Every finding on record at Countryside Health Center

The facility had a census of 95 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report). This placed the residents at risk for impaired care due to unidentified staffing issues. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year 2024, all four quarters indicated the facility triggered for excessively low weekend staffing. On 04/29/25 at 09:10 PM, Administrative Nurse D stated that the weekend staffing was not low. Administrative Nurse D stated that the level of weekend staffing was the same as during the week for direct care staff. Administrative Nurse D stated there must be an error in the reporting of the hours. The facility's Competent and Sufficient Staffing policy, dated 09/2024, documented direct care staffing information was submitted to the payroll-based journal (PBJ) system on the schedule specified by the Centers for Medicare & Medicaid Services (CMS), but no less than once a quarter.

The facility identified a census of 95 residents. The sample included 19 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 95 residents residing in the facility. Findings included: - On 04/28/25, Administrative Nurse D provided a Facility Assessment updated 01/30/25. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs by shifts for the weekends. On 04/29/25, a review of the facility's Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 to 03/31/25 revealed excessively low weekend staffing triggered on all four quarters. On 04/30/25 at 08:41 AM, Administrator A stated the nursing hours were set by the corporate office, and the assessment was recently updated to reflect the hours needed for days and nights. He stated the assessment did not differentiate between the weekdays and the weekends. He stated weekends were staffed differently from the normal nursing hours due to the increased staff presence during the weekdays. He stated the facility put a program in place to ensure consistent staff hours on the weekends to prevent staffing shortages. The facility's Facility Assessment policy, revised 06/2018, indicated the facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents during day-to-day operations and emergencies.

The facility identified a census of 95 residents. The sample included 19 residents, two Certified Nurse Aides (CNA), and three Certified Medication Aides (CMA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the two CNAs and three CMA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs and CMAs were employed with the facility for more than 12 months: CMA T, hired on 04/18/18, had no yearly performance evaluation upon request. CMA S, hired on 11/27/20, had no yearly performance evaluation upon request. CNA M, hired on 01/21/23, had no yearly performance evaluation upon request. CMA R, hired on 01/08/24, had no yearly performance evaluation upon request. CNA N, hired on 03/25/24, had no yearly performance evaluation upon request. On 04/29/25 at 10:12 AM, Administrative Staff A stated the employee's supervisor was responsible for completing the yearly performance review. Administrative Staff A stated that the facility completed the employees' yearly performance reviews in November. Administrative Staff A stated that the five nursing staff had not received a yearly performance review in the past 12 months. The facility was unable to provide a policy related required yearly performance reviews.

The facility identified a census of 95 residents. The facility identified three residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP and personal protective equipment (PPE) for Resident (R) 36 and R52. The facility additionally failed to cover linens in the hallways and further failed to ensure the dirty laundry sorting area was equipped with a gown and mask. This defiant practice placed the residents at risk of infectious diseases. Findings included: - On 04/28/25 at 07:15 AM, an inspection of R36's room revealed no EBP indicator signage to inform visitors or staff. On 04/28/25 at 07:15 AM, an inspection of R52's room revealed no EBP indicator signage to inform visitors or staff. On 04/28/25 at 7:42 AM, Laundry Staff U pushed a cart of blankets down Hall B; the cart was not covered. On 04/30/25 at 08:10 AM, a tour of the laundry room revealed no PPE to sort dirty laundry. On 04/30/25 at 08:15 AM, Laundry Staff U stated he had not been at the facility very long. He stated he was unaware he would need PPE to sort dirty laundry. Laundry Staff U stated he did know he needed to have the linen covered in the hallways. He stated the smaller carts did not have covers, and he uses a sheet to cover the linens when in the hallway. On 04/30/25 at 11:25 AM, Certified Nurse's Aide (CNA) O stated she would ask the charge nurse who was on EHB (enhanced barrier) and what PPE should be worn. On 04/30/25 at 11:40 AM, Licensed Nurse (LN) G stated that any resident with an open wound should have EHB precautions. She stated that there would usually be an orange dot by the resident's name card on the door if the resident was on EHB precautions. On 04/30/25 at 12:17 PM, Administrative Nurse E stated the resident's room would have an orange dot on the resident's name plate outside the room. She stated it was through the training of staff that the staff would know what PPE staff were required to wear during resident tasks. Administrative Nurse E stated there was no signage inside the resident's room. The facility's Infection Tracking and Trending policy, dated 11/17, documented an infection control program would be utilized to investigate, control, and prevent infections in the facility. The facility's infection prevention and control program prevents, identifies, investigates, and controls infections and communicable diseases for all residents and staff, providing services under a contractual agreement and following accepted national standards.

The facility reported a census of 95 residents. The facility identified 85 residents who had requested to be full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest). 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 these residents who desired CPR if needed at risk for inadequate resuscitative measures. Findings included: - On [DATE] at 12:32 PM, CPR verification wass requested for the following dates and shifts: day shift on [DATE] and [DATE], evening shift on [DATE] and [DATE], and night shift on [DATE] and [DATE]. The facility was unable to provide verification of CPR certification for staff members on the evening and night shifts as requested. On [DATE] at 02:35 PM, Administrative Staff A stated he was unable to locate CPR certification for staff who had worked on the dates of the evening and night shifts that were requested. Administrative Staff A stated the facility did not have a system in place to track staff CPR certification. The facility's [NAME]-Pulmonary Resuscitation (CPR) policy, last revised [DATE], documented that emergency basic life support would be provided when needed, including cardio-pulmonary resuscitation (CPR) in accordance with physician orders and the resident's advance directives. Basic life support and cardio-pulmonary resuscitation would be initiated for any resident whose advance directive indicates them to be a full code. This would be continued until the arrival of emergency medical personnel.

The facility identified a census of 95 residents. The sample included 19 residents, with two medication rooms. Based on observation, record review, and interviews, the facility failed to properly label and store medications in the medication room, and further failed to secure medication carts containing residents' insulin (a hormone that lowers the level of glucose in the blood) pens and needles. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On 04/28/25 at 07:05 AM, a medication cart sitting in the dining room was unlocked, and the medication cart had an insulin pen laid on top of the cart. The medication cart had a box that included an insulin pen, needles, and a glucose monitor in a plastic box. The medication cart revealed several residents' insulin pens and needles. On 04/30/25 at 8:15 AM, the medication refrigerator contained an opened, undated vial of tuberculin test serum(method of determining whether a person is infected ). On 04/30/25 at 10:55 AM, the medication cart in the commons area was unsecured. Administrative Nurse E secured the medication cart. On 04/28/25 at 07:07 AM, Licensed Nurse (LN) H stated medication carts should never be left unattended. She stated insulin pens and needles should be locked in the cart when staff are not within eyesight of the medication cart. On 04/30/25 at 12:17 PM, Administrative Nurse E stated medication carts should be locked and never left unattended. She stated it is the policy of the facility to keep keys on person at all times, and keep carts locked. The facility's Storage of Medication and Biologicals dated 03/11 documented medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

The facility identified a census of 96 residents. The sample included 19 residents, with four residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Residents (R) 45's and R10 post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R45 and R10 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R45's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), nicotine dependence on cigarettes, posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R45 had an active diagnosis of PTSD. The MDS documented R45 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS documented R2 had received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of drugs that calm and relax people), antidepressant (a class of medications used to treat mood disorders), and a hypnotic (a class of medications used to induce sleep). R45's Psychosocial Wellbeing Care Area Assessment (CAA) dated 05/27/24 documented R45 was a new admit to the facility. The CAA documented R45 would be encouraged to put up personal belongings and items in her room. The CAA documented R45 would be encouraged to participate in activities and meals to meet and begin to form friendships. R45's Care Plan dated 05/23/2024 documented R45 would manage her symptoms of anxiety to be able to function in day-to-day situations. The plan of care documented R45 would no longer have control over all aspects of my life. Staff were to include R45 and her guardian in all care planning and decision-making. The plan of care documented R45 would keep her routine the same to help me manage her anxiety. R45's plan of care documented she took medication for my anxiety, staff were to monitor my medication for effectiveness, side effects, and adverse reactions. The plan of care for R45 documented if she began to show signs of anxiety, such as having trouble going to sleep, decreased appetite, weight loss, crying, increased agitation, and disruptive behavior, staff were directed to notify the physician. The plan of care lacked what trauma had caused her PTSD or what might have caused her to be retraumatized. The plan of care lacked personalized interventions to assist her with coping with her PTSD. R45's EMR under the Assessment tab revealed the following: Primary Care PTSD Screen dated 05/20/24 documented no PTSD issues reported. On 04/28/25 at 08:22 AM, R45 sat in her chair in her room, looking at her hats. On 04/28/25 at 08:25 AM, R45 stated she did have some things in her past she worried about, but her sisters have had more to worry about. On 04/30/25 at 11:25 AM, Certified Nurse Aide (CNA) O stated that if a resident had PTSD, she would know what the triggers are, either by asking her nurse or looking in the resident's care plan. CNA O stated she had access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 04/30/25 at 11:40 AM, Licensed Nurse (LN) G stated residents with a diagnosis of PTSD have a care plan, which states what their triggers were and what the staff should do to deescalate those triggers. LN G stated that all nursing staff have access to the plan of care. On 04/30/25 at 12:17 PM, Administrative Nurse E stated that with most of the residents who had PTSD, the staff communicated by word of mouth. Administrative Nurse E stated she expected the care plan to address triggers for residents with PTSD. The facility's Trauma Informed Care policy, undated, documented the facility would ensure residents who were trauma survivors receive culturally competent, trauma-informed care, accounting for the resident's experiences and preferences. Trauma-informed care recognizes the effects of physical, psychological, and emotional trauma on the overall well-being of residents. Trauma can result from a variety of experiences that may occur at any time throughout the resident's lifetime. 41713 - R10's Electronic Medical Record (EMR) recorded diagnoses of schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language, and communication, and fragmentation of thought) disorder, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and posttraumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). R10's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R10 was independent with his functional abilities and activities of daily living (ADL). R10 had a diagnosis of PTSD. R10's Psychotropic Drug Use Care Area Assessment (CAA) dated 06/28/25 documented he took psychotropic (alters mood or thought) medications to manage his moods and behaviors related to his mental health disorders. R10 would be care planned for the management of psychotropic medications as per order and standards of practice. R10's Psychosocial Care Plan was revised on 11/16/22, directed staff that he had a history of PTSD but had not suffered from many side effects lately. Staff were directed that he could be easily startled or feel detached from others. Staff were directed that if he displayed any of those symptoms or did not seem himself, to talk to him to see if he needed help coping. R10's care plan lacked staff direction that addressed his triggers or interventions to prevent further re-traumatization. R10's EMR Assessments tab documented Primary Care PTSD Screen- V2 completed on 10/27/21, 10/27/22, 10/23/23, and 11/12/24. These assessments lacked the specific trauma or possible triggers for R10. On 04/29/25 at 10:26 PM, R10 and a couple other male residents met to talk about resident council. R10 had no behaviors noted. On 04/30/25 at 11:40 AM, Licensed Nurse (LN) G stated that R10's care plan should reflect the cause of his PTSD and what might trigger it, so staff would be aware and monitor him for possible re-traumatization. On 04/30/25 at 12:19 PM, Administrative Nurse E stated that staff should be made aware of what R10's trauma was and possible triggers that could cause re-traumatization. Administrative Nurse E stated R10's care plan would be updated to reflect that information. The facility policy Trauma Informed Care was updated 11/09/21 and documented that the facility would ensure residents who were trauma survivors received culturally competent, trauma-informed care, accounting for the resident's experiences and preferences. Trauma-informed care recognized the effects of physical, psychological, and emotional trauma on the overall well-being of residents. Trauma could result from a variety of experiences that may occur at any time throughout the resident's lifetime. A screening would be completed on residents to identify any potential experiences that may impact care needs. The Post-Traumatic Stress Disorder (PTSD) Screening would be completed during the lookback period for the admission, significant change, and annual MDS.

