Every finding on record at Diversicare of Hutchinson

The facility reported a census of 37 residents. The sample included seven residents, with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion), care, and services. Based on observation, record review, and interviews, the facility failed to initiate a dementia plan of care that identified and honored Resident (R) 1's desire for physical engagement, which included direction to staff on how to identify voluntary engagement, and how to monitor for potential negative outcomes associated with physical engagement. Findings included:- R1's Electronic Health Record (EHR) under the Census tab documented R1 admitted to the facility on [DATE].R1's EHR revealed diagnoses of dementia, major depressive disorder (a major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and unspecified sexual dysfunction.R1's 09/28/25 Modified admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) interview could not be completed. Per staff interview, R1 had severely impaired cognition. The assessment documented R1 displayed no behavior towards herself or others. She utilized a manual wheelchair and/or walker for locomotion. The assessment documented R1 required supervision or touching assistance for eating, and otherwise, R1 was dependent on staff assistance for all care. R1's 09/28/25 Cognitive Loss / Dementia Care Area Assessment (CAA) documented R1 was unable to participate in the BIMS interview due to severe cognitive impairment. R1 was inattentive and had disorganized thinking processes.R1's 09/25/25 Care Plan had a Focus dated 01/16/26 which noted R1 had potential to be physically aggressive related to her diagnosis of dementia and provided the following interventions, all dated 01/16/26:Staff would administer medications as ordered and monitor/document side effects (unintended reaction to medication) and the effectiveness of medications.Staff would analyze times of day, places, circumstances, and triggers as well as what measures de-escalated behaviors and document the responses.Staff would assess and address contributing sensory deficits.Staff would anticipate R1's needs (hunger, thirst, toileting needs, comfort level, body positioning, pain, etc.).Staff would provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of the source of agitation, assist in setting goals for more pleasant behavior, and seek out staff when agitated.Staff would give the resident as many choices as possible about care and activities.Staff would monitor, document, and report as needed any signs or symptoms of the resident posing a danger to herself or others.R1's EHR Prog Note tab documented the following notes:On 01/18/26 at 02:57 AM, a Weekly Nurses Note documented R1 would transfer herself into other residents' beds and had attempted to disrobe in common areas. She approached male residents with sexually driven remarks; staff were usually able to redirect R1.On 01/23/26 at 03:12 PM, an Alert Note documented R1 had a socially inappropriate behavior; however, on assessment, R1 was smiling and self-propelling up the hallway with no behaviors displayed.On 01/30/26 at 12:12 PM, a General Notes documented R1 was found in R2's (a cognitively intact male resident) room with the door closed. R1 sat in her wheelchair in front of R2, who was in his wheelchair. R1's pants were down, and the male resident was touching R1's peri-area (area of the body around the genitals). Staff separated the residents, redressed R1, and removed her from the male resident's room. Staff provided frequent visual checks to keep the residents separated.R1's Care Plan, revised on 02/10/26, documented R1 sometimes demonstrated sexually inappropriate behaviors such as inappropriate touching or sexual comments, and provided the following interventions revised on 02/04/26:Staff would quietly attempt to redirect R1 if she displayed inappropriate behavior and remind R1 that the behavior was not appropriate.Staff would treat R1 with dignity and respect regardless of any behaviors. Staff would help R1 avoid situations or people that tend to trigger the behaviors.An intervention revised on 02/10/26 directed staff to offer R1 something she liked as a diversion such as baby dolls to hold, revised on 02/10/26.R1's EHR Prog Note tab documented the following notes:On 02/02/26 at 10:31 AM, a General Notes documented R1 was monitored through the weekend and continued to seek male companionship and stated she wanted a man, but was easily redirected into different conversation topics.On 02/15/26 at 01:58 AM, a Weekly Nurses Note documented R1 transferred herself into another resident's bed and attempted to disrobe in common areas. R1 also attempted to approach male residents with sexually driven remarks.On 02/19/26 at 02:35 AM, a General Notes documented a Certified Nurse Aide (CNA) alerted the nurse that R1 was in a common room on a couch and verbalized she was horny to another resident and his family members. Staff removed R1 from the situation and apologized to the male resident and his family.On 02/19/26 at 07:27 PM, a General Notes documented R1 was agitated and combative with staff. She went into other residents' rooms, attempted to take other residents' belongings, but was redirected for two to three minutes with each occurrence. Staff documented R1 said she was looking for a man and approached a male resident and asked him to go to her room. Staff documented R1 was informed the male peer was married and her behavior was inappropriate; R1 continued to yell at staff and was unable to be consoled despite pharmacological and nonpharmacological interventions.On 02/19/26 at 07:35 PM, a General Notes documented R1 was combative with staff and went into other residents' rooms and could not be redirected. R1 required one-on-one observation.On 02/19/26 at 09:48 PM, a General Notes documented R1 was verbally inappropriate with sexually explicit language to staff. Staff documented that one-on-one observation was resumed.On 02/24/26 at 12:53 AM, a General Notes documented R1 saw a male resident coming down the hallway and started to lift her shirt to expose her breasts to him. R1 became angry with the staff when they redirected her and assisted her with placing clothing in appropriate positions. Staff quoted R1 saying, I need a man. Staff provided R1 with food and drink and took her to the bathroom, after which she sat on the couch and fell asleep.On 02/24/26 at 04:20 PM, Administrative Staff B provided a printed copy of Behavior Monitoring and Interventions Report, dated 11/01/25 to 02/24/26, that documented inappropriate behaviors, which included but were not limited to entering into other residents' rooms and/or public sexual acts on 12/16/25, 12/30/25, 01/02/26, 01/04/26, 01/22/26, 01/30/26, 02/12/26, 02/14/26, and 02/19/26.On 02/24/26 at 12:35 PM, staff propelled R1 in her wheelchair.On 02/24/26 at 12:35 PM, an interview with R1 could not be completed due to R1's incomprehensible speech.On 02/24/26 at 10:23 AM, in an interview with Administrative Staff A and Administrative Nurse D