Every finding on record at Botkin Care and Rehab

The facility reported a census of 40 residents with 14 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for five of the Resident's sampled, including R9, R30 and R17, regarding failure to review and revise the care plan to include Enhanced Barrier Precautions (EBP-a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs), R17, regarding the use of antianxiety medication (medication used to calm and relax people) and R18, regarding the use of footrests on the resident's wheelchair. Findings included: - Review of Resident (R)9's electronic medical record (EMR) revealed a diagnosis of urinary retention (the inability to pass urine). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Functional Abilities Care Area Assessment (CAA), dated 09/26/24, documented the resident required staff assistance with emptying his indwelling urinary catheter. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. He had a indwelling urinary catheter. The care plan, revised 01/28/25, lacked staff instruction regarding Enhanced Barrier Precautions (EBP-a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) for the use of his indwelling urinary catheter. On 02/24/25 at 11:05 AM, the resident's room door lacked signage indicating the resident was on EBP due to the indwelling urinary catheter. On 02/26/25 at 08:04 AM, Administrative Nurse D stated the resident's care plan had not been reviewed and revised to include EBP related to his indwelling urinary catheter. The facility policy for Comprehensive Care Plans, revised 08/22, included: The Interdisciplinary Team (IDT) shall be responsible for the periodic review and updating of the resident care plans. The facility failed to review and revise this resident's care plan to include EBP related to his indwelling urinary catheter. - Review of Resident (R)17's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. She did not receive antianxiety medication (medication that helps to calm and relax people) during the assessment period and had an unhealed stage III pressure ulcer (PU-a full-thickness tissue loss where subcutaneous fat is visible), not pressent on admission. The Psychotropic Drugs Care Area Assessment (CAA), dated 02/08/25, documented the resident's psychotropic medications were discontinued during the assessment period due to the resident's inability to take medications and being put on comfort care. The Pressure Ulcer CAA, dated 02/08/25, documented the residen was at high risk for the development of PUs. The Significant Change MDS, dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident did not receive antianxiety medication during the assessment period and had a stage III PU, not present on admission. The care plan, revised 01/24/25, lacked staff instruction on the use of the antianxiety medication and the need for EBP due to the resident's PU. Review of the resident's EMR revealed the following physician's order: Lorazepam (an antianxiety medication), 0.5 milligrams (mg), by mouth (po) or sublingual (sl), every (Q) four hours, as needed (PRN), for anxiety, ordered 02/07/25. Review of the resident's Medication Administration Record (MAR) for February 2025, revealed the resident had received the medication on three occasions with effective results. Review of the resident's EMR revealed the resident had a stage III PU to her right heel with treatments ordered twice weekly. On 02/24/25 at 01:19 PM, the resident's room door lacked signage indicating the need for EBP related to the resident having a PU. On 02/26/25 at 08:04 AM, Administrative Nurse D stated the resident's care plan had not been reviewed and revised to include EBP related to her PU and had not been reviewed and revised to include staff instruction regarding the use of the antianxiety medication. The facility policy for Comprehensive Care Plans, revised 08/22, included: The Interdisciplinary Team (IDT) shall be responsible for the periodic review and updating of the resident care plans. The facility failed to review and revise the resident's care plan to include EBP related to her PU and failed to review and revise the resident's care plan related to the use of the antianxiety medication. - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. She used a wheelchair for mobility with substantial to maximal staff assistance for distances for 150 feet. The Functional Abilities Care Area Assessment (CAA), dated 10/08/24, documented the resident self-propelled her wheelchair for short distances. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She used a wheelchair for mobility with partial to moderate staff assistance for distances for 150 feet. The care plan, revised 10/31/24, lacked staff instruction regarding the resident's need for staff assistance with propelling her wheelchair and the use of foot pedals while staff propel her in her wheelchair. Review of the resident's EMR, from 01/28/25 through 02/25/25, revealed she used a wheelchair for mobility throughout the facility. On 02/26/25 at 08:04 AM, Administrative Nurse D stated the resident's care plan had not been reviewed and revised to include staff instruction to utilize footrests while propelling the resident in her wheelchair. The facility policy for Comprehensive Care Plans, revised 08/22, included: The Interdisciplinary Team (IDT) shall be responsible for the periodic review and updating of the resident care plans. The facility failed to review and revise this resident's care plan to include staff instruction to utilize footrests while propelling the resident in her wheelchair. - Review of Resident (R)30's electronic medical record (EMR) revealed a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The Admission 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 (tube placed in the bladder to drain urine into a collection bag). The Functional Abilities Care Area Assessment (CAA), dated 09/06/24, documented the resident was dependent on staff for activities of daily living (ADL). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He had an indwelling urinary catheter. The care plan, revised 01/07/25, lacked staff instruction regarding Enhanced Barrier Precautions (EBP-a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) for the use of his indwelling urinary catheter. On 02/24/25 at 10:31 AM, the resident's room door lacked signage indicating the resident was on EBP due to the indwelling urinary catheter. On 02/26/25 at 08:04 AM, Administrative Nurse D stated the resident's care plan had not been reviewed and revised to include EBP related to his indwelling urinary catheter. The facility policy for Comprehensive Care Plans, revised 08/22, included: The Interdisciplinary Team (IDT) shall be responsible for the periodic review and updating of the resident care plans. The facility failed to review and revise this resident's care plan to include EBP related to his indwelling urinary catheter.

The facility reported a census of 40 residents with 14 residents sampled including six residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor two Residents (R)17 and R 19, regarding failing to have a stop date for as needed (PRN) Lorazepam (an antianxiety medication). Findings included: - Review of Resident (R)17's electronic medical record (EMR) revealed a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. She did not receive antianxiety medication (medication that helps to calm and relax people) during the assessment period. The Psychotropic Drugs Care Area Assessment (CAA), dated 02/08/25, documented the resident's psychotropic medications were discontinued during the assessment period due to the resident's inability to take medications and being put on comfort care. The Significant Change MDS, dated 12/20/24, documented the staff assessment for cognition revealed severe impairment. The resident did not receive antianxiety medication during the assessment period. The care plan, revised 01/24/25, instructed staff the resident had been put on comfort care. Review of the resident's EMR revealed the following physician's order: Lorazepam (an antianxiety medication), 0.5 milligrams (mg), by mouth (po) or sublingual (sl), every (Q) four hours, as needed (PRN), for anxiety, ordered 02/07/25. Review of the resident's Medication Administration Record (MAR) for February 2025, revealed the resident had received the medication on three occasions with effective results. On 02/26/25 at 10:23 AM, Administrative Nurse D stated PRN antianxiety medications required a stop date and confirmed this resident's Lorazepam lacked a stop date. The facility lacked a policy for PRN psychotropic medications. The facility failed to ensure R17's PRN Lorazepam order had a stop date. - The Electronic Health Records (EHR) documented R19 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), psychosis (any major mental disorder characterized by a gross impairment in reality perception), a history of falling, and chronic pain. The 06/20/24 Significant Change Minimum Data Set (MDS) documented R19 had impaired short term and long-term memory and severely impaired decisions making skills. Staff interview documented for that R19 was not understood by others or able to understand others. It documented R19 did not know staff, where her room was, the season, or that she was in a nursing home. Staff interview for mood documented a Total severity score of eight which indicated mild depression. R19 had delusions, received antipsychotic medication, and R19 had two or more falls from 03/29/24 to 06/20/24. The 06/20/24 Falls Care Area Assessment (CAA) documented R19 was at risk for falling and has a history of falling. All previous fall interventions to remain in place unless otherwise indicated. The 06/20/24 Cognitive Loss / Dementia: CAA documented R19 received hospice services for overall decline in health related to senile degeneration of the brain. The 11/29/24 Quarterly MDS documented R19 had impaired short term and long-term memory and severely impaired decisions making skills regarding tasks of daily life. Staff interview documented R19 was not understood by others and not able to understand others. It documented R19 did not know staff, where her room was, the season, or that she was in a nursing home. Staff interview for mood documented a Total severity score of eight which indicated mild depression. R19 had hallucinations. She was dependent on staff for wheelchair mobility. She required partial to moderate assistance from staff for toileting, bathing, lower body dressing and footwear. She required supervision or touching assistance for transfers and walking with a walker. R19 had two or more noninjury falls and no injury falls between 08/29/24 and 11/29/24. Review of the Care Plan on 02/24/25 documented R19 lacked any documentation of Ativan as needed. The Electronic Health Records (EHR) Physician Orders documented Ativan 0.5mg tablet by mouth as needed for restlessness or yelling out, started on 02/20/25 with no stop date. During an observation on 02/24/25 at 01:37 PM, R19 was climbing out of bed. The surveyor alerted a staff member who assisted R19. During an interview on 02/26/25 at 10:29 AM, Certified Nurse Aide (CNA) P revealed that R19 was on hospice services and had behaviors. She looked for the door and called out for her family. During an interview on 02/26/25 at 10:38 AM, Licensed Nurse (LN) G revealed that R19 had behaviors at times. She had sundowners and yelled out for parents. Staff talked with her when she did that. She had an order for Ativan that could be given when needed. During an interview on 02/25/25 10:22 AM, Administrative Nurse D revealed there was a stop date for as needed psychotropic medications, but not if the resident was on hospice services. During an interview on 02/26/24 at 02:31 PM, Administrative Nurse D revealed there should have been a stop date on all psychotropic medications, and she would update the orders. The facility lacked a policy for PRN psychotropic medications. The facility failed to provide a stop date for as needed Ativan medication for R19.

