Every finding on record at Dawson Place

The facility had a census of 36 residents. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in the facility's kitchen. Findings included:- On 10/21/25 at 11:30 PM, during food preparation, observation revealed the following:1. Three overhead fluorescent light fixtures, four feet by 12 inches with two light bulbs in each fixture, located directly above the food preparation area, and three overhead fluorescent light fixtures, four feet by 18 inches with four light fixtures, located above the dishwashing area and hot food preparation area with grey hanging lint.2. Three 24-inch by 24-inch air vent grills located above the cooking stove and food prep area, covered with brownish grease/sticky substance and gray fuzzy substance blowing directly on the food preparation and stove cooking area.3. One 24-inch by 24-inch, exhaust vent located above the dishwashing area, grills covered with brownish/black sticky grease substance and black fuzzy substance.4. Continued observation revealed multiple fire suppression spigots with metal pipes connected to the system, covered with brownish, fuzzy grey substance on the pipes and spigot area.On 10/21/25 at 11:35 AM, Dietary Staff BB verified the dirty register grills, dirty exhaust vent, and fuzzy substance on the fire suppression pipes and spigots. Dietary Staff BB verified she had worked at the facility for three months and was unsure who was responsible for the cleaning of the exhaust vent, register grills, and fire suppression spigots and pipes. On 10/21/25 at 11:45 AM, Maintenance Staff U verified the overhead fluorescent lights that were covered with grey lint, the fire suppression pipes, and spigots covered with a fuzzy grey substance, and the dirty registered grills. The facility's Sanitization policy, dated November 2022, documented the food service area is maintained in a clean and sanitary manner. The policy documents all kitchen and dining areas were kept clean, free from garbage, rodents, and insects. The policy documented the equipment, food contact surfaces, and utensils are cleaned and sanitized using heat or chemical sanitizing solutions

The facility identified a census of 36 residents. The sample included 12 residents. The facility had four residents required to be on enhanced barrier precautions (EBP- interventions designed to reduce the transmission of multi-drug-resistant organisms (MDRO- microorganisms, primarily bacteria, that have developed resistance to multiple antibiotics) during high contact resident care activities). Based on observation, interview, and record review, the facility failed to ensure that EBP signage was posted in or near the residents' rooms, which communicated the types of precautions and the personal protective equipment (PPE) required before performing resident cares. Findings included:- On the initial tour of the facility on 10/20/25 at 08:20 AM, four residents had PPE inside their rooms. Resident (R) 8, R11, R17, and R19 rooms had evidence of PPE in the room, but lacked signage inside or outside of the rooms that indicated that a resident was on EBP.On 10/20/25, a list of the residents on EBP was requested and provided by Administrative Nurse E. The list documented that R8, R11, R17, and R19 were on EBP.On 10/22/25 at 08:28 AM, Administrative Nurse E stated that residents on EBP had a yellow sticker on the trim outside the door. Administrative Nurse E stated each of the residents on EBP had the PPE supplies available in the room, and the floor nurses made care staff aware of who was on the EBP. Administrative Nurse E further stated that the residents should have a sign in their room with info on the EBP and what PPE should be worn.On 10/22/25 at 11:30 AM, Administrative Nurse D stated that the residents on EBP did have the yellow stickers outside of their rooms to indicate they were on EBP. Administrative Nurse D stated that one of the resident's family had an issue with the dignity aspect of the PPE being in the rooms of resident. Administrative Nurse D stated that she informed and educated the family on the need for EBP and the PPE access. Administrative Nurse D stated she was not certain about the signage aspect, but would review information about the EBP and would ensure that signage would be obtained and placed in the residents' rooms.The facility policy Enhanced Barrier Precautions dated December 2024, documented EBP is utilized to prevent the spread of MDROs to residents. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. Staff are trained prior to caring for residents on EBPs. Signs are posted on the door or wall outside the residents' room, which communicate the type of precautions and PPE required.

The facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide the services of a full-time certified dietary manager for the 36 residents who resided in the facility and received their meals from the kitchen. Findings included:- On 10/20/25 at 08:20 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 10/20/25 at 08:30 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had five residents with a mechanical soft diet. On 10/22/25 at 01:00 PM, Administrative Staff A verified Dietary Staff BB was not certified.The facility's Dietician policy, undated, documented that a qualified, competent, and skilled dietician would help oversee the food and nutrition services in the facility. A food and nutrition services manager will oversee the production, storage, and delivery of food. The dietician will work closely with the food and nutrition service manager and clinical staff. Dietary managers who are not yet certified may document the clinical record only after receiving documented training from the facility's licensed dietician on appropriate documentation standards and regulatory requirements. Documentation must be reviewed by the supervising dietician to ensure clinical accuracy and compliance with federal and state regulations. If a dietician is not employed full-time (35 or more hours per week), a director of food and nutrition services would be designated. That individual would be a Certified Dietary Manager, or be a certified service manager, or be nationally certified in food service management and safety, or have an associate's or higher degree in food service management from an accredited institution. Have 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and have completed a course of study in food safety and management, no later than October 1, 2023. That includes topics integral to managing dietary operations, including, but not limited to, foodborne illness, sanitization, and food purchasing and receiving, and meet state requirements for food service or dietary managers. The Dietary manager should receive frequent scheduled consultation from a qualified dietician or qualified professional.

The facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure adequate daily nursing staff were always available to meet the needs of the residents who resided in the facility.Findings included:- The Facility Assessment, revised 06/23/25, documented the general approach to staffing was to ensure the facility had sufficient staff to meet the needs of the residents at any given time. The nursing staff were evaluated at the beginning of each shift and adjusted as needed (PRN) at the beginning of each shift and adjusted PRN to meet the care needs and acuity of the resident population.Review of the nursing daily staffing schedules from 07/01/24 to 09/29/24 revealed on 08/10/24 and 09/21/24 a lack of licensed nurse coverage 24 hours a day.On 10/21/25 at 08:37 AM, Administrative Staff A stated she was responsible for completing the daily nurse staffing schedules. Administrative Staff A stated Administrative Nurse D worked on the days above in the missing time slot. Administrative Staff A revealed Administrative Nurse D was salary and did not clock in, so the facility had no documentation to verify Administrative Nurse D worked during the missing time slots.The facility's Staffing, Sufficient and Competent Nursing Policy, revised August 2022, documented licensed nurses and certified nursing assistants would be available 24 hours a day, seven days a week to provide competent resident care services.

The facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for hospitalization. Based on observation, interviews, and record review, the facility failed to provide a written notification of transfer to Resident (R) 5 or their representative for all applicable transfers/discharges. The facility failed to ensure the written notification of transfers given to R5 had the required information. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of transfers/discharges for R5. Findings included:- R5's Electronic Medical Record (EMR) documented diagnoses of overactive bladder (a condition characterized by frequent, sudden, and uncontrollable urge to urinate, often accompanied by urinary incontinence), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the urethra (small tubular structure that drains urine from the bladder), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) urinary incontinence, and hypertension (HTN- elevated blood pressure). The Quarterly Minimum Data Set (MDS) dated 09/10/25 documented R5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Functional Abilities Care Area Assessment (CAA) dated 12/31/24 documented R5 needed assistance with his self-care and mobility, and had chronic pain. R5's Care Plan dated 09/29/25 documented R5 had bladder incontinence and a history of urinary tract infections. Staff would encourage the resident to drink fluids during the day to promote a prompted voiding response. The care plan directed staff to have the resident clean the peri-area with each incontinent episode. The Nurses' Note dated 08/19/25 at 08:00 PM documented the nurse was called to the resident's room and noted R5 to be pale, shaking and had a temperature of 103.6 degrees (normal 96.4 to 98.5 degrees), blood pressure of 120/60 (normal blood pressure less than 120/80), heart rate of 108 (normal 60 -100 beats per minute), and oxygen saturation of 90% (normal between 95-100). R5 complained of back pain, was incontinent of loose stool. The primary care physician was notified of the resident's condition, and R5 was transferred to the hospital. R5 was unable to stand and a sit-to-stand lift with two staff members was utilized to transfer R5 to the wheelchair, and then to the hospital. The Hospital Note dated 08/19/25 documented R5 had a diagnosis of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) from a diagnosed urinary tract infection and was admitted to the hospital. The Nurses' Note dated 08/22/25 at 09:43 AM documented R5 returned to the facility accompanied by the hospital nurse. Upon request, the facility was unable to provide a written notification of transfer and bed hold acknowledgment for R5's transfer to the hospital on [DATE]. Upon request, the facility was unable to provide documentation of LTCO notification for R5's transfer to the hospital on [DATE] and returned to the facility on [DATE]. On 10/21/25 at 10:45 AM, R5 ambulated from his room to the bathroom, which is located down the hall from his room. R5 ambulated with a walker and aide beside him, dressed in street clothes. On 10/20/25 at 02:10 PM, Administrative Staff A stated she sent a transfer notification to the Ombudsman if the resident was discharged from the facility to home or to another facility, but did not send the notification if the resident was transferred to the hospital since she started at the facility a year and a half ago. Administrative Staff A stated she would contact the LTCO and get guidance on the procedure for discharges. On 10/21/25 at 03:10 PM, Social Services X stated the facility did not have a written notification of transfer for R5's transfer to the hospital an 08/19/25. The facility's Transfer and Discharge policy, dated March 2025, documented the residents or residents' representatives were notified of an impending transfer or discharge and the reason for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Ombudsman, the Notice of Facility Bed-Hold, and the policies. The notice of transfer is given as soon as it is practicable, but before the transfer or discharge. The resident and representative are notified in writing of the specific reason for transfer or discharge, the effective date of discharge or transfer, the specific location, and an explanation of the resident's rights to appeal the transfer or discharge to the state.

The facility identified a census of 36 residents. The sample size included 12 residents, who were reviewed for care plans. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 3's care plan was revised and interventions implemented to direct staff on resident care for her insulin pump (a small, computerized device that delivers insulin through a thin tube inserted under the skin).Findings included:- R3's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin).R3's Annual Minimum Data Set (MDS) dated [DATE], documented R3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R3 required maximal assistance from staff for her activities of daily living (ADL). R3 received insulin (a hormone that lowers the level of glucose in the blood) regularly.R3's Functional Abilities Care Area Assessment (CAA) dated 12/10/24 documented she had a diagnosis of Parkinson's disease. R3 required extensive assistance with all ADLs except eating. R3 required the use of a sit-to-stand lift (specialized medical devices designed to assist individuals with limited mobility in transitioning from a seated to a standing position). R3 had diabetes and had an insulin pump. R3 used a wheelchair to assist with mobility and was usually dependent on staff to propel the wheelchair.R3's Care Plan, revised on 07/17/25, directed staff that she had depression related to her Parkinson's disease. The care plan directed staff that R3's medications would be reviewed by the pharmacist consultant monthly, by the physician every 60 days, and both as needed. The care plan directed staff to give R3 her diabetic medications as ordered by the doctor and monitor and document for side effects and effectiveness. R3's care plan lacked staff direction for cares related to the use of her insulin pump. R3's Order Summary of the EMR documented an order dated 03/18/25 for a MiniMed insulin pump, basal rate is monitored and adjusted by the physician at the endocrinology clinic.On 10/21/25 at 08:15 AM, R3 sat in her wheelchair at the dining table to eat breakfast with other residents.On 10/22/25 at 10:06 AM, Administrative Nurse E stated that R3's insulin pump was preprogrammed and set by the endocrinologists (a medical doctor who specializes in diagnosing and treating hormone-related diseases and conditions). Administrative Nurse E stated that yes, the information about the insulin pump should be on the care plan and would be added today.On 10/22/25 at 11:30 AM, Administrative Nurse D stated that she had been working on improving the care plans and that R3's care plan should have included interventions regarding the insulin pump. Administrative Nurse D stated that R3's care plan had been revised today to address the use of the insulin pump and how staff should care for R3 with its use.The facility's policy Care Plans, Comprehensive Person-Centered dated March 2022, documented the interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing, and care plans are revised as information about the residents and their conditions changes. The IDT reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome was not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly assessment.

