Every finding on record at Brookdale Rosehill

The facility identified a census of 75 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure linens were stored in a sanitary manner, the facility further failed to ensure Bilevel Positive Airway Pressure (BIPAP- a device that helps with breathing), nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs), and an oxygen cannula were stored in a sanitary container when not in use. The facility further failed to ensure the blood pressure cuff, pulse monitor, and temporal thermometer on a monitoring machine were sanitized after each resident's use. Findings included:- On 12/08/25 at 07:24 AM, an inspection the 400-hallway revealed clean towels placed on a portable toilet outside of empty room [ROOM NUMBER].On 12/08/25 at 07:45 AM, a walkthrough of the secured Long-term Care unit was completed.An inspection of R69's room revealed three bags of soiled linen sat directly on the floor. Two soiled hospital gowns lay directly on the floor next to the bags.An inspection of R22's room revealed clean towels placed directly on the personal protective equipment (PPE) cart outside his room.An inspection of R71's room revealed two clean towels placed on the handrails next to her room's entry door.An inspection of R42's room revealed a clean hospital gown placed on the handrail next to her room's entry door.An inspection of R24's room revealed clean towels placed directly on the counter outside her room. - On 12/08/25 at 09:53 AM, R95's BIPAP, nebulizer, and an oxygen cannula laid unbagged and directly on the bottom of her bedside cabinet. No storage device was noted.On 12/09/25 at 07:27 AM, License Nurse (LN) K obtained R2's blood pressure, temporal temperature, and pulse in the main dining room. LN K did not sanitize the pulse monitor, temporal temperature monitor, or blood pressure cuff before and after R2's use.On 12/10/25 at 10:37 AM, Administrative Nurse D stated all respiratory equipment not in use should be placed in a sanitary bag. She stated she was unsure if the blood pressure cuff, pulse monitor, and temporal temperature monitor should be sanitized between each resident's use. Administrative Nurse D stated she would have to look at the facility's policy. She stated clean linen should not be placed on a Personal Protective Equipment (PPE) cart or on the resident's hall rails. She stated linen should be stored in a sanitary manner. The facility's Laundry and Bedding policy, revised 09/2019, documented laundry and bedding should be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen.The facility's Standard Precautions policy, revised 10/2025, documented standard precautions should be used in the care of residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all bodily fluids except sweat contain transmissible infectious agents. The facility did not provide a policy pertaining to the storage of respiratory equipment when not in use, as requested on 12/10/25.

The facility identified a census of 75 residents. The sample included 18 residents, with two residents sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's plate guard was applied to his breakfast plate.Findings included:- R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of ten, which indicated moderately impaired cognition. The MDS documented R2 had an impairment on one side of his upper body. The MDS documented R2 needed supervision or touching assistance with eating.The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/04/25 documented R2 had a decline with activities of daily living (ADL) due to a significant change due to falls with injury. R2's CAA documented due to the progression of R2 disease therapy was to start training on wheelchair therapy. The CAA documented R2 received speech therapy for oropharyngeal dysphagia (difficulty starting a swallow, involving problems moving food/liquid from the mouth to the esophagus), where the long-term goal was to improve swallow abilities to independence, modified independence.R2's Care Plan documented the following interventions:07/14/25 - Encourage swallow strategies/ positions, small bites, small sips, and slow rate of oral intake.10/30/25 - Encourage R2 to use and set up the plate guard at meals.12/01/25 - Diet as ordered.On 12/08/25 at 08:37 AM, R2 sat at the dining room table. R2 had his breakfast tray with a fried egg. R2 was cutting up the egg. R2's egg was sliding on his plate. R2 did not have a plate guard. On 12/10/25 at 10:04 AM, Licensed Nurse (LN) I stated the plate guard was something new for R2. The LN I stated there was a process to ensure R2 had his plate guard. She stated the dietary ticket should state plate guard, the staff member taking R2's tray should do a second check, and nursing staff should be monitoring to ensure the plate guard was in place. On 12/10/25 at 10:37 AM, Administrative Nurse D stated R2's plate guard should be on his meal ticket. She stated nursing staff would ensure the plate guard was in place. The facility did not provide a policy for adaptive equipment, as requested on 12/10/25.

The facility identified a census of 75 residents. The sample included 18 residents, with five residents reviewed for medication administration. Based on observation, record review, and interviews, the facility failed to meet professional standards when staff failed to administer Resident (R) 21's medication.Findings included:- R21's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), falls, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (a progressive mental disorder characterized by failing memory and confusion).R21's Quarterly Minimum Data Set (MDS) dated 11/05/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The MDS documented R21 was dependent on staff assistance for all activities of daily living (ADL) except eating, which R21 needed supervision of touching assistance from staff.R21's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 12/23/24 documented R21 received therapy service and had opted for hospice services due to his comorbidities. R21 had dementia and other debilities that impaired his ability to perform ADLs. R21 had a history of falls, and the nursing staff were to monitor him and initiate interventions as needed.R21's Care Plan documented the following interventions:10/21/24 - Nursing staff to give R21's medications as ordered by the physician and monitor side effects and effectiveness.12/18/24 - Staff to observe R21 closely for signs of pain and administer pain medications as ordered.R21's EMR under physicians' Orders lacked an order related to self-administration medication.On 12/08/25 at 07:22 AM, mediation in a clear cup sat on R21's overhead table in his doorway. There was no nursing staff in the area to monitor R21's medication.On 12/08/25 at 07:26 AM, Licensed Nurse (LN) H stated she had stepped away to look at another resident's skin. She stated the process was to ensure medications meant for a resident were given to the resident and not sat down out of her view.On 12/10/25 at 10:04 AM, LN I stated R21 did not have a self-administration assessment and was unable to give himself his medications. LN I stated medication that was not in the nurse's view should be wasted. She stated medication meant for a specific resident should be given to the resident after they are popped.On 12/10/25 at 10:36 AM, Administrative Nurse D stated medication should never be out of the view of the nurse.The facility's Resident Self-Administration of Medication revised 03/2019 documented it was the policy of the facility that those residents who desired to self-administer medication could do so if the review determined the resident was capable.

The facility identified a census of 75 residents. The sample included 18 residents, with one resident reviewed for tube feeding complications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 8's tube feeding bags were marked with the date, time, and contents in the feeding bag. Findings included:- R8's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of myasthenia gravis (an abnormal condition that causes muscles to tire and weaken easily), muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and need for assistance with personal care.The admission Minimum Data Set (MDS) for R8 dated 11/20/25 recorded a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented supervision or touching assistance from staff for eating. R8's Feeding Tube Care Area Assessment (CAA) dated 11/20/25 documented R8 was admitted to the facility with multiple nutrition related comorbidities. The CAA documented R8 received tube feeding (tube for introducing high-calorie fluids into the stomach) three times a day after his meals, due to R8's consuming less than 25 percent of his meals.R8's Care Plan documented the following feeding tube interventions: 11/15/25 - Enteral tube feeding order every shift, staff to monitor for adverse effects. 11/15/25 - Enteral tube feeding site care, clean area with soap and water, observe for skin breakdown.11/15/25 - Staff to check tube feeding placement before beginning feeding and administration of medication. R8's EMR under the Orders tab documented the following physicians' orders:Give every night shift, tube feeding, and change the enteral feeding bag and tubing, dated 11/14/25.Replace syringe for Flushes, dated 11/14/25.Enteral Feed Order one time a day for nutritional maintenance, continuous feed from 6 PM to 7 AM 40 milliliters (ml)/ hour (hr.) increasing by 20 ml/hr. every 4 hours until the goal of 80 ml/hr. for 12 hours was reached, dated 12/05/25.On 12/09/25 at 09:33 AM, R8's enteral feeding bags were hung on the pole next to R8. R8's bag had water in one bag, and the line to R8's feeding bag had brown colored substance in the feeding tube. R8's bags were not dated with the content, date, time, or the staff initials.On 12/10/25 at 10:04 AM, Licensed Nurse (LN) I stated feeding tube bags should be labeled with content, date, and time. She stated when the feeding bags were hung, the bags should be labeled.On 12/10/25 at 10:37 AM, Administrative Nurse D stated the enteral feeding tube bags should be labeled with the date, time, contents, and the nurse's initials. She stated education would be given to nursing. The facility's Enteral Nutrition revised 09/2025 documented adequate nutritional support enteral nutrition would be provided to residents as ordered.