The facility identified a census of 95 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to recognize or address the potential for developing a pressure ulcer. The facility failed to identify the risks, develop a plan of care, and implement interventions when Resident (R) 36 developed at Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R36 at risk for pain, complications, and possible infection associated with pressure ulcers. Findings included: - R36's Electronic Medical Record (EMR) documented diagnoses of type 2 diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), seborrheic dermatitis (chronic skin condition characterized by inflammation and scaling), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R36's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. R36 was independent with most functional abilities and required set-up for eating, showering, oral hygiene, and personal hygiene. R36 was at risk for pressure ulcer development. A formal assessment, the Braden Scale (a risk assessment tool used to predict the risk of developing pressure injuries), was used. R36 had a pressure-reducing device for his bed. R36's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 10/04/24 documented he had the potential to develop altered skin integrity and pressure ulcers/injuries related to his diabetes diagnosis. R36's Care Plan was initiated on 09/19/24, directed staff that he was independent with most of his activities of daily living (ADL) care, and was able to ask for assistance as needed. R36's care plan lacked a care area for skin care and pressure ulcer prevention. R36's Orders tab of the EMR documented a physician's order dated 04/16/25 for Blastx (a wound gel, intended for the management of various wounds) with collagen (protein-derived wound treatment used to promote wound healing) every day shift for the wound on the right upper buttock. Cleanse the right upper buttock wounds with cleanser, apply Blastx with collagen, and cover with a foam dressing. Monitor the dressing each shift. R36's EMR documented in the Orders tab a physician's phone order dated 04/21/25 for active liquid protein two times a day for the wound. Given 30 ml and discontinue when wounds heal. R36's Braden Scale for Predicting Pressure Sore Risk assessment, dated 04/04/24, documented a risk score of 20, which indicated a low risk of pressure ulcer development. R36's Weekly Wound Assessment in the EMR dated 04/15/25 documented the first observation of a pressure wound, Stage 2, to the upper right buttock proximal to the torso. The area was pink and moist with scant drainage. The wound measured 1.2 centimeters (cm) in length by 0.3 cm in width, and 0.1 cm in depth. The physician and the resident's representative were notified. A new order placed to cleanse the wound, apply Blastx with collagen, cover with a foam dressing, and change daily. R36's Progress Notes tab of the EMR documented a Communication Note dated 04/14/25 at 08:38 PM, that during the evening treatments, two open areas were located on the right buttocks near the intergluteal cleft (groove that lies between the two gluteal regions). The area was cleansed with wound cleanser, patted dry, and an Opti foam (a soft, absorbent foam dressing) dressing was applied. On 04/15/25 at 03:28 PM the Skin/Wound Note, under the Progress Notes, tab of the EMR, documented that it had been noted R36 had two open areas on his upper right buttock. R36's son was contacted and informed of the areas. A pressure-relieving cushion was placed in his recliner, and he was educated on hygiene and to ask for assistance with peri care after he has a bowel movement. On 04/16/25at 03:12 PM the Nutrition/Dietary Note, under the Progress Notes, in the EMR documented the dietitian had been notified of the two open areas to the right upper buttock. It might be beneficial to offer Pro-stat (a ready-to-drink concentrated liquid protein supplement) 30 milliliters (ml) twice daily until the areas heal. On 04/29/25 at 11:50 AM, R36 sat in the dining room with other residents waiting for lunch. On 04/30/25 at 11:25 AM, Certified Nurse Aide (CNA) O stated that a resident should have something on the care plan regarding skin care and wound prevention. CNA O stated she would report any new skin concerns to the nurse when noticed during bathing. CNA O stated R36 should have something on his care plan about his wound care, but could not say for certain that it did. On 04/30/25 at 11:40 AM, Licensed Nurse (LN) G stated that R36's care plan should have had an intervention in place for generic skin care to prevent wound development. LN G stated R36's care plan should have been updated with interventions after he developed the pressure area. On 04/30/25 at 12:17 PM, Administrative Nurse E stated that all residents got a weekly skin check. Administrative Nurse E stated that the aides looked over the resident's skin during bathing and should be reporting any new skin issues. Administrative Nurse E stated that each resident should have a care area that addressed the skin and have interventions in place to decrease the chance of a pressure area developing. Administrative Nurse E stated R36's care plan should have been updated to reflect interventions for further pressure ulcer development. The facility's Wound Assessment, Prevention and Treatment policy, dated 11/28/17, documented a resident who entered the facility without pressure ulcers would not develop them unless the individual's clinical condition demonstrated that they were unavoidable. Residents would be evaluated and monitored to prevent the development of pressure ulcers and promote rapid healing of any pressure ulcers that were present. Pressure ulcer risk prevention would be accomplished by completion of the Braden Pressure Ulcer Risk Assessment; identifying and evaluating the risk factors and changes in resident condition; identifying and evaluating factors that can be removed or modified; implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors; and monitoring the impact of the interventions for effectiveness and modifying them as appropriate. A comprehensive, individualized care plan would be developed to address the prevention of the development of pressure ulcers, management of risk factors, and treatment strategies for residents with pressure ulcers. The strategies would be developed through collaboration between the resident, his/her representative, the physician, the dietitian, and the clinical staff.

The facility identified a census of 95 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to develop a plan of care, and implement skin care interventions for Resident (R) 36, who developed at Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R36 at risk for pain, complications, and possible infection associated with pressure ulcers. Findings included: - R36's Electronic Medical Record (EMR) documented diagnoses of type 2 diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), seborrheic dermatitis (chronic skin condition characterized by inflammation and scaling), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R36's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. R36 was independent with most functional abilities and required set-up for eating, showering, oral hygiene, and personal hygiene. R36 was at risk for pressure ulcer development. A formal assessment, the Braden Scale (a risk assessment tool used to predict the risk of developing pressure injuries), was used. R36 had a pressure-reducing device for his bed. R36's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 10/04/24 documented he had the potential to develop altered skin integrity and pressure ulcers/injuries related to his diabetes diagnosis. R36's Care Plan initiated on 09/19/24 directed staff that he was independent with most of his activities of daily living (ADL) care, and was able to ask for assistance as needed. R36's care plan lacked a care area for skin care and pressure ulcer prevention. The care plan was not revised with interventions after the development of his Stage 2 pressure ulcer. R36's Orders tab of the EMR documented a physician's order dated 04/16/25 for Blastx (a wound gel, intended for the management of various wounds) with collagen (protein-derived wound treatment used to promote wound healing) every day shift for the wound on the right upper buttock. Cleanse the right upper buttock wounds with cleanser, apply Blastx with collagen, and cover with a foam dressing. Monitor the dressing each shift. R36's EMR documented in the Orders tab a physician's phone order dated 04/21/25 for active liquid protein two times a day for the wound. Given 30 ml and discontinue when wounds heal. R36's Braden Scale for Predicting Pressure Sore Risk assessment, dated 04/04/24, documented a risk score of 20, which indicated a low risk of pressure ulcer development. R36's Weekly Wound Assessment in the EMR dated 04/15/25 documented the first observation of a pressure wound, Stage 2, to the upper right buttock proximal (nearer to a point of reference or attachment) on the torso. The area was pink and moist with scant drainage. The wound measured 1.2 centimeters (cm) in length by 0.3 cm in width, and 0.1 cm in depth. The physician and the resident's representative were notified. A new order placed to cleanse the wound, apply Blastx with collagen, cover with a foam dressing, and change daily. R36's Progress Notes tab of the EMR documented a Communication Note dated 04/14/25 at 08:38 PM, that during the evening treatments, two open areas were located on the right buttocks near the intergluteal cleft (groove that lies between the two gluteal (pertaining to the buttocks or buttocks muscles) regions). The area was cleansed with wound cleanser, patted dry, and an Opti foam (a soft, absorbent foam dressing) dressing was applied. On 04/15/25 at 03:28 PM the Skin/Wound Note under the Progress Notes tab of the EMR documented that it had been noted R36 had two open areas on his upper right buttock. R36's family member was contacted and informed of the areas. A pressure-relieving cushion was placed in his recliner, and he was educated on hygiene and to ask for assistance with peri care after he has a bowel movement. On 04/16/25at 03:12 PM the Nutrition/Dietary Note, under the Progress Notes, in the EMR documented the dietitian had been notified of the two open areas to the right upper buttock. It might be beneficial to offer Pro-stat (a ready-to-drink concentrated liquid protein supplement) 30 milliliters (ml) twice daily until the areas healed. On 04/29/25 at 11:50 AM, R36 sat in the dining room with other residents waiting for lunch. On 04/30/25 at 11:25 AM, Certified Nurse Aide (CNA) O stated that a resident should have something on the care plan regarding skin care and wound prevention. CNA O stated she would report any new skin concerns to the nurse when noticed during bathing. CNA O stated R36 should have something on his care plan about his wound care, but could not say for certain that it did. On 04/30/25 at 11:40 AM, Licensed Nurse (LN) G stated that R36's care plan should have had an intervention in place for generic skin care to prevent wound development. LN G stated R36's care plan should have been updated with interventions after he developed the pressure area. On 04/30/25 at 12:17 PM, Administrative Nurse E stated that each resident should have a care area that addressed the skin and have interventions in place to decrease the chance of a pressure area developing. Administrative Nurse E stated R36's care plan should have been updated to reflect interventions to prevent further pressure ulcer development. The facility's Wound Assessment, Prevention and Treatment policy, dated 11/28/17, documented a resident who entered the facility without pressure ulcers would not develop them unless the individual's clinical condition demonstrated that they were unavoidable. Residents would be evaluated and monitored to prevent the development of pressure ulcers and promote rapid healing of any pressure ulcers that were present. Pressure ulcer risk prevention would be accomplished by completion of the Braden Pressure Ulcer Risk Assessment; identifying and evaluating the risk factors and changes in resident condition; identifying and evaluating factors that can be removed or modified; implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors; and monitoring the impact of the interventions for effectiveness and modifying them as appropriate. A comprehensive, individualized care plan would be developed to address the prevention of the development of pressure ulcers, management of risk factors, and treatment strategies for residents with pressure ulcers. The strategies would be developed through collaboration between the resident, his/her representative, the physician, the dietitian, and the clinical staff.