The facility had a census of 36 residents. The sample included 12 residents, with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility's consultant Pharmacist failed to obtain an approved indication for use for Seroquel (antipsychotic -class of medications used to treat psychosis and other mental emotional conditions) for Resident (R) 7, and Risperdal (antipsychotic) for R7, and failed to have monthly pharmacy Medication Regimen Reviews (MRR) for R3 and R4. Findings included:- R7's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes persistent feelings of sadness), and sleep apnea (a disorder of sleep characterized by periods without respirations). R7's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R7 had severely impaired cognition. The MDS recorded R7 required staff assistance with most activities of daily living (ADL). The MDS recorded R7 received antipsychotic and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA) dated 04/28/25 recorded R7 received Seroquel 50 milligrams (mg) every night and documented a diagnosis of insomnia and dementia. The CAA documented the diagnosis was not an approved diagnosis. R7's Care Plan dated 10/13/25 recorded R7 had impaired cognitive function and impaired thought process due to dementia, and staff would cue, reorient, and supervise R7 as needed. The care plan documented staff would administer medications as ordered and monitor for side effects and effectiveness. The Physician's Order, initial order date 04/22/25, directed the staff to administer Seroquel 50 mg, one tablet, at bedtime for a day for the diagnosis of insomnia. The Physician Order dated 10/07/2, directed staff to administer Risperdal 0.5 mg, one tablet, two times a day for the diagnosis of dementia with agitation. R7's EMR lacked a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and a risk versus benefits statement for the Seroquel and Risperdal use. R7's Pharmacy Review, dated 05/12/25, documented R7 received Seroquel 50 mg at bedtime and requested the provider for a diagnosis for the use of the antipsychotic medication. The pharmacist documented antipsychotic use for the behavior of dementia shows a 35 percent increase in mortality and a 50 percent increase in hospitalization. Continued review of the pharmacist's request revealed the physician documented No change. Review of the pharmacist review after 05/12/25 until the present revealed the pharmacist had not addressed the continued inaccurate diagnosis for the antipsychotic medication use. On 10/21/25 at 08:15 AM, observation revealed R7 sat in a wheelchair, dressed in street clothes and nicely groomed, in the dining room. Continued observation revealed R7 ambulated independently to his room and started talking to his roommate about getting out of the facility, and did not know how much longer he could stay here, and did not know what to do. On 10/21/25 at 11:20 AM, observation revealed Certified Medication Aide (CMA) R administered the residents' noon medications with no concerns identified. On 10/20/25 at 02:05 PM, Administrative Nurse D verified the resident received Seroquel, with a diagnosis of insomnia. Administrative Nurse D verified the diagnosis was inappropriate for the medication and would contact the provider for the appropriate diagnosis for the medication use. Administrative Nurse D verified the pharmacist had not identified and recommended a CMS appropriate diagnosis for R7's Seroquel and Risperdal. On 10/22/25 at 11:30 AM, Administrative Nurse D verified the resident received Risperdal, with the diagnosis of dementia and verified the diagnosis was inappropriate for the medication. Administrative Nurse D stated she would contact the provider for the appropriate diagnosis for the medication use. The facility's Medication Regimen Review policy dated May 2019 documented the consulting pharmacist reviews the medication regimen of each resident at least monthly. The consulting pharmacist performs a medication review regimen (MRR) for every resident in the facility receiving medication. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication-related problems, medication errors, and other irregularities. The medication regimen and associated treatment goals involve collaboration with the resident, the resident representative, interdisciplinary team. The MRR includes a review of the resident's stated preferences, the comprehensive care plans, and information provided about the risks and benefits of the medication. Within 24 hours of the MRR, the consulting pharmacist provides a written report to the attending physician for each resident identified as having a non-life-threatening medication irregularity. The report contains the resident's name, the name of the medication, the identified irregularity, and the pharmacist's recommendation. The attending physician documents in the medical record that the irregularity has been reviewed and what, if any, action was taken to address it. The facility's Psychotropic Medication Use dated February 2025, documented residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications, anti-psychotics, antidepressants, anti-anxiety medications, and hypnotic and sedatives. Adequate indications for use refer to the identified, documented clinical rational for administering medication that is based on an assessment of the resident's condition and therapeutic goals, a determination that non-pharmacological interventions are clinical contraindicated, and manufactures recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidenced based review articles that support the us of the medications. The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record. Diagnosis alone does not necessarily warrant the use of antipsychotic medication. If a psychiatric diagnosis is part of the rationale for the use of the psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for that diagnosis. - R3's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R3's Annual Minimum Data Set (MDS) dated [DATE], documented R3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R3 required maximal assistance from staff for her activities of daily living (ADL). R3 received insulin (a hormone that lowers the level of glucose in the blood) regularly. R3's Functional Abilities Care Area Assessment (CAA) dated 12/10/24 documented she had a diagnosis of Parkinson's disease. R3 required extensive assistance with all ADLs except eating. R3 required the use of a sit to stand lift (specialized medical devices designed to assist individuals with limited mobility in transitioning from a seated to a standing position). R3 had diabetes and had an insulin pump (a small computerized device that delivers insulin through a thin tube that goes under your skin). R3 used a wheelchair to assist with mobility and was usually dependent on staff to propel the wheelchair. R3's Care Plan revised on 07/17/25 directed staff that she had depression related to her Parkinson's disease. The care plan directed staff that R3's medications would be reviewed by the pharmacist consultant monthly, by the physician every 60 days and both as needed. The care plan directed staff to give R3 her diabetic medications as ordered by the doctor and monitor and document for side effects and effectiveness. A review of the Consultant Pharmacist's month regimen review (MRR) revealed the facility lacked documentation/record of R3's medication review for the months of September 2024, November 2024, December 2024, January 2025, and March 2025. On 10/21/25 at 08:15 AM, R3 sat in her wheelchair at the dining table eat breakfast with other residents. On 10/20/25 at 01:15 PM, Administrative Nurse D stated she had the emails with the physician responses for the MRRs but did not print them out and keep them in a binder and was not able to find all of them for R3. Administrative Nurse D stated that staff had just recently started to scan the MRRs into the EMR. The facility's policy Medication Regimen Reviews dated May 2019, documented the CP performed a MRR for every resident in the facility receiving medication. MRRs are done upon admission and at least monthly thereafter, or more frequently if indicated. The CP provides the director of nursing services and the medical director a written, signed, and dated copy of all MRRs. Copies of the MRR reports, including physician responses, were maintained as part of the permanent medical record. - R4's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (HTN- elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R4's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R4 required partial assistance with her activities of daily living (ADL). R4 received an antidepressant (a class of medications used to treat mood disorders) and an anticoagulant (a class of medications used to prevent the blood from clotting) regularly. R4's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/18/25 documented she receives Zoloft (an antidepressant medication) for depression. R4's daughter had passed. R4 participated in most group activities. R4 has had a decline in her cognitive status, behaviors, and mobility. R4's episodes and symptoms of depression were monitored every shift. R4's Care Plan last revised on 10/07/25 directed staff to administer medications as ordered and to monitor for side effects and effectiveness. The care plan directed staff that her medications would be reviewed by the pharmacist consultant monthly, by a physician every 60 days, and by both as needed. A review of R4's Consultant Pharmacists (CP) monthly medication regimen review (MMR) from August 2024 to present revealed the facility was unable to provide documentation of the CP MMR for the months of September to December 2024, as well as January and February 2025. On 10/22/25 at 08:10 AM, R4 sat in her wheelchair at the dining table eating breakfast with other residents. On 10/20/25 at 01:15 PM, Administrative Nurse D stated she had the emails with the physician responses for the MRRs, but did not print them out or keep them in a binder, and she was not able to find all of them for R4. Administrative Nurse D stated that staff had just recently started to scan the MRRs into the EMR. The facility's policy Medication Regimen Reviews dated May 2019 documented the CP performed an MRR for every resident in the facility receiving medication. MRRs were done upon admission and at least monthly thereafter, or more frequently if indicated. The CP provides the director of nursing services and the medical director with a written, signed, and dated copy of all MRRs. Copies of the MRR reports, including physician responses, are maintained as part of the permanent medical record.

The facility had a census of 36 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R) 7's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. Findings include: - R7's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes persistent feelings of sadness), and sleep apnea (a disorder of sleep characterized by periods without respirations).R7's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R7 had severely impaired cognition. The MDS recorded R7 required staff assistance with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic and antidepressant (a class of medications used to treat mood disorders) medication during the observation period.The Psychotropic Drug Use Care Area Assessment (CAA) dated 04/28/25 recorded R7 received Seroquel (antipsychotic medication) 50 milligrams (mg) every night and documented a diagnosis of insomnia and dementia. The CAA documented the diagnosis was not approved. R7's Care Plan dated 10/13/25 recorded R7 had impaired cognitive function/impaired thought process due to dementia, and staff would cue, reorient, and supervise as needed. The care plan documented staff would administer medications as ordered and monitor for side effects and effectiveness.The Physician's Order, initial order date 04/22/25, directed the staff to administer Seroquel 50 mg, one tablet, at bedtime for a day for the diagnosis of insomnia. The Physician Order, dated 10/07/25, directed staff to administer Risperdal (antipsychotic medication) 0.5 mg, one tablet, two times a day for the diagnosis of dementia with agitation. R7's EMR lacked a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and a risk versus benefits statement for the Seroquel and Risperdal use.R7's Pharmacy Review, dated 05/12/25, documented the resident received Seroquel 50 mg at bedtime and requested the provider for a diagnosis for the use of the antipsychotic medication. The pharmacist documented antipsychotic use for the behavior of dementia shows a 35 percent increase in mortality and a 50 percent increase in hospitalization. Continued review of the pharmacist's request revealed the physician documented No change. Review of the pharmacist review after 05/12/25 until the present revealed the pharmacist had not addressed the continued inaccurate diagnosis for the antipsychotic medication use.On 10/21/25 at 08:15 AM, observation revealed R7 sat in a wheelchair, dressed in street clothes and nicely groomed, in the dining room. Continued observation revealed the resident ambulated independently to his room and started talking to his roommate about getting out of the facility, and did not know how much longer he could stay here, and did not know what to do. On 10/21/25 at 11:20 AM, observation revealed Certified Medication Aide (CMA) R administered the residents' noon medications.On 10/20/25 at 02:05 PM, Administrative Nurse D verified the resident received Seroquel, with a diagnosis of insomnia. Administrative Nurse D verified the diagnosis was inappropriate for the medication and would contact the provider for the appropriate diagnosis for the medication use.On 10/22/25 at 11:30 AM, Administrative Nurse D verified the resident received Risperdal, with the diagnosis of dementia, and verified the diagnosis was inappropriate for the medication and would contact the provider for the appropriate diagnosis for the medication use. The facility's Psychotropic Medication Use dated February 2025, documented residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications, anti-psychotics, antidepressants, anti-anxiety medications, and hypnotic and sedatives. Adequate indications for use refer to the identified, documented clinical rational for administering medication that is based on an assessment of the resident's condition and therapeutic goals, a determination that non-pharmacological interventions are clinical contraindicated, and manufactures recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidenced based review articles that support the us of the medications. The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record. Diagnosis alone does not necessarily warrant the use of antipsychotic medication. If a psychiatric diagnosis is part of the rationale for the use of the psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for that diagnosis.

The facility had a census of 36 residents. Based on the interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1- September 30) indicated the facility had no licensed nurse coverage 24 hours a day on the following dates: 07/07/24, 07/27/24, 07/28/24, 08/11/24, and 09/29/24.Review of the facility's daily nursing staff coverage revealed the facility had licensed nurse coverage 24 hours a day on the above dates, and revealed the facility had adequate licensed nurse coverage.On 10/21/25 at 08:37 AM, Administrative Staff A stated the human resource staff was responsible for submitting the PBJ during that period of time, and she no longer worked for the facility.The facility's Reporting Direct Care Staffing Information (PBJ) Policy, revised May 2024, documented that complete and accurate direct care staffing information would be reported electronically to the Centers for Medicaid, Medicare Services (CMS) through the PBJ system in a uniform format specified by CMS.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to employ a full-time certified dietary manager for the 32 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 07/09/24 review of the noon meal consisted of baked honey-glazed ham, oven-browned potatoes, seasoned green beans, and Amish sugar cookies. On 07/09/24 at 10:20 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 07/09/24 at 10:20 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had completed the classes but was not scheduled for the exam. On 07/10/24 at 09:07 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Food and Nutrition Services, undated, documented the facility would employ a qualified, registered dietitian or other clinically qualified nutrition professional, either full-time or part-time or on a consultant basis, who meet the criteria set by the state of Kansas for such a position. if the facility does not employ a full-time qualified dietitian or other clinically qualified nutrition professional, the facility would designate a person to serve as the director of food and nutrition services who was for designations prior to November 2016 and meets the following requirements no later than 5 years after November 28, 2016, or no later than one year after November 28, 2016, for designations after November 28, 2016. a certified dietary manager a certified food service manager or an individual who has similar national certification for food service management and safety from a national certifying body or an individual who has an associate's or higher degree in food service or restaurant management, from an accredited institution of higher learning; and in states that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers and receiving frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional The facility failed to employ a full-time certified dietary manager for 32 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk for inadequate nutrition.