via telephone, Administrative Staff A revealed R1 had vocalized several times, since her admission to the facility in 09/2025, that she had been married seven times. Administrative Staff A revealed R1 had been pointing out and gravitating towards males since her admission. R1 had only recently been seeking the attention of male residents.On 02/24/26 at 02:05 PM, Certified Medication Aide (CMA) R stated the only training she had received related to residents with dementia who expressed sexual desires was to let one of the nurses or a member of administration know. CMA R stated she was unable to recall if she had received specific training related to sexuality with elders. CMA R stated that if two elders were discovered engaged in sexual or intimate activities, staff should attempt to approach and separate the elders and alert other staff for assistance. CMA R said she was unsure of how to address confused elders with dementia who wished to engage in sexual or intimate activities. CMA R said she was aware of R1's intimate attraction and/or fixation with male residents and recalled an instance in January 2026 where she observed R1 kissing a male resident other than R2. CMA R said she implemented distraction techniques, separated the residents, and notified the nurse on duty of what had happened. On 02/24/26 at 02:32 PM, CNA M said staff received dementia training via online learning modules. CNA M could not recall having received any training related to residents with dementia who expressed desires that were sexual or intimate in nature. CNA M said that if a resident was gravitating or fixating towards a resident of the opposite gender, staff would attempt distraction techniques and separate the residents. CNA M went on to say she was unable to recall any training related to sexuality and/or intimacy for elders. CNA M stated she had received training related to R1 about a month ago and was instructed that if R1 expressed sexual or intimate fixation on another resident, to stop the residents, separate the residents, monitor the situation, and inform the nurse. CNA M said she had not observed R1 engaged in sexual or intimate activities with male residents and that R1 was usually in her wheelchair at the nursing station.On 02/24/26 at 02:53 PM, Licensed Nurse (LN) G stated she had received dementia training via online learning modules but was unsure about any training related to sexual or intimate relations for elders or elders with confusion caused by dementia. LN G said she was aware of R1's gravitation towards males without there being a specific resident or staff member. LN G reported R1 says she has six boyfriends. LN G said she was unaware of any specific training provided by the facility related to R1's sexual or intimate interactions with males. LN G recalled the facility instructed staff to prevent any sexual/intimate encounters because that act or set of acts must be consented to by both parties. Further, LN G said if an intimate or sexual encounter was discovered, the facility has instructed staff to separate the residents and instruct the residents to stay away from one another. R1's dementia doesn't allow her to understand that not all men are single. LN G stated she was unaware of any instances where R1 had engaged in sexual or intimate relations with male residents, only that R1 likes to be near or around men.On 03/02/26 at 07:44 AM, Administrative Staff A stated the care plan interventions related to R1's sexually inappropriate behaviors were opened on the date of the incident on 01/30/26 and were not finalized until 02/04/26 with a revision that occurred on 02/10/26 by Administrative Nurse H. On 03/02/26 at 12:25 PM, Administrative Staff A said the facility does a social services evaluation on admission that involves the resident's family relationship and support systems that would indicate the presence or absence of a spouse or significant others, as well as the presence of abnormal behaviors, and upon admission, there was nothing on R1. We had very little social history for R1. The facility's Dementia Care policy, dated 01/2016, did not address the topic of sexuality or intimate relationships in persons with a diagnosis of dementia.The facility's Behavioral Health Services Guideline, dated 10/2025, documented that the facility would ensure all residents received necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being. The guideline documented that meaningful activities were critical for preventing challenging behavior in older adults, particularly those with dementia, and behaviors often arise from unmet needs such as boredom, loneliness, or confusion. The guideline documented that inappropriate sexual behavior could occur for a variety of reasons, some of which were related to disease processes and could be verbal or physical in nature. The document defined nonconsensual sexual contact as sexual abuse and required immediate notification due to the immediate threat it presents to others and the potential criminal nature of the act. The document provided potential responses to inappropriate sexual behaviors that included but not necessarily limited to: look for clues to the potential for such behavior, responding firmly and respectfully, redirecting behavior, discuss the behavior with the interdisciplinary team (IDT - a team of individuals from various disciplines who collaborate to provide comprehensive care), ask for help and respect sexual behaviors between consenting, competent adults.

The facility had a census of 70 residents. Based on observation and interview, the facility failed to ensure a clean, safe, homelike environment for the residents who ate in the dining room and the residents who resided on two of the four resident halls. Findings included: - On 01/30/25 at 08:55 AM, observation during a tour of the facility revealed the following: The dining room floor had a broken tile with a missing piece, approximately five by six inches. The dining room exit to the east had missing door trim, and the foam insulation was visible. The dining room wall behind the ice machines had a hole, approximately one foot by two and a half feet, with the inside wall and pipes visible. The northwest resident hall had numerous damaged or ill-fitting ceiling tiles. The northeast resident hall had numerous damaged or stained ceiling tiles. The northeast hall shower room had a framed hole in the wall, approximately 15 by 15 inches, with the pipes and inner wall visible. On 01/30/25 from 08:55 to 09:05 AM, Administrative Staff A verified the findings and stated the facility had not developed plans to repair the maintenance issues observed. The facility's Room Audit policy, dated 09/01/2014, stated damaged drywall, furniture, or nonfunctioning equipment should be noted, and a work order created and addressed to ensure a homelike standard that meets acceptable standards. The facility failed to ensure a clean, safe, homelike environment for the residents who ate in the dining room and the residents who resided on two of the four resident halls.