The facility identified a census of 75 residents. The sample included 18 residents, with six residents reviewed for unnecessary medications. Based on interviews, observation, and record review, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 10. Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of osteoarthrosis (chronic arthritis without inflammation), atrial fibrillation (rapid, irregular heartbeat), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated 11/13/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R10 had occasional pain during the observation period. R10's Pain Care Area Assessment (CAA) dated 05/14/25 documented after a recent hospitalization R10 required more assistance with the activities of daily living. R10's Care Plan dated 11/05/25 documented:11/05/25 - Staff would administer R10's pain medication as ordered. R10's EMR under the Orders tab revealed the following physician orders: Voltaren external gel (an anti-inflammatory class of medication used to reduce inflammation), one percent (%) (diclofenac sodium) (topical), apply to lower to mid buttocks topically two times a day for pain, dated 2/07/25. The order lacked a dose for administration. On 12/09/25 at 7:52 AM, R10 sat in his wheelchair with his urinary leg strapped to his left leg. R10 propelled his wheelchair from his room and into the hallway. On 12/10/25 at 10:04 AM, Licensed Nurse (LN) I stated every medication required a dosage for administration. LN I stated Voltaren gel needed a dose for administration. LN I stated she would notify the physician to clarify an order that lacked a dose. On 12/10/25 at 10:38 AM, Administrative Nurse D stated she would expect all medication orders would have a dose to be administered as ordered by the physician. Administrative Nurse D stated she would expect the nurse to clarify the medication order with the physician. The facility was unable to provide a policy, as requested on 10/10/25.

The facility identified a census of 76 residents. The sample included three residents reviewed for medications. Based on record review and interviews, the facility failed to ensure staff accurately transcribed orders from the hospital on admission and failed to follow the physician's orders for Resident (R) 1. This deficient practice placed R1 at risk for unwarranted physical complications and less-than-therapeutic effects related to medication use. Findings included: - R1 admitted to the facility on [DATE], discharged to the hospital on 01/04/24, readmitted to the facility on [DATE], and discharged home 01/24/24. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and Hashimoto's encephalopathy (a rare disease that involves impaired brain function and is a steroid-responsive acute or subacute encephalopathy characterized by autoimmune thyroiditis [autoimmune disorder where the immune system attacks the thyroid gland] associated with elevated levels of antithyroid antibodies). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Functional Abilities Care Area Assessment (CAA) dated 01/23/24, documented R1 had a decline in activities of daily living (ADLs) from her previous level of functioning related to multiple hospitalization s with the most recent due to head pressure, slurred speech, vision changes, confusion, hallucinations, and urinary tract infection. R1's Care Plan last revised 01/23/24, documented R1 had a cerebral vascular accident (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and Hashimoto's encephalopathy. The care plan documented an intervention, dated 01/10/24, that directed staff to give medications as ordered by the physician and monitored/documented side effects and effectiveness. R1's EMR revealed a Discharge Order Report dated 12/27/23, that documented an order for prednisone 10 milligrams (mg) in the morning. R1's EMR lacked evidence the prednisone order from 12/27/23 was entered and administered. R1's EMR revealed a Consultation Report on 12/28/23 that documented R1 recently admitted to the facility and the medication review process revealed the following discrepancies on the admission orders: there was an order for prednisone, but there was no current order in THE EMR. Recommendation to consider clarifying the medication orders and communicate with the prescriber and pharmacy as appropriate. The Notes tab of R1's EMR revealed the following: A Physician Progress Note on 12/28/23 at 11:08 AM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. A Physician Progress Note on 01/02/24 at 04:30 PM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. R1's EMR revealed Consult Notes on 01/05/24 at 01:06 PM that documented R1 had not been receiving her daily prednisone that past week and there was a concern that given her recurrent hospitalization , it was related to a relapse of Hashimoto's encephalopathy. The note documented that it was not unheard of as there were case reports with relapsing symptoms, however, it was presumed to be only present in about 10 to 15 percent of cases. The note documented R1 had poor sleep over the past several days which was also an area of concern in previous hospitalization s leading to ongoing confusion. That could have been a stronger contributor to her current presentation. The note documented from an encephalopathy picture, R1 did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. The facility's investigative report, dated 01/08/24, documented R1 was admitted to the facility on [DATE] and had a BIMS score of 14. R1 had a history of Hashimoto's encephalopathy. The nurse practitioner (NP) noted a change in condition and spoke to R1 and her representative about possible options to evaluate symptoms. The NP, R1, and her representative agreed to further evaluation at the emergency department (ED) to rule out infection or worsening Hashimoto's encephalopathy. The NP reviewed R1's chart and repeated a medication reconciliation on 01/04/24 at approximately 04:05 PM and it was noted that prednisone was not currently on the Medication Administration Record (MAR). Upon investigation, it was discovered that prednisone was missed on the admission orders by the admitting nurse, the second nurse, and the interdisciplinary team (IDT). A pharmacy recommendation was received on 12/28/23 stating that there were discrepancies on the admission orders which involved an order for prednisone but no current order in the chart. According to the hospital physician's note on 01/04/24, the probability of R1's Hashimoto's encephalopathy relapsing was only 10 to 15 percent. It was also noted that R1 had poor sleep over the last several days which had been an area of concern in previous hospitalization s leading to ongoing confusion. From an encephalopathy picture, she did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. On 01/30/24 at 01:23 PM, Administrative Nurse E stated when a resident is admitted to the facility, the nurse and aide help the resident settle. She stated the floor nurse put in the admission orders and the nurse manager helped. Every morning, the nurse managers reviewed the orders when they did chart review. Administrative Nurse E stated when the provider visits, the nurse on duty reviews the notes for new orders, and any new orders the provider puts in, show up in red in the chart. She stated the night nurses double-check the new orders. On 01/30/24 at 01:31 PM, Licensed Nurse (LN) G stated admission orders were done by the nurse or nurse managers. She stated the nurses double-checked the admission orders and the managers checked after that. LN G stated the providers put orders in and the nurse confirmed any pending orders. On 01/30/24 at 01:42 PM, Administrative Nurse D stated when a resident was admitted , the nurse received orders from the hospital and verified them with the provider. The admitting nurse transcribed the orders into the system, a second nurse reviewed them, and IDT reviewed them after that. Administrative Nurse D stated when a provider visited, some of them put their own orders in and some gave verbal orders. She stated the nurse reviewed the orders but not the provider's progress notes because they visited so often. Administrative Nurse D stated the pharmacy sent recommendations to the nurse managers, herself, and the administrator. Between those people, the recommendations were reviewed and sent to the physician. She stated staff saw what the recommendation was and if it was something they could address, they updated it, initialed, dated it, and uploaded the recommendation into the miscellaneous tab of the EMR. On 01/30/24 at 01:54 PM, Administrative Nurse F stated when she received a pharmacy recommendation, she did not sign her name until it was completed in the EMR. She stated she wanted to say that was what she did with R1's recommendation from 12/28/23 but it did not get put in. Administrative Nurse F stated when she received an admission pharmacy recommendation, she printed it off, verified the order with the hospital discharge orders, and made sure the provider did not put a note in not wanting the medication. Once she did that, she put the order in the EMR per the discharge orders, confirmed it in the EMR, signed the recommendation, and put a nurse's note in that it was completed. The facility's Reconciliation of Medications on Admission/Re-Admission and Monthly Orders policy, last revised in March 2019, directed medication reconciliation reduced medication errors and enhanced resident safety during the admission/transfer process by identifying the medications the resident needed and administering without interruption, the correct dosages and routes. The policy directed the facility used an approved medication reconciliation form or other record to list all medications from the medication history, the discharge summary, the previous MAR, and the admitting orders. The facility reviewed the list carefully to determine if there were any discrepancies, conflicts, or severe drug-to-drug interactions. The facility's Physician Visits policy, last revised in April 2013, directed the attending physician performed relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. The facility's Medication Regimen Review (MRR) Policy, dated July 2018, directed medication regimen reviews were completed upon admission, and completed MRR reports were sent to the medical director, director of clinical services, and healthcare provider to review the recommendations. The facility failed to ensure staff accurately transcribed orders from the hospital on admission and failed to follow the physician's orders for R1. This deficient practice placed R1 at risk for unwarranted physical complications and less-than-therapeutic effects related to medication use.