The facility had a census of 87 residents. Based on observation, interview, and record review the facility failed to employ a full time certified dietary manager for the 87 residents who resided in the facility and received meals from the facility kitchen. This deficient practice placed the 87 residents at risk for receiving inadequate nutrition. Findings included: - On 08/09/23 at 08:32 AM, observation revealed Dietary Staff (DS) BB supervising staff in the kitchen. DS BB stated the facility did not have a Dietary Manager and the administrator and director of nursing supervised the dietary department. On 08/14/23 at 09:34 AM, Administrative Staff A verified the facility did not have a certified dietary manager since the last one quit. He stated the Registered Dietician, who checked the kitchen, came to the facility monthly and the director of nursing placed the food orders with vendors. The facility's Director of Dining Services Roles and Responsibilities policy, dated 04/03/20, stated the Director of Dining Services meets one of the following requirements: is a qualified dietician; is a certified dietary manager; or has an associate's or higher degree in food service management from an accredited institution of higher learning. The Director of Dining Services is a full-time employee and responsible for the day-to-day functions of the dining services. The facility failed to employ a full time certified dietary manager for the 87 residents who resided in the facility and received meals from the facility kitchen, placing the 87 residents at risk for receiving inadequate nutrition.

The facility had a census of 87 residents. The sample included 18 residents. Based on record review, and interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, for the 87 residents who resided in the facility. This placed the facility and residents at risk for inadequate nurse guidance and decreased quality of care. Findings included: - Review of the Registered Nursing Staffing Schedule for May, June and September 2022, recorded the facility lacked a RN for eight consecutive hours on the following dates: 05/22/22, 05/30/22, 06/04/22, 06/05/22, 06/18/22, 06/19/22 and 09/05/22. On 08/10/23 at 08:50 AM, Administrative Nurse D verified the facility did not have a RN in the building or working as a charge nurse for the above documented dates. The facility's Nursing Services policy, dated 04/17/18 recorded the facility would provide nursing services to maintain resident safety and attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The policy recorded a registered nurse (RN) would be present in the facility for 8 consecutive hours a day. The facility failed to provide a RN for the 87 residents who resided in the facility for at least eight consecutive hours a day, seven days a week, placing the facility and residents at risk for inadequate nurse guidance and decreased quality of care.

The facility had a census of 87 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident(R)41, R53, R65, R72, R55 and R56s' insulin (hormone which allows cells throughout the body to uptake glucose) flex pens and non-insulin flex pens with the date opened and expiration date and failed to discard expired stock medication on one medication cart. These deficient practices placed the affected resident at risk for ineffective medications. Findings included: - On 08/09/23 at 08:30 AM, observation of Hall D medication cart revealed the following: Magnesium Oxide (antacid or used to treat low magnesium) 400 milligrams (mg) 100 tablets expired 06/2023. On 08/09/23 at 09:15AM, observation of the Hall A and B treatment cart revealed the following: R41's Ozempic (insulin medication used to help the body make and release insulin) flex pen lacked an open date and expiration date. R53's Victozia (non-insulin injection used to lower blood sugar) flex pen lacked an open date and expiration date. R65's Novolog (rapid acting insulin) flex pen lacked an open date and expiration date. R72's Levemir (long-acting insulin) flex pen lacked an open date and expiration date. R55's Novolog lacked an open date and expiration date. R56's Novolog flex pen lacked an open date and expiration date. On 08/09/23 at 09:45 AM, Licensed Nurse (LN) G verified the nurses were to date the flex pens when opened and discard the expired insulin and discard expired medications. On 08/10/23 at 8:45 AM, Administrative Nurse D verified the nurses should label and date the flex pens with the resident's name and discard expired pens and discard expired medications. The facility's Storage of Medications policy, undated, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall discard outdated, contaminated, or deteriorated medications. The facility failed to label, and date the resident's flex pens, with date opened and expiration dates and failed to dispose of expired medication placing the residents at risk for ineffective medication.

The facility had a census of 87 residents. The sample included 18 residents with Resident (R) 14 reviewed for Hospice services. Based on observation, record review and interview, the facility failed to ensure R14 had a hospice plan of care in place and available for facility staff direction on hospice provided care. This deficient practice placed R14 at risk for unmet hospice care/services and a decline in his well-being. Findings included: - R14's Electronic Medical Record (EMR) documented he had diagnoses of kidney failure (severe failure of kidneys to function), neurogenic bladder (lack of bladder control due to a disease process), and schizophrenia (serious mental condition). R14's Significant Change Minimum Data Set(MDS), dated [DATE], documented the resident received hospice services. Review of the EMR documented hospice services for end stage kidney failure started 07/13/23. Further review of the EMR lacked a facility hospice care plan which contained the hospice contact information, frequency of visits, supplies provided, and medications covered. On 08/10/23 at 11:15AM, observation revealed R14 seated in a wheelchair in the front lobby. On 08/10/23 at 12:45PM, Administrative Nurse E verified R14 lacked a facility hospice care plan. On 08/15/23 at 08:10AM, Administrative Nurse D verified R14 lacked a facility hospice care plan for coordination of hospice services. The facility's Hospice/End of Life policy, dated 11/2017, stated the facility will collaborate with hospice on a plan of care to be developed jointly between the hospice and facility. The facility failed to coordinate Hospcie cares for R14 who received hospice services. This deficient practice placed R14 at risk for unmet hospice care/services and a decline in his well-being.

The facility had a census of 87 residents. The sample included 18 residents of which Resident (R) 14 was reviewed for dignity. Based on observation, record review and interview the facility failed to promote dignity for R14 who had a urinary catheter (a tube in the bladder to drain urine). This placed the resident at risk for embarrassment and an undignified experience. Findings included: - R14's Electronic Medical Record (EMR) documented he had diagnoses of kidney failure (severe failure of kidneys to function), neurogenic bladder (lack of bladder control due to a disease process), and schizophrenia (serious mental condition). R14's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a urinary catheter. The urinary catheter Care Area Assessment (CAA), dated 07/20/23, documented the resident had end stage kidney failure and neurogenic bladder and required the use of a urinary catheter. The updated Urinary Catheter care plan, dated 07/12/23, instructed staff to cover the urinary drainage bag with a cover. On 08/09/23 at 1:00PM, observation revealed R14 sat in a wheelchair in the front lobby. Further observation revealed the uncovered urinary drainage bag attached to the side of the wheelchair with urine visible in the bag. On 08/10/23 at 11:15AM, observation revealed R14 sat in a wheelchair on C hallway. Further observation revealed the uncovered urinary drainage bag attached to the side of the wheelchair, with urine visible in the bag. On 08/14/23 at 02:10PM, observation revealed R14 sat in a wheelchair coming in from the outside patio. Further observation revealed the uncovered urinary drainage bag attached to the side of the wheelchair with urine visible in the bag. On 08/14/23 at 02:15PM, Licensed Nurse (LN) H verified the urinary drainage bag uncovered on the side R14's wheelchair. LN H verified the bag should be in a cover. On 08/15/23 at 09:00AM, Administrative Nurse D verified R14's urinary drainage bag should be in a covered bag. The facility's Dignity Resident Rights policy, dated 04/27/18, stated residents' have a right to a dignified existence. The facility's Catheter Care policy, dated 04/27/18, stated residents' with a urinary catheter are to have the urinary bag covered when up and when in bed to provide dignity. The facility failed to cover the urinary drainage bag for R14, placing the resident at risk for embarrassment and an undignified experience.

The facility had a census of 87 residents. The sample included 18 residents with one reviewed for hospitalization . Based on observation, interview, and record review the facility failed to provide a written notice of bed hold for Resident (R) 11 when he was hospitalized . This placed the resident at risk of being unable to return to the facility and in his prior room. Findings included: - R11's Electronic Medical Record documented diagnoses of heart disease and high blood pressure. The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R11 was independent with most activities of daily living and received pain medication. The Cardiac Care Plan, dated 07/08/23 directed staff to provide cardiac and respiratory medications or treatments as ordered, including Nitrostat (a medication that dilates blood vessels) for chest pain, as prescribed by his physician and observe for medication effectiveness. The Progress Note, dated 06/10/23 at 06:16 AM, documented staff notified the physician of R11's continued complaint of chest pain and requested to R11 to the emergency room (ER). The EMR documented R11 was hospitalized from 06/10/23 to 06/12/23 due to chest pain. R11's clinical record lacked evidence the facility gave R11 a bed hold form as required. On 08/15/23 at 07:35 AM, observation revealed Certified Medication Aide (CMA) R knocked on R11's door, took his pulse and administered medications. R11 took them whole, in applesauce, without problems. On 08/15/23 at 08:59 AM, Administrative Nurse D stated she thought the resident was only out for observation not in-patient hospitalization and verified the facility had not provided the resident a bed hold notice. The facility's Bed Hold Notice policy, dated 11/28/17, stated a written notice which specified the duration of the bed hold policy would be provided at the time of the transfer of a resident for hospitalization or therapeutic leave. The policy stated Medicaid allows up to 10 days per confinement for reservation of a bed when a nursing facility resident leaves and is admitted to an acute care facility. The facility failed to provide a written notice of bed hold for R11 when he was hospitalized , placing R11 at risk to not be placed in his prior room.