The facility had a census of 70 residents. The sample included 18 residents, with two reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R) 8 and R62. This deficient practice placed R8 at risk for preventable injury. Findings included: - The Electronic Medical Record (EMR) for R2's diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), cerebrovascular accident (CVA -stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R8's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS documented R8 required substantial assistance with mobility-rolling left to right. The MDS lacked documentation the resident had siderails. R8's medical record recorded a Side Rail Assessment completed on 03/11/24 for assist rails used by the resident, documenting the resident had poor safety awareness due to decreased cognitive function. The side rail safety did not check that the side rails had been measured, the gaps between the rails themselves, or the gaps between the side rails and the mattress were conducive to resident safety as based on this individual resident. The assessment documented the side rail was not a restraint and would be utilized to enable the resident to attain or maintain her highest practicable level. On 01/28/25 at 02:30 PM, a one-half side rail was on the left side of R8's bed. The side rail on the top left side with openings approximately 3.75 inches by 32.0 inches. On 01/28/24 at 04:50 PM, Administrative Staff A and Administrative Nurse E verified the staff should measure the bed rail gaps for safety quarterly or with a significant change in the resident's status, and R8's bed rails had too large of openings. Upon request, the facility failed to provide a side rail policy. The facility failed to adequately assess R8's actual rail in use to ensure safe openings and failed to assess for safe use of a side rail prior to placing it on R8's bed. This deficient practice placed R8 at risk for preventable entrapment, accident, or injury. 26768 - Resident (R) 62's Electronic Medical Record documented diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R62 had no behaviors, required set up with eating, and partial to maximum staff assistance with activities of daily living. R62 was independent with bed mobility and required substantial staff assistance for transfers. The MDS documented R62 used a wanderguard alarm daily and no bed rails. R62's Care Plan, dated 11/30/24, lacked any information regarding the use of bed rails. The Fall Note, dated 10/25/24 at 09:55 AM, documented R62 was found on the floor by his nurse. He was wrapped up in his blankets, and the bed was in the low position. R62 stated he was trying to move his bed. The Fall Follow-up Note, dated 10/25/24 at 11:32 PM, documented R62 was alert to self only with near-continuous confusion regarding the situation and exhibited paranoid and impulsive behaviors at times. R62 remained a high-fall risk due to multiple attempts to stand, transfer, or toilet self. R62 could become difficult to redirect and exhibited instances of agitation and voicing refusal of cares. R62 required the assistance of one staff with transfers, and his gait is very unsteady and uncoordinated. The Side Rail Assessment, dated 12/24/24, was incomplete, and the assessment for measuring gaps was blank. 01/28/25 at 01:02 PM, R62 sat in a chair for an hour prior to lunch across from the nurse's station with his head down, not looking around. On 01/28/25 at 04:20 PM, R62's bedside rails were up on both sides of the bed and had approximately 4.5 by 24-inch gaps between the bars. On 01/29/25 at 04:45 PM, Administrative Nurse D verified staff should have measured the side rails gaps and assessed the side rails quarterly. She verified the width of the gap was greater than 4 and 3/4 inches. On 01/29/25 at 04:50 PM, Administrative Staff A stated staff were to measure bed rail gaps for safety at least quarterly. Upon request, the facility failed to provide a bed rail policy. The facility failed to assess the R62's risk of entrapment by measuring the gaps between the bars for safety. This deficient practice placed R62 at risk for unsafe use of bed rails and preventable entrapment.

The facility identified a census of 71 residents. The sample included 18 residents, with five residents reviewed for falls and accidents. Based on observation, record review, and interviews, the facility failed to implement grip strips in front of Resident (R) 20's toilet and failed to implement anti-rollbacks on his wheelchair. This deficient practice placed R20 at risk for future preventable falls. Findings Include: - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hyperlipidemia (condition of elevated blood lipid levels), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), overactive bladder, dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), psychosis (any major mental disorder characterized by gross impairment in reality perception), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time). The Quarterly Minimum Data Set (MDS) for R20 dated 01/15/24 recorded a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R20 had one fall since admission. The MDS documented R20 had an impairment to one side of his body. The MDS documented R20 needed substantial to maximum assistance with putting on and taking off shoes. The MDS documented R20 needed set up and clean up for oral hygiene and eating. The Significant Change (MDS) for R20 dated 10/15/24 recorded a BIMS score of four, which indicated severely impaired cognition. The MDS documented R20 had a fall with an injury since admission. The MDS documented R20 was impaired on one side of his body. The MDS documented R20 needed substantial to maximum assistance with putting on and taking off shoes. The MDS documented R20 needed set up and clean up for oral hygiene and eating. R20's Falls Care Area assessment dated [DATE] documented R20 had a fall with injury, and staff would implement fall precautions. R20's Care Plan dated 07/30/24 documented R20 had a history of falls, and staff were to encourage R20 to participate in activities that promote exercise and physical activity for strengthening and improved mobility. The nursing staff was to encourage R20 to be cautious and slow when changing elevations to ensure proper circulation to avoid dizziness or disruption in his gait, and staff were to offer toileting every two hours. R20's plan of care documented on 07/30/24 R20 had a fall in his room after tripping over his wheelchair pedals during an attempted self-transfer. R20 did not call for staff assistance, and the intervention was to remove the pedals from R20's wheelchair. R20's plan of care dated 10/13/24 documented a fall with no apparent acute injury, the intervention was that maintenance was to be informed to place grip strips in front of R20's toilet. On 01/01/2025, a documented non-injury falls in his room, and the intervention was that therapy was to evaluate the need for anti-rollback locks to R20's wheelchair dated 01/19/25. On 01/29/24 at 08:30 AM, R20 lay in his bed asleep, with his wheelchair next to his bed. R20 did not have grip strips in front of his toilet, and his wheelchair did not have anti-roll backs on his wheelchair. On 01/130/24 at 10:22 AM, R20 lay in his bed asleep, with his wheelchair next to his bed. R20 did not have grip strips in front of his toilet, and his wheelchair did not have anti-roll backs on his wheelchair. On 01/30/24 at 08:32 AM, Certified Nurse's Aide (CNA) M stated the charge nurse, or the morning meeting team implemented fall interventions. She stated all nursing staff have access to each resident's care plan. On 01/30/24 at 08:40 AM Licensed Nurse (LN) G stated all nursing have access to the resident's care plan, she stated the updated care plans are done by the director of nursing, and nursing staff are updated on what interventions were put in place for falls. On 01/30/24 at 09:13 PM, Administrative Nurse D stated the management team looked over the interventions put in place by nursing. Administrative Nurse D stated she was responsible for following up and ensuring the interventions were put in place had been done. The facility's Fall policy was undated and documented the patient was physically assessed for injuries, and medical attention was rendered as needed. The physician and resident's representative were notified of the fall. A fall huddle was called to investigate circumstances around the fall. The risk event was initiated to capture a detailed description of the event and vital signs, with witness statements and notification of the physician and resident's representative. The risk event prompts the completion of the nurse progress notes and the post-fall analysis (PFA). The post-fall analysis (PFA) was completed to develop all appropriate interventions, record the care plan, review, record notification of caregivers of the new intervention, and documentation of the interdisciplinary team (IDT) decision-making process to prevent future falls. The facility failed to implement grip strips in front of R20's toilet and failed to implement anti-rollbacks on his wheelchair. This deficient practice placed R20 at risk for future preventable falls.