The facility reported a census of 40 residents with 14 residents sampled, including two residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide one Resident (R)30 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. Findings included: - Review of Resident (R)30's electronic medical record (EMR) revealed a diagnosis of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He used oxygen while a resident while a resident in the facility. The Functional Abilities Care Area Assessment (CAA), dated 09/06/24, documented the resident required staff assistance with all Activities of Daily Living (ADL). The Quarterly MDS, dated 02/01/25, documented the resident had a BIMS score of 15, indicating intact cognition. He used oxygen while a resident while a resident in the facility. The care plan, revised 01/07/25, instructed staff the resident utilized oxygen. Review of the resident's EMR revealed the resident admitted to the hospital on [DATE] with a diagnosis of sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). Review of the resident's EMR revealed the facility lacked a signed bed-hold for the resident's hospital admission on [DATE]. On 02/26/24 at 09:19 AM, Administrative Nurse D stated it was the expectation for staff to obtain a signed bed-hold for all residents upon admission to the hospital. Administrative Nurse D confirmed the facility lacked a bed-hold for the resident's admission on [DATE]. The facility policy for Bed Hold, revised 05/23, included: The facility will provide the resident and the resident representative with information concerning the bed-hold policy. The facility failed to provide the 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.

The facility reported a census of 40 residents with 14 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide safe transportation for one dependent Resident (R)18, regarding failure to utilize footrests while transporting the resident in a wheelchair. The facility also failed to ensure care planned fall interventions were in place for R19. Findings included: - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. She used a wheelchair for mobility with substantial to maximal staff assistance for distances for 150 feet. The Functional Abilities Care Area Assessment (CAA), dated 10/08/24, documented the resident self-propelled her wheelchair for short distances. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She used a wheelchair for mobility with partial to moderate staff assistance for distances for 150 feet. The care plan, revised 10/31/24, lacked staff instruction regarding the resident's need for staff assistance with propelling her wheelchair and the use of foot pedals while staff propel her in her wheelchair. Review of the resident's EMR, from 01/28/25 through 02/25/25, revealed she used a wheelchair for mobility throughout the facility. On 02/24/25 at 11:51 AM, Certified Medication Aide (CMA) S propelled the resident in her wheelchair from her room to the dining room for lunch. The resident wore non-skid socks which skimmed the floor during transport. The wheelchair lacked footrests. On 02/25/25 at 08:27 AM, Certified Nurse Aide (CNA) M propelled the resident in her wheelchair from her room to the dining room for lunch. The resident wore non-skid socks which skimmed the floor during transport. The wheelchair lacked footrests. On 02/24/25 at 11:551 AM, CMA S stated the staff did not use footrests on the resident's wheelchair because the resident was able to propel herself for short distances at times and the footrests would prevent her from being able to propel the wheelchair with her feet. On 02/26/25 at 07:21 AM, CNA O stated staff used the footrests on the resident's wheelchair when she felt weak and would not be able to hold her feet up while staff propelled her wheelchair. On 02/26/25 at 07:41 AM, CNA N stated the resident was able to propel her wheelchair using her feet at times, otherwise staff would propel her wheelchair. Staff did not use footrests for her wheelchair. On 02/26/25 at 09:19 AM, Administrative Nurse D stated it was the expectation for staff to utilize footrests while propelling residents in their wheelchairs. The facility policy for Ambulation Assistance, revised 01/23, included: While propelling a resident in their wheelchair, ensure the footrests are down and the resident's feet are properly placed on the footrests to avoid getting their feet caught under the wheelchair as they are being propelled. The facility failed to provide safe transportation for this dependent resident by failing to utilize footrests while being propelled in her wheelchair. 51334 - The Electronic Health Records (EHR) documented R19 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), psychosis (any major mental disorder characterized by a gross impairment in reality perception), a history of falling, and chronic pain. The 06/20/24 Significant Change Minimum Data Set (MDS) documented R19 had impaired short term and long-term memory and severely impaired decisions making skills. Staff interview documented for that R19 was not understood by others or able to understand others. It documented R19 did not know staff, where her room was, the season, or that she was in a nursing home. Staff interview for mood documented a Total severity score of eight which indicated mild depression. R19 had delusions. She was dependent on staff for wheelchair mobility. She required partial to moderate assistance from staff for toileting, bathing, lower body dressing and footwear. She required supervision or touching assistance for transfers and walking with a walker. R19 had two or more falls from 03/29/24 to 06/20/24. The 06/20/24 Falls Care Area Assessment (CAA) documented R19 was at risk for falling and has a history of falling. All previous fall interventions to remain in place unless otherwise indicated. The 06/20/24 Cognitive Loss / Dementia: CAA documented R19 received hospice services for overall decline in health related to senile degeneration of the brain. The 11/29/24 Quarterly MDS documented R19 had impaired short term and long-term memory and severely impaired decisions making skills regarding tasks of daily life. Staff interview documented for that R19 was not understood by others and not able to understand others. It documented R19 did not know staff, where her room was, the season, or that she was in a nursing home. Staff interview for mood documented a Total severity score of eight which indicated mild depression. R19 had delusions. She was dependent on staff for wheelchair mobility. She required partial to moderate assistance from staff for toileting, bathing, lower body dressing and footwear. She required supervision or touching assistance for transfers and walking with a walker. R19 had two or more noninjury falls and no injury falls between 08/29/24 and 11/29/24. Review of the Care Plan on 02/24/25 documented R19 was at risk for falls related to macular degeneration and dementia. She also had an unsteady gait and at times would walk without her walker. The 02/24/25 Care Plan documented the following fall prevention interventions: Initiated on 06/14/20: Non-slip strips put in front of chair and bed. Initiated on 12/27/20: Ensure R19 had on nonskid socks or appropriate shoes. Initiated on 07/15/21: Provide R19 her walker when she attempts to leave her room without it Initiated on 05/12/24: Staff to assist R19 to put on nonskid socks before bed, and remove boots before sleeping. Initiated on 10/04/24: Fall mat next to bed. Initiated on 10/06/24: Pick floor mat off floor when R19 was not in bed. The 02/24/25 Care Plan lacked mention of a wheelchair R19 used when she had pain or weakness. The Fall Risk Evaluation for R19, documented the following: On 06/03/24 a score of six, which indicated a low risk for falls. On 07/02/24 a score of 12, which indicated a high risk for falls. On 08/30/24 a score of 12, which indicated a high risk for falls. On 12/01/24 a score of 14, which indicated a high risk for falls. Review of the Progress Notes indicated the following: The Nursing Note on 07/30/24 at 08:56 AM, documented an unwitnessed fall. R19 was on the floor in her bathroom without her walker. The IDT Note: Patient at Risk on 07/31/24 at 01:43 PM documented R19 had a non-injury fall on 07/30/24. Resident was found in her bathroom on the floor between the toilet and the wall. Nonskid strips were added to the floor. All previous fall interventions were to remain in place unless otherwise indicated. The Nursing: Skilled Note on 10/04/24 at 02:10 AM documented an unwitnessed fall. R19 was on the floor beside her bed. R19 denied pain with no apparent injuries. The Nursing: Skilled Note on 10/04/24 at 09:50 AM documented an unwitnessed fall. R19 was laying on her left side on the floor facing towards the bathroom with a pool of blood under her head. She complained of pain on the left side of her head and left shoulder. R19 had a laceration approximately one inch long above her left eyebrow. Steri-strips (adhesive wound closures) applied to laceration. R19 was sent to the hospital for further evaluation. The Nursing: Skilled Note on 10/06/24 at 07:16 PM documented an unwitnessed fall. R19 was sitting on the floor in her room on the fall mat. R19 stated she had fallen out of bed. The Progress Note from the provider for date of service 10/09/24 documented bruising around her left eye and face from a fall on 10/04/24. The IDT Note: Patient at Risk on 10/09/24 at 01:18 PM documented R19 had a noninjury fall on 10/04/24. A new fall intervention included a fall mat on the floor next to her bed. R19 had a second fall that night while walking with no assistance. She received a laceration above her left eye and was taken to the emergency room for treatment. R19 again fell on [DATE]. The note documented that the cause of the fall was her tripping over the fall mat getting into bed not falling out of bed as she had stated. The new intervention was to keep the fall mat off the floor unless R19 was in bed. The plan was to report the fall on 10/04/24 and follow the care plan as directed. During an observation on 02/24/25 at 01:37 PM, R19 was climbing out of bed. There was no fall mat in place, and no nonskid strips were on the floor. The surveyor alerted a staff member who assisted R19. During an observation on 02/25/25 at 07:47 AM, R19 was not in her room. Her walker was at her bedside, nonskid strips were not on the floor. R19 was in the dining area in a wheelchair. During an observation on 02/25/25 at 08:49 AM, R19 was in the hallway in her wheelchair, independently and slowly propelling to her room. During an observation on 02/25/25 at 09:22 AM, R19 reported pain to her shoulders. She was in bed, with no nonskid strips by bed or chair, no fall mat, and she had her boots on. During an observation on 02/25/25 at 12:47 PM, Certified Nurse Aide (CNA) P assisted R19 to her room from the dining room. CNA P guided R19 as she walked with a walker and assisted her into bed. CNA P lowered her bed and asked her if she wanted her shoes off, but R19 did not. CNA P assured R19's call light was in reach, washed her hands, and left the room. During an interview on 02/26/25 at 10:29 AM, CNA P revealed that R19 had a wheelchair since she started hospice and sometimes used it if her legs were hurting, or if she was tired. CNA P was unaware if it was in the care plan and stated that the Director of Nursing, Administrative Nurse D, or Administrative Nurse E usually updated the care plan. CNA P stated the fall interventions were the low bed, and she used to have a fall mat, but she was unsure what happened to it. During an interview on 02/26/24 at 10:38 AM, Licensed Nurse (LN) G revealed R19 fell and interventions included nonskid socks and a fall mat. LN G said she was not sure if the fall mat was still in her room. During an interview on 02/26/25 at 02:12 PM, Administrative Nurse E revealed that she expected the fall interventions for R19 to be used. Administrative Nurse E said R19's room was to have nonskid strips in front of her chair, her bed, and in the bathroom. she said staff were to take her shoes off and put on nonskid socks before bed, and said sometimes she refused taking off her shoes. Administrative Nurse E said R19 had a fall mat but tripped over it, so they removed it, and she discontinued it from the care plan during the interview. Administrative Nurse E revealed R19 sometimes used a wheelchair when she was tired or in pain, and that should have been in the care plan. During an interview on 02/26/24 at 02:31 PM, Administrative Nurse D revealed it is her expectation that the care plans be accurate so the staff will know how to care for the residents and that all interventions be followed to prevent further falls. The facility policy for Comprehensive Care Plans, revised 08/2022, included: The Interdisciplinary Team (IDT) shall be responsible for the periodic review and updating of the resident care plans. The facility failed to ensure care planned fall interventions were in place for R19. This placed the resident at risk for continued falls.