The facility had a census of 87 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain activities of daily living (ADLs) for two sampled residents, Resident (R)71 and R78. This placed the residents at risk for poor hygiene and decline in ADLs. Findings included: - R71's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition, wandering, and required extensive assistance of one staff for transfers, dressing, personal hygiene, and bathing. The resident had range of motion impairment to upper and lower extremities of one side and used a wheelchair for mobility. The MDS further documented it was very important for R71 to choose between a bath, shower, bed bath, or sponge bath. The ADL Care Area Assessment (CAA), dated 12/13/21, documented the resident had [CONDITION(S)] related to a stroke and had ADL deficits which required assistance of staff. The Care Plan, dated 12/22/21, documented R71 had [CONDITION(S)] affecting his dominant side, needed assistance with most ADL cares, needed increased toileting plan to include before and after meals or every two to three hours while awake due to receiving a diuretic (medication to promote the formation and excretion of urine). The Care Plan documented R71 required assistance for cutting up food, used large handled utensils, and directed staff to provide non-medication pain relief measures such as positioning and warm shower. The resident's bathing choice was Monday, Wednesday, and Friday. The Restorative Progress Note dated 01/04/22, documented R71 required limited to extensive assistance with ADL's, wore adult incontinence briefs, and was checked and changed every two hours and as needed. The MDS Progress Note dated 12/10/21, documented R71 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The note further documented the resident's regular diet was served on a divided plate with large handled utensils and he ate at the restorative table for monitoring and assistance with cutting his foods. The note also documented the need of one staff for personal hygiene, dressing, and showering. Review of the Bathing Record for R71 revealed the resident had no recorded bathing from 11/01/21 until (resident refused on 11/05/21) 11/17/21 (17 days). Further review of December 21 through January 10, 22 lacked documentation the resident had received or refused bathing (54 days). On 01/05/21 at 08:34 AM, observation revealed R71 sat in the dining room, in a wheelchair, and received medications from the nurse. On 01/05/21 at 11:52 AM, observation revealed the resident remained in the dining room, and had not been removed or offered toileting assistance. Meal service had started and he waited to be served his noon meal. On 01/05/21 at 12:42 PM R71 received his meal in a divided plate with large handled utensils. The plate contained a meat stuffed green pepper. R71 stabbed the meal item with a fork, and ate the meat off the fork, getting food on his beard. R71 tried to wipe his beard/face with his right hand by lifting the impaired right hand with his left hand. Observation revealed staff did not offer or assist R71 with cutting the meat and pepper into bite size pieces. On 01/05/21 at 02:04 PM, continued observation revealed the resident had remained in the dining room and staff took the resident from the dining room to his room for toileting. The resident had not been offered toileting for over six hours. On 01/10/21 at 12:43 PM R71 sat in the dining room at the usual restorative table. Staff served him manicotti (large pasta noodle stuffed with cheeses) on a divided plate. R71 was provided regular utensils, not large handled as directed in his plan of care. Observation revealed a long piece of noodle hung from R71's mouth as he ate since staff had not cut the meal item into bite size pieces. On 01/10/22 at 01:01 PM, Certified Medication Aide (CMA) S stated staff charted the baths in the electronic record. CMA S reported refusals should be recorded in the electronic record also. On 01/10/22 at 01:55 PM, Administrative Nurse D stated R71 should have been toileted per his plan of care. Administrative Nurse D further stated staff should have cut R71's food into bite size pieces, and provided large handled silverware. Administrative Nurse D said staff should bathe the resident per his bathing preferences. Administrative Nurse D verified the lack of documentation R71 had received bathing between 11/17/21 to 01/10/22. The facility's Activities of Daily Living policy, dated 04/27/18, recorded the facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choices for the following activities of daily living: Hygiene, bathing, dressing, grooming, elimination, and toileting. The policy further recorded residents who are not able to carry out activities of daily living and are dependent on staff will receive the necessary services to maintain good nutrition, grooming and personal hygiene. The facility failed to provide R71 with consistent bathing, toileting, and eating assistance which placed the resident at risk for further decline in ADLs. - The Electronic Medical Record (EMR) for R78 recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R78's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition, required supervision with one staff assistance for personal hygiene, and dependent upon one staff for bathing. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 09/16/21, documented R78 was mostly independent for ADL care, however, he had days when he required supervision or limited assistance to complete a task. The ADL Care Plan, dated 12/28/21, documented R78 required assistance of one staff member for nail care and shaving, had diabetes and required a licensed nurse or podiatrist (a person who treats the feet and their ailments) to perform nail care. On 01/04/21 at 10:56 AM, observation revealed R78 sat in the commons area without shoes and socks. Further observation revealed R78's toenails were longer than the end of his toes, thick, and brown in color. On 01/05/21 at 09:05 AM, observation revealed R78 with Certified Nurse Aide (CNA) M and R78 stated his shoes were making his big toe hurt. Continued observation revealed CNA M did not take off the resident's shoe to see if there was injury to the resident's toe nor did CNA M tell a nurse the resident complained his toe hurt. On 01/05/21 at 01:40 PM observation revealed R78's fingernails were longer than the tips of his fingers, jagged, and had brown debris under them. On 01/05/22 at 01:49 PM, R78 stated he had not had nail care in a very long time and didn't know if his toenails were causing his shoes to be too little and hurt his feet. On 01/05/22 at 09:30 AM, CNA M verified she had not taken the resident's shoes off to check to see if his big toe was red and verified she did not tell a nurse the resident's toes were hurting. On 01/05/22 at 01:49 PM, Licensed Nurse (LN) G stated the podiatrist had not been at the facility in a long time and stated all nurses can do the resident's nail care, they just are busy and do not have time because the resident's toenails are thick and hard to cut. On 01/06/22 at 09:37 AM, Administrative Nurse D stated the facility had a nurse that provided all the resident's nail care and would look into getting R78's fingernails and toenails cut. Administrative Nurse D further stated the nurse would look at the resident's toes to make sure there was not any injury. The facility's Activities of Daily Living policy, dated 04/27/18, documented the facility would provide the necessary care and services to ensure a resident's abilities in the activities of daily living did not diminish unless circumstances of the individuals clinical condition demonstrated such diminution and was unavoidable. The policy further stated, residents would be given appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living and any resident who was unable to carry out activities of daily living and are dependent on staff would receive the necessary care and services to maintain good nutrition, grooming, personal and oral hygiene. The facility failed to provide nail care for R78, placing him at risk for poor hygiene.

The facility had a census of 101 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to store and prepare food in accordance with professional standards for food service safety in one of one kitchen. Staff failed to store three different kinds of thawing meat in separate pans in a refrigerator, staff failed to label and date food in three refrigerators and one freezer, and complete refrigerator and freezer temperature logs. Staff failed to discard outdated sanitizer test strips and clean the microwave and a shelf above the grill. Findings included: - On [DATE] at 10:33 AM, observation revealed during the initial tour of the kitchen, the following: Refrigerator #1 had a 15 pound (lb) box of bacon, 11.35 lb box of roasted seasoned turkey thighs, and a 20 lb box of diced beef tips and gravy thawing on the bottom shelf, stacked on top of each other in the same pan. Refrigerator #2 had an unsealed, undated open plastic bag of sliced tomatoes and sliced cucumbers, and an unlabeled, undated large bowl of cream cheese frosting. Freezer #5 had an unlabeled, undated plastic bag of French toast sticks and two plastic bags of chocolate chip cookies. The temperature logs from [DATE] to [DATE] had the following missing documentation: Freezer #1 had four missing afternoon temperatures. Freezer #3 had five missing afternoon temperatures. Freezer #4 had five missing afternoon temperatures. Refrigerator #1 had six missing afternoon temperatures. Refrigerator #2 had two missing afternoon temperatures. Refrigerator #3 had five missing afternoon refrigerator temperatures. On [DATE] at 10:17 AM, observation revealed, during follow up to the kitchen the following findings: The snack refrigerator in a locked room off the kitchen had a 17 ounce (oz) bowl labeled with a resident's name with expiration date [DATE], a four oz jar of strawberry jam with expiration date [DATE], and a 16 oz bottle of ranch dressing with expiration date [DATE]. Two 50 count sanitizer test strips with expiration date ,[DATE], and one with expiration date ,[DATE]. A microwave with an area of chipped paint, approximately 12 inches (in) by one in, in the front and numerous other sizes of chipped paint inside the microwave. The microwave had numerous sized food particles on inside top and bottom. A shelf above the grill, approximately two feet by eight in with fuzzy particles all along the edge. On [DATE] at 10:33 AM, Dietary Aide (DA) BB verified the above findings on initial tour, stated the boxes of bacon, roasted seasoned turkey thighs, and diced beef tips and gravy should not be left to thaw stacked on top of each other. DA BB stated the sliced tomatoes, sliced cucumbers, bowl of cream cheese frosting, French toast, and plastic bags of chocolate chip cookies should be labeled and dated and discarded them all. On [DATE] at 10:33 AM, during follow up to the kitchen, Dietary Manager (DM) CC verified the missing refrigerator and freezer documentation, expired foods in the snack refrigerator, fuzzy particles on the shelf above the grill, and microwave chipped paint. DM CC stated staff should check the temperatures of the refrigerators and freezers twice a day and document them and discard food items when expired. The facility's Food Storage policy, dated [DATE], documented staff should label all food items. The label must include the name of the food and the date it was opened or prepared, to the date it should be sold, consumed or discarded. Staff should discard food that has passed the expiration date. The policy documented staff should check refrigerator temperatures regularly. The facility's Thawing Food policy, dated [DATE], documented all foods will be thawed in the refrigerator at 41 degrees or lower. The facility failed to store and prepare food in accordance with professional standards for food service safety, placing the 101 residents who received food from the facility kitchen at risk for food borne illness.