The facility identified a census of 76 residents. The sample included three residents reviewed for medications. Based on record review and interviews, the facility failed to address the admission medication regimen review for Resident (R) 1 when the Consultant Pharmacist (CP) found irregularities with her admission orders. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use for R1. Findings included: R1 admitted to the facility on [DATE], discharged to the hospital on 01/04/24, readmitted to the facility on [DATE], and discharged home 01/24/24. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and Hashimoto's encephalopathy (a rare disease that involves impaired brain function and is a steroid-responsive acute or subacute encephalopathy characterized by autoimmune thyroiditis [autoimmune disorder where the immune system attacks the thyroid gland] associated with elevated levels of antithyroid antibodies). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Functional Abilities Care Area Assessment (CAA) dated 01/23/24, documented R1 had a decline in activities of daily living (ADLs) from her previous level of functioning related to multiple hospitalization s with the most recent due to head pressure, slurred speech, vision changes, confusion, hallucinations, and urinary tract infection. R1's Care Plan last revised 01/23/24, documented R1 had a cerebral vascular accident (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and Hashimoto's encephalopathy. The care plan documented an intervention, dated 01/10/24, that directed staff to give medications as ordered by the physician and monitored/documented side effects and effectiveness. R1's EMR revealed a Discharge Order Report dated 12/27/23, that documented an order for prednisone 10 milligrams (mg) in the morning. R1's EMR lacked evidence the prednisone order from 12/27/23 was entered and administered. R1's EMR revealed a Consultation Report on 12/28/23 that documented R1 recently admitted to the facility and the medication review process revealed the following discrepancies on the admission orders: there was an order for prednisone, but there was no current order in THE EMR. Recommendation to consider clarifying the medication orders and communicate with the prescriber and pharmacy as appropriate. The Notes tab of R1's EMR revealed the following: A Physician Progress Note on 12/28/23 at 11:08 AM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. A Physician Progress Note on 01/02/24 at 04:30 PM, documented R1 had chronic steroid use and Hashimoto's encephalopathy with a plan to continue prednisone 10 mg. R1's EMR revealed Consult Notes on 01/05/24 at 01:06 PM that documented R1 had not been receiving her daily prednisone that past week and there was a concern that given her recurrent hospitalization , it was related to a relapse of Hashimoto's encephalopathy. The note documented that it was not unheard of as there were case reports with relapsing symptoms, however, it was presumed to be only present in about 10 to 15 percent of cases. The note documented R1 had poor sleep over the past several days which was also an area of concern in previous hospitalization s leading to ongoing confusion. That could have been a stronger contributor to her current presentation. The note documented from an encephalopathy picture, R1 did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. The facility's investigative report, dated 01/08/24, documented R1 was admitted to the facility on [DATE] and had a BIMS score of 14. R1 had a history of Hashimoto's encephalopathy. The nurse practitioner (NP) noted a change in condition and spoke to R1 and her representative about possible options to evaluate symptoms. The NP, R1, and her representative agreed to further evaluation at the emergency department (ED) to rule out infection or worsening Hashimoto's encephalopathy. The NP reviewed R1's chart and repeated a medication reconciliation on 01/04/24 at approximately 04:05 PM and it was noted that prednisone was not currently on the Medication Administration Record (MAR). Upon investigation, it was discovered that prednisone was missed on the admission orders by the admitting nurse, the second nurse, and the interdisciplinary team (IDT). A pharmacy recommendation was received on 12/28/23 stating that there were discrepancies on the admission orders which involved an order for prednisone but no current order in the chart. According to the hospital physician's note on 01/04/24, the probability of R1's Hashimoto's encephalopathy relapsing was only 10 to 15 percent. It was also noted that R1 had poor sleep over the last several days which had been an area of concern in previous hospitalization s leading to ongoing confusion. From an encephalopathy picture, she did not have true confusion at that time, provided a good history, and performed extremely well on bedside cognitive testing. On 01/30/24 at 01:23 PM, Administrative Nurse E stated when a resident is admitted to the facility, the nurse and aide help the resident settle. She stated the floor nurse put in the admission orders and the nurse manager helped. Every morning, the nurse managers reviewed the orders when they did chart review. Administrative Nurse E stated when the provider visits, the nurse on duty reviews the notes for new orders, and any new orders the provider puts in, show up in red in the chart. She stated the night nurses double-check the new orders. On 01/30/24 at 01:31 PM, Licensed Nurse (LN) G stated admission orders were done by the nurse or nurse managers. She stated the nurses double-checked the admission orders and the managers checked after that. LN G stated the providers put orders in and the nurse confirmed any pending orders. On 01/30/24 at 01:42 PM, Administrative Nurse D stated when a resident was admitted , the nurse received orders from the hospital and verified them with the provider. The admitting nurse transcribed the orders into the system, a second nurse reviewed them, and IDT reviewed them after that. Administrative Nurse D stated when a provider visited, some of them put their own orders in and some gave verbal orders. She stated the nurse reviewed the orders but not the provider's progress notes because they visited so often. Administrative Nurse D stated the pharmacy sent recommendations to the nurse managers, herself, and the administrator. Between those people, the recommendations were reviewed and sent to the physician. She stated staff saw what the recommendation was and if it was something they could address, they updated it, initialed, dated it, and uploaded the recommendation into the miscellaneous tab of the EMR. On 01/30/24 at 01:54 PM, Administrative Nurse F stated when she received a pharmacy recommendation, she did not sign her name until it was completed in the EMR. She stated she wanted to say that was what she did with R1's recommendation from 12/28/23 but it did not get put in. Administrative Nurse F stated when she received an admission pharmacy recommendation, she printed it off, verified the order with the hospital discharge orders, and made sure the provider did not put a note in not wanting the medication. Once she did that, she put the order in the EMR per the discharge orders, confirmed it in the EMR, signed the recommendation, and put a nurse's note in that it was completed. The facility's Reconciliation of Medications on Admission/Re-Admission and Monthly Orders policy, last revised in March 2019, directed medication reconciliation reduced medication errors and enhanced resident safety during the admission/transfer process by identifying the medications the resident needed and administering without interruption, the correct dosages and routes. The policy directed the facility used an approved medication reconciliation form or other record to list all medications from the medication history, the discharge summary, the previous MAR, and the admitting orders. The facility reviewed the list carefully to determine if there were any discrepancies, conflicts, or severe drug-to-drug interactions. The facility's Physician Visits policy, last revised in April 2013, directed the attending physician performed relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. The facility's Medication Regimen Review (MRR) Policy, dated July 2018, directed medication regimen reviews were completed upon admission, and completed MRR reports were sent to the medical director, director of clinical services, and healthcare provider to review the recommendations. The facility failed to address the admission medication regimen review for R1 when the CP found irregularities with her admission orders. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use for R1.