The facility reported a census of 40 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to failing to clean the vent on the oxygen concentrator for resident (R)30 and R18, and failed to follow enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) R19 and R30. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - During an observation on 02/24/25 at 10:31 AM, R30 rested in bed with eyes closed. R30's nebulizer was not put away properly, with the face mask and medication barrel still attached. R30's face mask had dried debris on the inside, and it rested on top of the dresser and lacked a cover. During an interview on 02/24/25 at 01:30 PM, R30 stated that he had been to the hospital twice a few months back for pneumonia, but was feeling better now. R30 stated he gets four breathing treatments per day. During an observation on 02/25/25 at 08:23 AM, R30 sat on the side of the bed. The nebulizer face mask remained in the same location on R30's dresser. The oxygen concentrator had a heavy build-up of dust and debris covering the vent on the back of the machine. During an interview on 02/26/24 at 09:19 AM, Administrative Nurse D stated that nebulizers are cleaned with soap and water and put on a paper towel to dry after each use. Administrative Nurse D stated that oxygen concentrators should be cleaned between use of residents, and staff changed and dated the tubing weekly. Administrative Nurse D stated staff cleaned the filters as needed and staff were to ensure there was a bag for storage of the tubing. During an observation on 02/25/25 at 01:20 PM, CNA P and CMA S went into R30's room to empty the urinary catheter. CNA P and CMA S wore gloves, performed proper hand hygiene, but failed to wear the gown required for the EBP for R30. During an interview on 02/25/25 at 01:05 PM, Administrative Nurse D stated she did not know why the pump was on the floor. She would expect it to be hanging on the bed or have some type of barrier rather than rest directly on the floor. During an observation on 02/24/25 at 01:19 PM, R19 was resting in his bed, with pillows to float the right heel. R19 had a pressure ulcer currently. The door to R19's room lacked EBP instructions for staff. During an interview on 02/26/25 at 07:21 AM, CNA O was unsure about EBP. She would have to ask someone about that. During an observation on 02/24/25 at 02:37 PM, R18's oxygen concentrator filter was filled with dust. The distilled water for the oxygen humidifier rested directly on the floor. During an observation on 02/25/25 at 08:17 AM, R18 rested in bed with eyes closed wearing oxygen. Bottle of water for humidifier sat between the foot of the bed and the wall, rested directly on the floor. The filter on the oxygen concentrator was heavily soiled and discolored from dust and debris. During an interview on 02/26/25 at 07:21 AM, CNA O revealed R18 always used oxygen. The nurses were responsible for changing tubing, usually, but sometimes the CNAs did it. During an interview on 02/26/25 at 07:41 AM, CNA N stated R18 used the oxygen at night while in bed. The night nurse was responsible for changing the tubing and cleaning the filters of the concentrator. During an interview on 02/26/25 at 07:41 AM, CNA N stated that EBP was something new the facility was doing. Staff were to put on PPE when going into residents' rooms who have a catheter or a wound. CNA N stated they had not done that, until the day before. During an interview on 02/26/25 at 07:57 AM, CMA R reported staff needed to gown and glove when going into a resident's room who had a wound or a pressure ulcer. CMA R said this was new and they had not always done that. During an interview on 02/26/25 at 07:37 AM, Licensed Nurse (LN) G stated the facility practiced EBP for residents with a catheter or wound care. During an interview on 02/26/25 at 08:04 AM, Administrative Nurse D stated EBP applied to the residents with chronic wounds or an indwelling catheter of some type. They were to wear gowns and gloves to give high contact care. This included toileting, bathing, high contact care. This was not being done before yesterday. During the infection control interview on 02/26/25 at 01:05 PM, Administrative Nurse D confirmed that the facility had not been following the EBP but is now following the policy for all residents that had an open wound or a catheter, etc. Also confirmed that the dirty oxygen filters were an infection control issue and have been changed out. It was her expectation that the catheter bag and tubing would be covered and not dragging on the ground. Administrative Nurse D confirmed that the air bed hose should not have been on the floor. The facility lacked a policy for the care and upkeep of oxygen concentrators. The facility policy for Enhanced Barrier Precautions, revised 03/24, included: The use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions did not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDROR colonization as well as for residents with MDRO infection or colonization. The facility failed to maintain an effective infection control program related to improper infection control practices which included failed to wear the proper PPE when staff cared for residents on EBP to prevent cross contamination in the facility.

The facility reported a census of 40 residents with one main kitchen to serve meals to 39 of the 40 residents. Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner when staff handled ready to eat foods, touched the food surfaces of the plates as staff were ready to serve to residents after staff touched their face and the diet sheets. This had the potential to affect 39 of the 40 residents in the facility. Findings included: - During initial tour of the kitchen on 04/03/23 at 8:30 AM, revealed dietary staff BB handled plates on the serving line. He wore gloves, touched the stove, then picked up a wet cleaning rag he had on the counter next to utensils. He then cut toast in half handling a knife that was laid directly on the counter beside the cleaning rag. He placed the toast with the same gloved hands on a plate with other food items. Staff failed to change his gloves and failed to provide hand hygiene. On 04/04/23 at 12:05 PM, dietary staff CC prepared a peanut butter and jelly sandwich for a resident request. She put the package of bread on the counter and retrieved the peanut butter and jelly and placed them on the counter. She then donned gloves and picked up the package of bread and took the wire breadwrapper off. She then reached into the package and took two slices out of the package and put the bread on a plate. She closed the package and set the bread package aside. She then took the lid off the peanut butter and the jelly, picked the bread up and while holding the tub of peanut butter stable, and used a spatula to put the peanut butter on the bread. She then repeated the process with the jelly. Dietary staff CC wore the same gloves throughout the whole making of the sandwich touching multiple surfaces including the bread for the resident. On 04/04/23 at 12:10 PM, dietary staff CC began serving the plates for the noon meal with the assistance of dietary staff BB. Dietary Staff CC served the plates as dietary staff BB told her what the resident wanted by reading the diet slip. Dietary staff BB kept touching his face and nose and licking his thumb to separate the tickets. He then would pick up the plate and would touch the eating surface as well as placed cups of sour cream and salsa on the tray with the plate while touching all these surfaces. On 04/04/23 at 12:25 PM, Dietary staff DD reported staff BB was in orientation. She agreed that a person should have been assigned to supervise dietary staff BB since he was new to the kitchen. She also would have expected better hand hygiene from a seasoned staff while making the sandwich. Review of the facility policy called Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices dated 10/24/22 revealed: Staff do not need to wear gloves .unless touching ready to eat food. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. The facility failed to serve food in a sanitary manner by touching ready to eat foods without proper hand hygiene, touching the food surfaces of the plates when they were ready to serve after touching his face and licking his fingers to separate the diet sheets.

The facility reported a census of 40 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide a sanitary environment to prevent spread of infection and illness in the facility by failing to clean and store Resident (R) 36 nebulizer and continuous positive airway pressure (CPAP) mask. In addition, the facility failed to prevent potential infections when the laundry room washing machine had a heavy build-up of black grime. Findings included: - Observation on 04/03/23 at 10:11 AM, R36 had a nebulizer on her bedside table and the mask laid directly on the bare table, with no covering. On a table right inside the resident's room, a CPAP mask, connected by the hose to the machine, lacked a barrier and stored on the bare wood of the table. Observation on 04/04/23 at 01:38 PM, revealed the resident sat in her room with oxygen (O2) at 2 liters per minute per nasal cannula. The resident's nebulizer mask laid directly on the bedside table without a barrier or covering. The nebulizer chamber had moisture droplets inside the chamber. On a table by the bed was the residents CPAP mask, that laid directly on a table, without a barrier or covering. Observation on 04/06/23 at 08:25 AM, the resident was on the way to her room, propelled by Licensed Nurse (LN) H. Upon entering the resident room, the resident's nebulizer mask remained on the table beside her bed, without a barrier or a covering. The nebulizer chamber had moisture droplets that remained in the chamber. On 04/06/23 at 10:17 AM, Administrative Nurse D reported she expected the nurses to be cleaning the nebulizer mask after use, per the facility's policy. The CPAP mask should be in a bag on the nightstand when not in use. Review of the facility's policy Administering Medications through a Small Volume Nebulizer dated 05/22, revealed when a treatment is complete, rinse and disinfect the nebulizer equipment according to facility protocol- wash pieces with warm, soapy water, rinse with hot water, place all pieces in a bowl and cover with isopropyl alcohol. Soak for five minutes, then rinse in sterile water and allow to air dry on a paper towel. The facility failed to provide a sanitary environment to prevent spread of infection and illness in the facility by failing to clean and store the nebulizer and CPAP mask in a sanitary manner, for this resident that required CPAP use and nebulizer treatments. Observation of the facility's laundry room on 04/05/23 at 02:45 PM with housekeeping staff V, revealed the facility identified the washing machine used for the residents personal laundry. Observation of the inside upper area of the washing machine had a build-up of black grime and debris. Housekeeping Staff V verified the dirty build-up inside the upper rim of the washer. The facility failed to provide a policy for infection control. The facility failed to maintain the cleaning of the resident's washing machine to prevent possible infections.

The facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment by failure to repair, clean, or maintain the laundry room. Findings Included: - Observation during the initial tour on 04/06/23 at 08:51 AM, revealed the laundry room entry was too small for the barrels of laundry brought in and to be sorted. The entry into the washing area revealed the walls of the laundry room did not go completely to the floor, were in poor condition with holes in several places, with approximately four inches of space between the floor and the bottom of the sheet rock. The area behind the two washing machines had trash, dust, and dried dusty water marks down the walls. The pipes were covered with a dark thick dusty film substance, that appeared to be slush. A cabinet in the corner behind the door in the washing area had laminate on the top and sides that peeled back which exposed the raw wood underneath. The edge trim had large areas that lacked a covering that exposed the wood underneath. This cabinet was not a cleanable surface. There was a rack for different cleaning agents and various other items stored on top of the cabinet. A tour was conducted on 04/06/23 at 3:00 PM with Maintenance staff U reported unaware of a solution for the unrepaired cabinet and reported the walls were going to be replaced but was unable to provide a definite plan. On 04/06/23 at 11:30 AM, Administrative Staff A toured the laundry room with surveyor and problem areas reviewed. She was unaware of the condition of the laundry room and would try to get something done to fix the issues. The facility failed to provide a policy for maintainance of the laundry. The facility failed to ensure a safe, functional, sanitary, and comfortable environment to include laundry facilities.