The facility had a census of 33 residents. Based on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precautions (EBP-an infection control practice that uses personal protective equipment (PPE) to reduce the spread of multi-drug resistant organisms (MDROs) for Resident (R) 10 who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and R3 who had an enteral (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food) feeding tube while providing direct care contact. The facility also failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). These deficient practices placed the facility's residents at risk of contracting or spreading infectious processes. Findings included: - On 07/08/24 at 03:52 PM observation revealed Licensed Nurse (LN) H administered R3's medication via feeding tube. LN H donned gloves, but not a gown. No signage or additional PPE related to ENP was noted in the resident's room. On 07/09/24 at 01:52 PM, observation revealed Certified Nurse Aide (CNA) N, donned gloves and proceeded to empty R10's indwelling catheter drainage bag. No signage or additional PPE related to EBP was noted in the resident's room. On 07/09/24 at 01:37 PM, Administrative Nurse D stated there were no residents on EBP. Administrative Nurse D stated she was not aware of what defined EBP and that staff was to utilize standard precaution (an infection control technique of avoiding contact with patients' bodily fluid by wearing nonporous articles, such as gloves) for all residents. On 07/09/24 at 03:01 PM, Administrative Nurse E reported she had a meeting about a month or so ago with nursing and housekeeping regarding EBP and was not aware staff were not following the protocol. Administrative nurse E said she was unsure of who was responsible for initiating EBP for residents who required it. On 07/10/24 at 09:25 AM, Administrative Staff A reported the maintenance department lacked information and verified the lack of procedures related to the waterborne pathogens system management. On 07/10/24 at 09:35 AM, Administrative Nurse D stated the Infection Preventionist was responsible for implementing EBP. The facility's Infection Prevention and Control Program policy, dated 04/01/20, documented the facility maintains an organized, effective facility-wide program designed to symptomatically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and healthcare workers. This program involves the collaboration of all staff and services within the facility and is designed to meet the needs and safety of our residents. Authority of the Infection Prevention and Control program has been delegated by the Director of Nursing (DON) to the facility's Infection Preventionist. In collaboration with the DON and the Medical Director, the Infection Preventionist has the authority to institute emergency medical and/or administrative actions when there is danger or threat to residents and/or staff regarding infection prevention/control matters. The facility has infection prevention policies and procedures, which outline strategies designed to reduce the risk of transmission of infectious agents among healthcare workers, residents, and visitors. Policies and procedures are based on relevant guidelines. The facility's Legionella Risk Management Policy dated 07/18/18, documented the purpose of the policy is to ensure, that as far as possible, all users of this facility are protected from the incident of Legionnaire's disease. The Maintenance Supervisor is responsible for all relevant details regarding roles and responsibilities and testing regimes contained in this policy and procedure. It is the policy of this facility to ensure that appropriate precautions for the control of legionella bacteria are identified through a Legionella risk assessment process and appropriate control measures implemented to ensure, so far as is reasonably practicable, the health, safety, and welfare of residents, visitors, staff members, and volunteers. The facility failed to implement EBP for R10 who had an indwelling urinary catheter and R3 who had an enteral feeding tube and failed to implement a water management program for Legionella disease which placed the facility's residents at risk of contracting or spreading infectious processes.

The facility had a census of 33 residents. The facility had one kitchen. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in one of one kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 07/08/24 at 07:28 AM, observation in the kitchen revealed the following: In the walk-in refrigerator, an unlabeled, undated container with 10 green peppers had a white substance on it. Dietary Staff (DS) CC verified the finding and discarded the green peppers. DS CC stated they were molded, and the fresh vegetables were not staying fresh like they should. In the area by the walk-in refrigerator, two loaves of whole grain bread with an expiration date of 07/06/24. DS DD verified the finding and discarded the loaves of bread. On 07/09/24 at 10:20 AM, observation in the kitchen revealed the upper white metal cabinets above the three-sink had numerous size brownish-black substances around the two cabinet handles. On 07/9/24 at 10:50 AM, Dietary Manager (DM) BB verified the issue with the cabinets and stated all staff were responsible for cleaning the kitchen, with tasks to complete daily. DM BB stated all staff should check the food items' expiration dates daily. The facility's Food Storage Policy, revised 06/14/16, documented that food service or other designated staff would always maintain clean food storage areas. The policy documented foods should be rotated as delivered and used the first in, first out method. Items would be dated on receipt to facilitate this procedure. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the residents who received their meals from the facility's kitchen. This placed the residents at risk for foodborne illness.

The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to conduct or implement nursing competencies required for residents' care needs, as identified through resident assessments and plans of care. This placed the residents at risk for decreased quality of care. Findings included: - On 07/10/24 at 11:15 AM, Certified Medication Aide (CMA) R stated the facility had not provided any competency skill checks with her. On 07/10/24 at 11:15 AM, Certified Nurse Aide (CNA) O stated the facility had not provided any competency skills checks with him. On 07/10/24 at 09:30 AM, Administrative Nurse D verified she had not performed any competency checks with the staff. The June 24, 2024 Facility Assessment included the resident population profile, resident acuity profile, staff training, licensing, and required continuing education. The assessment recorded the facility would provide ongoing education and staff training. The staff training and education program is designed to ensure knowledge competency for all staff. Education is provided through online training, monthly employee in-service, peer mentoring, and instructor-led sessions. The training and competency program are reviewed and revised each time the Facility Assessment is reviewed or revised. The facility failed to implement a competency evaluation program, placing the residents who resided in the facility at risk of receiving impaired quality of care.

The facility had a census of 33 residents. Based on interview and record review, the facility failed to consistently utilize an antibiotic stewardship program that included tracking, monitoring, and attempts to decrease the use of unnecessary antibiotic (a class of medications used to treat infections) treatments which placed Resident (R) 17 at risk of adverse outcomes associated with the inappropriate use of antibiotics and development of antibiotic-resistant organisms. Findings included: - R17's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), schizoaffective (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) disorder bipolar type (major mental illness that caused people to have episodes of severe high and low moods), personal history of urinary tract infection (UTI-an infection in any part of the urinary system), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and had not exhibited behaviors. R17 had a functional range of motion of the lower extremities and required partial to moderate assistance with functional abilities and substantial to maximal assistance with mobility. R17 utilized an external urinary catheter, had a toileting program, and was frequently incontinent of urine. The MDS further documented R17 received scheduled and as-needed pain medication, an antidepressant (class of medications used to treat mood disorders), an anticoagulant (class of medications to prevent blood from clotting), and an antibiotic. The Urinary Incontinence Care Area Assessment (CAA), dated 01/17/24, documented R17 had an overactive bladder, a history of UTI with scheduled prophylactic (preventative in nature) antibiotic, used a sit-to-stand lift for transfers, wore incontinent products, declined a toileting schedule and was incontinent. R17's Care Plan, dated 03/02/23, documented R17 had an activity of daily living self-care performance related to impaired balance, Parkinson's disease, and mood disorder. The care plan directed staff to provide extensive assistance with all activities of daily living. The care further directed R17 required extensive assistance with toileting tasks and with peri-care by staff to ensure proper wiping; R17 wore pull-ups and staff were directed to apply the external catheter at night. The Physician Order dated 02/01/23, directed staff to administer cephalexin (antibiotic) oral tablet 250 milligrams (mg) at bedtime. The Pharmacy Consultant Note dated 09/12/23, documented a periodic review is needed for prophylactic antibiotics due to the risk of resistant organisms. Pushing non-sugar fluid and good peri-care and catheter care show evidence for the prevention of UTI infections. Suggestion to switch cephalexin to methenamine Hippurate (medication used to prevent UTI) 1 gram twice a day for UTI prophylaxis and requested a note of benefit versus risk. The physician's response was no changes. However, the physician did not document a risk versus benefit statement. R17's clinical record lacked evidence of a physician-documented rationale for the ongoing use of antibiotics for prophylaxis. On 07/08/24 at 03:52 PM, R17 reported continued use of the external catheter at night and stated she took an antibiotic daily to prevent UTIs. On 07/09/24 at 02:39 PM during the review of the infection control survey task along with reviewing R17's antibiotic use, Administrative Nurse E and Administrative Nurse F who shared duties of Infection Preventionist (IP) role, explained the antibiotic stewardship began with the floor nurses when observation of changes in a resident's condition were identified. The nurse filled out a form that documented signs, symptoms, vital statistics, and other concerns associated with the condition change. The form was sent to the physician for review and orders if needed. The form was also processed through medical records for documentation in the medical record. Once an antibiotic order was prescribed, the antibiotic information was logged for specific requirements to further assess the appropriateness of the treatment. The IPs reported when the antibiotic order did not meet the criteria, they notified the physician to discontinue the medication and/or consider another course of treatment. If the prescriber did not respond or provide a risk versus benefit statement, the antibiotic would continue as ordered. The IPs verified this process lacked documentation of communication with prescribers. The IPs reported the continued use of antibiotic therapy without meeting the criteria for an infectious process and further verified R17's ongoing prophylactic use of an antibiotic without recent confirmation of signs or symptoms of infections or supportive lab evidence. The IPs said the information was brought to the monthly risk/quality assurance meeting but lacked further action from the facility or prescribers. The facility's Antibiotic Stewardship Program policy, dated 01/04/21, documented the facility will implement an Antibiotic Stewardship Program (ASP) which will promote the appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use, potential to limit antibiotic resistance in the care setting, improving treatment efficacy and resident safety. Activities include these basic elements: leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures, reporting data, education for clinicians, nursing staff, residents and families. The mission of the ASP is to provide the best antimicrobial therapy (right dose, right drug, and right duration) to residents that results in the best outcome with the least amount of toxicity and resistance. The facility failed to ensure an effective antibiotic stewardship program which included a system to assess the appropriateness of antibiotic usage in the facility, which placed the resident at risk of unnecessary antibiotic treatments.

The facility had a census of 33 residents. The sample included 12 residents with two reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)14 and R 16. This placed R14 and R16 at risk for inappropriate end-of-life care. Findings included: - R14's Electronic Health Record (EHR) revealed diagnosis of protein-calorie malnutrition (inadequate intake of food and other essential nutrients that result in changes to the body composition and function), hypertension (HTN-elevated blood pressure, chronic kidney disease (mild to moderate damage and they are less able to filter waste and fluid from your body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R14's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R14 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS documented the resident received hospice services. R14's Care Plan, dated 04/10/24, recorded R14 required extensive assistance with most activities of daily living (ADL) care. R14's Care Plan documented the resident received hospice services due to severe protein-calorie malnutrition and directed staff to administer pain medication as ordered and notify the hospice nurse if there is breakthrough pain. The plan lacked instruction on the services provided by hospice including hospice staff visits, supplies and medical equipment provided by hospice, and medications covered by hospice. A review of R14's medical records revealed the resident was admitted to hospice care on 11/26/22 but lacked evidence of coordination of care between hospice and the facility. The facility had received a hospice plan of care dated 03/08/24 and an end date of 05/08/24. The review revealed there was no communication book or external document. On 07/09/24 at 07:45 AM, R14 sat in a Broda chair (special chair with tilt and recline capability) at the dining room table. Certified Nurse Aide (CNA) MM assisted the resident to eat her breakfast On 07/10/24 at 09:45 PM, Administrative Nurse D stated she expected the facility to have a hospice care plan for R14 to be able to coordinate care with hospice services. Administrative Nurse D verified the facility lacked a hospice care plan that coordinated with the facility care plan. The Hospice Policy and Procedure policy, dated 05/24/24, documented the nursing facility and the hospice are responsible for performing each of their respective functions that have been agreed upon and included in the Plan of Care. Hospice retains overall professional management responsibility for directing the implementation of the Plan of Care related to terminal illness and related conditions. When a resident is admitted to Hospice Care the Plan of Care reflects the participation and responsibility of the hospice staff, the nursing facility staff, and the resident or representative. The Plan of Care will include directives for ongoing pain management and the hospice and nursing facility staff will communicate with each other regarding indications of need for care plan adjustment. The facility failed to coordinate care between the facility and the hospice provider for R14, who received hospice services. This deficient practice placed her at risk for inappropriate end-of-life care. 37450 - R16's Electronic Medical Record (EMR) included diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), mood disorder, dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and respiratory failure with hypoxia (inadequate supply of oxygen), and adult failure to thrive. R16's Significant Change Minimum Data Set (MDS), dated [DATE], documented R16 had moderately impaired cognition, rejected care behaviors that occurred one to three days during a seven-day observation period, and other changes in behavior that worsened. R15 had a functional range of motion impairment of both lower extremities and required substantial/maximal assistance with functional abilities and mobility. R16 was always incontinent of urine and had pain which occasionally interfered with daily activities. The MDS further documented R16 had shortness of breath or trouble breathing with exertion and lying flat, and had a condition or chronic disease that may result in a life expectancy of less than six months. R16 received an antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), oxygen therapy, and hospice care (care of the terminally ill). R16's Care Plan, dated 06/11/24, documented R16 had been admitted to hospice services with diagnoses of heart disease, failure to thrive, low endurance, anorexia (loss of appetite), and unavoidable weight loss. The care plan directed staff to monitor signs of pain or distress while providing care and notify hospice nursing staff if interventions for pain or distress are ineffective. The plan lacked instruction on the services provided by hospice including hospice staff visits, supplies and medical equipment provided by hospice, and medications covered by hospice. A review of R16's medical records revealed the resident was admitted to hospice care on 06/11/24 but lacked evidence of coordination of care between hospice and the facility for a certified period of 06/11/24 to 09/08/24. Further review revealed no communication book. The Progress Note dated 06/27/24 at 05:26 PM, documented a care plan meeting was held in the morning, and family members attended. No concerns were voiced and R16 expressed happiness with care. The goal was comfort and the family requested food not to be pushed to eat. On 07/09/24 at 12:15 PM observation revealed R16 sat in the dining room, in a wheelchair being assisted with eating lunch. On 07/09/24 at 03:52 PM, Certified Nurse Aide (CNA) N reported R16 was on hospice services. CNA N stated hospice usually provided incontinent briefs, pads, and wipes, but if she had questions about care she would consult the charge nurse or Director of Nursing. On 07/10/24 at 09:45 PM, Administrative Nurse D stated she expected the facility to have a hospice care plan for R16 to be able to coordinate care with hospice services. Administrative Nurse D verified the facility lacked a hospice care plan that coordinated with the facility care plan. The Hospice Policy and Procedure policy, dated 05/24/24, documented the nursing facility and the hospice are responsible for performing each of their respective functions that have been agreed upon and included in the Plan of Care. Hospice retains overall professional management responsibility for directing the implementation of the Plan of Care related to terminal illness and related conditions. When a resident is admitted to Hospice Care the Plan of Care reflects the participation and responsibility of the hospice staff, the nursing facility staff, and the resident or representative. The Plan of Care will include directives for ongoing pain management and the hospice and nursing facility staff will communicate with each other regarding indications of need for care plan adjustment. The facility failed to coordinate care between the facility and the hospice provider for R16, who received hospice services. This deficient practice placed her at risk for inappropriate end-of-life care.