The facility identified a census of 78 residents. The sample included 18 residents. Based on record review, interviews, and observations, the facility failed to ensure sufficient staffing was provided to maintain the residents' physical and psychosocial wellbeing. This placed the residents at risk for impaired quality of life. Findings Included: - The Payroll Based Journaling (PBJ) report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 1 and 3 indicated the facility had excessively low weekend staffing. Review of the facility's Resident Council Minutes from 12/2022 through 11/2023 indicated the council had recurring concerns with call light response times. (The complaint of slow call lights was not on the 01/23, 03/23, and 08/2023 council minutes). (Refer to F565) On 12/18/23 at 12:43PM R43 sat in her bed with her bedside table pulled overlap. Staff delivered and prepped her meal. Staff then left the room with the door slightly propped open. R43 had bit sized meat and cut potatoes on her tray. R43 began eating her meal. From 12:45PM to 01:20PM no supervision or check-in was provided to R43 during her meal. On 12/19/23 at 07:20AM R43 ate her breakfast without staff supervision in her room with her door barely open. Observation on 12/19/23 at 01:06 PM R37 laid on her right side on the bed. R37's was uncombed and matted upward. On 12/14/23 at 01:10PM Resident (R)19 reported the facility was slow to get her up and had not given her a bath in weeks. She stated the only one who bathed her was hospice services because the facility staff repeatedly told her they didn't have enough staff. She stated since starting hospice services, the visiting nurse ensured she was bathed and provided hygiene care. R19 reported she preferred to be bathed more than twice weekly and did not understand why the facility could not do it. (Refer to F677) On 12/18/23 at 02:00PM, the Resident Council reported ongoing concerns with staffing, call light response times, and activities of daily living not being completed. The council reported it took sometimes over 30 to 45 minutes for staff to respond to call lights. The council reported the facility staffing was lower on weekends and the wait times could go up to an hour. The council reported the facility was working on finding permanent staff and getting rid of agency staff. The council reported the staffing concerns were affecting bathing, toileting, weekend activities, and meals. On 12/18/23 at 03:30PM Administrative Staff A stated the facility was currently attempting to improve staffing by hiring more permanent staff and getting rid of agency staff. He said the facility currently had a performance improvement plan to address the low staffing and issues related to care concerns affected by staffing. On 12/19/23 at 12:34 Certified Nurse Aid (CNA) O stated weekend staffing was a struggle. She stated the weekend didn't have enough help to complete the assist the resident's need. She stated the residents usually must wait for staff from other units to come over to complete lifts and transfers that require more than one staff. She stated resident's baths get delay or pushed off to the next shift. On 12/19/23 at 01:04 Licensed Nurse I stated the facility has been low on staffing the units. She stated the facility was not looking at patient acuity and the needs of the residents when making assignment for the staff. She stated the lack of assistance made it hard to complete Hoyer (full body mechanical lift) lifts, transfers, bathing, toileting, and individualized care needs outside of the times when the nurse managers worked. She stated the lack of assistance caused residents to have to reschedule or wait long times for toileting and bathing. On 12/19/23 at 02:34 Activities Staff Z reported stated weekend activities were mainly one-one with the residents and completing activities assessment. She stated the facility was often staffed less on the weekends and residents were frequently provided solitary activities such as coloring, puzzle, and electronic tablets to play games. She was not sure why, but weekends have always been lightly staff compared to weekdays. She stated instead of having an activities staff for each unit (three units), one staff would work the weekend to cover all the units. (Refer to F679) On 12/19/23 at 02::45 Social Services X reported she had received a lot of grievances related to weekend staffing and reported them to the nursing department and administrator. She stated much of the focus was on slow call light times and staff response. She stated a social service staff is always working in the building seven days a week to meet with the residents and address their needs. On 12/19/23 at 03:16 Administrative Nurse D stated the facility was currently working to replace agency staff with more permanent staffing to improve resident care and response times. She reported call light response times was an ongoing issue and she felt it had improved recently. The facility failed to ensure sufficient staffing was provided to maintain the resident's physical and psychosocial wellbeing. This placed the residents at risk for impaired quality of life.

The facility identified a census of 76 residents. The facility identified one main kitchen and five satellite kitchenette areas. Based on observation, record review and interview, the facility failed to ensure kitchen staff appropriately sanitized a probe-type thermometer used to check food temperatures prior to meal service. The facility failed to ensure staff cleaned and maintained a satellite kitchen ice machine. This deficient practice left residents at risk for food borne illnesses and cross-contamination. Findings included: - During the initial tour of the facility on 12/14/23 shortly after 07:00 AM, the ice machine on the 400 hall had a brown gooey substance on the inside drain. The outside of the ice machine was visibly soiled. On 12/18/23 at 12:01 PM Dietary Staff DD prepared to check the temperature of the hot foods she placed on the steam table for meal service on the long-term care unit of the facility. Dietary Staff DD put on gloves without performing hand hygiene and grabbed a probe-type thermometer. Dietary Staff DD removed the cover of the probe and placed the probe end of thermometer into the metal container with the Salisbury steaks without sanitizing it first. Dietary Staff DD removed the probe from the steaks and then inserted the probe into the metal container that contained chicken breasts. Dietary Staff DD then removed the probe from the chicken breasts. Dietary Staff DD continued to check the temperature of each food item on the steam table (corn, Brussel sprouts, macaroni and cheese, mashed potatoes, and brown gravy) without sanitizing the probe of the thermometer after insertion into each food. On 12/18/23 at 12:05 PM Dietary Staff DD stated she did not have any of the sanitizing wipes to sanitize the thermometer probe and was not sure where to find them. On 12/19/23 at 08:51 AM Dietary Staff BB stated that the servers were expected to sanitize the thermometer after temperatures were obtained of each food item. Dietary Staff BB stated she would do some more education with her staff on proper procedure when checking the temperatures of the foods. Dietary Staff BB stated she expected the ice machines to be wiped down daily and cleaned weakly. Dietary Staff BB stated she would go over the policies and procedures again to re-educate her staff on the cleaning of the ice machines. The undated facility policy Food Temperatures documented: Foods should be served at proper temperatures to ensure food safety and palatability. Wash, rinse and sanitize a dial face, metal probe-type thermometer with an alcohol wipe. Re-sanitize the thermometer after each use. The undated facility policy Ice Machine documented: Sanitation of equipment- daily- wash the exterior of machine with hot water and detergent. Rinse with clean water and cloth. Use sanitizing solution and clean cloth to sanitize. Remove the drainage grate and tray and send through dishwasher. Allow drainage grate and tray to air dry and replace the drainage grate and tray. Store the ice scoop free from ice in a sanitary enclosed container. Document cleaning on the cleaning schedule. The facility failed to ensure kitchen staff appropriately sanitized the probe-type thermometer before and after obtaining each food temperature prior to service. The facility failed to ensure kitchen staff properly maintained and cleaned an ice machine used by staff for resident's drinks. This deficient practice had the potential for food borne illnesses and cross-contamination of food for the residents.