The facility identified a census of 71 residents. The sample included 18 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 7 and R62 posttraumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R7 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R7's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of posttraumatic stress disorder, lupus (an autoimmune disease that makes the immune system damage organs and tissue throughout the body), altered mental status, rheumatoid arthritis (chronic inflammatory disease that affects joints and other organ systems), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and asthma (a disorder of narrowed airways that causes wheezing and shortness of breath). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R7 had no behaviors during the observation period. The MDS documented R7 had received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) drug and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R7 had no behaviors during the observation period. The MDS documented R7 had received antipsychotic medication and antidepressant medication during the observation period. R7's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/03/24 triggered secondary to the use of psychotropic medication to manage psychiatric illness/condition. A licensed nurse monitors for side effects every shift, and the physician was to be notified of any abnormal findings. A pharmacist consultant would review R7's medications monthly, and the physician would review medications with each visit. Contributing factors include the current history of depression, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), mood disorder, and PTSD. Risk factors include increased falls, impaired balance, and potential for adverse effects of medication. R7's care plan would be reviewed to monitor the effectiveness of psychotropic medication and any adverse effects of medication. R7's Care Plan, revised on 09/19/22, documented R7 had a potential psychosocial well-being problem related to a history of depression and PTSD and a disinterest in her favorite activities. Staff were to allow R7 time to answer questions and to verbalize feelings, perceptions, and fears as indicated. Nursing staff were to consult with the pastoral care, social services, and psychological services. R7's plan of care documented if a conflict arises, staff were to remove R7 to a calm and safe environment and allow R7 to vent and share her feelings. R7's plan of care documented staff was to document R7's feelings and provide opportunities for R7 and her family to participate in her care. R7's 'Care Plan lacked documentation of trauma-based triggers and individualized interventions for R7's diagnosis of PTSD. On 01/29/25 at 08:06 AM, R7 was wheeling herself around the halls with her dog, visiting with peers. On 01/29/25 at 09:13 AM, Administrative Nurse E, the MDS coordinator, stated R7 was very private and did not talk about her childhood. Administrative Nurse G stated she would call her resident representative and talk with her about triggers and what staff would need to know to consult R7. On 01/30/25 at 08:32 AM, Certified Medication Aide (CMA) M stated she was unsure if R7 had PTSD. CMA M stated she did not know what R7's triggers were and was unsure what she would do. CMA M stated she would probably call her supervisor. On 01/30/25 at 08:40 AM, Licensed Nurse (LN) G stated she did not know R7 had PTSD as she had not been at the facility very long. LN G stated she would look in her care plan and see what triggers R7 and what she needed to do. On 01/30/25 at 02:33 PM, Administrative Nurse D stated the care plan should be individualized, and the facility would talk to R7 and her family about behaviors or triggers that staff would need to be aware of. Administrative Nurse D stated the facility would update R7's care plan. The facility's Trauma Based Care policy undated documented trauma survivors have unique care needs that must be incorporated into the plan of care. Team members must understand types of traumatic experiences and their impact on residents. Recognition of different kinds of trauma that impact our residents and identifying triggers that may cause negative effects, along with care strategies that can eliminate these triggers and prevent re-traumatization is vital to providing care for our patients. The facility failed to identify trauma-based triggers related to R7's history of trauma and implement individualized interventions to prevent re-traumatization. These deficient practices placed R7 at risk for decreased psychosocial well-being and ineffective treatment. 26768 - Resident (R) 62's Electronic Medical Record documented diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R62 had no behaviors, required set up with eating, and partial to maximum staff assistance with activities of daily living. R62 was independent with bed mobility and required substantial staff assistance for transfers. The MDS documented R62 used a wanderguard alarm daily and no bed rails. R62's Care Plan, dated 11/30/24, directed staff to encourage ongoing family involvement and invite the resident's family to attend special events, activities, and meals. The care plan directed staff to establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and, as necessary, initiated 11/30/24. R62's care plan directed staff to use R62's preferred name. Identify yourself at each interaction. The care plan stated R62 had a diagnosis of Post-Traumatic Stress Disorder related to a history of witnessing a Traumatic Event (military service) and directed staff to allow the patient time to complete tasks without feeling rushed or hurried and provide a calm and reassuring environment, initiated 11/30/2024. The Fall Note, dated 10/25/24 at 09:55 AM, documented R62 was found on the floor by his nurse. He was wrapped up in his blankets, and the bed was in the low position. R62 had a dry brief on, the call light was not activated, and he denied pain or discomfort. R62 stated he was trying to move his bed. The Fall Follow-up Note, dated 10/25/24 at 11:32 PM, documented R62 was alert to self only with near-continuous confusion regarding the situation and exhibited paranoid and impulsive behaviors at times. R62 remained a high-fall risk due to multiple attempts to stand, transfer, or toilet self. R62 could become difficult to redirect and exhibited instances of agitation and voicing refusal of care. R62 required assist of one staff with transfers and his gait is very unsteady and uncoordinated. 