The facility had a census of 33 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or specified duration with physician rationale for Resident (R)14's, R16's, and R33's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R14, R16, and R33 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R14's Electronic Health Record (EHR) revealed diagnosis of protein-calorie malnutrition (inadequate intake of food and other essential nutrients that result in changes to the body composition and function), hypertension (HTN-elevated blood pressure, chronic kidney disease (mild to moderate damage and they are less able to filter waste and fluid from your body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R14's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R14 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS did not document the resident received antianxiety medication. R14's Care Plan, dated 06/27/24 recorded R14 received medications with a Black Box Warning (BBW-highest safety-related warning) and had nursing considerations that need to be monitored. The care plan recorded staff to monitor for respiratory depression and sedation. The Physician's Order, dated 02/09/22, directed the staff to administer lorazepam (antianxiety) 1.0 milligrams (mg) every two hours a day as needed for anxiety. The order lacked a stop date. R14s EHR lacked an end date for the lorazepam. On 07/09/24 at 07:40 AM, observation revealed R14 sat in a Broda chair (special chair with tilt and recline capability) in the dining room. Certified Medication Aide (CMA) NN administered Keppra (anti-seizure medication) 500 mg, one half tab equal to 250 mg crushed in applesauce. On 07/09/24 at 09:30 AM, Administrative Nurse D verified the resident received PRN lorazepam that lacked a stop date. The Psychotropic Medication Monitoring policy, undated, documented the facility would use and administer psychotropic medications appropriately with the interdisciplinary team to ensure the appropriate use, evaluation, and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dosage, side effects, risks, and/or benefits. The facility supports the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychopharmacologic medications for dementia-related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual resident needs, preferences and routines is the most appropriate and first-line treatment for dementia-related behaviors. Efforts to reduce dosage or discontinue psychopharmacological medications will be ongoing, and appropriate, for the clinical situation. Psychotropic medications included: anti-anxiety/hypnotic, antipsychotic, and antidepressant classes of drugs. The policy documented that orders for as-needed (PRN) psychotropic medications would be time-limited to fourteen days or less and only for specific clearly documented circumstances. The policy documented the pharmacist would monitor psychotropic drug use in the facility to ensure that medications are not used in excess or for excess duration. The pharmacist would notify the physician Medical Director and Director of Nursing whenever a psychotropic medication is past due for review. Upon monthly review, the consultant pharmacist would make recommendations for dosage reductions/adjustments of antipsychotic medication for residents with dementia in accordance with the CMS regulations and guidelines. The consultant pharmacist would recommend to the physician, any specific dose reduction, additions/changes, and/or discontinuations, based on needs, labs, and current dose. The facility failed to ensure R14's lorazepam had a 14-day stop date or specified duration placing R14 at risk for adverse side effects. 37450 -R16's Electronic Medical Record (EMR) included diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), mood disorder, dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and respiratory failure with hypoxia (inadequate supply of oxygen), and adult failure to thrive. R16's Significant Change Minimum Data Set (MDS), dated [DATE], documented R16 had moderately impaired cognition, rejected care behaviors that occurred one to three days during a seven-day observation period, and other changes in behavior that worsened. R15 had a functional range of motion impairment of both lower extremities and required substantial/maximal assistance with functional abilities and mobility. R16 was always incontinent of urine and had pain which occasionally interfered with daily activities. The MDS further documented R16 had shortness of breath or trouble breathing with exertion and lying flat, and had a condition or chronic disease that may result in a life expectancy of less than six months. R16 received an antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), oxygen therapy, and hospice care (care of the terminally ill). R16's Care Plan, dated 06/11/24, documented R16 had been admitted to hospice services with diagnoses of heart disease, failure to thrive, low endurance, depression, anorexia (loss of appetite), and unavoidable weight loss. The care plan directed staff to monitor signs of pain or distress while providing care and notify hospice nursing staff if interventions for pain or distress are ineffective. The Physician Order dated 06/11/24, directed staff to administer Ativan 0.5 milligrams (mg) tablet by mouth every four hours as needed for anxiety. The order lacked the required stop date. The Progress Note dated 06/27/24 at 05:26 PM, documented a care plan meeting held in the morning, and a family member attended. No concerns were voiced and R16 expressed happiness with care; the goal was comfort and the family requested food not to be pushed to eat. On 07/08/24 at 12:10 PM observation revealed R16 in the dining room. R16's oxygen tubing and the nasal cannula were coiled and placed on the oxygen concentrator uncovered. On 07/09/24 at 09:23 AM, Administrative Nurse D stated the Ativan order came from hospice. Administrative Nurse D said she was unaware the order did not have a stop date. The facility's Psychotropic Medication Monitor updated policy, documented orders for as-needed psychotropic will be limited to fourteen (14) days or less and only for specific clearly documented circumstances. The facility failed to ensure R16 had the required stop date for the use of Ativan, a psychotropic medication which placed the resident at risk of receiving unnecessary psychotropic medications. 32358 - R33's Electronic Medical Record (EMR) documented R33 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R33's Quarterly Minimum Data Set (MDS), dated [DATE], documented R33 had a Brief Interview of Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS documented R33 did not receive an antianxiety medication during the observation period. R33's Care Plan, revised 05/09/24, documented R33 received Ativan (medication used for anxiety) and instructed staff to monitor R33 for side effects from the medication. R33's Physician Order, dated 05/10/24, instructed staff to administer Ativan, 0.25 milligram (mg) as needed (PRN), without a stop date. On 07/09/24 at 07:50 AM, observation revealed R33 sat quietly in a chair at the dining room table with other residents. On 07/10/24 at 10:00 AM, Administrative Nurse D verified R33's physician's order for PRN Ativan failed to have a stop date, and stated she was unaware that hospice residents who had PRN Ativan required a stop date. The facility's Psychotropic (alters mood or thought) Medication Monitoring Policy, undated, documented physician orders for PRN psychotropic medications would be time limited to 14 days or less and only for specific clearly documented circumstances. The facility failed to identify and report to the facility that R33's PRN Ativan lacked a stop date. This placed the resident at risk for unnecessary medications and related complications.

The facility had a census of 33 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of a 14-day stop date or specific duration with physician rationale for Resident (R) 14 and R33's as needed (PRN) psychotropic (alters mood or thoughts) medication. This placed the resident at risk for unnecessary medication with side effects. Findings include: - R14's Electronic Health Record (EHR) revealed diagnosis of protein-calorie malnutrition (inadequate intake of food and other essential nutrients that result in changes to the body composition and function), hypertension (HTN-elevated blood pressure, chronic kidney disease (mild to moderate damage and they are less able to filter waste and fluid from your body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R14's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R14 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS did not document the resident received antianxiety medication. R14's Care Plan, dated 06/27/24 recorded that R14 received medications with a Black Box Warning (BBW-highest safety-related warning) and had nursing considerations that need to be monitored. The care plan recorded staff to monitor for respiratory depression and sedation. The Physician's Order, dated 02/09/22, directed the staff to administer lorazepam (antianxiety) 1.0 milligrams (mg) every two hours a day as needed for anxiety. The order lacked a stop date. R14's EHR lacked an end date for the lorazepam. Review of the Consultant Pharmacist monthly reviews for R14 revealed on 06/06/24, 05/07/24, 04/16/24, 03/11/24, 02/08/24, 01/11/24, 12/08/23, 11/13/23, 10/10/23, 09/12/23, 08/08/23, and 07/10/23 the reviews lacked a recommendation the lorazepam needed a 14 day stop date. On 07/09/24 at 07:40 AM, observation revealed that R14 sat in a Broda chair (special chair with tilt and recline capability) in the dining room. Certified Medication Aide (CMA) administered Keppra (anti-seizure medication) 500 mg, one half tab equal to 250 mg crushed in applesauce and the resident tolerated it well. On 07/09/24 at 09:30 AM, Administrative Nurse D verified the resident received lorazepam PRN and that the order lacked a stop date. The Psychotropic Medication Monitoring policy, undated, documented the pharmacist would notify the physician Medical Director and Director of Nursing whenever a psychotropic medication is past due for review. Upon monthly review, the consultant pharmacist would make recommendations for dosage reductions/adjustments of antipsychotic medication for residents with dementia in accordance with the CMS regulations and guidelines. The consultant pharmacist would recommend to the physician, any specific dose reduction, additions/changes, and/or discontinuations, based on needs, labs, and current dose. The facility failed to ensure the Consultant Pharmacist identified and reported R14's lorazepam lacked a 14-day stop date. This placed the resident at risk for unnecessary antipsychotic medication with side effects. 32358 - R33's Electronic Medical Record (EMR) documented R33 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R33's Quarterly Minimum Data Set (MDS), dated [DATE], documented R33 had a Brief Interview of Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS documented R33 did not receive an antianxiety medication during the observation period. R33's Care Plan, revised 05/09/24, documented R33 received Ativan (medication used for anxiety) and instructed staff to monitor R33 for side effects from the medication. R33's Physician Order, dated 05/10/24, instructed staff to administer Ativan, 0.25 milligram (mg) as needed (PRN), without a stop date. The Consultant Pharmacist (CP) drug regimen reviews revealed the following: On 05/07/24, the CP found no irregularities. On 06/06/24, the CP found no irregularities. A review of R33's clinical record lacked evidence the CP identified and notified the facility regarding the lack of a stop date for R33's PRN Ativan. On 07/09/24 at 07:50 AM, observation revealed R33 sat quietly in a chair at the dining room table with other residents. On 07/10/24 at 10:00 AM, Administrative Nurse D verified the CP had not alerted the facility of the lack of a stop date for R33's PRN Ativan. The facility's Consultants Policy, revised 11/21/17, documented that CP would provide to the Director of Nursing (DON) and Administrator written, dated, and signed findings, recommendations, plans for implementations, and plans for continued assessments. The CP failed to identify and report to the facility that R33's PRN Ativan lacked a stop date. This placed the resident at risk for unnecessary medication side effects.

The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide regular in-service education based on the outcome of performance reviews and failed to ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for impaired care. Findings included: - The facility's employment records documented 5 nurse aides were employed at the facility for at least one year. The facility's in-service records documented that three of those nurse aides had not completed the required 12 hours of in-service training in the past year. On 07/09/24 at 09:30 AM, Administrative Nurse D stated she had a system in place to monitor the completion of in-service hours, but it was not up to date and failed to provide the needed hours for the by nurse aide staff. On 07/09/24 at 04:00 PM, Administrative Staff A stated they were unaware there was no system in place to monitor the completion of in-service hours. Administrative Staff A said the facility was implementing a new program to track staff hours and verified that the facility did not currently complete performance reviews of nurse aide staff on a regular basis. The Facility Assessment, dated 06/24/24, documented the resident population profile, resident acuity profile, staff training, licensing, and required continuing education. The assessment recorded the facility would provide ongoing education and staff training sufficient to ensure the continued competencies of nurse aides but no less than 12 hours per year. The staff training and education program is designed to ensure knowledge competency for all staff. Education is provided through online training, monthly employee in-service, peer mentoring, and instructor-led sessions. The training and competency program are reviewed and revised each time the Facility Assessment is reviewed or revised. The facility failed to ensure nurse aides employed for at least one year received a performance evaluation and completed the required in-service education, placing the residents who resided in the facility at risk of impaired care.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide effective pain management for Resident (R) 15, who experienced pain. This deficient practice placed R15 at risk for ongoing pain and impaired quality of life. Findings included: - R15's Electronic Medical Record (EMR) included diagnoses of bilateral osteoarthritis (chronic arthritis without inflammation) of the knee, constipation (difficulty passing stools), chronic pain, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), pain in the right and left knee, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R15 had moderately impaired cognition and had verbal behavioral symptoms directed toward others which occurred one to three days of the seven-day observation period. R15 required partial/moderate assistance with toileting hygiene, upper body dressing, and transfers to the bed and chair. R15 required partial/moderate assistance with showering and lower body dressing. The MDS further documented R15 was frequently incontinent of urine and occasionally of bowel. R15 received scheduled and as-needed (PRN) pain medication and had pain frequently which interfered with day-to-day activities. R15 had shortness of breath with exertion and two or more falls with no injury. R15 also received an anticoagulant (class of medication to prevent blood from clotting), an antidepressant (class of medications used to treat mood disorders), a diuretic (medication to promote the formation and excretion of urine), an opioid (medication to treat pain) and a hypoglycemic (class of medication used to lower blood glucose levels). The Pain Care Area Assessment (CAA), dated 02/29/24, documented R15 had osteoarthritis of both knees and chronic pain. R15's knee pain limited his mobility, and his primary caregiver reported the pain had been getting worse at home. R15's Care Plan, dated 03/14/24, stated R15 required limited to extensive assistance with all activities of daily living. R15 had a diagnosis of bilateral osteoarthritis, pain (especially knee pain), difficulty going from a lying to a sitting position, difficulty getting out of bed and chair, and used an electric recliner and rollator for ambulation with one staff assistance. The care plan further documented a new onset of incontinence since admission. The care plan lacked staff direction for non-medication pain relief measures to alleviate pain. The Physician Order dated 03/05/24, directed staff to administer Tylenol 8-hour oral tablet, extended-release, 650 milligrams (mg) four times a day for bilateral osteoarthritis of the knee and chronic pain. The Physician Order dated 02/20/24, directed staff to administer meloxicam 7.5 mg (an anti-inflammatory) by mouth every 24 hours PRN for pain related to bilateral osteoarthritis. R15's Medication Administration Record (MAR) revealed R15 received the PRN meloxicam and was utilized 02/20/24, 02/27/24, and 02/27/24. The Physician Order dated 02/23/24, directed staff to administrate oxycodone 2.5 mg (opioid) by mouth every four hours PRN for back pain related to chronic pain. R15's MAR revealed that oxycodone was utilized one time in February 2024. During the month of March 2024, R15's oxycodone was administered 13 times. During the month of April 2024, oxycodone was administered eight times. During the month of May 2024, R15's oxycodone was administered three times. During the month of June 2024, the oxycodone had been administered 12 times. From July 1 through July 7, 2024, R15'soxycodone was given five times. The PRN oxycodone is utilized during the nighttime hours. The Progress Note dated 05/18/24 at 11:53 PM, documented R15 had diagnoses that do cause him a great deal of discomfort and he had the tendency to become verbally aggressive and short-tempered when experiencing pain. R15 was noted to yell at staff during transfers and toileting if hurting. On 07/09/24 at 11:20 AM, observation revealed R15 exiting his bathroom using a wheeled walker. R15 moved slowly and stiffly, and he walked to his electric recliner. R15 stated both knees had been replaced when he was in his sixties, and the left knee had the most pain now. R15 said when he has pain, he cannot sleep and he asks for pain pills. R15 also reported having to get up through the night to use the bathroom, stating he could not use a urinal because he was not able to stand and hold the urinal without losing his balance, so he called for assistance as instructed by staff. On 07/09/24 at 02:35 PM, Certified Nurse Aide (CNA) MM, stated R15 complained of pain mostly in his left leg. He called for staff to help with moving the left leg. CNA MM reported that she tells the charge nurse when R15 is in pain. On 07/10/24 at 07:30 AM, Licensed Nurse (LN) G reported she was not aware of R15's increased use of oxycodone during the night and stated they had given R15's PRN pain medication only a few times during day shift hours. LN G was unsure what nonpharmacological interventions were in place or attempted for R15. On 07/10/24 at 09:29 AM, Administrative Nurse D verified R15 had pain which could affect his mood, mobility, and continence. Administrative Nurse D verified R15's frequent use of PRN pain medication but was unsure if R15's physician had been notified. Administrative Nurse D verified that R15's plan lacked nonpharmacological intervention for pain. The facility's Pain Management policy, dated 10/29/09, documents that pain management will be a part of each resident's initial and ongoing assessment. The resident's individual plan of care will address medication and non-medication-based intervention that will promote the residents' comfort and enhance their quality of life. Nursing will monitor for adverse effects and impact on activities of daily living of prescribed analgesics such as falls, constipation, drowsiness, etc., and implement interventions in the resident's care plan to address adverse effects and provide optimal safety for the resident. The facility failed to provide effective pain management related to the increased use of PRN oxycodone, and lack of non-medication interventions for R15 who experienced ongoing pain which impaired R15's quality of life.

