, the time resident #1 inflicted physical abuse on another resident in the SCU, until resident #1 was sent out of the facility at 2:06 PM on 12/30/17 to a behavioral health facility. This placed all 14 residents of the SCU in immediate jeopardy. This deficiency was cited at past non-compliance, as of 1/5/18 at 2:34 PM when the facility management: 1. Completed training with all the facility staff on what one on one monitoring entailed, and re-training on abuse and neglect, as of 1/5/18 at 2:34 PM. 2. Developed a system for the director of nursing to monitor resident #1's medication with the medical director, as well as reviewing behavior logs at least weekly to identify trending. 3. The facility held a Quality Assurance meeting with the medical director, on 1/4/18 at 1:00 PM, reviewing the incident and will follow-up during the next QA meetings.

The facility reported a census of 30 residents, with 15 residents residing within the special care unit. Based on observation, interview, and record review, the facility failed to ensure all residents of the SCU (special care unit) remained free from physical abuse, when 1 resident (#1) of 3 reviewed for abusive behaviors attacked another resident (#2) on 3 different occasions, twice on 12/29/17 and once on 12/30/17, which resulted in resident #2 receiving a [MEDICAL CONDITION] (wound to the skin) requiring steri-strips, an ear laceration, a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the forehead, and a scrape to the bridge of the resident's nose. The facility failed to provide adequate supervision to prevent abuse, which placed resident #2 in immediate jeopardy for abuse from resident #1. Findings included: - Resident #1's physician's orders [REDACTED]. what may normally be felt from time to time)), [MEDICAL CONDITION] type (major mental illness that caused people to have episodes of severe high and low moods) and [MEDICAL CONDITION] (any major mental disorder characterized by a gross impairment in reality testing). The admission Minimum Data Set, dated dated [DATE], recorded staff assessed the resident with long and short term memory loss and moderate impairment of daily decision making. The assessment evidenced the resident experienced inattention, had little interest in doing things, had trouble concentrating and displayed actions indicative of being short tempered, easily annoyed, and had physical behavioral symptoms directed toward others (1-3 days of the lookback period), however, indicated this did not occur toward other residents or disrupt the environment. The 3/7/17 Care Area Assessment for behaviors documented the resident displayed some inappropriate behaviors since admission towards nursing staff. Staff educated the resident that treating staff this way was not appropriate and no further incidents occurred. Staff assessed the resident as an elopement risk and placed a wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) related to the resident's history of eloping from a previous facility. A Care Area Assessment for [MEDICAL CONDITION] medications, dated 3/7/17, included the physician prescribed [MEDICATION NAME] related to a [DIAGNOSES REDACTED]. The resident's care plan, dated 12/7/17, directed staff to: Provide resident education on inappropriate behaviors. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document. Assess and address for contributing sensory deficits Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Behavioral health to evaluate and treat via inpatient services. Provide physical and verbal cues to alleviate anxiety. Give positive feedback. Assist verbalization of the source of agitation, and assist to set goals for more pleasant behaviors. Encourage seeking out of staff members, when agitated. Give the resident as many choices as possible about care and activities. Monitor/document/report PRN (as needed) any sign/symptom of the resident posing a danger to self and others. Psychiatric/Psychogeriatric consults, as indicated. Every 15 minute checks discontinued on 8-2-17 related to no recent behaviors. Attempt to find a way to meet the resident's needs, without telling the resident, No. Staff to approach the resident calmly, in order to attempt not to agitate the resident. Re-approach later. When the resident became agitated intervene before agitation escalated; guide the resident away from the source of the distress; engage calmly in conversation; if response was aggressive, staff walk calmly away, and approach later. Review of a facility investigation recorded on 12/29/17 at approximately 7:45 PM, staff observed resident #2 walking towards the table where resident #1 sat for meals. Staff observed resident #1 was not at the table as resident #2 approached and reached out to touch the fluid filled glasses on the table, resident #1 rushed to the table, and pushed the table into resident #2 which shoved resident #2 onto the floor. Licensed nursing staff D notified the DON (director of nursing) who then instructed the facility staff to keep the residents away from each other. At 7:50 PM resident #1 sat in a recliner in the lobby area (without supervision), jumped up and ran to nearby resident #2 and hit resident #2 in the face with a closed fist. Again, staff separated the residents. Staff called the DON, EMS (emergency medical services) and the police. Upon the DON's arrival to the facility, resident #2 walked about the facility, with blood noted on his/her forehead. Resident #1 slept in his/her room. The DON instructed a CNA (certified nurse aide) to stand outside of