The facility had a census of 101 residents. The sample included 18 residents, with three reviewed for limited range of motion (ROM). Based on observation, record review, and interview, the facility failed to provide restorative services to maintain and/or prevent further decrease in range of motion for sampled Resident (R) 9. Findings Included: - R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact), inattention, and disorganized thinking. The MDS recorded R9 required extensive staff assistance with transfers, dressing, toileting, personal hygiene, unable to walk, limited ROM on one side of his body, and received no restorative services. The Activities of Daily Living (ADL) Care Plan, dated 11/21/19, recorded R9 had left side [MEDICAL CONDITION] (paralysis on one side of the body), a history of [MEDICAL CONDITION] (sudden disturbance in the brain causes uncontrolled body movements), and a history of falls related to impulsive behaviors and poor safety awareness. The care plan lacked documentation R9 received restorative services to maintain and/or prevent decrease in range of motion. The 02/03/2020 MDS Charting Note recorded R9 a fall risk, wore a safety helmet due to occasional [MEDICAL CONDITION], and continued to transfer himself without asking for staff assistance. On 02/17/2020 at 08:07 AM, observation revealed R9 wore a safety helmet, propelled his wheelchair with his right foot, and his left foot rested on the wheelchair foot pedal. On 02/17/2020 at 10:17 AM, Licensed Nurse (LN) G stated the facility did not have a restorative aide, and Certified Nurse Aides (CNAs) and activity staff provided restorative services. LN G stated R9 did not receive restorative services or participate in group exercises. On 02/19/2020 at 11:30 AM, Administrative Nurse D stated R9 had limited range of motion, at risk for falls, and should receive restorative services to maintain and/or prevent further decrease in range of motion. The facility's Restorative Nursing policy, dated (MONTH) (YEAR), directed staff to utilize a restorative nursing program to maintain, or improve a resident's mobility, ADL function, and ROM. The facility failed to provide restorative services to maintain and/or prevent further decrease in range of motion for R9, placing the resident at risk for falls and decreased ADL function.

The facility identified a census of 83 residents. The sample contained 12 residents. Based on observation, interviewe and record review the facility failed to ensure the resident environment remained free of accident hazards by properly storing hazardous chemicals -On 1/27/19 at 5:55 P.M., during initial tour observation revealed an unlocked door on the north end of hall C which contained the following: 1 gallon of Explorer Hight Solid Floor Finish, with product warning to avoid long exposure, wear appropriate protective equipment. This product caused skin irritation, eye irritation and to drink water if ingested and seek medical attention if discomfort. An interview on 1/27/19 at 6:05 PM with direct care staff Q revealed that the doors should automatically lock and the chemical should not be in the closet. An interview on 1/27/19 at 645 PM with administrative nursing staff D revealed the door should not be unlocked and the storage area should not have chemicals. An interview on 1/27/19 at 650 PM administrative staff A confirmed the door should be locked and the chemical should not be stored in it. He/she removed the chemical and tested the door for a secure lock. The facility failed to provide a policy regarding handling and storing hazardous chemicals. The facility failed to provide a safe environment for 21 cognitively impaired, independently mobile residents who reside in the building.

The facility identified a census of 83 residents. Based on observation and interview the facility failed to provide a safe sanitary environment. Findings included: -On 1/27/19 at 5:55 P.M., during initial tour observation revealed community bathroom between A and B hall to have a dirty toilet. On 1/27/19 at 5:58 P.M., during initial tour observation revealed a large splash mark on the wall between rooms [ROOM NUMBERS]. On 1/27/19 at 6:00 P.M. the floors throughout the facility were dirty with spilled drink marks, and dirt from foot traffic. On 1/28/19 at 9:18 A.M. the medication room down the D hallway had spill marks against the wall by trashcan. The sink was found to be uncleaned. During interview on 1/28/29 at 10:07 staff A stated the floor and bathrooms are cleaned daily. Our residents are very mobile and independent, and they tend to be messy with their drinks and by tracking in mud when coming back from smoking. During interview on 1/31/19 at 2:28 PM administrative staff A stated we clean on a regular basis, it is up to the staff and residents to let us know if there are big spills. Our residents are mobile and track in a lot of mud from smoking outside and they tend to spill their drinks. I was not aware of a big splatter in the medication room or between rooms [ROOM NUMBERS]. The facility failed to provide a safe sanitary environment for the residents who reside in the building.