The facility reported a census of 40 residents. Based on record review and interview, the facility failed to notify/ send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman of the reason as required, for the transfers for one Resident (R36)that required hospitalization . Findings included: - Review of R36's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on 03/02/23 and returned to the facility on [DATE]. Review of R36's Medical Record lacked evidence of a written notification of the facility-initiated hospitalization s transfer/discharges to the Office of the State Long-Term Care Ombudsman. On 04/05/23 at 04:00 PM, Social Service staff X confirmed she did not send a notice to the Office of the State Long Term Care Ombudsman when this resident discharged to the hospital and was not sure how she had missed it. The facility lacked a policy for Ombudsman notification when a resident required discharge to the hospital. The facility failed to notify/ send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman of the reason as required, for the transfer for R36's required hospitalization .

The facility reported a census of 40 residents, with 12 sampled, including one resident sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide care consistent with standard of practice for Resident (R) 11 to maintain good grooming and personal hygiene related to showers, nail care and facial hair removal. Findings included: - The 09/29/22 Electronic Health Record (EHR) documented R11 had the following diagnosis of orthopedic aftercare (aftercare following a joint replacement). The 09/29/22 Significant Change Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of nine, indicating moderately impaired cognition. R11 required supervision and set up assistance of one staff for all ADL. The 09/29/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R11 needed assistance with dressing of the resident's lower body and required reminders to change clothing daily. The 01/19/23 Care Plan lacked documentation regarding bathing preferences for R11. The Progress Notes from January 2023 through March 2023, lacked documentation of the resident's refusals of showers/baths. The Tasks document in the last 30 days, revealed eight scheduled opportunities, R11 received six of the eight showers, with one refusal noted, and three not given. On 04/03/23 at 01:00 PM, R11 observed with long fingernails with a dark substance under them. The resident had facial growth and was unshaved. On 04/04/23 at 08:03 AM, R11 observed with long fingernails with a dark substance under them. The resident had facial growth and was unshaved. On 04/05/23 at 03:41 PM, R11 observed with long fingernails with a dark substance under them. The resident had facial growth and was unshaved. On 04/06/23 at 07:48 AM, R11 observed with long fingernails with a dark substance under them. The resident had facial growth and was unshaved. On 04/03/23 at 01:00 PM, R11 revealed someone had told him they would help him shave and clip his nails. On 04/04/23 at 03:34 PM, R11 revealed he had gotten no help to shave or clip his nails. On 04/05/23 at 03:38 PM, Certified Nurse Aide (CNA) M revealed she gave the resident a shower occasionally. There was always one CNA assigned to give showers and staff should document them in the electronic record and on the shower sheet. On 04/06/23 at 09:09 AM, CNA N, revealed he was the shower aide assigned to showers for the day. He stated he would try three times to give a shower to a resident, if they refused all three, he would get the charge nurse. He stated showers were to be documented in the electronic record and on a shower sheet. On 04/06/23 at 09:54 AM, Licensed Nurse (LN) H revealed staff should document showers in the electronic record as well as on shower sheets that the nurse would sign and place in the medical records box. On 04/06/23 at 10:14 AM, Administrative Nurse D revealed she expected her staff to provide bathing as per the residents' preference, to document it in the electronic record, on a shower sheet, and the nurse to sign it. The facility policy dated May 2022, documented the community environment and staff behaviors are directed toward assisting the resident in maintaining and /or achieving independent functioning, dignity, and well-being. Residents who were unable to carry out ADL, receive the necessary care and services to maintain good nutrition, grooming, and personal hygiene. The facility failed to provide care consistent with professional standard of practice, for R 11 to maintain good grooming, and personal hygiene related to showers, nail care and facial hair removal.

The facility reported a census of 42 residents. Based on interview and record review the facility failed to complete a performance review for 5 of 5 certified nurse aides (CNA) reviewed, at least once every 12 months and failed to provide regular inservice education based on the outcome of those reviews to ensure competency in care for the residents of the facility. Findings included: - Review of five staff personnel files revealed the selected staff received no annual performance evaluations in the past year. Interview, on 01/06/20 at 01:53 PM, with Administrative Staff A, confirmed staff failed to complete annual performance reviews for the five staff members. The facility lacked a policy for annual staff evaluations and inservice education. The facility failed to complete annual performance reviews and provide regular inservice education for the five CNAs to ensure competency in care for the residents of the facility.

The facility reported a census of 42 residents. Based on observation and interview, the facility failed to provide housekeeping and maintenance services to maintain an orderly, sanitary and comfortable environment, in resident rooms on the 3 hallways, for the residents in the facility. Findings included: - Environmental tour, on 01/06/20 at 04:11 PM, with maintenance staff U, revealed the following: 100 Hall 1.) Multiple resident rooms with black grimy build-up in the corners of the floors. 2.) Two dirty towels on the floor surrounding a toilet in one resident's bathroom. 3.) Black marks and mars on a wall behind one resident's bed. 4.) Black grimy build-up under the sealant of a toilet along the floor in one resident's bathroom. 5.) A shower with multiple stains on the ceiling over the shower head in one resident's bathroom. 6.) Multiple resident rooms with marred bathroom doors and paint missing on the door frames. 200 Hall 1. Multiple resident rooms with a black grimy build-up in the corners of the floors. 2. Multiple resident rooms with scraped walls and missing paint. 3. One resident room with marred floor tiles. 300 Hall 1.) Multiple resident rooms with black grimy build-up in the corners of the floors. 2. A tv stand missing laminate in one resident's room. 3. Multiple resident rooms with marred doors and missing paint on the door frames. Interview, on 01/06/20 at 04:25 PM, with maintenance staff U, verified the above findings. He stated the facility is an ongoing and constant work in progress. He did touch-up painting as needed and the facility was in the process of repainting due to the changing of color schemes. The facility lacked a policy for maintenance and housekeeping. The facility failed to provide maintenance and housekeeping services to maintain an orderly, sanitary and comfortable environment, in these areas, for the residents in the facility.

The facility reported a census of 42 residents, with 12 residents reviewed including one for urinary catheter. Based on observation, interview and record review, the facility failed to ensure the catheter drainage bag remained below the level of the bladder, as is current standards of practice, to prevent urinary tract infection for this one Resident (R) 26. Findings included: - The signed physician's orders [REDACTED]. The annual Minimum Data Set, (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. There was impairment to one side of lower extremity for range of motion. The resident had an indwelling catheter. The ADL (activity of daily living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 2/4/19, documented R26 is alert with impaired memory and requires assistance with decisions. He had an indwelling catheter due to [MEDICAL CONDITION] The quarterly MDS, dated [DATE], recorded the resident with a BIMS of 99. The resident needed extensive assistance with all activities of daily living. Had impaired range of motion of both sides of the lower extremities. No other changes from previous assessment. The Comprehensive Care Plan, dated 10/16/19, documented the resident was totally dependent for activities of daily living. He required a mechanical lift with two staff for assistance with transfers and had a 15 French/10ml (milliliter) catheter. Monitor output, sign and symptoms of infection, and pain, and when obstructed flush as needed. The PO, dated 10/16/19, instructed staff to change the indwelling urinary catheter monthly and to monitor and record output each shift. On 12/2/19 at 10:22 am, the Interdisciplinary team note evidenced, Urinary Catheter Use. Risk factor of possible port of entry for bacteria into urinary system. The [DIAGNOSES REDACTED]. On 12/31/19 at 08:03 AM, the resident finished his morning meal and told staff he needed changed. Certified Nurse Aide (CNA) M and CNA N, wheeled R26 to his room and brought in the lift to transfer the resident back to bed. CNA M hooked the straps to the lift and then hooked the catheter bag, which was approximately 1/3 full of urine, and to the bar on the lift which was approximately one foot above the level of the resident's bladder. Staff then transferred the resident back to bed and staff completed perineal care. As CNA M was placing the catheter bag through the resident's pant leg, she lifted the catheter bag approximately two feet above the level of the resident's bladder. The resident was again placed in the mechanical lift and the catheter bag again placed on the lift above the level of the resident's bladder and staff transferred the resident back to his wheel chair. Both CNAs confirmed that this was the usual way they transferred the resident. On 12/31/19 at 1:48 PM, CNA M confirmed staff were to keep the urine bag where the urine flows down and was always to be kept below the level of the resident's bladder to prevent backflow. She stated she should not have placed the bag on the lift or when pulling the bag through the resident's pants. Sheshould not have raised the bag so high. On 01/06/2020 at 3:21 PM, Administrative Nurse D confirmed the expectation was when transferring a resident with a catheter bag, that it be kept below the level of the bladder to prevent backflow and potential infections. The policy for Perineal Care, dated 05/17, instructed staff to keep the drainage bag of a catheter below the level of the resident's bladder. The facility failed to provide appropriate treatment and care based upon current standards of practice to prevent urinary tract infection for this resident, when staff raised the drainage bag for the catheter above the level of the bladder during cares.