resident #1's room, until resident #1 transferred from the facility to the ER (emergency room ) for evaluation by the local mental health clinic. The resident was taken to the ER for evaluation and then returned to the facility around 1:30 AM, with no new orders. On 12/30/17 at 7:30 AM staff noted resident #1 awakened and went to the television area, and sat, unsupervised. After a few minutes, staff observed resident #2 standing near the tables in the dining area, heard resident #1 running from the television area to the dining area and staff yelled out to stop. Staff were unable to reach either resident, before resident #1, again attacked resident #2, hitting and knocking the resident to the floor. The staff called EMS and the police. Staff found placement for the resident in a BHU (behavioral health unit). Review of the investigation documents indicated the staff documented one-on-one supervision on 12/30/17 from 2:30 AM to 5:45 AM then from 8 AM to 1:30 PM. The remainder of the one-on-one supervision documentation was incomplete. The facility lacked documentation of one-on-one supervision for 12/29/17. The facility report indicated that at shift change on 12/30/17 at 6:00 AM, off-going CNAs instructed oncoming CNA staff to keep an eye on the resident. Staff reported they checked the resident a couple of times that morning and the resident slept in his/her room. At 7:30 AM, staff observed the resident in the lobby, seated in the recliner. At 7:45 AM resident #1 observed resident #2 in the dining room, walked up to him/her, hit the resident and caused resident #2 to fall down. After the incident resident #1 again returned to his/her room. At 8:00 AM administrative staff A arrived at the building and instructed all staff in the unit on the understanding that staff were to monitor resident #1 one on one at all times. The staff reported finding a BHU to accept the resident, transportation arrangements were made and the resident exited the building with 3 staff members at 2:00 PM on 12/30/17. On 1/11/18 at 1:34 PM, direct care staff E reported the resident seemed in a good mood on 12/30/17. Staff E indicated he/she assisted another resident with a cup of coffee, when he/she heard a noise and turned around to see resident #1 run out of the television area into the dining room, headed straight toward resident #2, hit the resident in the back and knocked the resident to the floor. Staff immediately intervened to protect resident #2. The staff member reported that another CNA that morning indicated he/she was to provide one to one supervision with resident #1, when he/she got out of bed. On 1/11/18 at 1:40 PM, licensed nursing staff C reported the morning of 12/30/17 the nurse received report from the off-going nurse that resident #1 was on one to one observation. The staff further indicated that due to the unit coordinator being on the unit, he/she did not immediately go to the unit to check on anything. At about 7:30 AM the staff requested the nurse to come to the unit. Upon arrival, staff C checked resident #2 for injury, made notifications and checked on resident #1, who seemed his/her normal self. On 1/11/18 at 1:55 PM, administrative nursing staff B reported that around 7:35 PM, (on 12/29/17), the facility called him/her and reported that resident #1 pushed the table into resident #2, causing resident #2 to fall. At that time, staff B reported he/she instructed staff to monitor resident #1, one on one. A short time later the facility called again to report resident #1 had again attacked resident #2, punching the resident in the face. Staff B instructed the staff to call EMS and the police. Again, staff were instructed to monitor resident #1, one on one. Resident #1 went to the ER prior to staff B leaving the facility that night. Staff B reported that during shift change the staff were instructed to provide one on one supervision. In the morning resident #1 got out of bed, went to the living area, where he/she sat until seeing resident #2 up and about, and then attacked resident #2, hitting the resident in the back and knocking the resident to the floor. On 1/11/18 at 2:08 PM, administrative staff A reported staff failed to handle the incidents as he/she expected, as Staff were to provide one on one observation, as instructed, and that did not occur. The facility policy, dated 11/16, regarding Abuse Prevention, documented the definition of abuse included hitting, slapping, pinching and kicking. If abuse is suspected the DON or the designee would separate the residents to ensure no access to each other occurs until the circumstances of the alleged incident can be determined. The facility failed to provide adequate supervision to ensure resident #2 remained free from physical abuse on 3 occasions, twice on 12/29/17 and once on 12/30/17, when resident #1 attacked resident #2. On the second occasion, resident #2 suffered facial injuries requiring first aid treatment. This deficiency was cited at past non-compliance, as of 1/5/18 at 2:34 PM when the facility management: 1. Completed training with all the facility staff on what one on one monitoring entailed, and re-training on abuse and neglect, as of 1/5/18 at 2:34 PM. 2. Developed a system for the director of nursing to monitor resident #1's medication with the medical director, as well as reviewing behavior logs at least weekly to identify trending. 3. The facility held a Quality Assurance meeting with the medical director, on 1/4/18 at 1:00 PM, reviewing the incident and will follow-up during the next QA meetings.