The facility reported a census of 83 residents with 3 residents sampled and reviewed for accidents. The facility failed to provide adequate supervision for 1 (#1) of the 3 residents reviewed when the resident left the facility for extended periods of time and during inclement weather when the resident left the facility during a heat advisory and severe weather alert. The facility also failed to provide assistive devices (paper and pen) to assist the resident, with deaf mutism (unable to hear or speak) in communicating his/her needs while out of the facility. Furthermore, the resident left the faciity on [DATE], and was arrested by local police and incarcerated for criminal trespass and criminal damage to property. The resident remained incarcerated by local law enforcement on 6/30/16. The facility ' s failure to provide adequate supervision while the resident was out of the building placed the resident in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. in breathing) and deaf mutism (unable to hear or speak). The Annual MDS (minimum data set), dated 1/28/16, documented the resident's BIMS (brief interview for mental status score) of 99, indicating the resident was unable to complete the assessment. The staff assessment for mental status documented the resident's cognitive skills for daily decision making with modified independence with intact short and long term memory. The assessment identified signs of delirium including inattention (easily distracted and out of touch or difficulty following what was said) and disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching from subject to subject) both present and fluctuated. The assessment identified the resident had trouble concentrating on things present nearly every day. Staff identified the resident with behaviors including delusion (misconceptions or beliefs that are firmly held, contrary to reality) and other behaviors not directed toward others (examples include physical symptoms, pacing or rummaging) on 4-6 days out of 7. The resident did not exhibit wandering behaviors. The assessment identified independence in all ADL's (activities of daily living). The resident received antipsychotic, antianxiety, and antidepressant medications daily. The annual CAA (care area assessment), dated 1/28/16, for cognition documented the resident had [DIAGNOSES REDACTED]. According to staff, the resident was alert and oriented to name, location of his/her room, staff and peer faces. The resident presented with signs of inattention and disorganized thinking and communicated through gestures and writing with difficulty staying on topic. The resident answered best to yes or no questions. Because of the communication barrier and [DIAGNOSES REDACTED]. The CAA's for communication, psychosocial well-being, behavioral symptoms, and activities documented the same information as the cognition CAA, but also included because of the mental health [DIAGNOSES REDACTED]. The CAA for psychotropic medication use documented the resident received scheduled psychotropic medication for schizophrenia, depression and insomnia. Staff currently monitored for behaviors which included isolation, delusions and sleeplessness. The significant change MDS, dated [DATE], documented resident with a BIMS score of 15, indicating cognitively intact. The assessment identified no signs of delirium, mood symptoms or behaviors and documented the resident's current behavior had improved from the previous assessment. The assessment identified independence in all ADL's (activities of daily living) except personal hygiene, which required supervision. The resident received antipsychotic and antidepressant medications daily. The significant change CAA, dated 3/31/16, for cognition did not trigger. The CAA for communication documented [DIAGNOSES REDACTED]. The resident received scheduled prescribed medications which appeared to be effective. The resident was deaf and non-speaking and had hearing aids, which he/she chose not to wear all the time, and/or report that they were broke when they only needed new batteries. The resident communicated through writing and gestures, answered best to yes/no questions, but was able to make needs and wants known. The resident did not display any memory problems. The resident was independent with leaving the facility by him/herself and scored 15 on the BIMS assessment. There were no obvious signs of increased hearing abilities when wearing the hearing aids. Using written words, the resident was able to communicate his/her wants and needs effectively, but did continue to pursue his/her own thoughts independently and needed reminders to go through nursing for his/her appointments. The CAA for ADL's documented the same information but also included the resident was independent with ADL's with required occasional reminders to change a dirty shirt or comb his/her hair. The CAA for psychotropic medication use documented no change from the previous assessment CAA. The care plan, last updated 4/6/16, documented the resident, beginning 6/13/14, with cognitive loss and the potential for alterations in cognition due to his/her diagnoses. The resident had delusions and believed things about him/herself and his/her circumstances that were not true. The care plan directed staff if those things were not causing the resident to be agitated or upset, do not try to redirect as that could make the resident become upset. The resident walked up and down the halls and outside the building. The resident knew where he/she wanted to go and what he/she was doing, but tended to pace occasionally while thinking about his/her plans. The resident previously lived in the community, therefore would take it upon him/herself to seek out community assistance independently. Staff educated the resident that while living in the facility, he/she did not qualify for cash assistance/food cards, but the resident continued to seek these services to increase his/her income. The resident wore a wet towel on his/her head under his/her hat when it was warm outside. The care plan directed staff to get the resident a towel for this if the resident asked for one. The resident did not have a history of elopement (the resident left the facility without staff knowledge for approximately 48 hours from 3/9/16 to 3/11/16). The resident was able to demonstrate signing in/out when he/she left the facility and could do so independently but may not always do this, and staff educated the resident on the importance. The resident had a tendency to take him/herself to hospitals/clinics out in the community to make his/her own appointments, and staff educated the resident to let them know when he/she need something. The resident also knew the facility doctors could take care of any issues as well. The resident was familiar with the surrounding community and frequently took him/herself around town on his/her bike. The resident had a history of [REDACTED]. The resident was deaf, unable to speak, and usually communicated with sign language, gestures, lip reading, and writing. The resident can read so staff could write down on a whiteboard or piece of paper what they want to say to the resident if he/she had trouble understanding, or to help the resident tell staff what he/she needed. Staff educated the resident to drink plenty of fluids and take water with him/her while out walking in the community to stay hydrated, especially when the temperatures were warmer. The resident sometimes needed reminders to come out to meals. The care plan lacked interventions for the resident's unsafe wandering. The elopement risk assessment, dated 3/31/16, (22 days after the resident left the facility for 2 days without staff knowledge) documented the resident was alert and oriented and familiar with the community. The resident had in the past always made his/her own appointments while in the community. Staff encouraged the resident to allow nursing staff to assist him/her with making his/her appointments. The resident left the facility independently and knew he/she should sign in and out, but often chose not to. A review of the PASRR (Preadmission Screening and Resident Review: a federal requirement to help ensure that individuals with mental illness and intellectual/developmental disability were not inappropriately placed in nursing homes for long term care) determination letter from the Kansas Department for Aging and Disability Services (KDADS), dated 4/4/16, noted the resident benefited from staff's interventions to help decrease risk of wandering and the letter documented a group home or assisted living facility in the resident's care plan for discharge, so that he/she had a goal to transition back into the community. A review of the facility's incident report, dated 1/7/16 (incorrect date), recorded the resident left the faciity on [DATE] at 6:45 PM and rode a bike to the bus station to go to a metropolitan city without staff's knowledge and the facility did not notify law enforcement until 10:00 PM. The metropolitan city police department located the resident on 3/11/16 at 12:57 PM. The report also noted the resident went to the metropolitan city for dental services. The elopement risk assessment, dated 5/18/16, documented the resident did not have elopement behaviors observed or noted. The elopement risk assessment, dated 6/15/16, documented no elopement behaviors noted. The resident was able to leave the facility independently and to demonstrate facility policy by using the sign and out sheet when he/she left. There were no issues noted when out of the facility. The behavior risk assessment, dated 3/31/16, documented the resident paced and aimlessly wandered once or twice a week. On 3/11/16, the state agency received a facility reported complaint alleging the resident left the facility without staff knowledge on 3/9/16 at approximately 6:45 PM, took a bus to a metropolitan area approximately 65 miles away. The investigation revealed law enforcement found the resident at that metropolitan area on 3/11/16 at 12:57 PM. Review of the local police department report revealed they issued a missing person's report for the resident on 3/9/16 at 11:23 PM. The report documented that facility staff stated to the reporting officer they were not concerned about the subject; they were making the report for corporate to have. The report documented the metropolitan police department found the resident on 3/11/16 at 12:57 PM. The social serves note, dated 3/11/16 at 2:29 PM, documented the resident went to (the metropolitan area) to see the dentist and get his/her dentures fixed. The social worker explained to the resident he/she could get those serviced at the facility and he/she did not need to go to the metropolitan area for services. Social service staff explained the importance of communicating with staff his/her needs to get appointments set up and transportation arranged. The resident appeared to understand the information provided. On 6/13/16, the state agency received a second complaint at approximately 12:00 PM, the resident arrived at a location approximately 2.1 miles from the facility seeking food stamps and housing. Complainant R telephoned Administrative Staff A at the time who stated he/she did not know the resident ' s whereabouts as the resident walked all over town. The complainant requested that the facility pick up the resident from that location at that time. According to www.wunderground.com, on 6/3/16 at 11:53 AM, the temperature measured 81 degrees Fahrenheit with a heat index of 82.7 degrees Fahrenheit. Review of the facility 2 hour resident check sheet, dated 6/3/16, revealed staff documented the resident was out of the facility at 10:00 AM and 12:00 PM. The facility failed to provide a copy of the sign out log, dated 6/3/16 for review. On 6/16/16, the state agency received a third notification by phone that the resident was again located at the same location as on 6/3/16. The resident was again seeking public assistance and food. On 6/16/16 the National Weather Service issued a heat advisory at 3:32 AM to remain in effect until 7:00 AM on 6/17/16. The National Weather Service defined a heat advisory as an expected prolonged period of hot temperatures. The heat and humidity would make heat related illness such as heat stress, heat cramps, and possibly heat stroke more likely. The combination of hot temperatures and high humidity would combine to create a situation in which heat illnesses were possible and directed people to drink plenty of fluids, and stay out of the sun. On 6/16/16 9:47 AM, the National Weather Service also issued a severe thunderstorm warning, with hail measured at 0.88 inches in size affecting the location where the resident was at that time. According to www.wunderground.com, on 6/16/16 at 8:53 AM, the temperature measured 77 degrees Fahrenheit, at 9:53 AM 73.9 degrees Fahrenheit with wind gust speeds at 25.3 mph (miles per hour) and light rain, at 10:53 AM 75.9 degrees Fahrenheit, and at 11:53 AM 80.1 degrees Fahrenheit with a heat index of 82.9 degrees Fahrenheit. Review of resident sign out log, dated 6/16/16, documented the resident signed out of the facility at 8:50 AM, with the destination documented as walk of Kansas st . Review of the facility 2 hour resident check sheet, dated 6/16/16, revealed the resident documented as on Hall A at 10:00 AM, and in the dining room at 12:00 PM, when in fact observation revealed the resident was out of the facility at those times at the state office building. On 6/16/16 at 11:25 AM, observation revealed the resident at the above mentioned location, approximately 2.1 miles from the facility. The local public digital temperature, visible from the resident ' s location, read 81 degrees Fahrenheit. The resident wore orange sweat pants, combat boots, and a black short sleeve shirt. He/she carried a backpack. The resident did not have a hat or towel on his/her head or water with him/her (as care planned). There was not a bicycle present with the resident. Through written communication, the resident indicated he/she walked to his/her current location, had signed out of the facility. When asked if he/she was thirsty, the resident shook his/her head yes. The surveyor provided the resident with a large Solo cup of ice water, which he/she consumed in a few minutes. The surveyor then provided the resident with a second cup of water, which he/she mostly consumed within a few additional minutes. On 6/16/16 at 11:49 AM, State Surveyor Q phoned Administrative Staff A to ask about the resident's whereabouts at that time. Administrative staff A stated he/she was not aware of the resident's current location, or when the resident was expected to return. The resident signed out that he/she went on his/her walk to the state of Kansas building. Staff A was unsure of the temperature outside and stated the resident had towels on his/her head. Staff A stated, He/She was usually good about these things. Observation of the facility door, on 6/16/16 at 1:45 PM, revealed the door lacked a sign alerting residents to inclement weather. On 6/16/16 at 3:14 PM, direct care staff L stated the resident frequently left the facility without signing out or notifying the staff. On 6/16/16 at 4:50 PM, through written communication, the surveyor asked the resident if staff had reminded him/her to take towel and water that morning when he/she left the facility, the resident responded yes . However the resident did not