01/28/25 at 01:02 PM R62 sat in a chair for an hour prior to lunch across from the nurse's station with head down, not looking around. On 01/28/25 at 03:30 PM, R62 sat in his wheelchair across from the nurse's station, watching people with a flat affect (absence or near absence of emotional response to a situation that would normally elicit emotion). On 01/29/25 at 01:02 PM, Certified Nurse Aide (CNA) N stated she had not been told anything specific to watch for regarding R62's PTSD. On 01/29/25 at 01:20 PM, CNA O stated she had not been made aware of R62's PTSD and did not know what triggers to avoid. On 01/29/25 at 04:02 PM, Administrative Nurse E stated the resident's wife had not reported any issues regarding PTSD, and the facility had not pursued information regarding what might trigger an episode. She verified the care plan lacked information on what triggers to avoid a PTSD episode. The facility's undated Trauma Informed Care policy stated trauma survivors had unique care needs that must be incorporated into the plan of care. Team member must understand types of traumatic experiences and their impact on residents. Recognition of different kinds of trauma that impact our residents and identifying triggers that may cause negative effects, along with care strategies that can eliminate these triggers and prevent re-traumatization was vital to providing care for the residents. The facility failed to ensure care and services for R62 were delivered using approaches that address the needs of trauma survivors by minimizing triggers and/or re-traumatization, placing R62 at risk for re-traumatization.

The facility had a census of 70 residents. Based on observation, interview, and record review, the facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk to receive ineffective medication. Findings included: - On 01/28/25 at 01:35 PM, observation in the facility's only medication room revealed a bottle of 325 milligrams (MG) aspirin tablets with an expiration date of 08/2024 and a bottle of GeriMox (antacid medication), expired 11/2024. On 01/28/25 at 01:35 PM, Licensed Nurse (LN) J verified the expired drugs should have been disposed of. The facility's Medication Storage in the Facility policy, dated April 2020, stated drugs dispensed in the manufacturer's original container would be labeled with the manufacturer's expiration date. All expired medication would be removed from the active supply and destroyed in the facility. No expired medications would be administered to a resident. The facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk to receive ineffective medication.

The facility had a census of 70 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported an inappropriate indication for the use of an antipsychotic medication (a class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 5. This deficient practice placed the resident at risk for unnecessary medications and related side effects. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia with agitation (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition. R5 was dependent upon staff for toileting, lower body dressing, mobility, and transfers. R5 was always incontinent of bladder and frequently incontinent of bowel. R5 received an antipsychotic medication. R5's Care Plan, dated 10/29/24, directed staff to administer medication as ordered and observe for potential drug-related complications associated with the use of psychotropic medication Rexaulti. The 11/07/24 updated care plan directed staff to observe for side effects and report to the physician sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, sweating, loss of appetite, and urinary retention. The care plan documented the medication was used for dementia with agitation, and the facility would obtain consent from the resident/responsible party for the use of psychotropic medications. The care plan documented the facility would consult the pharmacy as needed. The Physician's Order, dated 08/21/24, directed staff to administer Rexaulti, 0.5 mg, by mouth, one time per day, for dementia with agitation. R5's EMR lacked evidence of a physician-documented rationale, which included the risks versus benefits for R5's Rexaulti. The Pharmacy Consult reviews on 09/14/24, 10/19/24, 11/20/24, 12/16/24, and 01/29/25 lacked a recommendation for an appropriate indication for use. R5's clinical record lacked evidence of documented physician rationale, which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of R5's Rexaulti. On 01/29/25 at 08:15 AM, R5 sat at the dining room table, nicely groomed and dressed, eating breakfast. Licensed Nurse (LN) I administered R5's morning medications, including his Rexaulti. On 01/29/25 at 09:00 AM, Administrative Nurse D verified the inappropriate diagnosis of dementia with agitation for R5's use of the Rexaulti medication. The facility's Medication Regimen Review policy, dated 11/28/2016, documented the facility would identify irregularities that require urgent action, that included timely notification, and what, if any, action was taken to address the issues. The policy documented if the Consulting Pharmacist identified an urgent medication irregularity during the medication regimen review that required immediate action, the consulting pharmacist would notify the nurse and request the center contact the attending physician to communicate the issue and obtain direction or new orders. The policy documented that if the attending physician decided to make no changes in the medication, the attending physician would document the rationale in the resident's health record. The facility failed to ensure the Consultant Pharmacist identified and reported to the facility, DON, medical director, and physician the inappropriate indication for R5's use of Rexaulti. This deficient practice placed the resident at risk for inappropriate use of an antipsychotic medication.