The facility reported a census of 35 residents, and identified 7 residents with insulin dependent diabetes. Based on observation, interview and record review, revealed the facility failed to administer the correct physician ordered amount of insulin for 3 consecutive doses for 1 (#01) of 3 sampled insulin dependent residents, which resulted in significant medication errors. The resident experienced [MEDICAL CONDITION] activity and became non-responsive due to severe [DIAGNOSES REDACTED] (low blood sugar). The resident required intensive care unit hospitalization , for 2 days. This deficient practice placed the resident in immediate jeopardy. Findings included: - The medical record evidenced the facility admitted resident #01 on 2/22/17, with the physician list of diagnoses, which included insulin dependent diabetes mellitus (inadequate production or utilization of insulin). The 3/9/17 MDS (minimum data set) assessment, identified the resident with severe cognitive deficit, in need of extensive assistance with activities of daily living, and received insulin injections daily. The 3/9/17 CAA (care area assessment) for cognition, included: The resident had severely impaired cognition related to a [DIAGNOSES REDACTED]. The resident was unable to complete the BIMS (brief interview for mental status). The resident had a short and long term memory problem, and had inattention that fluctuated in severity but was often constant. The resident also experienced disorganized thinking as he/she rambled and answered questions inappropriately. The resident required assistance with all ADLs (activities of daily living), being unable to make his/her needs known. Staff should monitor the resident closely for needs. The 2/23/17 plan of care included, instructions to the staff to monitor/report any signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar), which included: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, or a staggering gait. Physician's orders on 4/26/17, included: 1.) [MEDICATION NAME] (fast acting insulin): give 1 unit of insulin per every 15 grams of carbohydrates consumed (1:15) for breakfast, lunch, supper and bedtime (snack) for DM (diabetes mellitus). 2.) In addition give [MEDICATION NAME] per sliding scale, as related to the BS (blood sugar) reading (Glucometer- machine to test blood glucose level in the blood): If BS is 160 to 219, give 1 unit; If BS is 220 to 279, give 2 units; If BS is 280 to 339, give 3 units, check [MEDICATION NAME] (a build-up of glucose levels when there is not enough insulin procuded) if BS over 300 and call the physician's office immediately, if results are moderate to large; If BS is 340 to 399, give 4 units; If BS is 400 to 459, give 5 units; If BS is 460 to 519, give 6 units; If BS is 520 to 579, give 7 units; And if BS is 580 or higher, give 8 units. Give subcutaneously (injection given between the skin and muscle) with meals for DM. If the blood sugar is under 70 gm/dl (grams/deciliters), have the resident eat 15 gm (grams) of fast acting carbohydrates, or take away 15 grams from your meal/snack calculations (which would be minus 1 unit of insulin). Nurses notes, dated 5/6/17 at 1:30 PM, documented the staff called EMS (emergency medical service) called in regards to the resident's low blood sugar. The resident was admitted to the hospital in the ICU (intensive care unit). Nurses notes, dated 5/8/17 at 6:32 PM, documented the resident returned to the facility at 5:40 PM. On 5/9/17 at 4:40 P.M., interview with licensed nursing staff A, and review of the facility investigation, revealed licensed nurses B and C made errors in the amount of [MEDICATION NAME]administered, to the resident on Saturday, 5/6/17. Nurse B (a part time as needed nurse) read the insulin order and multiplied the units, instead of following the 1:15 units/carbohydrates ratio, as ordered. Nurse B administered 42 units of [MEDICATION NAME](should have only administered 2 units) at breakfast. Nurse B advised Nurse C (a part time, as needed nurse who split a shift with nurse B) on how he/she calculated the amount of [MEDICATION NAME] to administer. Nurse C did not look at the physician's order and administered 30 units of [MEDICATION NAME] at lunch time (he/she should have only administered 6 units) and then administered 30 units of [MEDICATION NAME] at supper time, (he/she should have only administered 2 units). Following the evening meal the resident began to show evidence of lethargy (tired) and then non-responsiveness. Staff attempted to administer sugared kool-aid and sugar into the resident's mouth, without a response. The staff had inadvertently locked the keys in the medication cart and the nurse could not get into the [MEDICATION NAME] (injectable used to counteract [DIAGNOSES REDACTED]). The resident developed [MEDICAL CONDITION] activity, and staff notified EMS (emergency medical services), who transported the resident to the hospital. Per facility investigation the resident had a blood sugar of 22 (with a desired range of 80 to 120) upon arrival at the emergency room . The wrong dose administration of insulin, on 5/6/17, following all three meals, resulted in a [DIAGNOSES REDACTED] reaction for the resident. The resident developed [MEDICAL CONDITION] activity and lost consciousness. The resident admitted to the hospital from the ER and was in ICU (intensive care unit) for 2 days. On 5/10/17 at 1:30 P.M., observation revealed the resident walking in the hallway of the facility special care unit with stand by staff