have these items with him/her when observed out of the facility. When asked if staff alerted him/her to the bad weather that day, the resident responded no. On 6/16/16 at 5:30 PM, observation revealed the resident entered the front door of the facility wearing a tank top and the same orange pants as earlier in the day. On 6/21/16 at 10:23 AM, Direct Care Staff N stated the resident was independent. On 6/16/16 at 4:00 PM, Administrative Social Service Staff B stated he/she had flash cards he/she showed the resident to assess the resident's BIMS. Staff B stated when the facility admitted a resident, staff observed the resident for 2 weeks for his/her safety awareness. This included observation for safety with smoking, ADL habits, preferences for meals, invited to outings to see behaviors, assessment for medication compliance and if the resident appeared to be able to follow directions. This resident was given written instructions on how to get somewhere, knew his/her way around the community and was very resourceful. Staff B stated the resident wore a towel under a cap and took a jug of water when he/she left the facility and there was a sign posted on the front door when there was a heat advisory or a thunderstorm warning. Staff B stated whoever checked the resident out today would have ensured the resident had his/her towel and a jug of water. Staff B felt the resident would know when he was thirsty and would know how to get something to drink. Staff B stated the resident would not necessarily have to check out with a staff member prior to leaving the facility. Staff B confirmed there were not any weather warnings posted on the door at the time. When asked to demonstrate the method used to assess the resident's cognition, Administrative staff B stated at 4:45 PM, he/she was not able to find the above mentioned flash cards used to perform the BIMS assessment. At 5:29 PM, Administrative Staff B stated the above mentioned 2 week assessment for safety awareness was not documented anywhere and stated it was only done on admission and if a resident's condition changed. Staff B did not think the resident's condition had changed since admission to the facility, therefor additional safety awareness assessments had not been completed on the resident. Staff B was not aware of a date or policy for posting inclement weather to alert the residents who left the facility. On 6/16/16 at 4:03 PM, Licensed Nursing Staff H stated when the residents wants to go out, they needed to sign out on the log sheet and document the time, location, mode of transportation, and expected time of return. If Staff H was unable to locate a resident in the building, he/she would check the sign out sheet to see if the resident had signed out of the building. However, some residents forget to sign out or alert the nurse that they are leaving. Staff H stated the facility used 2 hour visual checks to identify if a resident was missing. If that happened, all staff looked everywhere, and sent a van with a CNA (certified nursing assistant) to go out and look for the missing resident. Staff H would then alert the administrator and may alert the police as indicated. No one had been missing recently that Staff H was aware of. Staff H always reminded residents to sign out when they leave. Staff H stated the facility curfew was 10:00 PM, and if a resident was not in the facility after 10:00 PM, staff called the police. If the weather changes, the staff would try to locate the residents who are out of the facility and pick them up. The MDS nurses assess and decide if the residents were alert and oriented enough to go out unattended. Staff H was not aware of safety awareness assessments. On 6/16/16 at 5:30 PM, Licensed Nursing Staff I stated he/she had never seen a sign on the door or wall warning the resident's about inclement weather, storms or heat. On 6/16/16 at 5:10 PM, Licensed Nursing Staff J stated all residents should sign out when they go out of the building, but sometimes they forget to. Staff used the 2 hour visual rounds to determine if a resident was out of the building that had not signed out. If a resident was missing, everyone looked for that person and we will notify the DON. Staff J stated the facility did not have an inclement weather sign to alert resident's to potential harmful weather when they were out of the building. On 6/16/16 at 5:15 PM, Direct Care Staff L stated staff were expected to warn residents of the heat or of thunderstorms before the resident left the facility and denied knowledge of a sign posted for this. Staff L stated in the event of severe weather, staff were expected to go pick up residents who were out of the building. Staff L stated residents were to write down where they were going when they left the building so this can be done. Staff L was aware of towel and water on resident's care plan for leaving in hot weather. On 6/16/16 at 5:37 PM, Administrative Nursing Staff E stated he/she performed elopement risk assessments for residents quarterly. Staff E performed an elopement risk assessment for mental health when the resident returned from the metropolitan area. Staff E stated when residents were admitted , they were observed for safety awareness and the level of assistance needed. The resident's safety awareness was reassessed every year and with a change in their condition. Staff E stated the safety awareness was the MDS. Staff E stated the resident's mental health status had not changed since his/her admission to the facility in 2014. On 6/16/16 at 5:53 PM, Administrative Nursing Staff D stated there was signage written down and made if there was a heat or cold advisory. The nursing staff on duty were responsible for alerting the residents to inclement weather or a heat/cold advisory. Administrative Nursing Staff D did not feel there was a change that warranted reassessing safety awareness after the resident went to the metropolitan area without staff knowledge in March, and was gone from the facility for approximately 48 hours. On 6/23/16 at 11:07 AM, during a phone interview, administrative nursing staff D stated the nurses should notify the physician for missed medication doses. He/she was not aware the resident frequently missed nebulizer treatments. On 6/16/16 at 5:55 PM, Administrative Staff A stated he/she had not reported the above mentioned incidents on 6/3/16 and 6/16/16 to the State Agency, because the resident left on his/her own all of the time and usually had a towel and a jug of water. Staff A stated the resident did not write down a specific destination on 6/16/16, but Staff A suspected the resident went to the same building as he/she had done last week, on 6/3/16. Administrative Staff A stated the facility did not have a set plan for identifying when a resident had not returned to the facility, because it was all based on the resident's individual pattern. If the resident usually came back at noon, then the facility would expect him/her to be back at noon and would be concerned if he/she was not back by that time. Administrative Staff A stated the resident's pattern was he/she left the facility in the morning, came back to eat at noon, and left again in the afternoon. On 6/21/16 at 7:46 AM, Complainant R stated on 6/3/16, he/she was headed out from work for lunch around noon, and State Employee S reported to Complainant R that the resident was at their office building. Complainant R stated the resident did not speak, so they communicated with writing on note pads. The resident indicated he/she needed a vision card (state assistance for food). State Employee S then walked the resident down the street to the appropriate state agency, at which time the resident indicated he/she needed a place to stay. Staff from that agency then determined the resident lived in the facility. At that time, Complainant R called Administrative Staff A and asked if he/she knew the resident's whereabouts. Administrative Staff A replied, No, the resident walked all over the town. Complainant R asked State employee S to remain with the resident until the facility arrived to pick up the resident and return him/her to the facility. Complainant R stated it was warm that day, and the resident had a bag with random stuff in it, and no water. The resident wore a long sleeve shirt, long pants, had no hat and no towel. Complainant R stated it was not the first time the resident had come to this location. Complainant R stated on 6/16/16, around 11:00 AM, State Employee S again reported the resident was there. On 6/21/16 at 8:56 AM, Licensed Nursing Staff G stated the staff did not always monitor the resident's departures. Observation of the sign out log, on 6/21/16 at 9:00 AM, located at the nurse's desk in front of the front door of the facility revealed a sheet with the following column headings: Resident; Date Out; Time; Date Returned; Expected Time of Return; Actual Time of Return; Destination; Responsible Party & Phone Number. The current sheet, dated 6/21/16 documented Resident: (last name) , Out: 8:15 , Actual Time of Return: 8:45 , Destination: bike. On 6/21/16 at 9:01 AM, the front of the facility revealed a double door that exited to a patio and parking area in front of the facility. Posted on the inside left door a sign stated the following: Inclement weather: Heat advisory (in large bold print): Due to the current weather conditions we recommend that you do not leave the facility. If you choose to leave, please go to the nurse's station for instructions (in fine small print at the bottom of the sign). On 6/21/16 at 9:02 AM, observation revealed the resident rode a bicycle in the parking lot of the facility. He/she entered the front door, wore black shorts, a black t-shirt, black boots, and a pink bandana on his/her head. The resident had no bag or backpack with him/her, no water, no pen or paper, and had a pack of cigarettes visible tucked in the waist band of the shorts. The resident walked to his/her room. On 6/21/16 at 9:22 AM, the resident approached the nurse's desk from his/her room. Administrative Staff A stood at the desk. The resident picked up the pen for the sign out log and laid it back down without documenting anything and exited the building through the front door. Administrative Staff A followed the resident out the door. The resident and Administrative Staff A returned to the building, the resident walked down the hall to his/her room and returned to the nurse's desk with a large (approximately 44 oz) black water cooler. Administrative Staff A exchanged written notes with the resident at that time. The note read: Do you know when you will be back . Written Response: When did cross housing in to catch on a back side. When asked what that response meant, Administrative Staff A stated, I assume that means he/she is going up by the housing authority because that is where he/she always goes . When asked, So, based on the assumption, you really do not know where the resident is going? Administrative Staff A responded, He/she does not tell have to tell me where he/she is going, because he/she was independent, knows where he/she was going and what he/she was going to do, so I do not have to do anything. On 6/21/16 at 9:36 AM, Direct Care Staff M stated he/she was not aware where or when the resident left the faciity on [DATE]. Staff M added that there was not any intervention for the resident leaving the facility. On 6/21/16 at 10:47 AM, the resident walked out the front door of the facility without communicating with staff (6 administrative, licensed and direct care staff were visible from the nurses desk at that time), or signing the log, got on a bicycle and began riding around in front of the facility. Administrative Staff A followed the resident out the front door and immediately returned to the nurse ' s desk. Administrative Staff A took the sign out log outside to the resident who remained on his/her bicycle. Administrative Staff A returned with the sign out log and laid it on the nurse ' s desk. Review of the log revealed (resident's last name), date out 6/16, at time 10:48, destination Bike. Observation revealed the resident rode off the facility grounds on the bicycle, without water or a backpack to carry items such as a towel or pen and paper, and remained in the same clothes as previously documented. On 6/21/16 at 11:25 AM, observation revealed the resident walked into the facility though a back door, out of the dining room and down the hall where he/she resided, with a plastic store bag in his/her hand. The resident's face was visibly red, and there were visible beads of sweat on the resident ' s face and arms and the resident's black t-shirt (back and front) was visibly wet in a V pattern extending from the shoulders down to the bottom of the shirt. The resident did not have a backpack or jug of water with him/her at this time. Administrative Nursing Staff A and Licensed Nursing Staff G were at the nurse's desk at this time. Administrative Nursing Staff A looked at the sign out log at this time, which still did not have a time of return to facility documented and stated to the Licensed Nursing Staff G, He/She was back, he/she had been back for a while, he/she went to the store. Licensed Nursing Staff G responded, Yeah, I see him/her right there, and gestured by nodding his/her head in the direction of the resident as the resident walked down the hall to his/her room. According to www.wunderground.com, on 6/21/16 at 10:53 AM, the temperature recorded at 87.1 degrees Fahrenheit with a heat index (what the temperature feels like to the human body when relative humidity is combined with the air temperature) of 92.8 degrees Fahrenheit. At 11:53 AM, the temperature documented at 89.1 degrees Fahrenheit with a heat index of 96 degrees Fahrenheit. On 6/21/16 at 8:56 AM, Licensed Nursing Staff G stated the resident's let staff know when they were going to leave and return, most sign out but it was their right not to if they did not want to. Staff G stated the resident would sign out, but does not always, sometimes he/she communicated instead by writing notes. Staff G stated the resident had a pattern of riding his/her bike, usually in the morning and liked to go for a walk in the afternoon. Staff G stated he/she usually had to ask the resident where he/she was going and when he/she planned to return. But, the resident did not have to tell staff, because that was his/her right and he/she was independent. Staff stated the resident had a pen and paper he/she used to write communications, but staff did not make sure he/she had that when he/she left the building. On the 6/16/16, staff confirmed being the nurse on duty and stated the resident signed out and wrote he/she was going to Kansas. Staff G stated that meant the resident was going to try and get food stamps. Staff G was not sure how often the resident had done that, but more than once. Staff recalled that when the resident left that day it had just rained a little bit and the temperature was in the mid 80's. If he/she was leaving the building, we always make sure to check clothing and make sure he/she is properly dressed. Most of the time the resident wore a hat or bandana when it is was hot and had a wet rag or towel on his/her head. Staff G did not check the resident before he/she left that day. Staff G stated whatever staff were at the nurse's desk when a resident leaves was responsible to check the resident. Staff G stated that in this re