The facility identified a census of 76 residents. The sample included 18 residents. The facility identified two COVID-19 (highly contagious, potentially life-threatening respiratory virus) positive residents. Based on record review, observations, and interviews, the facility failed to ensure infection control standards were followed related to COVID-19 isolation precautions, clean supply/equipment storage, and hand hygiene during cares. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 12/14/23 at 07:05AM an unidentified staff member at the front desk wore her face mask around her chin while seated at the desk. The facility identified Residents (R)52 and R116 as positive for Covid-19. On 12/14/23 at 07:20AM an inspection of the clean linen rooms on the 300 and 400 halls revealed dirty vacuums stored next to the uncovered linen. Green lift slings sat directly on the floor in both rooms. On 12/14/23 at 08:22AM R119's supplemental oxygen nasal cannula (oxygen mask supplying air to both nostrils) and oxygen tubing rested directly on the seat of her recliner. No storage bag was present for the cannula or tubing. On 12/14/23 at 09:18AM an inspection of R114 room revealed no signage indicating her droplet precautions or required personal protective equipment (PPE). An isolation cart was placed outside her room. On 12/14/23 at 12:22PM R114's nasal cannula and oxygen tubing laid directly on her unmade bed. On 12/14/23 at 12:38PM Certified Nurse Aide (CNA) M entered R116's room without wearing PPE. CNA M reported R116 was not on isolation and staff did not need to wear PPE. Licensed Nurse (LN) G came and stated R116 was on isolation precautions, and everyone was required to wear PPE upon entry to the room. On 12/14/23 at 03:44PM R215's unbagged nasal cannula and oxygen tubing rested on the floor next to her bed despite the storage bag was present. On 12/18/23 at 01:01PM Administrative Nurse E completed hand hygiene before providing wound care to R52. Administrative Nurse E unplugged the wound-vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) and removed R52's dressing. She changed her gloves but failed to complete hand hygiene in between glove change. Administrative Nurse E cleansed the wound and touched her personal phone during the cleansing. She again changed her gloves but failed to complete hand hygiene in between glove change. A new dressing was then applied to complete the wound care. On 12/18/23 at 01:14PM LN H prepared R1's medication administration through her feeding tube (tube for introducing high calorie fluids into the stomach). LN H failed to complete hand hygiene before preparing the medication, upon entering the room, or upon administering the medication using the feeding tube. She completed hand hygiene upon exiting the room after the administration was completed. On 12/19/23 at 09:34 AM R115 laid on the bed. CNA P entered R115's room, washed her hands, donned gloves, and explained the procedure to R115 for catheter care. CNA P removed two wipes from the package and placed the wipes on R115's right thigh. CNA P used one wipe to clean R115's foreskin and around the base of the penis. CNA P placed the soiled wipe on the bed between R115's legs. CNA P used the second wipe to clean the tip of R115's penis and wiped away from the tip of the penis down the tubing with the wipe. CNA P removed the soiled wipes and placed items into the trash can next to the bed. With the same gloves, CNA P assisted R115 onto his left side, provided peri-care, and placed a clean incontinent brief under R115. CNA P doffed her right-hand glove only, donned a clean glove without performing hand hygiene, then adjusted R115's clothes, and bedding. Wearing the same gloves, CNA P touched the bedside table, adjusted the bed height with a remote control and assisted R115 with repositioning on the bed. CNA P removed the soiled trash from R115's room. At 12/19/23 at 12:35PM CNA O stated staff were expected to complete hand hygiene before providing cares to residents and when visibly soiled. She stated oxygen tubing should be stored in a clean bag next to the machine or tank. She stated staff received training monthly on the online training service and in meetings about how to apply PPE and remove it. She stated only clean linen should be stored in the closest and slings should never be placed on the floor. At 12/19/23 at 01:05PM LN I stated hand hygiene should be completed before passing meals, medications, providing cares, and when soiled. She stated residents in isolation should have signage posted outside their rooms showing what PPE was required before entering. On 12/19/23 at 02:29PM Administrative Nurse F stated the facility routinely held in-service training related hand hygiene related to basic cares for residents. She stated hand hygiene should always be completed before providing direct contact care for the residents that included wound care, catheter care, medication administration, activities of daily living, and when assisting residents. Administrative Nurse E stated isolations signs and PPE carts should be posted outside the resident's door for isolation residents. She stated R116 was on isolation precautions and signs should have been posted outside her door. She stated posted signs identifying Covid-19 exposure were at the front door and main desk. She stated oxygen tubing and cannulas should be stored in their provided clean storage bag to prevent contamination or infections. A review of the facility's Standard Precautions policy revised 09/2022 indicated hand hygiene and prevention practices should be used regardless of a resident's diagnoses. The policy indicated hand hygiene should be performed before, during, and after direct contact with residents. The policy noted hand hygiene was to be completed after removal of PPE. The policy indicated soiled facility equipment should not be stored around or in the same area as clean equipment, clothing, linen, hygiene products, food, or furniture to prevent contamination. A review of the facility's Isolation policy revised 09/2022 indicated staff were follow were the appropriately indicated personal protective equipment outlined for residents in isolation precautions. The policy noted the facility will communicate and ensure staff are informed of the appropriate levels of precautions to prevent further spread infection. The policy indicated sings will be placed in visible areas to describe to level of precautions and PPE required. The facility failed to ensure infection control standards were followed related to COVID-19 and isolation precautions, clean supply/equipment storage, and hand hygiene during cares. This deficient practice placed the residents at risk for infectious diseases.

The facility reported a census of 76. Based on observations, record review, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life. Findings included: - A review of the facility's Resident Council Minutes from 12/2022 through 11/2023 indicated the council had recurring concerns with call light response times. The Resident Council Minutes for 01/2023 noted under new business concerns over call light response time. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 02/2023 noted under old business the previous call light concern was resolved and noted no other new/old concerns. No other issues were reported on the minutes. The Resident Council Minutes for 03/2023 noted long call light waits under new business concerns. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 04/2023 noted under old business the previous the long call light wait was better. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 05/2023 noted under old business the previous the long call light wait was resolved. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 06/2023 noted under new business concerns the Hoyer (full body mechanical lift) lifts were being left in the resident's rooms. The form did not list actions taken or resolutions provided. This issue was not addressed by the facility. No other issues were reported on the minutes. The Resident Council Minutes for 08/2023 noted long call light waits under new business concerns. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 09/2023 noted under old business the previous the long call light wait was resolved. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. On 12/18/23 at 02:00PM, the Resident Council reported ongoing concerns with staffing, call light response times, and activities of daily living not being completed. The council reported it took sometimes over 30 to 45 minutes for staff to respond to call lights. The council reported the facility staffing was lower on weekends and the wait times could go up to an hour. The council reported the facility was working on finding permanent staff and getting rid of agency staff. The council reported the Hoyer lifts were still being left in resident rooms. The council reported the staffing concerns were affecting bathing, toileting, activities, and meals. On 12/19/23 at 02:45PM Social Service X stated the concerns were directed to the appropriate department listed to resolve the issues or concerns. She stated the forms were signed off as resolved once the actions had been taken and improvement occurred. On 12/19/23 at 03:16PM Administrative Nurse D stated the facility was currently working to replace agency staff with more permanent staffing to improve resident care and response times. She reported call light response times was an ongoing issue and she felt it had improved recently. A review of the facility's Resident Council policy indicated the resident response form were to be utilized to track council concerns and facility resolution. The policy indicated the department related to any issue will be responsible for addressing the concerns. The facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life.

The facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representative to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Finding Included: - On 12/18/23 at 07:05AM an inspection of the facility revealed no designated grievance drop -box or alternative system available accessible to the residents and visitors of the facility to allow submission of grievances anonymously On 12/18/23 at 02:00PM, the Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported Social Services X was responsible for complaints or grievances. The council stated they would contact staff or social services. On 12/19/23 at 12:30PM Certified Nurses Aid (CNA) O reported she was not aware of an anonymous way the residents could report grievances other than giving staff the forms directly. She stated she was not aware of a drop box or secured area the forms could be placed anonymously by the residents or their representatives. On 12/19/23 at 01:05PM Social Services Staff X stated that facility had grievance forms at the front desk. She stated there was no drop box for the forms to be placed anonymously but staff could slide the forms under her door. A review of the facility's Grievance policy revised 10/2022 indicated the facility must enable each resident the right to file grievances verbally, orally, and anonymously to the designated officer, administrator, or staff member for review. The facility failed to implement a system to allow anonymous grievances. This deficient practice placed all the residents at risk for decreased psychosocial wellbeing.

The facility reported a census of 76 residents. The sample included 18 residents. Based on interview and record review, the facility failed to establish and maintain a system to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR- a life-saving medical procedure that consists of chest compressions to allow oxygenated blood to circulate to vital organs, such as the brain and heart and artificial ventilation) certification for healthcare providers. This deficient practice placed all residents who desired CPR at risk for inadequate resuscitative measures. Findings included: - On [DATE] Licensed Nurse (LN) K's CPR certification had an issue date of [DATE] and a renew (expiration) date of ,d+[DATE]. On [DATE] at 03:43 PM Administrative Staff A stated LN K was a newer nurse and had previously worked at the facility as a Certified Nurse Aide. Administrative Staff A stated that LN K's CPR certification expired at the end of October. Administrative Staff A stated the facility had had not self-identified LN K's expired CPR certification. The facility failed to establish and maintain a system to ensure nursing staff maintained current CPR certification for healthcare providers. This deficient practice placed all residents who desired CPR at risk for inadequate resuscitative measures.

The facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom. Findings included: - A review of the facility's Activity Calendar for September, October, and November 2023 was completed. The review revealed two consistent activities of movie matinee and activities connection as shown for both Saturday and Sundays. The calendar indicated church services were provided Sunday mornings. The calendar indicated the activity B-fit was provided by the therapy department on weekends. On 12/18/23 at 02:05PM, Resident Council members reported activities minimally occurred on weekends compare to the weekdays. The council reported due to the low staffing in the facility and limited activities provided, the resident usually watched television or wheeled themselves around to see each other. The council reported the facility did provide an Activities Connection basket that had crossword puzzles and coloring pages the residents could complete. The council reported they wanted the facility to provide more engagement activities like Bingo or interactive groups for the residents on the weekend. On 12/14/23 at 08:12AM Resident (R)216 sat in her room. She reported she was not aware the facility provided activity on the weekend. She stated she did attend some of the activities during the week. She reported she did not have a calendar in her room to know there were activities on Saturday and Sunday. An inspection of her room revealed no activity calendar. On 12/18/23 at 11:30AM the facility had a Caroling group singing next to the piano area for the 300 hallway residents. R19 reported she was not informed about the event and would have liked to see it. On 12/19/23 at 12:35PM Certified Nurses Aid (CNA) O stated some activities staff do come in on the weekends. She stated the residents were often provided with the activity connection stuff or therapy would come in the have exercise (B-fit) groups. She stated movies would be played on television. On 12/19/23 at 02:34 Activities Staff Z reported stated weekend activities were mainly one-one with the residents and completing activities assessments. She stated the facility was often staffed less on the weekends and residents were frequently provided solitary activities such as coloring, puzzle, and electronic tablets to play games. A review of the facility's Quality of Life policy revised 10/2021 indicated the residents will be provided and encourage to attend activities that meet each resident's interest, hobbies, worship, beliefs, and social needs. The facility failed to provide consistent activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom.

The facility identified a census of 76 resident. The facility had three medication storage rooms and five medication carts. Based on observation, record review and interview, the facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk for adverse side effects and ineffective medication administration. Findings included: - On 12/14/23 at 09:25 AM the medication cart on the 300 hallway was left unsecured and unlocked in an area where residents were present. Licensed Nurse (LN) J came running out of a resident's room in the 300 hall when she realized she left the medication cart unlocked. On 12/14/23 at 09:45 AM the treatment cart in the 400 hall was left unsecured and unlocked. On 12/14/23 at 09:25 AM LN J stated the medication and treatment carts should be secured when not in use. On 12/19/23 at 03:16 PM Administrative Nurse D stated that the medication cart, medication room, and treatment carts should all be securely locked when staff was not using them. The facility policy Storage and Expiration of Medications, Biologicals, Syringes and Needles revised 01/01/13 documented the facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. The facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk for adverse side effects and ineffective medication administration.

The facility identified a census of 76 residents. The sample included 18 residents with one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure a dignified care environment for Resident (R) 47 related to her incontinence management. This deficient practice placed R47 at risk unnecessary embarrassment and decreased psychosocial wellbeing. Findings included: - On 12/14/23 at 02:05 PM an inspection of R47's room revealed a heavy urine smell. R47's room floor had a wet substance leading around the room and into the restroom. Parts of R47's floor had a dried / sticky substance covering it. On 12/18/23 at 12:34 PM R47 was in her room standing next to the closet in her room. R47 had a pair of white pants on the floor next to her recliner. R47 stated she just changed her pants and was going to lunch. R47 had a pile of clothing in her laundry basket. She reported she could do most things for herself but needed staff assistance from time to time. Staff were not in the room to assist her changing. R47 smelled of urine as she went to the dining room. On 12/19/23 at 12:31PM Certified Nurse Aid (CNA) stated she was not sure if R47 was incontinent, but all residents were checked on every three hours. She stated if a resident or their room smelled like bladder or bowel incontinence staff was to immediately ask the resident if they need assistance using the restroom and check them. She stated soiled clothing and linen should be immediately sent to the laundry services to be washed to prevent the room from smelling. At 12/19/23 at 01:08PM Administrative Nurse D stated staff should be assisting residents with incontinence and providing frequent toileting to prevent incontinent episodes. She stated if a resident or their rooms smells of urine the staff should assess them to ensure they were not incontinent. A review of the facility's Dignity policy revised 10/2022 indicated each resident shall be care for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. The facility failed to ensure a dignified care environment for R47 related to her incontinence management. This deficient practice placed R47 at risk unnecessary embarrassment and decreased psychosocial wellbeing.