assist. The facility's (undated) [DIAGNOSES REDACTED] protocol included, for residents who use insulin or oral diabetes medication that can cause low blood glucose, recognizing and treating hypoglycemic episodes appropriately is imperative. If the resident is unable to swallow, give [MEDICATION NAME], 1 mg. (milligram), SQ (subcutaneously) or IM (intra muscularly). Wait 15 minutes. If the resident does not respond, the dose can be repeated and staff should call EMS. The facility failed to administer insulin according to the physician's orders, for three consecutive doses, which resulted in significant medication errors. The resident became unresponsive, experienced [MEDICAL CONDITION] and required hospitalization in ICU, from 5/6/17 through 5/8/17, due to severe [DIAGNOSES REDACTED]. This deficient practice placed the resident in immediate jeopardy. The immediate jeopardy was abated, on 5/11/17 at 2:30 P.M., when the facility educated all nurses related to how to calculate the accurate dosage of insulin to administer, different types of insulin, signs and symptoms of [DIAGNOSES REDACTED] and review of the facility policy and procedures related to diabetes mellitus. The facility will complete weekly audits and discussed in the QA (quality assurance) meetings. This deficient practice remained at the scope and severity of a G.

The facility reported a census of 35 residents with 3 residents identified and sampled, as a high risk for elopement with wandering tendencies. Based on observation, interview, and record review, the facility failed to supervise and provide assistive devices, as needed, to ensure 1 resident (#1) remained in the facility or a safe area of the facility. The resident exited the facility without staff knowledge, crossed a busy street, to an area with 3 businesses with high traffic, which placed the resident in immediate jeopardy. Furthermore, the facility failed to provide adequate supervision and/or assistive devices for resident #2, a resident identified as a high risk for elopement, when the facility failed to monitor and ensure the proper function and placement of a wanderguard bracelet. Findings included: - Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set, dated dated [DATE], included the resident unable to complete the Brief Interview for Mental Status assessment, and staff identified long and short term memory problems with moderately impaired decision making. Additionally the staff noted the resident exhibited inattention and disorganized thinking, with wandering behavior noted. The resident required supervision for locomotion and mobility without assistive devices. The Care Area Assessment, dated 3/6/17, for behaviors indicated the resident wandered frequently throughout the day, and lacked exit seeking behaviors, at that time. The resident ambulated independently, without difficulty. Staff assessed the resident at high risk for elopement (exiting he facility without staff knowledge), on 3-6-17. Staff noted the resident enjoyed going from office to office, and conversing with staff. The staff planned to continue to monitor the resident for exit seeking behaviors. Review of the initial care plan, dated 2/27/17, lacked evidence of interventions related to the potential for elopement. However, the care plan reflected the resident exhibited poor safety awareness. A care plan dated, 3/6/17 included the following instructions: The resident ambulated independently, without difficulty. Assess for fall risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident prefers: (incomplete). An elopement risk assessment completed on 3-6-17 indicated the resident at high risk for elopement. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Admit to memory care unit (a locked unit) on 3-27-17, added on 3/28/17. Incident noted, on 4-8-17, where the resident exited the memory care unit door, then went out the back door of the facility and walked across the street to the gas station. Resident was brought back to the facility from the gas station. Staff educated that memory care unit residents are not to be let out of the memory care unit unsupervised. Staff educated to redirect residents that they see trying to get out of the facility, added 4/11/17. An elopement risk assessment, completed on 4-11-17, identified the resident remained a high elopement risk, added 4/11/17. A physician order, dated 3/27/17 indicated to admit the resident to the memory care unit on 3/28/17. The facility failed to notify the physician of the resident's elopement until 4/11/17, (3 days later). Review of the facility logs for door monitoring, from 11/1/16 to 4/8/17 identified the staff monitored the doors, weekly, and noted no concerns. Interview with maintenance staff D, on 4/11/17 during door alarm checks, at 8:20 AM, reported the staff monitored the doors every week for proper function. Observation, on 4/11/17 at 8:10 AM, identified the city street, containing residences as well as businesses, identified the street speed limit of 30 miles per hour. Review of the weather, on the date of the elopement, per information from Wunderground.com identified the temperature ranged from 64 to 81 degrees Fahrenheit. Observation, on 4/11/17 at 9:20 AM, identified the resident listening to music, in his/her room. An attempt at conversation resulted in the resident exhibiting inattention, and not responding to the questions asked about the resident leaving the facility over the weekend. The resident did acknowledge leaving the building and going across the