The facility reported a census of 42 residents with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure identification of drug irregularities and/or follow-up on pharmacist recommendations for 2 of the 5 residents reviewed. including failure to ensure the director of nursing and attending physician acted upon recommendations from the Consultant Pharmacist for Resident (R) 33 related to laboratory tests to monitor medication administration and a change in antidiabetic medication and failure of the consultant pharmacist to identify staff administration of antihypertensive medication outside the physician ordered parameters for not following the parameters for R10. Findings included: - The Physician order [REDACTED]. The PO, dated 12/11/19, documented the following orders: 1.) TSH/T4 (stands for [MEDICAL CONDITION] stimulating hormone. A TSH test is a blood test that measures this hormone) annually (December) for [MEDICAL CONDITION]. ordered on [DATE]. 2.) [MEDICATION NAME] (an antidiabetic medication), 100 units (u)/milliliter (ml), inject as per sliding scale: if 61-150 = 12 units; notify physician if blood glucose is less than 60; 151-200 = 14 units; 201-250 = 16 units; 251-300 = 18 units; 301-350 = 20 units; 351-400 = 22 units; 401-449 = 24 units. Notify the physician if the blood glucose is greater than 450, subcutaneously 4 times daily for type 2 diabetes mellitus. ordered on [DATE]. 3.) [MEDICATION NAME] (an antidiabetic medication) 500 milligrams (mg), give one tablet by mouth daily for type 2 diabetes mellitus. ordered on [DATE]. Review of the monthly pharmacy drug regimen review, dated 11/28/19, documented a request to the physician to consider a decrease of the resident's sliding scale insulin ([MEDICATION NAME]) and increase the order for [MEDICATION NAME] 500 mg to twice daily by mouth. The facility lacked documentation of follow-up with the physician regarding the recommendation. Review of the monthly pharmacy drug regimen review, dated 12/26/19, documented a request that the resident's TSH/T4 test be obtained per physician order. The facility lacked documentation that the test was completed. Upon further review of R33's pharmacy reviews, (MONTH) 2019 through (MONTH) 2019, revealed the facility lacked documentation of completion of the monthly pharmacy drug regimen review for (MONTH) 2019. Interview, on 01/06/20 at 3:00 PM, with Administrative Nursing Staff D, verified the above findings. He stated that the monthly pharmacy drug regimen reviews should be available in the electronic medical record and staff should follow-up with the physician on all recommendations made by the pharmacist. The facility lacked a policy for following pharmacy durg regimen reviews. The facility failed to ensure the director of nursing and attending physician acted upon the consultant pharmacist's recommendations and failed to ensure completion of the monthly pharmacy drug regimen reviews. - The signed physician's orders [REDACTED]. The admission Minimum Data Set (MDS), dated [DATE]. documented the resident with a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. She needed supervision with bed mobility, transfers, walking, locomotion, dressing, eating, toileting and personal hygiene. She was unsteady but able to stabilize without human assistance for moving from seated to standing, walking turning around and facing the opposite direction while walking and moving on and off the toilet and surface to surface transfers. The [MEDICAL CONDITION] Drug Use Care Area Assessment (CAA), dated 6/11/19, documented the resident was alert and oriented and was able to make needs known. She uses a walker by herself and does most of her activities of daily living per herself. The quarterly MDS, dated [DATE], documented the resident with a BIMS of 15, indicating cognition intact. She was independent with bed mobility, transfers, walking, locomotion, dressing, eating, toileting and personal hygiene. She used a walker and a wheelchair. The Comprehensive Care Plan, dated 10/16/19, instructed staff to emphasize the positive aspects of compliance related to altered cardiovascular status and a history of hypertension. Administer medications as ordered by the physician. Monitor/document/report as needed any signs or symptoms of [MEDICAL CONDITION] (CAD): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent [MEDICAL CONDITION], changes in cap refill, and color/warmth of extremities. The PO, dated 12/19/19, documented ordered on [DATE], [MEDICATION NAME] (medication for high blood pressure B/P)10 milligrams, one daily for elevated blood pressure. Please hold is systolic blood pressure is less than 100 or diastolic blood pressure less than 60. Review of the electronic medical record documented [MEDICATION NAME] was given outside of the parameters on these dates: October 5, 2019 with a B/P of 156/50 December 3, 2019 with a B/P of 117/59 December 14, 2019 with a B/P of 122/59 December 28, 2019 with a B/P of 112/50 December 29, 2019 with a B/P of 136/55 On 01/06/2020 at 2:49 PM, Licensed Nurse G confirmed the electronic medical record (EMR) recorded staff administered this medication on the above dates and were out of parameters set by the physician order. On 01/06/2020 at 3:21 PM, Administrative Nurse D stated it would be his expectation to give [MEDICATION NAME] as ordered and not to give if the resident's blood pressure was out of the parameters the physician set. On 01/06/2020 at 04:03 PM, Consulting Pharmacist GG, stated he does monthly reviews for the facility and did not find the above discrepancies. The facility lacked a policy for pharmacy durg regimen reviews. The consultant pharmacist failed to identify staff not following the parameters for the administration of anti-hypertensive medications.

The facility reported a census of 42 residents, with 12 residents reviewed including five for unnecessary medication. Based on observation, interview and record review the facility failed to ensure one resident reviewed remained free of unnecessary medications when staff failed to follow physician ordered parameters for the administration of anti-hypertensive medications for Resident (R) 10. Findings included: - The signed physician's orders [REDACTED]. The admission Minimum Data Set (MDS), dated [DATE]. documented the resident with a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. She needed supervision with bed mobility, transfers, walking, locomotion, dressing, eating, toileting and personal hygiene. She was unsteady but able to stabilize without human assistance for moving from seated to standing, walking turning around and facing the opposite direction while walking and moving on and off the toilet and surface to surface transfers. The [MEDICAL CONDITION] Drug Use Care Area Assessment (CAA), dated 6/11/19 documented resident was alert and oriented and was able to make needs known. She uses a walker by herself and does most of her activities of daily living per herself. The quarterly MDS, dated [DATE], documented the resident with a BIMS of 15, indicating cognition intact. She was independent with bed mobility, transfers, walking, locomotion, dressing, eating, toileting and personal hygiene. She used a walker and a wheelchair. The Comprehensive Care Plan, dated 10/16/19, instructed staff to emphasize the positive aspects of compliance related to altered cardiovascular status and a history of hypertension. Administer medications as ordered by the physician. Monitor/document/report as needed any signs or symptoms of [MEDICAL CONDITION] (CAD): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent [MEDICAL CONDITION], changes in cap refill, and color/warmth of extremities. The PO, dated 12/19/19, documented ordered on [DATE], [MEDICATION NAME] (medication for high blood pressure B/P)10 milligrams, one daily for elevated blood pressure. Please hold is systolic blood pressure is less than 100 or diastolic blood pressure less than 60. Review of the electronic medical record documented [MEDICATION NAME] was given outside of the parameters on these dates: October 5, 2019 with a B/P of 156/50 December 3, 2019 with a B/P of 117/59 December 14, 2019 with a B/P of 122/59 December 28, 2019 with a B/P of 112/50 December 29, 2019 with a B/P of 136/55 On 01/06/2020 at 2:49 PM, Licensed Nurse G confirmed the electronic medical record (EMR) recorded staff administered this medication on the above dates and were out of parameters set by the physician order. On 01/06/2020 at 3:21 PM, Administrative Nurse D stated it would be his expectation to give [MEDICATION NAME] as ordered and not to give if the resident's blood pressure was out of the parameters the physician set. The Medication Administration Policy, dated 05/17, instructed staff to administer medication in the right dose. The facility failed to follow physician ordered blood pressure parameters for administration of anti-hypertensive medication for this resident. The resident received the medication 5 times from 10/05/19 thru 12/29/19, when her diastolic blood pressure was below the ordered parameter of less then 60.

Based on observation, interview, and record review the facility failed to protect resident dignity. This was true for 2 of 12 sampled residents. Specifically, Resident (R) 42 experienced the potential for embarrassment when his medications were administered in the dining room (and not privately) without his consent, and R12's privacy and dignity were not protected when his skin was exposed as he was transferred in the hallway. Findings include: Review of R42's Quarterly MDS dated [DATE] revealed R42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued MDS review documented R42 had long term and short-term memory deficits, severely impaired decision-making ability, and needed extensive assistance for eating and drinking. Observation on 12/05/18 at 12:24 PM, revealed LPN #1 was assisting R42 at the lunch meal. While R42 was chewing his sandwich, Med Tech #1 approached the table holding a medicine cup with crushed pills. After R42 swallowed his sandwich, Med Tech #1 stated, Here you go, and spooned the medications into his mouth. Med Tech #1 did not alert R42 that he was receiving medications instead of his sandwich. When questioned about the observation on 12/06/18 at 2:52 PM, Med Tech #1 stated she often passed resident medications in the dining room because, It's easier when they are all in the same place with a drink in front of them. Med Tech #1 stated, Oh, I thought I told him I was going to give him pills. Review of R12's Quarterly MDS dated [DATE] revealed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. On 12/5/18 at 9:56 AM, R12 was observed in Hallway 2. CNA #1 and CNA #2 assisted R12 to use a sit to stand mechanical lift to move from his wheelchair to a restroom attached to the hallway. As they lifted R12 from his wheelchair, his shirt became ensnared in the sling on the lift. As the resident stood, his shirt rose up his back to the mid-chest level, exposing his bare skin. On 12/7/18 at 9:30 AM, CNA #1 stated it was common for many residents to have their skin exposed when using the sit to stand machine, and because the entrance to the bathroom was right on the hallway, such incidents were often seen by passersby. CNA #2 stated, The real problem is the bathroom is too small, so we have to use the machines in the hallway, if we could do everything behind closed doors, it would be fine.