The facility identified a census of 76 residents. The sample included 18 residents with two residents reviewed for transfers. Based on observation, record review and interview, the facility failed to provide written notification of facility-initiated transfers with the required information to Resident R165 or their family/durable power of attorney (DPOA) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R165. Findings included: - The electronic medical record (EMR) for R165 documented diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure (a condition when your body does not have enough oxygen), and dependence on supplemental oxygen. The Admission Minimum Data Set (MDS) dated [DATE] for R165 documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated a moderately impaired cognition. R165 required partial/moderate to substantial/maximal staff assistance for functional abilities. R165 utilized the use of a wheelchair for mobility assistance. R165 required oxygen therapy while a resident. The Discharge MDS dated [DATE] for R165 documented a discharge to short term stay hospital. The Activities of Daily Living (ADL) Care Area assessment dated [DATE] for R165 documented she was a long-term care resident due to heart failure. R165 was weak and had other co-morbidities that impaired her ability to perform ADL and personal cares. R165 was on oxygen and staff monitored her for oxygen needs as needed. The Respiratory Failure Care Plan last revised 11/25/23 directed staff to monitor for difficulty in breathing on exertion. Staff was to monitor/document changes in orientation, increased restlessness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and air hunger (form of respiratory distress characterized by gasping and labored breathing). Staff was to monitor for signs and symptoms of respiratory distress and report to physician. A Nursing Progress Report dated 11/19/23 at 11:17 PM for R165 documented it was reported that R165 was not feeling well that day. The nurse noted the resident was very weak, lethargic (an appearance of sluggishness, lack of energy) or less interactive. R165 was reassessed and was moaning and not opening eyes and did not respond to questions. The telehealth provider was notified and recommended the resident be sent to the hospital for further evaluation. R165's sister was notified of the change in condition. Emergency services was called and arrived at the facility around 11:00 PM and R165 was transported out of the facility at 11:20 PM. A Progress Note dated 11/20/23 at 03:57 PM documented R165 was admitted to the hospital due to pneumonia (inflammation of the lungs). A Progress Note dated 11/24/23 documented R165 readmitted after return from the hospital. The facility lacked written notification of transfer for R165's facility-initiated transfer to the hospital on 11/19/23. On 12/18/23 at 12:01 PM staff propelled R165 in her wheelchair to the dining room for lunch. R165 had her supplemental oxygen on via nasal cannula (a hollow tube used to deliver supplemental oxygen) that was connected to a portable oxygen tank. R165 had no complaints at that time. On 12/19/23 at 02:29 PM Administrative Nurse F stated that the nurses initiated transfers for a resident when sent out to the hospital. Administrative Nurse F stated the nurse called the physician to get the order to send resident to the hospital. Administrative Nurse F stated the hospital was called to give report on the resident and then the family/representative would be called to notify of transfer to the hospital. Administrative Nurse F stated she was not aware that written notification of transfer had to be sent to the family/representative for hospital transfers. On 12/19/23 at 03:16 PM Administrative Nurse D stated she was unaware that a written notification of transfer was required to be sent to the family/representative upon transfer to the hospital. The facility policy Resident Transfer and Discharge last revised August 2023 documented: Prior to transfer or discharge of a resident, the resident and resident's representative should be notified in writing of the reason, effective date, the location to which the resident was transferred or discharged , a statement of the resident's appeal rights, the name, address, and telephone number of the office of the stated long-term care ombudsman. A copy of the notice should be sent to the representative of the Office of the State [NAME]-Term Care Ombudsman at the time the notice was provided to the resident and the resident representative, or as soon as practicable after an emergency transfer or discharge. The facility failed to provide written notification of transfer with the required information to R165 or their family/DPOA in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R165.

The facility had a census of 76 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide a copy of the Bed Hold notice to Resident (R)63, or her representative, upon discharge to a hospital in November 2023. This deficient practice placed R63 at risk to not be allowed to return to their same room upon discharge from the hospital. Findings included: - R63's Electronic Medical Record documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, difficulty walking and reduced mobility. R63's Entry Tracker documented she admitted on [DATE]. R63's Care Plan with an initiated date of 10/31/23 documented R63 had an activities of daily living (ADLs) self-care performance deficit. An eINTERACT SBAR Summary for Providers note dated 11/02/23, documented R63 had an unwitnessed fall in her room. The note further documented R63 was found on the floor on her left side with no injury at the time of assessment. A Nursing Progress Note dated 11/02/23, documented R63 developed a bruise to her left eyebrow and side of her head. The note further documented R63 was sent to the hospital for further evaluation per R63's daughter's request. The note documented R63 left the facility at 11:00 AM via Emergency Medical Services (EMS). R63's clinical record lacked evidence and the facility failed to provide evidence the resident or representative was provided a Bed Hold notice after discharge to a hospital. On 12/19/23 02:43 PM Social Services X stated she handled the written notice for transfers if a resident was being discharged home. She said the nurses were supposed to have completed the written notice for transfer and bed hold notifications if a resident discharged to a hospital. Social Services X stated if a resident was discharged to a hospital the notifications did not always make it onto the sheet, they used to track them to ensure they were done. On 12/19/23 at 03:17 PM Administrative Nurse D stated nurses completed notification of discharge and Bed Hold notifications when residents were discharged to the hospital. Administrative Nurse D stated nurse managers were responsible for following up to ensure Bed Hold notifications were being done. The facility provided Resident Bed-Hold policy dated 12/2008, documented residents may exercise their right to secure a bed-hold during hospitalization or therapeutic leave from the community in accordance with applicable state and federal laws, including the requirements of participation for states and long-term care facilities. A notice of the community's bed-hold policy should be provided at the times of a resident's transfer for hospitalization or therapeutic leave, or as soon as possible thereafter. The manner of providing the notice should be documented. The facility failed to provide a copy of the Bed Hold notice to R63, or her representative, upon discharge to a hospital in November 2023. This deficient practice placed R63 at risk to not be allowed to return to their same room upon discharge from the hospital.

The facility identified a census of 76 residents. The sample included 18 residents with one resident reviewed for baseline care plan. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan to include an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) for Resident (R) 115. This deficient practice placed R115 at risk of impaired care related to uncommunicated care needs. Findings included: - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, disorder of kidney and ureter (duct that urine passes from the kidney to the bladder), femur (thigh bone) fracture (broken bone) of left leg, and encounter for fitting and adjustment of urinary device. The Admission Minimum Data Set (MDS) was in progress. R115's Care Area Assessment (CAA) was in progress. R115's Baseline Care Plan dated 12/10/23 documented staff would provide catheter care per facility policy. R115's Care Plan dated 12/13/23 documented staff would place catheter drainage bag below the level of R115's bladder every shift related left femur fracture. The plan of care for R115 lacked reason for the indwelling catheter. R115's clinical record lacked evidence of catheter cares provided for the indwelling catheter. On 12/19/23 at 11:39 AM Certified Nurse Aide (CNA) P stated she had access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident) which would provide the information for each resident's care needs. On 12/19/23 at 11:52 AM Licensed Nurse (LN) J stated the admission nurse would start the baseline care plan which would include an information related an indwelling catheter care. LN J stated the baseline care plan would include the type of indwelling catheter and diagnosis for the catheter. LN J stated the care plan information was what information was on the Kardex that directed the staff to meet the resident's individual care needs. On 12/19/23 at 03:15 PM Administrative Nurse D stated the baseline care plan was started on each resident at the time of admission. Administrative Nurse D stated the interdisciplinary team (IDT) would review the baseline plan of care to make revision and additions added to the plan of care from each department to develop a person-centered care plan for each resident. Administrative Nurse D stated the care plan information was what would build the information for the Kardex for the staff to know what care was needed for each resident. The facility's Interim Care Plan Policy last revised 02/2023 documented an Interim baseline care plan would be developed for each resident within forty-eight (48) hours of admission to the skilled healthcare community. Within forty-eight (48) hours of admission to the skilled healthcare community, an interim baseline care plan would be developed which includes the minimum healthcare information necessary to care for the resident's immediate health and safety needs. The interim care plan would be developed by the admission nurse with the assistance of interdisciplinary team members. The Interim care plan would use but not be limited to, the resident's initial goals of care, physician's orders, dietary orders and instructions, therapy orders, resident cognitive, physical, and psycho-social needs. The Interim care plan would be person-centered and include services and treatments administered by the community. The interim care plan would be used until the completion of the comprehensive assessment and the comprehensive care plan is developed. The Interim Care Plan would be maintained and updated as needed until the Comprehensive Care Plan is developed. The facility failed to develop a person-centered baseline care plan to include an indication and type of indwelling catheter for R115. This deficient practice placed R115 at risk of impaired care related to uncommunicated care needs.