The facility had a census of 33 residents. Based on the interview and record reviews the facility failed to offer pneumococcal (type of bacterial infection) PCV20 immunizations for Residents (R) 3, R4, and R19 per the guidance from the Centers for Disease Control and Prevention (CDC) This placed the residents at risk for pneumococcal infection. Findings included: - R3's Electronic Health Record (EHR) documented i R3 received one Pneumovax dose on 10/09/18. The facility lacked documentation R3 was offered or refused any further pneumococcal vaccinations. R4's EHR documented R4 received one Pneumovax dose on 04/12/22. The facility lacked documentation R4 was offered or refused any further pneumococcal vaccinations. R19's EHR documentation indicated R19 received one Pneumovax dose on 04/12/22. The facility lacked documentation R19 was offered or refused any further pneumococcal vaccinations. During an interview on 07/09/24 at 03:01 PM, Administrative Nurse E and F verified the three residents had not received or been offered a second pneumonia immunization since admission to the facility, and the facility had not screened the residents for eligibility for a second pneumovax. During an interview on 07/10/24 at 09:40 AM, Administrative Nurse D stated she was unsure what the pneumococcal vaccination requirements were, but she expected the Infection Preventionist (IP) to know and provide residents with the required immunizations. The facility's Immunization and Pneumococcal Immunizations policy, revised 01/27/10, documented all residents will be provided appropriate information in order for a resident to execute his or her right to make an informed choice about receiving influenza and/or pneumococcal vaccine. Offer a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. The facility failed to offer R3, R4, and R19 the updated pneumococcal immunization per current guidelines. This placed the residents at risk of acquiring pneumonia.

The facility identified a census of 26 residents. The sample included 14 residents with four residents reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to identify and respond in a timely manner and failed to notify the Registered Dietician (RD) in effort to prevent a significant weight loss for Resident (R)23. As a result, R23 had an unplanned weight loss of 13.6 percent (%) over six months. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R23's Admission Minimum Data Set (MDS) dated [DATE] indicated she required limited assistance from one staff with eating. The MDS noted she weighed 146 pounds (lbs.) with no weight loss, no nutritional approaches were performed, no diuretic (medication to promote the formation and excretion of urine) medications used, and noted R23 did not receive hospice services. R23's Quarterly MDS dated [DATE] noted a BIMS score of nine, indicating moderate cognitive impairment. The MDS indicated that she required extensive assistance from one staff for eating. The MDS revealed she weight 123 lbs. and had unintended weight loss. The nutritional approach noted a mechanically altered and therapeutic diet were in place, no diuretic medication used, and R23 did not receive hospice services. A review of R23's Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 01/12/2022 indicated she required limited assistance with her meals, but extensive assistance will all other ADL. R23's Visual Function CAA dated 01/12/2022 indicated staff were to ensure she had appropriate assistive devices during her mealtimes including plate guard, lids on her cup, and placement of her meal utilizing the clock method. The Nutritional Status CAA did not trigger for R23. A review of R23's Care Plan revealed an intervention initiated on 02/09/22 (revised on 04/20/22) that documented R23 was at risk for nutrition and dehydration related to her poor vision and comfort care. The care plan added interventions dated 02/14/22 for staff to offer additional fluids with meals, snacks, and activities and for staff to monitor ordered labs. On 03/30/22 an added intervention directed staff to utilize a plate guard for meals and for staff to monitor R23 for loose stool, due to lactose intolerance to dairy products. R23's Care Plan initiated 03/30/22 (revised on 04/20/22) noted she had an ADL self-care deficit related to dementia (progressive mental disorder characterized by failing memory, confusion). The care plan noted R23 was able to spoon feed herself if she could locate the plate and utensils, she required large handle silverware to maximize her independence, NS she might need supervision with setup to total assistance with meals, depending on the day. R23's Weight Summary recorded she weighed 146.6 lbs. on 01/04/22. A review of R23's Dietary Note on 01/14/22 indicated her weight was 146.4 lbs. showing a 2.4 lbs. weight gain since admission. The note indicated her body mass index (BMI, tool that measures the ratio of your height to your weight to estimate the amount of body fat) was slightly low. The note indicated R23 required varied assistance with meals and staff should encourage the use of the clock method. The note indicated staff should encourage meal intake; R23 was on a regular diet. R23's Weight Summary recorded she weighed 133.8 lbs. on 02/02/22 which indicated a 12.8 lb. loss in less than 30 days. R23's clinical record recorded an order dated 02/09/22 for comfort care. R23's Weight Summary recorded she weighed 132.6 lbs. on 03/01/22, and 135.6 lbs. on 04/05/22 for a significant loss of 7.5 % in 3 months. R23's clinical record lacked evidence the facility identified the significant loss and lacked evidence the facility consulted the Registered Dietician for evaluation. R23's Weight Summary recorded she weighed 126.6 lbs. on 05/31/22 which reflected an overall loss of 13.64 percent since admission. A Dietary Note dated 06/06/22 indicated R23 weighed 126.6 lbs. with a low BMI with a significant weight loss of greater than 10 %. The note indicated R23 received a regular diet and regular liquids. The note directed staff to offer fortified drinks with meals. R23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No other dietary notes, consultations, or interventions were in the chart or provided by the facility for R23. R23's Weight Summary on 10/04/22 documented she weighed 117.8 lbs. On 10/10/22 at 12:31PM R23 sat in dining room for lunch. She received her puree meal from the dining room. Her plate lacked the plate guard and staff feeding the resident her meal. She spat out the food from her mouth, after eating half of the meal and notified staff she did not like it and was done eating. R23 consumed 100% of her fortified shake . On 10/13/22 at 10:11 AM Certified Nurses Aid (CNA) M stated R23 was on a puree diet and needed assistance with her meals due to [CONDITION(S)]. She stated the direct care staff weighed the residents based on the list the nurses put out each day and turned in the results to the nurses for review. She stated there were days the resident did not eat as much, and staff tried not to force her to eat. She stated that staff would offer shakes and other snacks to her if she refused her meals. She had not recently seen any weight changes in R23 but would notify the nurse if it occurred. On 10/13/22 at 10:40 AM Licensed Nurse (LN) N stated the CNA staff weighed the residents based upon the created schedule and reported the weights. She stated if any weight changes occurred the physician would have been notified and the dietician would review the changes. She stated R23 rarely refused her meals but would be offered alternatives or snacks for later. On 10/13/22 at 10:11 AM Administrative Nurse D stated the residents should be weighed based upon their orders. She stated that if resident lost more than five pounds the physician is notified, and the resident would be put on a list for the dietician to review. She stated the dietician came every month to review the residents. She stated the dietician has seen R23 and started her on the fortified shakes. She stated when the dietician was last in the facility, the updates to the care plan were put in place. On 10/21/2022 at 09:00AM in an interview with Consultant HH she stated R23 was placed on comfort care earlier this year. She stated with comfort care residents, the staff were not as aggressive to ensure the resident was fully abiding by her diet but eating what they could tolerate at the time. She stated she often had to remind the facility that residents on comfort care should still be monitored closely for changes in weight and dietary habits. She reported that often she had to reach out to facilities about notifying her of changes in the resident. She stated she was in the facility monthly checking on each resident, but R23's most recent weight changes were not reported to her. A review of the facility's Unintended Weight Loss policy revised 07/2011 indicated that weight loss of five percent in 30 days or 10% or more in the last 180 days will be noted and reported to the physician and dietician. The policy noted that direct care staff will monitor residents for decreased appetite and report problems to change nurse and physician. The facility failed to implement timely interventions to prevent significant weight loss for R23. This deficient practice placed the residents at risk for complications with weight loss and malnutrition.