street. At 9:53 AM on 4/11/17, the resident entered the dining area of the unit and stood nearby, as though deciding about something. Eventually the resident approached the area where administrative nursing staff B sat. The resident indicated to the staff member about the need for cigarettes and chewing tobacco. The staff member reminded the resident of not smoking for quite some time, and the resident responded with, he/she needed it now. The resident then returned to his/her room. At 10:30 AM, on 4/11/17, the resident wandered aimlessly in the living and dining area and then returned to his/her own room. No exit seeking noted, at that time. At 12:30 PM on 4/11/17, the resident remained in his/her room, with the door closed. Observation, at 2:30 PM on 4/11/17, identified the resident outside in the locked unit courtyard of the facility, walking on the sidewalk. Direct care staff F reported, at that time, the resident went outside to feed the birds. At 3:20 PM on 4/11/17, the resident sat in a chair on the patio. The resident appeared relaxed. Interview, on 4/11/17 at 10:40 AM, with licensed nursing staff C, reported a book at the nursing desk identified all the residents at risk for elopement. The staff verified this resident was at high risk for elopement and went outside and walked to the gas station, over the weekend. The staff reported they did not believe the elopement was related to staffing in any way, and that the staff needed to pay better attention to the sounding of the alarms and responding to the alarms. On 4/11/17 at 10:50 AM, direct care staff M reported the resident wandered a lot and was independent with most cares. The staff verified the resident lacked the use of a wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) and sometimes went out into the locked/enclosed courtyard, without any assistance. Staff reported not being in the facility at the time of the elopement, and lacked information regarding what actually occurred. On 4/11/17 at 10:55 AM, direct care staff F reported the resident left the locked unit over the weekend then went outside and crossed the street to the convenience store. The staff reported the resident lacked any behaviors, other than wanting to drink lots of fluids while being on a fluid restriction. The staff verified the resident lacked a wanderguard alert, and that the resident frequently wandered and went outside into the locked courtyard, unattended. On 4/11/17 at 12:42 PM, direct care staff N reported they had passed morning medications, in the memory care unit, on the day the resident eloped. The resident approached the staff member regarding going to the kitchen to see about his/her lunch. The staff verified they took the resident to the front lobby of the nursing unit and watched him/her go to the kitchen, and then return to the television area. A little later another resident came up the hallway and stated the resident was outside in the parking lot. He/she then heard that the alarm was sounding, and approached the back door. Checking outside he/she only saw a staff member, and decided he/she should get car keys and go look for the resident. When going to the parking lot, the employee outside, told staff N the resident indicated he/she was going to the convenience store across the street. When staff N got there, he/she did not see the resident. When he/she didn't find the resident he/she returned to the facility and other staff informed staff N the resident had been returned to the facility, by a current and a former staff member, and the resident was back in the locked unit. Administrative nursing staff B reported, on 4/11/17 at 4:00 PM, an investigation of the elopement was done on 4/8/17, and determined to be a reportable event. However, staff verified the facility staff failed to act in the manner in which they were trained and training with the staff began almost immediately after the elopement occurred. The 8/06 policy and procedure for Elopement instructed staff to remain with a resident exiting the building/premises, however, failed to include any instruction to staff regarding the elopement of a resident from the locked memory care unit. The facility failed to ensure the resident remained in the facility with supervision and assistive devices in place to ensure the resident did not leave the facility without staff's knowledge. Furthermore, staff failed to react promptly to sounding door alarms, failed to intervene adequately when the resident left the building, and failed to prevent the resident from crossing a thoroughfare street. These failures placed the resident in immediate jeopardy. The immediate jeopardy was abated on 04/11/17 at 6:00 pm as the facility completed the following: 1). Provided inservice to staff from 04/08/17 through 04/11/17 at 6:00 pm related to ensuring staff remained with residents when going out of the locked unit and ensuring staff respond immediately to door alarms sounding to prevent residents from leaving the facility without staff knowledge. 2). Reviewed and revised the facility policy and procedure to include residents may only exit the locked unit area when accompanied by staff and that staff members must stay with the resident until they are returned to the unit area. The policy also included the need for staff to immediately respond to door alarms and stay with the resident until safely brought back into the facility. 