The facility identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide adequate care and services for activities of daily living (ADL) when staff failed to provide supervision with eating during meals for Resident (R)43. This deficient practice placed R43 at risk for complication related to aspiration (inhaling liquid or food into the lungs) and decline of overall abilities. Findings included: - The electronic medical record (EMR) for R43 documented diagnoses of hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing), cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), and hemiparesis (muscular weakness of one half of the body). R43 Quarterly Minimum Data Set (MDS) completed 11/16/23 noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe impairment. The MDS indicated she required setup or clean-up assistance with her meals. The MDS indicated no swallowing disorders. The MDS indicated she was totally dependent on staff assistance for toileting, dressing, and bed mobility. The MDS indicated R43 was rarely or never understood. R43's Cognitive Loss Care Area Assessment (CAA) completed 06/15/23 indicated she was non-verbal and frequently lacked psychical responses or reactions to questions. The CAA noted she had a cognitive communication deficit related to her medical diagnoses. The CAA indicated staff will anticipate her care needs. R43's Functional Abilities CAA completed 06/15/23 indicated she had right sided hemiplegia, aphasia, and cognitive communication deficits. The CAA noted she had functional limitations in her range of motion. The CAA noted she had decreased independence and safety, right lower extremity weakness, and right facial drooping. The CAA noted she communicated by nodding her head when asked questions. The CAA noted she required extensive assistance from two staff related to toileting, personal hygiene, and bathing. The CAA noted she required supervision and set-up assistance during meals due to swallowing difficulties. R43's Care Plan initiated 06/23/23 indicated she was at risk for aspiration related to difficulty swallowing. The plan instructed staff to ensure she maintained an appropriate position during meals. The plan indicated she was to be served a regular diet with small bites/sips and provided distant supervision due to difficulty swallowing. On 12/18/23 at 12:43PM R43 sat in her bed with her bedside table pulled overlap. Staff delivered and prepped her meal. Staff then left the room with the door slightly propped open. R43 had bit sized meat and cut potatoes on her tray. R43 began eating her meal. From 12:45PM to 01:20PM no supervision or check-in was provided to R43 during her meal. On 12/19/23 at 07:20AM R43 ate her breakfast without staff supervision in her room with her door barely open. On 12/19/23 at 12:34PM Certified Nurse Aid (CNA) O reported that R43 liked to eat in her room but was not sure if she was at risk for aspiration. She stated she was not sure what distant supervision meant but thought maybe that staff should watch her from a distance. She stated all staff had access to the care plans and reviewed the interventions. On 12/19/23 at 01:05PM Licensed Nurse (LN) I stated R43 preferred to eat in her room due to not wanting to eat around the other residents. She stated R43 was aphasic (difficulty communicating) and got anxious (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) around large groups of residents. She was not sure what distant supervision meant but stated it had to do with risk of aspiration and staff should not stand close to her while she ate. On 12/19/23 at 03:16PM Administrative Nurse D stated residents at risk for aspiration should be monitored closely during meals. She was unsure what distant supervision meant but stated it may have had to do with R43's difficulty communicating her needs. A review of the facility's Supporting Activities of Daily Living policy revised 04/2022 indicated each resident would be provided with the care, services, and treatment as appropriate to safely maintain or improve their ability to carry out activities. The policy indicated each resident would receive the appropriate level of assistance to maintain hygiene, mobility, dining, toileting, and communication. The policy noted each resident's abilities will be monitored, measured, and tracked. The facility failed to provide adequate ADL cares when staff failed to provide supervision during meals for R43. This deficient practice placed R43 at risk for complication related to aspiration and overall decline.

The facility identified a census of 72 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure 1 resident (#334) was free from a significant medication error. Findings included: - Review of resident #334's clinical record revealed this [AGE] year-old resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the 5-Day minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. The assessment lacked documentation of a pain assessment. The care plan dated 4/5/16 for pain directed staff to administer [MEDICATION NAME] as ordered, to observe and report changes in sleep patterns, decreased functional abilities, and withdrawal, and to monitor, document, and report changes in breathing. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the April 2016 Medication Administration Record [REDACTED].M. and at 8:00 P.M. Review of the April 2016 MAR indicated [REDACTED].M. and at 5:14 P.M. A progress note dated 4/5/16 and timed 5:10 P.M. revealed the resident was Spanish-speaking only but able to make his/her needs known. Review of the facility's self-report investigation indicated on 4/8/16 at 8:00 A.M., licensed nursing staff L administered scheduled MS-Contin 30 mg. At approximately 1:15 P.M., the resident reported his/her pain level was 7 out of 10 and was administered MS-Contin 30 mg instead of the documented [MEDICATION NAME] 15 mg. At approximately 5:15 P.M., the resident reported his/her pain level was 7 out of 10 and was administered MS-Contin 30 mg instead of [MEDICATION NAME] 15 mg. On 4/9/16, the resident was noted to be drowsy, but easily awakened. The physician was notified and new orders were received to hold the 4/9/16 A.M. dose of MS-Contin. On 4/9/16 after lunch, the resident was less responsive. Documented vital signs at this time were blood pressure 88/63, heart rate 83, respirations 12, and oxygen saturation 94%. At this time, the weekend supervisor was notified of the medication error and orders were received to send the resident to the emergency room for evaluation. An interview on 4/20/16 at 2:20 P.M. with administrative nursing staff F revealed on 4/8/16 licensed nursing staff L had worked a double shift (day and evening shift). Administrative nursing staff F stated the narcotic count was noted to be incorrect during the night shift. An interview on 4/20/16 at 2:46 P.M. with licensed staff H revealed the resident was Spanish-speaking but was able to use a pain scale to identify his/her pain level. An interview on 4/20/16 at 3:37 P.M. with administrative nursing staff D stated licensed nursing staff L did not follow the five rights of medication administration and administered the controlled release medication (MS-Contin) two times instead of the as-needed immediate release medication ([MEDICATION NAME]). Administrative nursing staff D stated the resident received a dose of intravenous [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation) at the hospital. An interview on 4/25/16 at 12:16 P.M. with consultant staff KK stated when he/she was notified of the significant medication error he/she ordered the resident to be sent to the hospital for evaluation. The facility provided policy General Dose Preparation and Medication Administration dated 1/1/13 directed staff to document the administration of controlled substances in accordance with applicable law and to verify each time a medication was administered that it was the correct medication, the correct dose, the correct route, the correct time, and was administered to the correct resident. The facility provided policy Medication Errors dated October 2015 indicated a medication error was classified as significant when the resident required hospitalization and immediate action would be taken to protect the resident's safety and welfare. The facility failed to ensure this resident was free of a significant medication error which resulted in hospitalization and treatment.