The facility identified a census of 29 residents with three reviewed for neglect. Based on observation, record review, and interview, the facility failed to ensure staff provided Resident (R)1 the necessary care and services he required to promote his highest level of physical comfort and psychosocial well-being from approximately 09:15 PM on [DATE] until the resident's death around 04:10 AM on [DATE]. R1 who was Covid (highly contagious respiratory infection) positive and had pneumonia (inflammation of the lungs), readmitted to the facility's isolation unit on comfort cares (cares provided during the dying process to provide comfort). Licensed Nurse (LN) G failed to monitor R1's respiratory status and respond to low oxygen saturations (level of oxygen in the blood) and shortness of breath as directed by the physician. LN G failed to respond to R1's pain after identifying R1's pain medication was ineffective. LN G further failed to obtain and administer [MEDICATION(S)] (class of medications that calm and relax people with excessive anxiety [mental or emotional reaction characterized by apprehension, uncertainty and irrational fear], nervousness, or tension) for R1 which the physician ordered to alleviate R1's anxiety and shortness of breath. LN G failed to respond to R1's change in status and declined to call R1's son, though R1 repeatedly called out for his son. LN G failed to assess R1 despite multiple alerts from Certified Nurse Aides (CNAs) who reported R1's discomfort, agitation, and inability to breath. LN G further failed to respond to an alert from the CNA that R1 was unresponsive and was not breathing. On [DATE] seven hours after the last administration of pain medication, R1 died . This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Annual Minimum Data Set (MDS), dated [DATE] documented R1 was rarely understood, had short term memory problems, had long term memory problems, and had moderately impaired cognition. The MDS further documented R1 required extensive assistance of one staff for transfers, walking in room, dressing, locomotion both on and off the unit, personal hygiene, toileting, and bathing. R1's Activity of Daily Living Care Area Assessment (CAA), dated [DATE], documented R1 would exhibit self-neglect and needed extensive assistance with bathing, dressing, and toileting. R1's Cognitive Loss/Dementia CAA, dated [DATE] documented R1 had dementia with self-neglect. The CAA documented staff would report changes in alertness and behavior. R1's Mood State Care Plan, dated [DATE], directed staff to monitor R1 for changes in mood, psychosocial status, or behavior including increased confusion, changes in sleep pattern, uncharacteristic behavior, increased anxiety, tearfulness, and crying. The care plan directed staff to notify the physician of any changes in mood, behavior or psychosocial status. R1's Psychosocial Care Plan, revised on [DATE], directed staff to encourage ongoing family involvement and to report signs and symptoms of depression to nursing and to monitor signs and symptoms of depression every shift by nursing. The Hospital Discharge Notes, dated [DATE] documented R1 admitted to the hospital on [DATE] and was on his ninth day of being Covid positive and had pneumonia. The Hospital Discharge Notes, dated [DATE], documented R1 dismissed back to the nursing home (connected to the hospital) on [DATE] at 03:00 PM with orders for oxygen saturation to stay above 86 percent (%) if able, give [MEDICATION(S)] 0.5 milligrams (mg) every two hours as needed for anxiety and shortness of air, and to contact the primary care physician or the on-call physician for recurrent shortness of breath, worsening oxygen saturation, agitation, anxiety, fever, or if R1 started to appear very ill. R1 dismissed back to the facility on comfort care. On [DATE] R1's EMR included a Covid test on his readmission to the facility and R1 was still Covid positive. R1 was in the Covid unit one on one with a Certified Nurse's Aide (CNA). The Facility Investigation documented on [DATE] at 04:00 PM, R1 was one on one in the Covid unit and CNA M documented she took R1 to the bathroom. R1 then laid down and was back up wanting to go to the wheelchair after a minute of laying down. R1 choked on sips of water. The Witness Statement written by CNA M, documented the following timeline: 04:21 PM R1 laid back down in bed and yelled out. 04:50 PM R1 took off his oxygen and kept saying he wanted to die. 05:00 PM R1 refused supper. 05:30 PM R1 took off his oxygen and his oxygen saturation dropped to 63%. R1 continued to repeat he wanted to die. The Facility Investigation documented on [DATE] at 05:45 PM Licensed Nurse (LN) H gave shift report to LN G and informed LN G R1 returned from the hospital and was on comfort care. R1 had a Do Not Resuscitate (DNR- advance directive to withhold resuscitative measures if clinical death occurs). LN H reported R1's [MEDICATION(S)] had not yet been delivered to the facility. The Facility Investigation dated [DATE] documented on [DATE] at 06:00 PM R1's son came to visit him and R1 continued to verbalize that he wanted to die. The investigation documented CNA N, who provided one on one care with R1, stated R1 dozed off and on and when he would wake up he would holler out. The Witness Statement, written by CNA N documented the following timeline for [DATE]: 07:30 PM R1 continued to holler out that he wanted to die and asked for his son. 08:30 PM R1 was incontinent of urine and was unable to get out of bed. Staff changed R1 while in bed. R1 could not get comfortable and sat on the edge of the bed, took a drink of water, choked, and laid back down in bed. R1 continued to repeat this behavior over and over. 09:00 PM R1's vital signs were as follows blood pressure ,d+[DATE] millimeters of mercury (mmHG- a normal blood pressure is ,d+[DATE] mmHg), pulse 53 beats per minute (normal pulse for adults is ,d+[DATE] beats per minute), temperature 96.4 degrees Fahrenheit (F), and oxygen saturation 66%. R1 continued to be very restless and called out for his son. CNA N called LN G and reported R1 needed something to assist him to calm down. R1's EMR recorded a note under the Notes tab on [DATE] at 09:16 PM, LN G administered 2.5 mg of [MEDICATION(S)] (pain medication) and charted the [MEDICATION(S)] administration was ineffective as R1 still exhibited signs and symptoms of pain. The EMR recorded a note under the Notes tab on [DATE] at 11:10 PM in which LN G documented R1 continued to say he wanted to die and complained of chest pain and arm pain. The note recorded R1 wanted to go to the emergency room (ER). LN G called the ER and the ER staff asked LN G if R1 was on comfort care. LN G told the ER staff that she was uncertain if R1 was on comfort care, and she did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LN G informed the ER staff she administered R1 an [MEDICATION(S)]. The note recorded ER staff asked LN G if R1 had [MEDICATION(S)] (pain medication) and LN G said no. LN G documented ER staff called her back and stated R1 was on comfort care and ER staff could administer a one-time dose of [MEDICATION(S)] through the door separating the hospital from the facility. Staff placed a gown and mask on R1 and took him to the door which separated the hospital from the facility. The note recorded unidentified ER staff administered [MEDICATION(S)], no dosage noted, to R1. LN G documented R1 continued to holler out he wanted to die. The note documented R1's vital signs were temperature 96.7 degrees F, pulse 94 beats per minute, blood pressure ,d+[DATE] mmHg, and oxygen saturations ,d+[DATE]%. R1 continued to remove his oxygen. The Witness Statement written by CNA N documented on [DATE] at 11:30 PM to 01:00 AM CNA N continued to provide one on one care to R1 and R1 was less restless during this time. The Facility Investigation dated [DATE] documented on [DATE] at 01:00 AM there was a shift change for the one on one CNAs providing care to R1. In a Witness Statement CNA O documented on [DATE] at 01:15 AM to 02:15 AM, R1 took two sips of peppermint schnapps. R1 was very restless and hollered out for his son. R1 stated he wanted to die, removed his oxygen, laid down, sat up, then laid down repeatedly. At 02:15 AM CNA O called to LN G to come back to the Covid unit to assess R1 because he sounded like he had a death rattle (gurgling sound made by dying people due to the inability to cough or swallow). LN G did not go back to the Covid unit to assess R1, but told CNA O it was just congestion. R1 continued to be restless, up and down, hollered for his son, and stated he wanted to die. At 02:40 AM R1's vital signs were temperature 96.2 F, pulse 83 beats per minute, blood pressure ,d+[DATE] mmHg, respirations 41 (normal respirations for an adult at rest is ,d+[DATE]), oxygen saturation 73% on 8 liters of oxygen per nasal canula ) device which delivered supplemental oxygen via the nose). CNA O notified LN G of R1's vital signs and suggested LN G call R1's son back up to the facility. LN G stated R1's son was at the facility earlier around 06:30 PM and LN G did not call R1's son. At 02:45 PM, R1 continued to be restless, wanted to go to bed, then on the edge of the bed, then got up to the wheelchair. R1 yelled and reached out for CNA O's hand. From 03:00 AM to 03:15 AM, R1 remained very restless and appeared uncomfortable. R1 had respiratory distress and the death rattle was deeper. R1 was clammy (unpleasantly damp and sticky or slimy to touch) and stated he was ready to go. CNA O notified LN G R1 was not doing well. CNA O told LN G she needed to come to the Covid unit. LN G told CNA O to leave R1 alone and stated he would calm down. CNA O stated she did not leave R1 alone. At 03:45 AM R1 had increased restlessness. CNA O placed a cool cloth on R1's forehead and gave him a sip of water. At 04:00 AM, CNA O attempted to get R1 up to the bathroom, but found R1 unresponsive and not breathing. CNA O called LN G on the handheld two-way radio and stated LN G needed to come to the Covid unit now. LN G responded Why? and CNA O told her R1 was not breathing and did not have a pulse. LN G asked CNA O how she knew that, and CNA O responded, because I looked, listened, and felt. LN G came to the Covid unit doors and stated, I can't come back there and asked CNA O to get R1 up to a wheelchair and bring R1 to her, at the door. CNA O told LN G there was no way she could get R1 up to the wheelchair. At 04:10 AM LN G finally entered the Covid unit and instructed CNA O to get a set of vitals. The vital machine did not register vital signs, but read Error. The Nurses Note, dated [DATE] at 04:27 AM, documented the Consultant GG was notified that R1's time of death was 04:20 AM and Consultant GG gave a verbal order to release R1's body to the mortuary and destroy all medications. In a typed statement dated [DATE] LN G recorded on [DATE] she came on duty and found papers on the desk that needed to be filed. She took a quick look at R1's orders and noted a new order for a DNR and [MEDICATION(S)]. LN G asked LN H if R1's [MEDICATION(S)] had arrived, and LN H stated no. LN H reported to LN G R1's oxygen saturations were running between 60 and 70%. LN G documented R1's son left the facility approximately 30 minutes later through the front door. LN G documented she administered [MEDICATION(S)], but R1 continued to out, was restless and grimaced. LN G asked the CNA to turn on a western on the television because R1 liked them. LN G further recorded CNA N called and stated R1 said he had pain and grabbed his left arm. LN G wrote that was ordinary for R1. LN G wrote she informed the CNA there was nothing more they could give R1 and said she would call over to the hospital and see what they wanted to do with R1. LN G documented she spoke to the hospital nurse and informed her R1 received [MEDICATION(S)] and there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LN G wrote they made the decision to take R1 through the hallway to the hospital door. The ER staff met the resident at the door. LN G watched the ER staff give R1 medication. LN G wrote as the CNA returned R1 to the unit, R1 looked at LN G and said, I want to die. LN G stated she asked R1 to go get some rest and wear his oxygen. LN G recorded she received a call from the CNA O, who told her R1 had a death rattle. LN G wrote when she entered R1's room, it was evident the resident had passed away. LN G stated she listened for a heartbeat and did not hear one and could not see any respirations. On [DATE] at 10:40 AM, CNA O stated LN G never came back to the Covid unit, even though she requested that LN G come back to the Covid unit multiple times. CNA O said LN G finally came back to the until after R1 passed away. CNA O stated she felt powerless, helpless, and ineffective when she tried to help R1 be comfortable because LN G would not come back to the Covid unit to assess or assist R1. On [DATE] at 01:00 PM LN G stated that she would not talk about the incident and said her charting and statement were enough. On [DATE] at 01:30 PM Administrative Nurse D stated there was much more care LN G could have provided to R1 to keep him comfortable during the dying process. Administrative Nurse D stated that LN G could have called the pharmacy and acquired the [MEDICATION(S)] and administered every two hours for anxiety and shortness of air. LN G could have called the Consultant GG, or the on-call doctor, if R1 needed pain medication to be comfortable. LN G could have assessed R1 throughout her shift and responded to the requests of the CNA O to assess and assist the resident. The facility's undated Abuse and Neglect policy documented all residents would be free from abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Supervision of staff by charge personnel, to identify inappropriate behaviors such as but not limited to the following: using derogatory language, rough handling of residents or failure to respond to resident needs, ignoring residents while giving care, directing residents who need to toilet to urinate or defecate in their beds, and failure to follow care plan guidelines. The facility failed to ensure staff provided R1 the necessary care and services he required to promote his highest level of physical comfort and psychosocial well-being from approximately 09:15 PM on [DATE] until the resident's death around 04:10 AM on [DATE]. This placed R1 in Immediate Jeopardy. On [DATE] the facility completed the following corrections: LN G was suspended. The occurrence was referred to the Board of Nursing and appropriate State Agencies. Staff were educated on responding to changes in status, assessment of resident's health status, ordering of medications, pain management and staff responsibility to deliver necessary care to the residents. The deficient practice was cited as past non-compliance.

The facility had a census of 30 residents. The sample included three residents reviewed for abuse. Based on observation, record review, and interview the facility failed to prevent an incident of abuse for Resident (R) 1, when Temporary Nurse Aide (TNA) M recorded a video on her cellular telephone of TNA N taunting R1 with a baby doll, making R1 grab and bite at the baby doll. TNA M then shared the video with others at a high school basketball game and posted to a social media web site. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Physician's Progress Note, dated 12/01/20 listed [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had highly impaired vision and severely impaired cognition. The resident required two-person extensive physical assistance with transfers, bed mobility, dressing, and toileting. The Psychosocial Well-Being Care Area Assessment (CAA), dated 06/03/20 documented R1 became agitated during hands on care. Her family visited almost daily before the pandemic and could not visit now. The Cognitive Impairment Care Plan, revised 03/09/20 directed staff to provide simple instructions and ask yes/no questions. The Mood Care Plan, revised 03/09/20 directed staff to document the number of episodes of agitation and crying every shift. On 02/17/21 at 03:20 PM, observation revealed R1 visited with family in the common living room and there were two baby dolls in a rocking chair in the resident's room. On 02/17/21 at 03:22 PM, TNA N stated in late January or early February he put R1 to bed. R1 slept with a baby doll, so he gave R1 the baby doll. TNA N stated he teased R1 with the baby doll by running the doll in front of her face and R1 swatted and bit the doll. He did not know TNA M made a video recording of his interaction with R1 on her cellular telephone. On 02/17/21 at 01:17 PM, TNA M stated two or three weeks ago she and TNA N put R1 in bed and TNA M recorded TNA N trying to get a baby doll out of R1's mouth. On 02/08/21 at approximately 07:35 PM she was at a high school basketball game and showed the video she previously recorded of TNA N teasing R1 with a baby doll and R1 bit the doll. One of the people watching the video told TNA M the resident in the video was a member of her family. R1's family member called the facility and reported the video. TNA M stated Administrative Nurse D called her and suspended her. On 02/17/21 at 12:05 PM, Law Enforcement Officer GG stated he talked to TNA N and he had her cellular telephone. He stated there was a criminal investigation for this case and could not discuss the case. On 02/17/21 at 02:30 PM, Administrative Nurse D stated TNA M and TNA N did not follow the facility's policies. She would not expect staff to make videos of a resident, nor post them on social media, or share the video in public. Administrative Nurse D called TNA M to the facility the evening she showed the video of R1 at the high school basketball game. When TNA M arrived at the facility, administrative staff suspended her and contacted local law enforcement. On 02/09/21 a law enforcement officer talked to TNA M who confessed to taking the video and posting the video to social media. After Administrative Nurse D heard this, she terminated TNA M and TNA N for not following facility policy. On 02/12/21 all staff received training on the Abuse, Neglect, and Exploitation Policy and the Social Media Policy. On 02/17/21 at 02:49 PM, Administrative Staff A stated staff were trained on the facility social media and abuse policy and she expected all staff to follow the policy. The facility's Abuse and Neglect Policy and Procedure, dated 04/19/17, documented all residents would be free from abuse, mistreatment, neglect, exploitation and misappropriation of resident property. The policy defined mental abuse as any verbal or physical action used to humiliate, harass, or threat of punishment of deprivation. Staff were educated and monitored to ensure camera equipped phones were used in a proper manner to ensure the privacy of residents and to protect resident from humiliation and/or mental abuse. The policy directed staff not to carry their cell/camera phone on the floor while they provided direct care to residents. The facility failed to protect R1 from abuse when TNA M made a video, which included R1, shared, and posted the inappropriate video of the resident to a social media site, placing the resident at risk for humiliation and embarrassment. The facility terminated TNA M and TNA N on 02/09/21, implemented in-service education for all staff regarding the Abuse, Neglect, and Exploitation Policy, Social Media Policy, and Employee Cell Phone Use Policy on 02/12/21. The facility took corrective actions before the start of the survey which resulted in past non-compliance at the time of the survey. This deficient practice was identified as past non-compliance with corrective actions completed on 02/12/21.