Based on observations, staff interviews, clinical record reviews, and facility policy review the facility failed to ensure the staff developed and implemented a person-centered, comprehensive plan of care for three of 19 sampled residents. Specifically, the facility failed to address the resident's hydration status and UTI for Resident (R)42, failed to address R28's desired weight loss, and failed to address R18's [MEDICAL CONDITION]. Findings include: Review of R42's Quarterly MDS dated [DATE] revealed R42 was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. Continued MDS review revealed he had long term and short-term memory deficits, severely impaired decision-making ability, was dependent on staff for toileting and hygiene needs, and needed extensive assistance for eating and drinking. The MDS documented R42 had not had a UTI within the past 30 days. The MDS documented the resident did not have a [DIAGNOSES REDACTED]. Medical record review of R42's physician's orders [REDACTED]. Review of a Long Term Specialists Physician's Progress Note dated 9/25/18, documented the resident had increased lethargy and decreased oral intakes. The progress note documented the facility should try to increase R42's fluid intakes. R42's clinical record documented no care plan updates for his [DIAGNOSES REDACTED]. On 12/6/18 at 5:22 PM, the MDS nurse stated she had not realized R42's care plan had not been updated to include dehydration and UTI and had initiated a change of condition MDS assessment and care plan update after being questioned by the surveyors. 3. Review of R18's, Face Sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R18's quarterly Minimum Data Set (MDS- an assessment tool completed by the facility to identify resident care problems and assist with care planning) with an Assessment Reference Date (ARD- the end point of the evaluation period) of 10/09/18, indicated, Section C: Cognitive Patterns indicated the resident was unable to be interviewed and had a problem with short and long term memory. Section E: Behavior Symptom-Presence and Frequency indicated the resident rejected care four to six days of the seven-day assessment period. Section N: Medication Received indicated the resident received an antidepressant/sedative each of the seven days. Review of R18's Care Plan dated 11/14/18 was silent to the resident's [MEDICAL CONDITION] and the use of a sedative (Trazadone) for [MEDICAL CONDITION]. On 12/07/18 at 09:58 AM, interview with R18 indicated she, has trouble falling asleep, but once she goes to sleep, she sleeps ok. She also state, the medication I take at night helps me sleep. Interview with the facility's Assistant Director of Nursing (ADON), on 12/06/18 at 3:00 PM, confirmed no care plan had been developed for R18's [MEDICAL CONDITION], or the for use of the sedative for the resident's [MEDICAL CONDITION]. Review of the facility's Care Plan Process policy and procedure revised date 05/01/11, identified the care plan must describe the services that are to be furnished to attain or maintain the resident's highest physical and mental well-being, including major medications. The care plan will be developed that is appropriate for the resident's needs and wishes. Review of the resident's (R) 28 annual Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 6/19/18. The MDS identifies her admitted as 6/7/18. She was admitted for self-care performance deficit with activities of daily living related to [MEDICAL CONDITION] arthritis. During the 10/30/18 nutrition assessment, R28 stated that she wished to lose weight and her goal weight was 135 pounds. At the time she weighed 178 pounds. There was no evidence that the facility instituted interventions to assist the resident reach her goal. The Nutritionist was interviewed on 12/7/18 at 3:00 PM and stated she had not discussed the goal weight with R28, at the time of her assessment, and had not followed up with resident regarding desired weight loss. The Nutritionist stated she was not consulted by the clinical staff for follow up with R28, despite continuing weight gain. She further stated she does nutrition reassessments for the residents on an annual basis, unless consulted by the Certified Dietary Manager (CDM) usually for significant weight loss or gain. The Nutritionist also stated that R28 ate a lot of snacks. Review of a Nursing Note (NN) dated 12/7/18 documented that R28 was found taking many snacks off the unattended snack cart at 2:20 AM. Review of R28's Care Plan did not address nutrition or the resident's preference for weight loss. R28 is enrolled in the Restorative Nursing program. In an interview on 12/7/18 at 3:15 PM the Restorative Nurse (RN) stated that exercise is necessary to maintain weight, but that R28 frequently refused exercise and that she keeps a lot of snacks in her room. The Restorative Nursing Program records for the week of 12/1/18 to 12/7/18, revealed R28 walked with assist twice and refused 5 times. R28 participated in active range of motion four times and refused three times in the same period. The Certified Dietary Manager (CDM) completed a nutrition assessment of R28 on 12/08/18 at 3:32 PM (after being questioned by the surveyor) and found that R28 had gained a significant amount of weight in the previous six months. R28 stated she did not have a goal weight in mind, but that she only wanted to lose 5-10 pounds, but no more than that due to the screws in her hip. R28 said she would give up desserts at meal time to accomplish this goal. The CDM made a referral to the nutritionist to update the care plan to reflect the resident's wishes.

Based on observation, interview, and record review, it was determined the facility failed to identify, implement, monitor, and revise interventions for a resident experiencing recurrent Urinary Tract Infections (UTIs). Resident (R) 42 was harmed when the facility failed to recognize continuing symptoms of a UTI following the completion of antibiotic therapy, and when the resident continued to receive an ineffective antibiotic by injection for 3 days after laboratory results were available. Findings include: Review of R42's Quarterly MDS dated [DATE] revealed R42 was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. Continued MDS review revealed he had long term and short-term memory deficits, severely impaired decision-making ability, was dependent on staff for toileting and hygiene needs, and needed extensive assistance for eating and drinking. The MDS documented R42 had not had a UTI within the past 30 days. R42'a Care Plan documented a focus area for urinary catheter use initiated on 11/15/16. The goals included: the resident would remain free from complications related to catheter use, and interventions included: the resident would be monitored for symptoms of a UTI. Review of a Long Terms Care Specialists note (physician's progress note) dated 9/25/18 identified R42 had a history of [REDACTED]. The progress note documented staff were to try to increase fluids. Review of R42's Nurse's Progress Notes (NN) documented: On 9/9/18 at 11:22 PM. It was reported that the resident had little to no urine output . Upon further inspection the catheter was removed and a new . cath was place (sic) . Resident had some tenderness during the procedure but handled well . He has had 550 ml (milliliters) output (sic) since catheter was changed . On 9/14/18 at 5:33 PM. Notified (physician) of residents (sic) UA (Urinalysis) results and that he has a temp of 100 and is difficult to arouse. Received orders for [MEDICATION NAME] 1 gm (gram) IM (Intramuscular injection) (times) 5 days for UTI. On 9/19/18 at 1:28 PM. . continues on [MEDICATION NAME] . urine is amber in color with some sediment Resident does c/o (complain of) right groin pain . On 9/20/18 at 3:26 PM. (Physician) here at facility and is aware of resident's change of condition and unsteadiness of gait. New order for BMP, CBC next lab day. On 9/23/18 at 6:28 PM. (R42) has been lethargic this shift. He had difficulty keeping his pills in his mouth at supper and had to be taken to his room in a wheelchair . On 9/24/18 at 5:30 PM. (R42) has been lethargic this shift. He needs assistance with feedings . Order for lab to be drawn tomorrow . Encouraging fluids this shift . On 9/25/18 at 5:48 AM, R42 had an unwitnessed fall in his room. On 9/26/18 at 12:56 PM. . remains lethargic . new orders for NS (Normal Saline) 1000 cc (cubic centimeters) . On 9/27/18 at 5:28 PM. . continues to be lethargic and unsteady on his feet . On 9/30/18 at 4:06 AM. . cont to be lethargic in evening and most of night . urine cont to be dark and fluids encouraged. Sometimes he takes them and sometimes he doesn't. On 10/1/18 at 6:31 AM. Change of condition note. .increased lethargy noted. Urine output decreased, and he has not been consuming fluids as well as normal . Urine is foul and concentrated in appearance, with white substance floating. On 10/1/18 at 4:31 PM. . has a (history) of becoming septic from his frequent UTI's . known for becoming lethargic and unsteady with his gait when he has a UTI . continues to have an unsteady gait, increased drowsiness, and elevated temps. (Physician) here .ordered repeat labs . encourage fluids . On 10/3/18 at 12:56 PM. Received lab from (physician). Has new order for [MEDICATION NAME] . Review of R42's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review R 42's NN's for 10/3/18 through 10/5/18 documented he was receiving [MEDICATION NAME] with no adverse reactions, but did not document his lethargy, gait patterns, fluid intakes, or urine characteristics. On 10/5/18, R42's Microbiology Reference (culture and sensitivity results) documented the resident's UTI was resistant to the antibiotic [MEDICATION NAME]. The report was documented as faxed to the physician on 10/5/18. Review of R42's (MONTH) (YEAR) MAR indicated [REDACTED]. On 10/8/18, R42's physician's orders [REDACTED]. In an interview on 12/6/18 at 5:22 PM, the Assistant Director of Nursing (ADON) and MDS nurse stated: a.) The facility did not typically follow up on the effectiveness of antibiotic treatment for [REDACTED]. The ADON stated it would have been appropriate to follow up on the effectiveness of R 42's antibiotic course ending 9/18/18 given his continued complaints of groin pain and amber colored following the completion of the antibiotic; b.) When the physician ordered laboratory studies on 9/20, to be completed on the next lab day, the draw was automatically scheduled for 9/25/18. However, when the resident continued to display symptoms of lethargy and functional decline, the facility should have arranged to have the labs drawn sooner. c.) When the facility conducted a urinalysis on 10/1/18, the amount of urine collected (2 ml) was probably not enough and may have resulted in delayed laboratory results. d.) The facility should have ensured R42's physician actually received their fax on 10/5/18 with the information the resident's UTI was resistant to the prescribed antibiotic. The ADON stated the delay between the time the facility sent R42's urine to be cultured (10/2/18), the time the culture and sensitivity results were received (10/5/18) and the order was received for the correct antibiotic (10/8/18) were unacceptable.