- Resident #18's annual Minimum (MDS) data set [DATE] identified the resident had modified independence cognitively skills for daily decision making, had no behaviors, was independent with eating, weighed 133 pounds, had not experienced a weight loss and received no nutritional approaches. The resident's Nutritional Care Area Assessment (CAA) dated 7/22/15 included the resident needed encouragement to attend meals due to history of weight fluctuations and the resident's weight had been stable the past 180 days. The resident's care plan with an effective date of 10/14/15 addressed since 1/24/14 the resident's Body Mass Index was 18, the resident's BMI was not high enough, the resident did not want to be on a plan to gain weight but wanted to maintain his/her BMI at 18 or above to maintain his/her health. Staff offered the resident a peanut butter and jelly sandwich every night before he/she went to bed. The resident's nutritional status was assessed at least once a year or he/she had a change in condition and staff reviewed his/her nutritional status every quarter to see if there were any changes. The resident received a regular diet with large portions to help maintain his/her weight. Staff offered the resident a snack of his/her choice each snack time to help maintain his/her weight. Some of the resident's favorite foods included corn and green beans. The resident's care plan did not address the facility educated the resident on the risk and benefits of not receiving all food items or snacks. A Nutritional Assessment completed and signed by a Registered Dietician on 8/7/15 included the resident continued on a regular diet with extra portions to help maintain his/her weight. The resident did not like house shakes and was not interested in receiving them. The resident's weight was stable at 132.2 pounds. The resident's BMI was 18 which was the low end of the normal range, but the resident was satisfied with his/her current weight and wanted to maintain his/her weight. Review of the resident's weight log revealed the resident's weight ranged from 129 to 132 pounds from 1/3/15 to 12/3/15. Review of the facility's snack roster revealed staff offered the resident a peanut butter and jelly sandwich each night. Review of the resident's clinical record lacked evidence to support staff offered the resident a snack during the morning and evening snack time scheduled at 9:30 A.M. and 3:30 P.M. The resident's electronic physician's orders [REDACTED]. an order for [REDACTED]. On 12/9/15 at 12:35 P.M. observation revealed the lunch meal was Ziti, green beans and carrots. Further observation revealed the resident received a double portion of the Ziti, a piece of cake and no green beans or carrots. At 12:45 P.M. the resident had consumed all of the Ziti and the cake and staff did not offer any more of the Ziti, the main entree. On 12/10/15 at 9:45 A.M. staff passed the morning snacks to residents who attended snack time in the dining room. Observation revealed the morning snacks included various food items including cheese curls, fruit and sweet treats such as honey buns. Further observation revealed the resident was not present and there was no evidence to support staff offered the resident the A.M. snacks. On 12/10/15 at 12:40 P.M. observation the lunch meal included sloppy joes, hash brown fried potatoes rounds and corn. Further observation revealed the resident received (2) sloppy joes, chocolate pudding and no potatoes or corn. At 12:50 P.M. the resident had consumed both of the sloppy joes and the pudding and staff did not offer the resident more sloppy joes or chocolate pudding. On 12/10/15 at 2:30 P.M. dietary staff FF stated prior to serving residents a meal, staff informed residents of the menu and asked residents what food items he/she would like to be served. The surveyor asked staff FF how the facility made up for the calories the resident missed when he/she did not receive all of the food items on the menu and staff FF stated the resident had a right to choose and refuse which food items he/she did not want. Dietary staff FF confirmed the resident had a physician's orders [REDACTED]. On 12/15/15 at 9: 00 A.M staff R stated the resident did not usually receive a morning snack He/she stated staff did not document if the resident was offered a snack nor did staff document the percentage of snacks consumed unless it was a house shake or nutritional supplement. On 12/15/15 at 9:05 A.M. staff H stated the resident usually asked for and received a sandwich in the late evening but the resident did not usually ask for or receive a A.M. or evening snack. He/she stated the facility did not document the percentage of snacks residents received. On 12/15/15 at 9:35 A.M. and 3:35 P.M. observation revealed staff passed out snacks in the dining room and the resident was not in attendance. On 12/15/15 at 11:28 A.M. nursing administrative staff D stated staff ask residents prior to each meal what he/she wanted. He/she stated the resident tended to choose the main entree and tended to stay away from everything except food items that contained protein and the main entree. Nursing administrative staff D stated staff offered the resident snacks and sandwiches and educated the resident on the risk and benefits of not receiving all food items. He/she stated the resident's care plan should include the education the facility provided the resident regarding his/her nutritional status. Nursing administrative staff D stated the facility offered snacks to all residents but did not document if the resident refused or consumed the snacks. The facility's Weight Loss Prevention Policy and Procedure reviewed 7/14/15 included residents with poor or declining nutritional intake, weight loss, BMI less than 22 and/or pressure ulcers would have nutritional interventions added as needed and the Registered Dietitian would be consulted. Interventions would be added according to resident preferences. The facility failed to offer this resident with a BMI of 18, less than his/her normal range extra servings of the main entree when the resident did not receive all food items included on the daily menu and also failed to have evidence to support the facility offered the resident snacks at each snack time as planned. This practice did not ensure the resident maintained acceptable parameters of nutritional status. The facility reported a census of 80 residents There were 18 residents in the sample. Based on observation interview and record review the facility failed to develop and implement timely and effective interventions to prevent a significant amount of weight loss for 1 of 3 residents reviewed for nutrition (#22) and failed to develop and implement interventions to prevent weight loss for 1 of 3 residents reviewed for nutrition. (#18) Findings included: - Review of resident #22's signed physician order [REDACTED]. Review of the admission MDS (Minimum Data Set) dated 6/26/2015 documented a BIMS (Brief Interview for Mental Status) score of 14, which indicated intact cognition. The resident had hallucinations (seeing and/or hearing things, which were not real), delusions (an untrue persistent belief), and mild depression. The resident was independent with eating, weighed 184 pounds, had no swallowing problems, no significant weight loss over the past 30 to 180 days, and did not receive a therapeutic diet. The resident received 7 days of antipsychotic and antidepressant medication during the 7 day observation period. Review of the quarterly MDS (Minimum Data Set) dated 9/24/2015 documented a BIMS score of 15, which indicated intact cognition. The resident had hallucinations, delusions, and moderate depression. The resident was independent with eating with set up assistance from staff, weighed 170 pounds, had no swallowing problems, no significant weight loss over the past 30 to 180 days, and did not receive a therapeutic diet. The resident received 7 days of antipsychotic and antidepressant medication during the 7 day observation period. Review of the Cognitive Loss CAA (Care Area Assessment) dated 7/1/2015 documented the resident had delusions and hallucinations, paced the halls, and talked to unseen persons on invisible phones. The Nutritional CAA did not trigger for review. Review of the care plan dated 9/24/2015 documented the resident was happy with his/her current weight, wanted to maintain his/her weight, and notified staff if he/she changed his/her mind. The care plan directed staff to provide a double meat sandwich if requested, offer a room tray if he/she did not want to eat in the dining room, provide a regular diet, and assess his/her nutritional status once a year or if his/her condition changed, weigh monthly and as needed, provide a snack every night before bed, and review nutrition quarterly. The care plan documented the resident slept much of the day, stayed up at night, and missed meals. He/she did not want staff to disturb him/her to ask about meals and would let staff know when he/she wanted to eat. The resident weighed 185 lbs (pounds) on 6/18/2015, 177 lbs on 7/15/2015, which indicated a loss of 4.32% (percent), and 170 lbs on 9/18/2015, which indicated a weight loss of 8.10% over 90 days. The resident weighed 166 lbs on 12/4/2015, which indicated a weight loss of 10.2% in less than 180 days. Review of laboratory results dated [DATE] recorded an [MEDICATION NAME] (protein in the blood) level of 4.0, which was within normal limits. The facility reported a census of 80 residents There were 18 residents in the sample. Based on observation interview and record review the facility failed to develop and implement timely and effective interventions to prevent a significant amount of weight loss for 1 of 3 residents reviewed for nutrition (#22) and failed to develop and implement interventions to prevent weight loss for 1 of 3 residents reviewed for nutrition. (#18) Review of meal intake records dated November and December 2015 lacked documentation of meal consumption for this resident. Review of a physician order [REDACTED]. Weigh monthly Regular Diet [MEDICATION NAME] (a medication used to treat depression, which may decrease appetite) 10 mg (milligrams) by mouth daily for depression During an observation on 12/09/2015 at 12:07 P.M. the resident sat at the dining room table and staff served him/her barbeque meatballs, green beans, cake, and juice. The resident ate 100% of meal independently and drank 75% of juice. Staff did not offer the resident more food. During an observation on 12/10/2015 at 7:11 A.M. the resident sat at the dining room table and was served scrambled eggs, French toast sticks with syrup, 2 bowls of cereal with 2 cartons of milk, and sausage links. The resident ate 90% of French toast, 100% of eggs and drank both cartons of meal independently. Staff did not offer the resident more food. During an interview on 12/09/2015 at 3:06 P.M. the resident said he/she lost 12 pounds in the past 2 months and he/she tried to eat more food. The resident said he/she had no appetite and did not try to lose weight. During an interview on 12/09/2015 at 3:36 P.M. direct care staff Q said the resident stayed up late at night, slept a lot during the day, took staff multiple attempts to awaken for supper, and ate well when he/she came out for supper. Staff Q was not sure if the resident lost weight. During an interview on 12/10/2015 at 9 :59 A.M. direct care staff R said the resident was independent with eating. He/she said the resident did not always come out of breakfast, but usually came to the dining room for lunch and usually ate 100%. Staff R said he/she was not sure if the resident lost weight. During an interview on 12/14/2015 at 10:20 A.M. licensed nursing staff I said the resident was on a regular diet and lost 19 pounds since he/she admitted on [DATE]. Staff I said MDS Coordinators tracked weight loss and usually put residents on weekly weights and supplements. Staff I confirmed the resident was not weighed weekly, did not receive a nutritional supplement, and staff did not document meal intake. During an interview on 12/14/2015 at 2:24 P.M. administrative nursing staff E stated he/she was made aware the resident lost weight on 12/13/2015 by dietary staff. He/she confirmed the resident lost a significant amount of weight his/her first 90 days of admission and continued to lose a significant amount of weight. Staff E said he/she revised the resident's care plan on 9/8/2015 and directed staff to remind the resident he/she had sandwiches available if the resident requested. Staff E confirmed the physician and dietitian were not notified of the resident's weight loss. During an interview on 12/10/2015 at 12:15 P.M. dietary staff NN said the resident was on a regular diet, was not on a nutritional supplement, and was not on the sandwich list for bedtime snacks. During an interview on 12/14/2015 at 9:30 A.M. dietary staff FF said he/she was not aware the resident lost a significant amount of weight and he/she was responsible for notifying the dietitian of weight loss. During an interview on 12/15/2015 at 10:55 A.M. administrative nursing staff D said he/she was not aware the resident lost a significant amount of weight, the facility overlooked the resident's weight loss, and staff made him/her aware of the weight loss of 12/14/2015. During an interview on 12/15/2015 at 12:21 P.M. dietary consultant GG said he/she was not aware the resident lost a significant amount of weight until he/she received a call yesterday from the facility. Staff GG said he/she expected to notify him/her of the continued weight loss and said he/she would have seen the resident in September if the facility informed him/her of the weight loss. During an interview on 12/15/2015 at 10:05 A.M. physician consultant LL said the facility did not inform him/her of any weight loss since the resident admitted in June of 2015. Staff LL said he/she expected the facility to inform him/her of significant weight loss and said the resident's antidepressant medication, [MEDICATION NAME], was an appetite depressant and may be a contributing factor to the resident's weight loss. Review of the facility's Weight Loss Prevention policy dated 7/14/2015 documented residents with weight loss would have nutritional interventions added as needed and the dietitian would be consulted. The facility failed to timely recognize, develop, and implement interventions to prevent significant weight loss for this resident with a decreased appetite and significant weight loss.