The facility had a census of 30 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to ensure staff provided a safe transport for 1 of 3 residents (#1) sampled for accidents when the staff failed to secure the resident's wheelchair in the facility van. The resident fell from the chair during the van transportation and sustained a fractured toe and a laceration which required 4 sutures. Findings included: - Resident #1's significant change (MDS) Minimum Data Set assessment, dated 9/18/14, indicated the resident had a (BIMS) Brief Interview for Mental Status Score of 3, which indicated he/she had severe cognitive impairment. The MDS indicated the resident required extensive assistance from the staff for transfers, bed mobility, and toileting, did not ambulate, and used a wheelchair for mobility. The MDS revealed the resident had unsteady balance, impairment of both his/her lower extremities, had one fall without injury and one fall with major injury since his/her admission. The 9/23/14 (ADL) activities of daily living (CAA) Care Area Assessment, indicated the resident required extensive to total staff assistance with all cares. The Falls CAA indicated the resident had a history of [REDACTED]. The resident had numerous falls with poor safety awareness and had a fall on 8/8/14 that resulted in a fracture of his/her right femur (leg). The 8/8/14 care plan directed the staff to provide extensive assistance of 2 staff for all transfer with the sling lift. The care plan also directed the staff to use a wheelchair for mobility, place a bed alarm on when the resident was in bed, a mat beside the bed and a "noodle" at the edge of the mattress under the sheet. The 9/22/14 at 8:10 AM, nurse's notes stated Nurse Aide A, called the facility and reported the resident fell out of his/her geri-chair (a recliner type chair that may be used in an upright position as a wheelchair to mobilize a person who is unable to walk), while in the van, and received a laceration between his/her right great toe and 2nd toe. Staff transported the resident to the emergency room for treatment. Staff strapped the geri-chair into place, but the resident was not secured in the chair. At 10:10 AM, Nurse Aide A called the facility and reported the resident's laceration required sutures, and he/she also had a fractured right great toe. The 1:20 PM, nurse's notes stated the resident returned to the facility. Review of the emergency room report, dated 9/22/14, revealed the resident had been treated for [REDACTED]. Review of the facility's transportation log, revealed the resident left the faciity on [DATE] at 6:15 AM, in the facility's van. Further review of the log revealed the staff had transferred two additional residents in the facility's van. On 10/21/14 at 8:00 AM, observation revealed the resident, seated in his/her wheelchair at the dining room table. Further observation revealed the resident had a transfer sling in his/her wheelchair, ace bandages wrapped around his/her feet and and he/she had gripper socks over the ace wraps. On 10/20/14 at 3:30 PM, Nurse Aide A, stated he/she had placed the resident, who was seated in his/her geri chair, into the facility van for a long distance transport. Nurse Aide A verified he/she secured the resident's geri chair to the floor of the van, but there were no seat belts in the van to go around the geri chair and secure the resident in his/her chair. Nurse Aide A verified the resident slid out of the chair while he/she was driving the van, and the resident sustained [REDACTED]. Nurse Aide A verified he/she was not trained on the proper way to secure a chair in the van. On 10/21/14 at 8:20 AM, Nurse Aide A further verified the van was new to the facility, and between the day the facility received the van (8/25/14), and 9/22/14, he/she had transported other residents in their wheelchairs without securing them. On 10/21/14 at 10:15 AM, Licensed Nurse C verified he/she received a telephone call on 9/22/14 around 8:10 AM, from Nurse Aide A that Resident #1 slid out of his/her geri chair in the van, and had a laceration between his/her toes. Licensed Nurse C further verified Nurse Aide A took the resident to the emergency room for treatment. On 10/21/14 at 2:30 PM, Nurse Aide B, verified he/she had helped transport Resident #1 in the van on 9/22/14. Nurse Aide B further verified there was no seat belt in the van to secure the resident in his/her geri chair, and he/she fell out of his/her geri chair while in the van. Nurse Aide B verified he/she received no training from the facility regarding the proper way to secure a resident who was not able to sit in the regular van seat, in the van. On 10/21/14 at 12:20 PM, Administrative Staff D, verified the facility received the new van on 8/25/14, and at that time, he/she, along with the Director of Nursing, the maintenance staff, and the facility van driver, met with the dealer to inspect the van. At that time, the dealer showed the staff how to properly secure a wheelchair to the floor using straps in the van. Administrative Staff D verified the van was not equipped with seat belt straps to secure a resident in a wheelchair. Administrative Staff D stated the van dealership said they would ship the proper straps to the facility. Administrative Staff D verified the staff had used the facility van to transport wheelchair residents without the proper seat belts in place. On 10/21/14 at 3:30 PM, Administrative Nurse E verified he/she inspected the van when it was delivered on 8/25/14 and it was determined there was no way to secure a resident who would be in a wheelchair. Administrative Nurse E further verified the van had been used to transport wheelchair residents without the proper seat belts in place. On 10/27/14 at 11:10 AM, Nurse Practitioner G, verified he/she would expect the facility to use seat belts to secure a resident in the facility van, and he/she verified Resident #1 would not be able to be transferred in a regular seat in the van, and required a wheelchair or geri-chair to be transported. The 1/24/12 facility policy and procedure for transporting residents lacked direction to the staff on the proper way to load, and secure residents in wheelchairs in the van. The facility failed to ensure staff provided a safe transport in the facility van for this cognitively impaired dependent resident, who fell from the wheelchair during a transport, and sustained a fractured toe, and received a laceration which required 4 sutures.