The facility reported a census of 37 residents with 12 selected for review. Based on observation, interview and record review, the facility failed to accurately assess the eating capabilities of 3 residents, (#31, #33 and #16) and inaccurately assessed pressure ulcers for 1 resident (#32). Findings included: - Review of resident #31's physician order [REDACTED]. Review of the residents Annual MDS (minimum data set), dated 2-17-17, assessed the resident with a BIMS (brief interview for mental status) score of 15, indicating normal cognitive function (13-15), no impairment in upper or lower extremities and independent with eating ability. The CAA for activities of daily living, dated 2-17-17, assessed the resident required supervision to limited assistance due to generalized weakness and impaired balance and coordination due to [DIAGNOSES REDACTED]. Review of resident # 31's quarterly MDS (minimum data set), dated 5-2-17, assessed the resident with a BIMS score of 15, no impairment in upper or lower extremities and independent with eating ability. Review of the resident's quarterly MDS, dated ,[DATE] -17, assessed the resident with a BIMS score of 15, no impairment in upper or lower extremities, and required supervision with eating. The care plan, revised 7-17-17, advised staff the resident comes out to meals, then returns to his/her room. The resident will refuse to come to the dining room for meals at times and was independent for meals. Observation, on 9-5-17 at 1:48 pm, revealed the resident seated on his/her bed, eating from a can containing small hotdogs with beans. Observation, on 9-6-17 at 8:29 am, revealed the resident dressed and seated in the dining room, feeding him/herself breakfast without difficulty. Interview, on 9-6-17 at 11:34 am, with direct care staff K, revealed the resident as independent for most activities of daily living, with a few episodes of weakness and incontinence. Staff K stated the resident was independent in eating. Interview, on 9-6-17 at 12:36 pm, with licensed nursing staff L, revealed the resident was independent with eating, but did have a decline in activities of daily living in the past due to death of spouse. Interview, on 9-6-17 at 2:49 am, with direct care staff G, revealed the resident was independent with eating, and most other activities of daily living. Interview, on 9-7-17 at 9:30 am, with licensed administrative nursing staff C, confirmed the resident as independent, but he/she received instruction from the a consulting firm to code any resident that ate in the dining room as requiring supervision because staff were present in the dining room and could provide supervision. The facility lacked a policy for completion of the RAI (resident assessment instrument), however, identified staff followed the RAI (resident assessment manual) for coding procedures. The facility failed to accurately assess this independent resident's eating abilities. - The POS (Physician order [REDACTED].#32 admitted with [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set), dated 3-21-17, documented the resident was at risk for developing pressure ulcers (PU) and had a stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling), which was present on admission, and 3 unstageable PUs due to suspected deep tissue injury ( Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). The CAA (Care Area Assessment) for PUs, dated 3-21-17, documented the resident was at risk for pressure wounds and had treatments in place. The quarterly MDS, dated [DATE], documented the resident had a stage IV PU which was present on admit and no unhealed PUs. The discharge, return anticipated MDS, dated [DATE], documented the resident had no unhealed PUs. The Medicare 5-day MDS, dated [DATE], documented the resident had a stage IV PU, which was present on admission. The care plan for pressure ulcers, dated 6-09-17, instructed staff the resident required extensive assistance of 2 for all transfers. The resident had a pressure relief cushion for his/her wheelchair and was to have moon boots (protective foot coverings) to both feet at all times. The resident had a pressure ulcer to his/her left heel. Review of PCC (Point Click Care), an electronic documentation system, revealed the resident's Braden score (tool for predicting the risk of pressure ulcers), dated 12-29-16, 2-23-17, 2-25-17, and 6-09-17 to be 12, indicating the resident was at a high risk for the development of pressure ulcers. On 9-08-17 at 9:02 a.m., administrative staff B entered the resident's room to change the dressing to the resident's left heel. Once the dressing was removed from the resident's left heel, the stage IV PU was visible. The wound contained intact, dry, flaky skin with an ill-shaped border. The resident had no other PUs. On 9-06-17 at 2:45 p.m., direct care staff I stated the resident had one PU on his/her left heel. On 9-07-17 at 10:45 a.m., direct care staff J stated the resident had a PU on his/her left heel. Staff turn and reposition the resident at least every two hours. On 9-07-17 at 3:12 p.m., licensed nursing staff C stated the significant change MDS, dated [DATE], which documented 3 unstageable PUs due to suspected deep tissue injury was incorrect. The resident only had a stage IV PU, which had been present on readmission from the hospital. The resident did not have the 3 unstageable PUs documented on the 3-21-17 significant change MDS. On 9-07-17 at 3:30 p.m., administrative nursing staff B stated, the significant change MDS, dated [DATE], was inaccurate. The resident only had 1 stage IV PU to his/her left heel. No other PUs should have been documented at that time, as the resident did not have any other PUs. The facility lacked a policy for completion of the MDS, however, identified staff used the RAI (Resident Assessment Instrument) manual as the guide to complete the MDS. The facility failed to accurately complete the comprehensive MDS for this resident. - The signed physician orders, dated 6-27-17, documented resident #33 admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. many joints characterized by swelling and pain. The annual MDS (minimum data set), dated 3-7-17 revealed the resident was independent in eating. The quarterly MDS, dated [DATE], revealed the resident was independent in eating. The CAA's (care area assessment summary), dated 3-7-17, has nothing for ADL's (activities of daily living), as the resident was idependant with cares. The quarterly MDS, dated [DATE] revealed the resident needs supervision or oversight with eating. The care plan, reviewed on 8-11-17 revealed that the resident was independent wtih meals. On 6-22-17, the quarterly nutrition assessment revealed the resident eats 75 to 100% of meals and he/she feeds self with no adaptive devices. On 9-7-17 at 9:00 AM, Observation revealed resident sitting at the dining room table, eating bacon, eggs with toast. and coffee. The resident was eating independently. On 9-6-17 at 1:52 PM, licensed staff L stated that there has been no changes in resident #33's eating pattern, he/she is very independent in all cares. On 9-6-17at 4:03 PM administrative staff C, stated that the facility had a consulting group come in (MONTH) of this year and reviewed the facility's records. This group came in and instructed staff that anyone eating in the dining area would need to be changed to supervision status. The facility failed to accurately assess, on 6-22-17, this resident related to his/her eating abilities. - The signed physician orders, dated 7-14-17, documented resident #16 admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. to the insulin), Chronic pain, Hypertension (elevated blood pressure), and joint pain. The quarterly MDS (minimum data set), dated 5-9-17 revealed the resident had a BIMS (brief mental status) score of 15, indicating cognitively intact, he/she was independent for meals, set up only for eating. The CAA's (care area assessment summary, dated 7-25-17 had nothing addressed for supervison with meals. The annual MDS dated [DATE], supervision set up only for eating. The care plan, reviewed on 8-8-17 revealed nothing for a change of staus in previous assessment from eating indepentant to now needing supervision-oversight, encouragement or cueing. On 7-24-17 the hot liquids safety evaluation revealed the resident was not at risk related to spilling of hot liquids at that time. On 7-25-17 the annual nutrition assessment revealed the resident feeds himself/herself and needs no adaptive devices. He/she tolerates 75 to 100%. On 9-7-17 at 7:33 AM, observed resident in the dining room feeding himself/herself, stated that the breakfast was very good. On 9-6-17 at 4:03 PM licensed staff L stated he/she had not noticed any changes in resident #16's eating pattern. On 9-6-17 at 4:03 PM with administrative staff C, stated that the facility had a consulting group come in (MONTH) of this year and reviewed the facility's records. This group came in and instructed staff that anyone eating in the dining area would need to be changed to supervision status. The facility failed to accurately assess, on 7-25-17, this resident related to his /her eating ability.

The facility reported a census of 37 residents with 12 selected for review, including 5 residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to notify the physician of low heart rates for 1(#10) resident and elevated blood sugars for 1 resident (#48) of the 5 residents reviewed for unnecessary medications. Findings included: - Review of resident # 10's physician order [REDACTED]. The Admission MDS (minimum data set), dated 7-6-17, assessed the resident with a BIMS (brief interview for mental status) score of 12 indicating moderate cognitive impairment (8-12). Review of the physician's orders [REDACTED]. Staff to hold and notify the physician if the resident's pulse was below 60. Review of MAR (medication administration record) for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), revealed the following pulses below 60 beats per minute: 7-1-17 pulse 55 medication held 7-17-17 pulse 54 medication held 7-18-17 pulse 50 medication held 7-29-17 pulse 54 medication held 8-6-17 pulse 55 medication held 8-9-17 and 8-11-17 no pulse recorded and medication not administered 8-12-17 pulse 56 medication held 8-13-17 pulse 57 medication held 8-14-17 pulse 59 medication held 8-16-17 pulse 50 medication held 8-17-17 pulse 57 medication held 8-18-17 pulse 52 medication held 8-19-17 pulse 54 medication held 8-22-17 pulse 48 medication held 8-23-17 pulse 46 medication held 8-25-17 pulse 48 medication held 8-27-17 pulse 52 medication held 8-29-17 pulse 52 medication held 8-31-17 pulse 52 medication held 9-1-17 pulse 58 medication held 9-2-17 pulse 58 medication held 9-3-17 pulse 60 medication held (the physician's orders [REDACTED]. 9-5-17 pulse 60 medication held (the physician's orders [REDACTED]. A nurses' note, dated 9-7-17, revealed nursing staff faxed the physician's office with a request an order to discontinue [MEDICATION NAME] due to pulse below 60. Interview, on 9-7-17 at 10:45 am, with direct care staff E, revealed if the resident's pulse was below 60 he/she would not administer the [MEDICATION NAME], and would notify the charge nurse. Interview, on 9-7-17 at 11:00 am, with administrative nursing staff B, confirmed the resident's MAR indicated [REDACTED]. The medication was held twice without a pulse recorded on 8-9-17 and 8-11-17, and the medication was held for a pulse of 60 twice 9-3-17 and 9-5-17. Administrative staff B further stated the order should have clarified the order. The facility failed to notify the physician of the resident's pulse rate below 60 and holding of this resident's [MEDICATION NAME], 21 times to ensure the resident did not experience adverse effects. - Review of resident #48's physician order [REDACTED]. The admission MDS (minimum data set), dated 4/13/17, assessed the resident with a BIMS (brief mental status interview) score of 6, indicating severely impaired cognition.; and received 7 days of insulin injections in the look back period. The quarterly MDS, dated [DATE], did not reflect any changes in BIMS score or insulin administration. The CAA (care area assessment), dated 4/19/17, did not address diabetes and the use of insulin. The care plan, dated 7/5/17, advised the staff the resident had Diabetes and received routine insulin; perform glucometer sticks per physician order, and notify physician of reading are out of parameters; and administer insulin per physician order. On 09/06/2017 at 10:05 AM, observed licensed nursing staff L obtain residents blood sugar reading of 133. Review of the physician orders, dated 7/14/17, revealed the following orders: 1.) Blood glucose test four times a day IDDM fasting and 2 hours after each meal, notify the PCP if <60 or >350, 4/20/17 Review of the residents EMARs (electronic medical record), dated 6/1/17 -9/5/17, revealed lack of physician notification greater than 350 on 9 occasions. On 09/06/2017 at 10:05 AM, licensed nursing staff L verified the resident's blood sugar was 133 and all blood sugars were documented in the computer. He/she stated the resident did not usually have a blood sugar over 350 during the day, but if there was a blood sugar over 350 the physician was to be notified. On 09/07/2017 at 2:13 PM, licensed nursing staff M verified the lack of physician notification, as ordered, for this resident's blood sugars over 350. On 09/07/2017 at 2:27 PM, administrative nursing staff B verified lack of physician notification of blood glucose levels greater than 350 on 9 occcasions. Staff B stated he/she expected nursing staff to notify the physician according to the order. On 9/12/17 at 9:31 AM, licensed nursing staff P, stated he/she did not notify the physician of blood sugars over 350 because he/she gave the sliding scale insulin. The facility lacked a policy regarding blood sugar parameters and notification. The facility failed to ensure the physician was notified of blood sugars over 350, as ordered for this resident.