The Facility had a census of 70 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 5 had an approved diagnosis or a physician-documented rationale which included risks versus benefits for R5's use of Rexaulti (an antipsychotic class of medication used to treat mental conditions which cause a break from reality), and R 36's Seroquel (an antipsychotic medication)s used to treat major mental conditions which cause a break from reality). The facility further failed to ensure R20 had a 14-day stop date for the use of Ativan (an antianxiety medication). This deficient practice placed the residents at risk for unnecessary medications and related complications. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia with agitation (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition. R5 was dependent upon staff for toileting, lower body dressing, mobility, and transfers. R5 was always incontinent of bladder and frequently incontinent of bowel. R5 received an antipsychotic medication. R5's Care Plan, dated 10/29/24, directed staff to administer medication as ordered and observe for potential drug-related complications associated with the use of psychotropic medication Rexaulti. The 11/07/24 updated care plan directed staff to observe for side effects and report to the physician sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, sweating, loss of appetite, and urinary retention. The care plan documented the medication was used for dementia with agitation, and the facility would obtain consent from the resident/responsible party for the use of psychotropic medications. The care plan documented the facility would consult the pharmacy as needed. The Physician's Order, dated 08/21/24, directed staff to administer Rexaulti, 0.5 mg, by mouth, one time per day, for dementia with agitation. R5's EMR lacked evidence of a physician-documented rationale, which included the risks versus benefits for R5's Rexaulti. The Pharmacy Consult reviews on 09/14/24, 10/19/24, 11/20/24, 12/16/24, and 01/29/25 lacked a recommendation for an appropriate indication for use. R5's clinical record lacked evidence of documented physician rationale, which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of R5's Rexaulti. On 01/29/25 at 08:15 AM, R5 sat at the dining room table, nicely groomed and dressed, eating breakfast, Licensed Nurse (LN) I administered R5's morning medications, including his Rexaulti. On 01/29/25 at 09:00 AM, Administrative Nurse D verified the inappropriate diagnosis of dementia with agitation for R5's use of the Rexaulti medication. The facility's Medication Regimen Review policy, dated 11/28/2016, documented the facility would identify irregularities that require urgent action, that included timely notification, and what, if any, action was taken to address the issues. The policy documented that if the Consulting Pharmacist identified an urgent medication irregularity during the medication regimen review that required immediate action, the consulting pharmacist would notify the nurse and request the center contact the attending physician to communicate the issue and obtain direction or new orders. The policy documented that if the attending physician decided to make no changes in the medication, the attending physician would document the rationale in the resident's health record. The facility failed to ensure an appropriate indication or the required documentation for the use of R5's Rexaulti. This deficient practice placed the resident at risk for adverse side effects. - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hyperlipidemia (condition of elevated blood lipid levels), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), overactive bladder, dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), psychosis (any major mental disorder characterized by gross impairment in reality perception), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time) The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented R20 had an impairment of the extremities on one side of her body. The MDS documented R20 needed substantial to maximum assistance for bathing, dressing, and toileting. The MDS documented R20 had days of feeling down and hopeless. R20's Mood State Care Area Assessment (CAA) dated 10/15/24 documented R20's patient health questionnaire (PHQ) score was 13. R20 reported that he had thoughts in the past of using a gun or pills to end his life. R20's Care Plan dated 10/17/23 documented R20 utilized medication that contained a Black Box Warning (BBW - highest safety-related warning that medications can have assigned by the Food and Drug Administration). The plan of care for R20 documented staff was to reduce the risk of complications and injury related to the use of medication that contains a BBW. The plan of care for R20 documented nursing staff was to administer medications as prescribed by the physician. R20's EMR under the Orders tab revealed the following physician orders: Ativan (antianxiety medication) Oral Tablet 0.5 milligram (mg) (Lorazepam) Give one tablet by mouth every two hours as needed for anxiety date 01/24/25. R20's physician's order for Ativan lacked a 14-day stop date. A review of R20's medical record in Misc. tab revealed a hospice order that documented a stop date for R20's Ativan order of 07/23/25. On 01/29/25 at 09:33 AM, R20 lay in his bed asleep, R20's wheelchair was next to his bed. On 01/30/25 at 09:24 AM, R20 sat in her wheelchair, waiting to go outside to smoke. On 01/30/25 at 08:40 AM, Licensed Nurse (LN) G stated she did not believe residents in hospice care needed a stop date for Ativan. On 01/30/24 at 09:13 AM, Administrative Nurse D stated she was not aware the Ativan order did not have a stop date. Administrative Nurse D stated the nurse taking off the order must have missed the date, and the order should have a 14-day stop date. The facility's Medication Management Review dated 11/16 documented that when the Consultant Pharmacist identified an urgent medication irregularity during MRR that required immediate action, the consultant pharmacist would notify the nurse and request the center contact the attending physician to communicate the issue and obtain direction or new orders. If an irregularity does not require urgent action but should be addressed before the consultant pharmacist's next monthly MRR, the center team and the consultant pharmacist would confer on the timeliness of the attending physician or prescriber's response to identified irregularities based on the specific patient/resident's clinical condition. The center would maintain readily available copies of MRRs on file in the Center as part of the patient/resident's permanent health record. The facility failed to ensure R20's Ativan had a 14-day stop date. This deficient practice placed the resident at risk for unnecessary medication effects. - The Diagnosis tab of R36's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), aphagia (loss of the ability to swallow), dependence on nicotine, bradycardia (low heart rate, less than 60 beats per minute), alcohol liver disease, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated severely impaired cognition. The MDS documented R36 did not have behaviors during the observation period. The MDS documented R36 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The