The facility reported a census of 30 residents with 18 sampled for review. The facility reported 21 residents as independently mobile and 17 of these independently mobile residents had cognitive impairment. The sample included 4 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free of accident hazards when water temperatures at the hand washing sink in the dining room (accessible to independently mobile residents) measured: * 160.1 degrees F. (Fahrenheit) on 7/8/13 at 7:57 a.m. * 152.7 degrees F. on 7/8/13 at 8:24 a.m. * 161.2 degrees F. on 7/8/13 at 8:38 a.m. This deficient practice placed the residents who potentially used the dining room hand washing sink in immediate jeopardy of burns. The facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents/falls for 3 of 4 residents sampled for falls. (#18, #11, and #10) The facility failed to ensure the resident environment remained free from potential accidents with the use of bed rails with large gaps that posed a potential for entrapment for 1 of 18 sampled residents. (#28) The facility failed to ensure the resident environment remained free of accidents/hazards for 17 independently mobile cognitively impaired residents when staff stored potentially hazardous chemicals in areas accessible to residents. Findings included: - During initial tour on 7/8/13 at 7:57 a.m., the water temperature in the dining area hand-washing sink presented as 160.1 degrees F (Fahrenheit). 25 residents sat in the dining area at that time. After checking with another thermometer in the same sink at 8:24 a.m., the water temperature presented as 152.7 degrees F. Upon alerting Administrative Staff B at 8:38 a.m., the water temperature of the dining room sink presented as 161.2 degrees F. During an interview and observation on 7/8/13 at 8:38 a.m., administrative staff B verified the water temperature presented as "too hot" for resident use. Staff B immediately instructed Maintenance Staff F to turn off the water to the dining room hand-washing sink. An observation on 7/8/13 at 9:01 a.m. revealed that water no longer flowed from the dining room hand-washing sink. Review of the maintenance water temperature check logs between 4/10/12 and 7/2/13 revealed that maintenance staff randomly checked 4 resident rooms on each hallway and rotated checking common area bathroom sinks. The log lacked evidence that staff checked the dining area hand-washing sink water temperature. During an interview on 7/8/13 at 8:44 a.m., maintenance staff F reported he/she routinely checked random hand-washing sinks temperatures in residents' and common areas and verified he/she never checked the temperature of the dining area hand-washing sink. Staff F reported the water temperatures should be at 115 -120 degrees F. and further stated he/she had not seen any residents using the dining room sink. During an observation and interview on 7/8/13 at 10:23 a.m., resident #31 ambulated with a walker independently to the ice machine adjacent to the dining room hand-washing sink and filled up his/her glass with ice without assistance. During an observation on 7/10/13 at 3:09 p.m., Maintenance Staff F reported he/she placed a mixing value and verified the water temperature registered between 112.5 degrees and 118.1 degrees F. According to the January 2005 Sunflower Connection, "Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even with 120 degrees, a five minute exposure could result in third-degree burns." The facility failed to ensure the residents' environment remained free of accident hazards when water temperatures in the dining room hand washing sink measured 160.1 degrees F on 7/8/13 at 7:57 a.m., 152.7 degrees F on 7/8/13 at 8:24 a.m., and 161.2 degrees F. on 7/8/13 at 8:38 a.m. The facility abated the immediate jeopardy related to hot water temperatures in excess of 140 degrees Fahrenheit on 7/15/13 at 5:00 p.m. when they implemented the following corrective measures: * Immediately turned off the water supply to the hand sink in the dining room and called a licensed plumber to assess the situation. The water supply to that sink will not be restored until the hot water situation is corrected via placement of a mixing valve. (Mixing valve was installed on 7/10/13) * Developed and implemented a "Maintenance Water Policy" which requires monitoring of water temperatures in the dining room on a daily basis, twice weekly water temperature checks of random resident rooms as well as twice weekly checks of shower rooms, bathrooms and the beauty shop. * Educated all staff in writing of proper notification of Administration and/or Maintenance staff if water temperatures seem excessively hot to the touch and provided evidence staff received the education. After removal of the immediate jeopardy, the deficient practice of facility failure to ensure the resident environment remained free of accident/hazards remained at a scope/severity of "E". - Resident #18's 6/6/13 physician's orders [REDACTED]. Resident #18's Annual 4/13/13 MDS (Minimum Data Set) Assessment reported the resident experienced short and long term memory problems with moderately impaired decision making skills and fluctuation inattention and disorganized thinking. The MDS reported the resident needed limited assistance of 1 staff for bed mobility and extensive assistance with 1 staff for transfers and toilet use. The MDS reported the resident had balance issues in all areas, used a walker and a wheelchair and experienced 2 falls with no injury and 1 fall with minor injury since the last assessment. Resident #18's 6/12/13 Quarterly MDS Assessment reported the resident experienced short and long term memory problems with moderately impaired decision making skills and fluctuating inattention and disorganized thinking. The MDS reported the resident needed limited assistance of 1 staff with bed mobility and extensive assistance of 2 staff for transfers and toilet use. The MDS reported the resident had balance issues in all areas, used a wheelchair and walker, and experienced 1 fall without injury and 2 falls with minor injuries since the last assessment. Resident #18's 4/8/13 Falls CAA (Care Area Assessment) summary reported that staff noted all of the resident's falls occurred when the resident attempted to transfer him/herself to or from the wheelchair. The CAA reported the resident had difficulty standing without assistance, had an unsteady gait, and poor safety decision making skills due to dementia. The CAA reported the resident received medications such as antipsychotic and diuretic medications that increased his/her risk for falling and the resident wandered, became agitated easily, and displayed anxiety and impulsive type behaviors at times. Resident #18's 4/8/13 Activities of Daily Living CAA summary reported that staff utilized a restraint called a "lap buddy" daily to deter the resident from falling out of the wheelchair. Resident #18's "Fall Risk Assessment" form revealed staff scored the resident as "30" on 5/30/13 and "28" on 8/8/12, 10/31/12, 1/22/13, 4/18/13, and 6/17/13, with indication that residents with scores greater than 10 posed as a higher risk for falling. Resident #18's 6/20/13 care plan informed the staff that the resident had hallucinations on frequent occurrences, received antipsychotic medications that increased his/her risk for falls, and lacked awareness to make good safety decisions. The care plan instructed staff to report increased episodes of restlessness or agitation and notify the nurse who may suspect that the resident developed a urinary tract infection. The care plan instructed staff to take the resident for a walk, call the resident's family member to visit, and to initiate an activity such as visiting when the resident became increasingly agitated. The care plan instructed staff to utilize a personal pressure alarm on his/her bed, wheelchair, and while in a chair, to provide 2 staff assistance for transfers and toileting with a gait belt, and to utilize a lap buddy restraint to remind the resident not to stand without assistance. The care plan included information that the resident fell on [DATE], 9/24/12, 10/4/12, 10/27/12, 11/18/12, 11/21/12, 11/28/12, 1/29/13, 3/16/13, and 4/15/13, but lacked implementation of fall prevention strategies after each fall to prevent future falls. Review of resident #18's nurses' notes included documentation of falls that occurred on 8/18/12, 9/24/12, 10/4/12, 10/27/12, 11/18/12, 11/21/12, 11/28/12, 1/29/13, 3/16/13, 4/15/13, and 6/15/13. During an observation on 7/9/13 at 6:58 a.m., resident #18 laid in bed with his/her eyes opened and attempted to sit up on the side of the bed independently. Direct Care Staff W and Q responded to the resident's room as the pressure alarm sounded. Staff W placed a gait belt around resident #18 and assisted him/her to walk to the bathroom using a walker. During an interview on 7/11/13 at 6:55 a.m., Licensed Nursing Staff C reported the charge nurse was responsible for updating and revising the care plan after a resident falls but lacked awareness to revise the care plan with new interventions to prevent future falls. During an interview on 7/11/13 at 2:06 p.m., Administrative Nursing Staff A reported the facility expected staff to revise the care plan with a new intervention to prevent further falls for resident 18. The facility's "Fall" policy, dated 1/11/11, instructed staff that after a resident falls, update the resident's care plan to reduce and/or prevent further falls. The facility failed to evaluate each fall and implement fall prevention strategies after each fall for resident #18 who had multiple falls. - Resident #11's 6/6/13 physician's orders [REDACTED]. Resident #11's 3/13/13 Annual and 5/22/13 Quarterly MDS (Minimum Data Set) Assessments reported the resident usually understood others while he/she usually made him/herself understood with no cognition impairment. The MDS reported the resident needed limited assistance of 1 staff with bed mobility and extensive assistance of 1 staff with transfers and toilet use. The MDS reported the resident had difficulty with balance in all areas with no falls since the previous assessment. Resident #11's Activities of Daily Living CAA (Care Area Assessment) summary reported the resident experienced confusion that varied from day to day and worsened when he/she experienced an urinary tract infection. The CAA reported the resident's need for assistance with daily activities varied and due to frequent falls in the past and use of antidepressant medications, the resident presented as high risk for falling. Resident #11's Fall CAA summary reported all of the resident's falls resulted from the resident attempted to transfer him/herself without assistance to and from his/her wheelchair or recliner, became weak, and fell to the floor, which made him/her a high fall risk. Resident #11's "Fall Risk Assessment" reported the resident scored as a "22" on 10/17/12, "20" on 1/8/13, and "20" on 3/20/13 with indication that residents with scores greater than 10 posed as high risk for falling. Resident #11's 5/30/13 care plan instructed staff to assist the resident to transfer with 1 staff and use of a gait belt. The care plan informed staff that the resident had history of falling prior to admission, took medications that increased his/her risk for falling, and to apply a pressure alarm to his/her chair to alert staff if he/she attempted to transfer without assistance. The care plan included documentation that the resident fell on [DATE], 6/8/12, 7/16/12, 8/13/12, and 1/4/13, but lacked revision to the care plan with new fall prevention strategies. Review of resident #11's nurses' notes included documentation of falls on 6/3/12, 6/8/12, 7/6/12, 8/13/12, 1/4/13, and 3/15/13. During an observation on 7/9/13 at 9:10 a.m., Direct Care Staff X assisted resident #11 to transfer from his/her wheelchair to the toilet with use of a gait belt. During an interview on 7/11/13 at 6:55 a.m., Licensed Nursing Staff C reported the charge nurse was responsible for revision of the care plan after resident #11 fell but lacked awareness to revise the care plan with new interventions to prevent future falls. During an interview on 7/11/13 at 2:06 p.m., Administrative Nursing Staff A reported the facility expected staff to revise the care plan with a new intervention to prevent further falls for resident 11. The facility's "Fall" policy, dated 1/11/11, instructed staff that after a resident falls, update the resident's care plan to reduce and/or prevent further falls. The facility failed to evaluate resident #11's falls and implement new fall prevention strategies to prevent future falls. - Resident #28's 6/6/13 physician's orders [REDACTED]. Resident #28's 6/5/13 Quarterly MDS (Minimum Data Set) Assessment reported moderate cognitive impairment, the need for extensive assistance of bed mobility with 1 staff and transfers with 2 staff. The MDS indicated the resident did not use restraints, such as side rails. Resident #28's 1/30/13 Cognition Loss and Activities of Daily Living CAAs (Care Area Assessment) summaries reported the resident had a [DIAGNOSES REDACTED]. Review of resident #28's clinical record lacked evidence that staff evaluated or assessed for safe use of side rails. Resident #28's 6/13/13 care plan lacked instructions related to use of the resident's side rails or bed mobility. The care plan instructed to assist the resident with 2 staff for transfers while using a gait belt. During an observation on 7/11/13 at 12:50 p.m., resident #28 sat in a wheelchair. An observation of the resident's bed revealed a full rail in the down position with 3 open gaps: two side gaps measuring 5 inches long by 19 inches wide and a middle gap of 5 inches long by 29 inches wide, creating a potential for entrapment of the head, neck, or torso. During an interview on 7/11/13 at 1:00 p.m., Administrative Staff B reported a lack of awareness of the presence of resident #28's full bed rail with gaps large enough to potentially entrap the resident. Although requested, the facility failed to provide a policy related to assessments and monitoring for the safety of side rails. The facility failed to provide resident #28 with bed rails for bed mobility that did not potentially entrap the resident's head, neck, or torso. - An observation on 7/10/13 at 10:23 a.m., revealed the following chemicals in resident #9's closet: * A one quart 1/2 full bottle of hydrogen peroxide cleaner with a label reading "causes moderate irritation" and "keep out of reach of children" * 1 spray cleaner with bleach 1 quart full with a label that read "eye irritant" and "keep out of reach of children" An interview on 7/10/13 at 11:21 a.m. with Maintenance staff F revealed that the chemical should not be in the closet. The facility identified 17 residents as independently mobile with cognitive impairment. The undated facility policy and procedure for Hazardous Materials/Substances instructed staff to store all hazardous materials, chemicals, substances such as cleaning supplies behind locked doors and not in any residents rooms. The facility failed to ensure the resident environment remained as free from accidents and hazards as possible for 17 cognitively impaired, independently mobile residents when staff failed to lock up chemicals found in resident #9's room. - Resident #10's quarterly MDS (Minimum Data Set) dated 5/1/13 identified the resident had long and short term memory problems, hallucinations and delusions, and moderately impaired decision making skills. The assessment further revealed the resident required assistance of one staff for bed mobility and toileting, assistance of 2 staff with transfers, and the resident had 1 fall with no injury since the last assessment. Resident #10's CAAs (Care Area Assessment) summary completed 3/18/2013 triggered for falls and stated the resident required one person assistance for transfers from a wheelchair to chair. The nursing care plan with a revision date of 5/9/13 instructed staff that resident # 10 presented as high risk for falls and he/she needed to be reoriented and reminded to use the call light. The care plan further stated the resident required the use of a personal alarm at all times when in the bed, recliner or wheelchair. The care plan listed dates of 4/20/12, 9/6/12, 1/21/13, 2/20/13, 3/4/13, 5/7/13. and 6/11/13 as dates resident #10 fell . The care plan lacked evidence of implementation of fall prevention strategies for the dates listed. A fall risk assessment completed on 4/18/13 revealed a score of 19, which indicated a "high risk" for falls. An observation of the resident on 7/8/2013 at 9:30 a.m. revealed staff P responded to the resident's personal alarm as the resident attempted to rise off the bathroom toilet on his/her own. During an interview on 7/9/2013 at 9:15 a.m., direct care staff Q stated the resident required assistance of 1 for bed mobility and toileting, and assistance of 2 staff during the night. Staff Q stated the resident experienced confusion at times and has had multiple falls trying to move from chair to chair. During an interview on 7/10/2013 at 10:40 a.m., Licensed Nurse T stated the licensed nurses should update the nursing care plan and implement new fall prevention strategies after a resident falls to prevent future falls. During an interview on 7/11/2013 at 9:30 a.m., Administrative Nursing staff A confirmed that the Charge Nurse should implement interventions on the care plan at the time of the incident. The facility's "Fall" policy and procedure with a revised date of 1/11/2011 instructed staff to "document interventions on the care plan". The facility failed to implement fall prevention strategies after resident #10 sustained falls on 4/20/12, 9/6/12, 1/21/13, 2/20/13, 3/4/13, 5/7/13, and 6/11/13.

The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free from potential accidents with the use of bed rails with large gaps that posed a potential for entrapment for 2 of 4 sampled residents and 5 non-sampled residents. (#26, #9, #33, #19, #14, #12, and #23) Findings included: - Resident #26's 8/30/13 signed physician's orders [REDACTED]. Resident #26's 7/24/13 Quarterly MDS (Minimum Data Set) Assessment reported the resident had moderately impaired cognition with fluctuating disorganized thinking. The MDS indicated the resident moved in bed and transferred independently. Resident #26's 12/12/12 ADLs (Activities of Daily Living) CAA (Care Area Assessment) summary reported that the resident maintained independence with all his/her ADLs and staff monitored the resident for worsening as his/her dementia slowly progressed. Review of the resident's clinical record lacked evidence of a bed rail assessment related to safety. Resident #26's care plan, last reviewed on 8/1/13, instructed staff that the resident independently cares for him/herself, and due to his/her cognitive impairment, give the resident frequent reminders of upcoming events. During an observation on 9/12/13 at 8:16 a.m., resident #26's bed revealed two upper and two lower quarter rails in the lowest position. Each lower rail had an outer bar that had a large, trapezoid shape with 2 internal, vertical bars that presented with 3 gaps: the 2 outer gaps measured 7 1/2 inches long by 9 inches wide and the middle gap measured 7 and 3/16 inches long by 7 and 1/2 inches wide. Each upper rail had an outer rail that had a large, trapezoid shape with one internal, vertical bar that presented with 2 gaps, each measuring 7 1/2 inches long by 7 1/2 inches wide. During a tour and interview on 9/12/13 between 8:12 a.m. and 8:18 a.m., Administrative Nursing Staff B identified that non-sampled residents #33, #19, #14, #12, and #23 also had bed rails with large gaps that posed a risk of entrapment on their beds. Staff B reported he/she audited all the residents' rails to see if a gap existed between the mattress and the rail but did not consider the gaps inside the rail itself as a potential for entrapment. The Center for Devices and Radiological Health Guidance dated 3/2006 revealed that the Food Drug Administration recommended that the greatest side rail gap to prevent head entrapment was 4.75 inches. The facility's "Proper Use of Side Rails" policy, last reviewed on 7/19/13, instructed that "when side rails usage is appropriate, the facility will... assess the space between mattress and side rails to reduce the risk of entrapment. There should be no gap wide enough to entrap a resident's head or body. If areas of concern are identified, the Director of Nursing and Maintenance Personnel will investigate and correct." The facility failed to ensure the resident environment remained free from potential accidents with the use of bed rails with large gaps that posed a potential for entrapment for residents #26, #9, #33, #19, #14, #12, and #23. - Resident #9 ' s 8/19/13 annual MDS (minimum data set) assessment identified the resident with a BIMS (brief interview for mental status) score of 10 which indicated moderate cognition impairment, did not exhibit behaviors. The assessment reported the resident required extensive assistance of 2 persons for bed mobility, total assistance of 2 staff for transfers, and the resident used bed rails daily. Resident #9 ' s 8/19/13 CAA (care area assessment) summary for falls revealed a history of falls at home, where spasms caused the resident to roll from the bed, and required extensive assistance for activities of daily living. The physical restraint CAA indicated the side rails did not restraint the resident. The resident ' s 8/22/13 nursing care plan identified resident #9 as at risk for falls, indicated the resident could not bear weight on his/her lower legs, and had poor voluntary movement of the legs. The care plan directed staff to transfer with a sling lift. The facility ' s 8/18/13 side rail evaluation lacked an assessment for safe use of the side rails in order to prevent entrapment. During an observation on 9/12/13 at 10:10 a.m., resident # 9 laid supine on the bed with two upper and two lower quarter rails in the highest position and a gap between the rails that measured 6 ? inches wide on each side. Each lower rail had an outer bar that had a large, trapezoid shape with 2 internal, vertical bars that presented with 3 gaps: the upper gap measured 7 1/2 inches long by 7 1/2 inches wide, the middle gap measured 7 3/4 inches long by 7 1/2 inches wide, and the lower gap measured 7 ? inches long by 7 ? inches wide. Each upper rail had an outer rail that had a large, trapezoid shape with 2 internal, vertical bars that presented with 3 gaps, the 2 outer gaps measured 7 ? inches long by 7 ? inches wide, the middle gap measured 7 1/2 inches long by 7 1/2 inches wide. During an interview on 9/12/13 at 11:50 a.m., licensed nurse J denied knowledge of the potential entrapment with resident #9 ' s side rails. He/she stated the facility completed side rail evaluations prior to their use. The Center for Devices and Radiological Health Guidance dated 3/2006 revealed that the Food Drug Administration recommended that the greatest side rail gap to prevent head entrapment was 4.75 inches. Review of the "Proper Use of Side Rail" procedure, last reviewed on 7/19/13, indicated in step 12: " assess the space between the mattress and side rails to reduce risk of entrapment. There should be no gap wide enough to entrap a resident's head or body. If areas of concern are identified, the Director of Nursing and Maintenance Personal will investigate and correct. " The facility failed to ensure the resident environment remained free from potential accidents with the use of bed rails with large gaps that posed a potential for entrapment for resident #9.