The facility reported a census of 53 residents with 4 residents identified as elopement risks. Based on observation, record review, and interviews the facility failed to provide adequate supervision to prevent 1 (#01) sampled resident from leaving the facility without staff knowledge, which resulted in a fall with injury for this resident. Findings included: - The medical record face sheet evidenced the facility admitted resident #01 on 2/14/12. [DIAGNOSES REDACTED]. On admission the family advised the facility the resident had a history of [REDACTED]. The facility placed a wanderguard on the resident. The 8/16/12 MDS (minimum data set) assessment identified the resident with moderate impaired cognition, with short and long term memory problems. The resident transferred and ambulated independently without any device. The 8/16/12 plan of care identified the resident as an elopement risk as evidenced by occasional wandering and impaired decision making skills. Interventions included a wanderguard bracelet to alert staff of attempts to leave the facility unassisted. Staff were to monitor the resident's whereabouts and respond immediately to alarms. On 9/17/12 at 6:20 P.M., nurses notes and review of the facility investigation, revealed the front door alarm wanderguard system sounded. Licensed staff C noted resident #1 at the door with coat and gloves on. Approximately 20 minutes later (6:40 P.M.), the hall 3 exit door alarm sounded. Licensed staff C walked to the hall exit door and opened the door, looked around the immediate area, removed a corner of the hall rug wedged in the bottom of the threshold, reset the alarm, and went back to the medication cart. The investigation dated, 9/18/12 revealed licensed staff C failed to go outside and observed the grounds, or count the residents in the facility. At 6:45 P.M., a citizen came into the facility through the front entry and stated an elderly person had been noted walking up the street heading west. Licensed nursing staff D left the facility and found the resident sitting in a grassy incline approximately 1 and 1/2 blocks from the facility. Another citizen witness remained with the resident. They reported the resident running west, then stumbled falling forward flat on his/her face. Licensed nursing staff D noted the resident with an abrasion near the left eye with swelling and bruising to the left orbital area and lower extremity contusions. The licensed nursing staff called 911 and the emergency medical service transported the resident to the emergency room by ambulance. Nurses notes and x-ray reports, dated 9/17/12, revealed the resident's findings included an impacted fracture to the left radius (wrist) and an abrasion to the left orbital area and lower extremities. The resident returned to the facility on [DATE] at 9:45 P.M. The resident told staff, "I was going home," (west and 6 miles south of the facility). On 10/9/12 at 11:30 A.M., resident #01 sat in the dining room with a cast on the left forearm. At that time the resident reported his/her arm got broke when, "I fell out of a car." On 10/9/12 at 3:45 P.M., direct care staff E acknowledged hearing the door alarm when resident #01 eloped. "We were busy getting residents out of the dining room and the nurse went and checked the door." On 10/9/12 at 7:10 P.M., licensed nursing staff C reported going to the door and looking out, removed the rug from the door, reset the alarm and returned to the medication cart. Staff C verified they did not go outside the facility to look for a resident after the wanderguard sounded, nor did staff search inside the facility or check the whereabouts of the residents identified as elopement risks. On 10/9/12 at 10:10 P.M., licensed nursing staff D acknowledged this resident often went to the doors and attempted to go outside. He/she was in report and knew licensed staff C went to check the door, when the alarm sounded. The facility elopement policy (no date) included, photos and resident descriptions in an elopement book for reference at all times, residents at risk of elopement wear wanderguard bracelets, door alarms and wanderguards are tested every shift, expiration dates of wanderguards are monitored monthly. When an elopement occurs or is suspected nursing home employees are to search the grounds and search all areas of the facility and count the residents. The facility nursing staff failed to provide adequate supervision and failed to adequately search the facility premises inside and outside, per facility policy when the wanderguard door alarm sounded, signifying an individual wearing a wanderguard bracelet had exited the facility. Resident #1 left the facility grounds and fell on an incline approximately 1 and 1/2 blocks from the facility. The resident sustained [REDACTED].

The facility census totaled 47 sampled residents. Based on observation, interview and record review the facility failed to identify,assess, plan, and provide appropriate treatments and services for 1 of 9 sampled resident (#51) who experienced an avoidable increase in the resident's psychosocial difficulties. The resident experienced an increase in indicators of depression: decreased appetite, refused care, displayed social isolation, the resident had episodes of crying and expressed the thought of dying. Findings Included: - Review of resident #51's significant change, Minimum data set assessment (MDS) 2.0 dated 7-19-10 revealed the resident was at ease interacting with others, had a depressive indicator of repetitive physical movements and not easily altered over the last 7 days. The resident assessment protocol (a further assessment) dated 7-21-10 further identified the resident experienced indicators of depression, anxiety, sad mood, the nurse documented the resident "does become restless and will remove (gender) oxygen at times and picked at things. (gender) also will become repetitive about (gender) disease when (gender) repetitively asked for pain medication until the nurse has had time to get it to (gender)." Record review of the resident's quarterly MDS 3.0 dated 10-19-10 revealed staff identified the resident's increased mood indicators "little interest or pleasure in doing things 2-6 days", "feeling or appearing down, depressed, or hopeless 2-6 days", "trouble falling or staying asleep or sleep too much 2-6 days"," feeling tired or having little energy 2-6 days", "poor appetite or overeating 2-6 days", "being short-tempered, easily annoyed 2-6 days." Review of the resident's Medicare 5 day and significant change assessment MDS 3.0 with an Assessment Reference Date (ARD) of 12-27-10 revealed a resident mood interview which identified the resident's increased mood frequency of feeling or being tired or having little energy, and a poor appetite half of the days during the assessment period of 14 days. Patient Health Questionnaire-9 (PHQ-9) dated 12-27-10 revealed the resident reported the problems of being tired or having little energy and poor appetite made it very difficult to get along with other people. The Care Assessment Area (CAA) dated 12-27-10 for mood indicators described "impact of the problem/need of the resident (gender) does refuse to get out of her bed and come out for meals at times and (gender) can be difficult to deal with at times. (gender) can be not very nice at times." Review of an Admission physician's orders [REDACTED]. (Stage 3 pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.) (http://www.npuap.org/pr2.htm) The care plan, dated 12-21-10 identified "the resident returned from the hospital with a right above the knee amputation and the resident had a pressure ulcer to coccyx", "I tend to withdraw myself from recreation activities". " I like to stay in my room." "I do have anxiety/agitation, resident does not always come out for meals, room tray's offered/resident refuses them." The careplan updated on 12-22-10 included a focus of "altered activities of daily living function related to an above the knee amputation to the right leg, mood and resistive behaviors." The facility identified the increased depressive mood indicators but failed to plan interventions for the resident. The record contained a signed consent by the family, dated 6-3-10 from the resident's admission to the facility,for psychiatric services as needed. The record lacked evidence that the facility obtained a psychiatric consult. "The resident mood by day report" an electronic documentation used by nursing staff to document mood indicators of the resident revealed documentation of the resident as follows: "being short tempered, easily annoyed on 1/10/11,1/24/11, and 2/6/2011, "little interest or pleasure in doing things" on 2/8/11, 2/18/11,2/21/11, 2/25/11, "feeling/ appearing down depressed hopeless 2/8/11,2/21/11, 2/25/11, feeling tired or having little energy on 2/8/11, 2/18/11,2/21/11, 2/25/11, poor appetite 1/17/11 2/8/11, 2/18/11, 2/21/11 and 2/25/11. Review of social services progress notes from 12/21/10 through 2/28/11 revealed no documentation that the facility addressed the resident's increased psychosocial needs or any interventions used for the resident experiencing depressive indicators. Interview with social service staff E on 2/28/11 at 2:25 p.m. reported they monitored the resident's mood indicators on the electronic documentation. Social Service staff E reported they did not identify increased depressive behaviors or recognize the need to address the resident's the behaviors. Social service E also confirmed the facility failed to recognize the need for the facility's consultant licensed social worker to assess the resident's mental and psychosocial needs. Review of physician note dated 12-30-10 revealed the physician identified the resident lost 22 pounds over the first 8 days of the resident's return to the facility. Dietitian's notes from 1-21-11 and 2-22-11 revealed the resident had poor food intake. During an observation on 2-23-11 at 7:45 a.m., the resident received breakfast and consumed two bites of biscuit and gravy and staff assisted them away from the table. At 12:30 p.m. the resident went to the dining room and received lunch. The staff encouraged the resident to eat and the resident refused. Observation on 2-23-11 at 10:00 a.m. revealed the resident alone in their dark room in bed. Observation on 2-24-11 at 7:40 a.m. nurse aide F asked the resident to get out of their bed for breakfast. The resident refused to get out of bed and refused breakfast. Observation on 2-24-11 at 3:30 p.m. revealed the resident alone in their dark room in bed. Interview with the resident on 2-28-11 at 4:45 p.m. revealed the resident at the end of the hall in their dark room alone, lying in bed. The resident reported in a quite soft voice, that they felt "depressed because of all that has happened to them". The resident explained they recently had an amputation and they feel sad and often think about dying. The resident explained "do you know what it feels like to hurt all the time, the medication controls the pain, but it always comes back." Then the resident started to cry. The facility failed to identify,assess,and plan appropriate treatment and services to address the resident's depressive mood indicators. The resident experienced a decrease in appetite, refused care, displayed decreased social interaction,episodes of crying and expressed the thought of dying.