3). Contact with the alarm company for further safeguard on the locked unit door, to include a magnetic lock to prevent residents from opening the door, unassisted. Once installed, maintenance will be responsible for checking the lock is working properly, on a weekly basis. However, the deficiency remained at a scope and severity of a D. - Resident #2's [DIAGNOSES REDACTED]. language and communication and fragmentation of thought) and a mood disorder (category of mental health problems. Feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), but fails to meet the criteria for either diagnosis), and unspecified psychosis (any major mental disorder characterized by a gross impairment in reality testing). The admission Minimum Data Set, dated dated , 3/7/17, included the resident unable to complete the Brief Interview for Mental Status assessment, and staff identified the resident moderately impaired of decision making and impaired of long and short term memory, with inattention. The staff assessment for mood included the resident had little interest in doing things, had trouble concentrating, was short tempered and easily annoyed. The resident displayed physical behaviors and wandering. The resident required supervision for mobility, without any assistive devices needed. The Care Area Assessment, dated 3/7/17, for behaviors included the resident occasionally wandered. The staff noted the resident as an elopement (exiting the facility without staff's knowledge) risk and a wanderguard bracelet was in use due to the resident's history of eloping from another facility. Elopement assessments, completed on 2/24/17 and 3/7/17, identified the resident at high risk of elopement. The resident's care plan, dated, 3/7/17 included instructions, as follows: Admission elopement risk assessment completed on 2-24-17 identified the resident as high risk for elopement, added 2/24/17. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The resident prefers: (incomplete), added 2/24/17. Identify a pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, added 2/24/17. Wanderguard bracelet added 2/24/17. Elopement risk assessment completed on 3-7-17 identified the resident as high elopement risk, added 3/7/17. Review of the February and March, 2017 MAR's (medication administration records) and TAR's (treatment administration records) lacked identification of wanderguard monitoring by any staff member. Interview with maintenance staff D reported the staff monitor the doors every week for proper function, however, maintenance does not check or monitor the function of the wanderguard system. On 4/11/17 at 8:30 AM, the resident sat at the dining table and independently ate breakfast. At 9:30 AM, the resident slept on the bed, fully clothed. A wanderguard bracelet noted in place under his/her sweatpants, on the resident's left ankle. Continued intermittent observations, at 9:50 AM and 10:30 AM, identified the resident remained asleep in his/her room. At 12:30 PM the resident ambulated with an uneven gait to the dining table and sat at the table to eat lunch. Staff provided a lunch plate and fluids in covered mugs to the resident. The resident ate independently. Following lunch the resident returned to his/her room and laid down on the bed. Attempts, at that time, to communicate with the resident were unsuccessful. Observations at 2:30 PM, 3:20 PM, and 4:00 PM identified the resident rested quietly in his/her bed. At 5:15 PM the resident exited the dining area through the locked unit doors into the courtyard. At that time, the alarm for the resident's wanderguard alerted staff to the resident exiting the unit. On 4/11/17 at 10:40 AM, licensed nursing staff C reported a book at the nursing desk with all the residents at risk for elopement. Staff C verified this resident was identified as a resident at risk for elopement and that staff were to keep a close eye on the resident. The resident was no longer allowed outside of the locked unit, and staff placed a wanderguard bracelet on the resident for additional protection. The staff believed that nursing verified placement and function of the unit daily and documented this in the TAR (treatment administration record), however, was not sure about that. On 4/11/17 at 10:45 AM, direct care staff M reported the resident was mostly independent with cares, and often came out of his/her room, in the afternoon, for a snack. The staff reported the resident came to the dining room for meals and sometimes watched television in the living area; otherwise he/she mostly stayed in his/her room. The resident occasionally went outside for short periods of time, into the locked courtyard of the locked unit. Staff reported the alarms on the doors alert staff whenever a resident goes out into the courtyard. The staff reported the resident also used a wanderguard bracelet for additional protection. On 4/11/17 at 10:55 AM, direct care staff F reported the resident needed assistance at times, for ADLs (activities of daily living). Furthermore, the resident exhibited behaviors including exit seeking, at times, and used a wanderguard bracelet for that reason. The staff reported the direct care staff do not document regarding the use of the wanderguard bracelet. The policy and procedure for Elopement, dated 08/06, lacked instructions in the use of and monitoring of the working order of the wanderguard bracelet/system for the prevention of elopement. The facility failed to develop a system to monitor and ensure the proper function and placement of a wanderguard bracelet, placed on the resident to ensure the resident remained in the special care unit of the facility.

The facility reported a census of 40 residents with 8 residents identified that required mechanical lift transfers. Based on observation, record review and interviews, the facility staff failed to follow lift guidelines to open the mechanical base lift and failed to provide a safe transfer for 1 (# 1) of 3 sampled mechanical lift residents. During an unsafe transfer the resident and lift tipped over and the resident sustained [REDACTED]. Findings included: - The electronic medical record for resident #1 identified the physician's [DIAGNOSES REDACTED]. The 9/9/15 MDS (minimum data set) assessment, included a weight of 288 pounds for the resident. The MDS documented the resident with cognition intact and basic mental interview score of 13 and totally dependent for all activities of daily living except eating. The 9/9/15 ADL (activity of daily living) care area assessment, identified the resident required total assist with 2 staff with hoyer (mechanical) lift for all transfers. The care plan first initiated, on 6/18/14, included the resident did not like mechanical lifts but was necessary with 2 staff for transfers. Nurses notes documented, on 9/19/15 at 9:45 A.M., direct care staff C and D attempted to mechanical lift the resident while wet from an extra large shower chair to the bed. Direct care staff C raised the lift all the way up and direct care D tried to get the shower chair out when the lift tipped over, causing the resident and lift to fall to the floor. Staff called emergency medical service and they transported the resident was transported to the emergency room . Following x-rays the resident returned to the facility. The x-rays taken did not verify any new fracture. Nurses notes on 9/20 and 9/21/15 documented the resident complained of pain, was lethargic (drowsy or sluggish behavior) and moaned when touched even after pain medication (Norco 5-325 milligrams every 4 to 6 hours) administration. Nurses notes on 9/22/15 at 5:05 P.M., the facility sent the resident back to the emergency room due to the unmanaged pain. Following additional x-rays, the resident admitted to the hospital, with a left femoral (thigh) fracture. On 9/24/15 hospital records documented the resident received a surgical procedure for reduction and internal fixation changes of the proximal left femoral fracture. The facility hydraulic lift policy (undated) provided by the director of nursing on 10/21/15 included, instructions for staff to open the lift base to the widest point and set brakes. On 10/21/15 at 9:00 A.M., administrative staff B stated he/she completed the incident investigation and he/she believed staff did not open the base of the lift. He/she also acknowledged the facility had not completed any type of training for direct care staff B or C related to the use of a mechanical lift. On 10/21/15 at 9:30 A.M., direct care staff C acknowledged the base of the lift was not opened wide because it would not fit under the shower chair. The direct care staff raised the lift all the way up and tried to pull the shower chair out but couldn't move it. Then the lift and resident tipped over. On 10/21/15 at 10:10 A.M., resident # 1 described his/her dislike for the lift but he/she understood it was necessary. On 10/21/15 at 10:20 A.M., maintenance staff E reported the facility had 2 mechanical lifts and both could lift up to 650 pounds. Following the incident he/she had checked both lifts and found them operating correctly. On 10/21/15 at 11:30 A.M. and again at 3:00 P.M., observations of staff transferring resident #1's mechanical lift revealed the resident still displayed some apprehension during the transfers. The transfer was safe. The facility failed to provide any training of staff abilities to operate the mechanical lift and had no documentation regarding these staff members knowledge or ability to operate the lift. The direct care staff failed to follow the facility guidelines for lift usage which instructed, open the lift to the widest point. The facility failed to ensure safe mechanical lift transfer when the resident fell and sustained a left hip fracture.