MDS documented R36 needed set up and clean up for oral hygiene and bathing. The MDS documented R36 was independent for eating and dressing. The Annual MDS dated 05/03/24 documented a BIMS score of ten, which indicated moderately impaired cognition. The MDS documented R36 had no behaviors. The MDS documented R36 received antipsychotics during the look-back period. The MDS documented R36 required set and clean-up assistance for eating, bathing, and dressing and was dependent on staff for oral hygiene. R36's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/03/24 documented the care plan would be reviewed to monitor the effectiveness of psychotropic medication and any adverse effects of medication. A licensed nurse monitored for side effects every shift, and the physician would be notified of any abnormal findings. A pharmacist consultant would review R36's medications monthly, and the physician would review medications with each visit. R36's risk factors include increased falls, impaired balance, and potential for adverse effects of medication. R36's Care Plan revised 11/27/24 documented R36 has a potential for drug-related complication associated with the use of psychotropic medications related to diagnoses of anxiety, dementia, and psychosis (any major mental disorder characterized by a gross impairment in reality perception). R36's plan of care documented R36 would have monthly pharmacy reviews of the medication regimen, and staff would observe for any side effects and report all findings to the physician. R36's plan of care documented that the nursing staff would provide medications as ordered by the physician. R36's EMR under Orders documented the following physician's order: Seroquel (antipsychotic medication) oral tablet 25 milligrams (mg), give one tablet by mouth one time a day related to dementia, psychotic disturbance, mood disturbance, and anxiety dated 08/22/24. A review of the Monthly Medication Review (MMR) from January 2024 to December 2024 lacked evidence of recommendations for physician documentation for the rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Seroquel for R36. A review of July 2024 MMR revealed a recommendation for the correct diagnosis for Seroquel for R36, the physician documented the antipsychotic was being used for dementia with behavioral disturbance. On 01/29/24 at 08:15 AM, R36 sat at the breakfast table, R36 sat at a table by himself eating breakfast. On 01/30/24 at 08:40 AM, Licensed Nurse (LN) G stated she was unsure of CMS approved indications for an antipsychotic medication. LN G stated she would ask her supervisor for CMS approved indications for psychotic medication. On 01/30/24 at 09:13 AM, Administrative Nurse D stated she had talked with the physician to clarify the indication for the residents who received antipsychotic medications. Administrative Nurse D stated the physician stated the indication was a recommended dietary allowance (RDA) approved indication for R36's diagnosis and that he did not know about CMS approval. The facility's Medication Management Review dated 11/16 documented that when the Consultant Pharmacist identified an urgent medication irregularity during MRR that required immediate action, the consultant pharmacist would notify the nurse and request the center contact the attending physician to communicate the issue and obtain direction or new orders. If an irregularity does not require urgent action but should be addressed before the consultant pharmacist's next monthly MRR, the center team and the consultant pharmacist would confer on the timeliness of the attending physician or prescriber's response to identified irregularities based on the specific patient/resident's clinical condition. The center would maintain readily available copies of MRRs on file in the Center as part of the patient/resident's permanent health record. The facility failed to ensure a CMS appropriate indication for the use of an antipsychotic for R36's Seroquel medication. This deficient practice placed R36 at risk for unnecessary psychotropic medications, related complications, and adverse side effects.

The facility identified a census of 64 residents, which included one resident reviewed for accidents and identified 12 residents that were confused and independently mobile. Based on observation, interview, and record review the facility failed to ensure cognitively impaired Resident (R)1 remained free from accident hazards when on 07/15/24 at approximately 10:15 AM, R1 left the facility through an unsecured gate in the west courtyard. R1 remained unsupervised until Law Enforcement Officers (LEO) contacted R1 outside of a local business, located approximately 2.8 miles away from the facility, at 11:10 AM (55 minutes after R1 left the facility unsupervised and without staff knowledge). R1 did not return to the facility until approximately 11:25 AM (one hour and 10 minutes after R1 left the facility). This deficient practice had the potential to lead to serious bodily harm to R1 and placed R1 in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) for R1 included the following diagnoses: unspecified psychosis (any major mental disorder characterized by a gross impairment in reality perception), history of traumatic brain injury (TBI - an injury to the brain caused by external forces), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), falls, cognitive communication deficits, and other symptoms involving cognitive functions and awareness. The Admission Minimum Data Set (MDS) dated [DATE] documented a staff assessment of R1's cognition as severely impaired. The assessment documented R1 had other behaviors not directed at others, which occurred 1-3 days during the seven-day look-back period, these behaviors interfered with the resident care, the resident's social activities, social interactions, and intruded on the privacy of others. The assessment documented that R1 had no wandering behaviors, he required extensive assistance with toileting, and limited assistance with dressing and personal hygiene, but was otherwise independent with his cares. R1 was frequently incontinent of bowel and bladder, had no history of falls, received an antipsychotic medication (a class of medications used to treat major mental conditions which cause a break from reality) daily during the seven-day look-back period. The assessment documented that R1 did not wear a wandering or elopement alarm. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 08/01/23 documented R1 had a BIMS score of 00, which indicated severely impaired cognition. The Communication CAA, dated 08/01/23 documented R1 had an impaired ability to understand others through verbal communication. The Behavioral CAA, dated 08/01/24 documented R1 had behavioral symptoms present. The Care Plan in place on 07/15/24 documented on 07/31/23 R1 was at risk for elopement related to previous attempts to elope and history of wandering and provided the following interventions: On 07/31/23, staff were to educate family and/or responsible party to talk positively about resident's placement at the facility. On 07/31/23, staff were to encourage family to bring in personal possessions. On 07/31/23, staff were to evaluate the effect of cognitive impairment upon R1's ability to understand changes in the environment. On 07/31/23, staff were to introduce R1 to his peers. On 07/31/23, staff were to involve R1 in activities of his choosing. On 07/31/23, staff were to redirect R1 away from exit doors due to R1's risk for elopement. On 07/31/23, staff were to obtain a photograph of R1 for identification and place the photograph in the elopement book. The Care Plan interventions added on 07/17/24 (after R1 left the building without staff knowledge and unsupervised) included reinforcing staff to redirect R1 away from exit doors and the utilization of a WanderGuard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) with instructions for staff to assess placement and function each shift. The facility's investigation of the elopement revealed the following information: On 07/15/24 at approximately 10:10 AM, an Administrative Nurse witnessed R1 ambulating in the courtyard window (as he was care planned to do). On 07/15/24 at approximately 10:15 AM, an independent lawn care contractor entered the west courtyard and left the north gate in the west courtyard unlocked and unsecured. On 07/15/24 at approximately 10:20 AM, another resident alerted staff she was concerned that the lawn care contractor left the courtyard gate open and R1 could no longer be seen from the window in her room. Staff then alerted leadership and initiated elopement protocol with an overhead announcement of Code [NAME]. On 07/15/24 from approximately 10:25 AM to 10:38 AM, the facility initiated a room-to-room search and noted R1 to be missing. Staff expanded their search to the courtyards where the lawn care contractor identified R1 as having left the courtyard and headed to the south. Staff re-secured the previously unlocked gate. On 07/15/24 at 10:38 AM, local law enforcement was notified R1 was missing, and the leadership team went out in vehicles to search for R1. On 07/15/24 at 10:40 AM, R1's guardian, family, and PCP were notified. On 07/15/24 at 10:41 AM, law enforcement arrived to the building and Administrative Staff A provided them with a statement and recent photo of R1. On 07/15/24 at 11:01 AM, law enforcement received a report that a person matching R1's description was located at a nearby business (approximately 1.2 miles away) walking south. On 07/15/24 at 11:10 AM, law enforcement made contact with R1 at a local business (approximately 2.8 miles away) and ensured R1's safety awaiting facility staff to come get R1. On 07/15/24 at 11:15 AM, Administrative Staff A arrived to the local business with law enforcement and made contact with R1. On 07/15/24 at approximately 11:19 AM, Administrative Staff A had R1 in her vehicle, where he reported he went through the gate that the guy left open. R1 reported no injuries. On 07/15/24 at approximately 11:25 AM, R1 and Administrative Staff A returned to the facility. R1 was assessed for injuries, and none were discovered. R1 was provided with water and a shower. Facility staff initiated one-on-one supervision for R1. Review of historical meteorological data from the National Weather Service (www.weather.gov) on 07/15/24 at 10:00 AM documented ambient temperature of 90 degrees Fahrenheit (?) with heat index of 93?, at 11 am, 95? with heat index of 98?, and at noon, 98? with heat index of 99?. There was clear sky with wind 17 miles per hour (mph) out of the southwest. On 09/05/24 at 12:14 PM, R1 observed wandering in hallway, through dining area and back into the hallway. On 09/15/24 at 12:32 PM, Certified Nurse Aide (CNA) C stated if staff discovered a resident missing, they would immediately tell the nurse, then follow whatever instructions were provided. CNA C confirmed since the incident with [NAME] 07/15/24, the facility provided training and frequent elopement drills had occurred. On 09/15/24 at 01:25 PM, CNA D stated if a resident was suspected to be missing, they were to immediately tell the nurse, then follow the instructions provided. CNA D confirmed that since the incident with R1 on 07/15/24 the facility provided training and frequent elopement drills had occurred. On 09/15/24 at 01:28 PM, Licensed Nurse (LN) E stated that if a resident was suspected or confirmed missing that nursing staff would announce a Code [NAME] over the overhead speakers and administration would get involved. Staff would be directed to monitor each exit, initiate a headcount, and if a resident was discovered missing after a headcount, law enforcement would be notified, and the staff would follow the instructions of law enforcement and administration. LN E confirmed since the incident with R1 on 07/15/24 the facility provided extensive education and elopement drills frequently occurred. On 09/05/24 at 01:30 PM, Maintenance Director F stated that in the event of a suspected or confirmed elopement that he would follow the instructions given by administration. He confirmed that since the incident on 07/15/24 that corrective measures were initiated and that he was responsible to check the locks on the gates at the start of every day and delegated this task to other maintenance personnel when he was not working so that the checks were performed every day. Maintenance Director F further stated that he performed checks on the exterior doors three times weekly to ensure that the magnetic locks were functioning properly and that the WanderGuard system was operational. Maintenance Director F confirmed the facility provided training since the incident with R1 on 07/15/24 and that he regularly participated in elopement drills. On 09/05/24 at 01:33 PM, Activities Director (AD) G stated that in the event of a suspected or confirmed elopement staff were to tell the nurse then follow whatever instructions were provided. AD G confirmed that since the incident with R1 on 07/15/24 the facility provided extensive training and that the facility regularly conducted elopement drills. On 09/05/24 at 09:53 AM, Administrative Staff A stated that in the event of a suspected or confirmed elopement, the staff member would contact the licensed nurse who would initiate the elopement protocol. Administration would be alerted and would direct the search, which included notification of law enforcement if needed. After the resident was returned to the facility, the resident would be assessed for injuries and treated appropriately, if required. The facility would then investigate the root cause of the elopement and develop/implement new interventions or adjust existing interventions to mitigate the risk for additional elopement. Observation of the exterior of the facility revealed a large courtyard on the west side with an 8-foot wrought iron fence that had two gates approximately four feet wide, which were secured with padlocks. The facility's Elopement policy dated 04/2017 documented the facility would have processes in place to mitigate the occurrences of elopements that included assessing residents on admission or when a newly identified elopement risk was identified. The facility would then develop and implement an individualized plan that established interventions to mitigate the risk of elopement. Further, the policy documented steps to follow when an elopement did occur as well as multiple suggestions for staff interventions to address residents at risk for elopement. The facility failed to ensure that R1 remained free from accident hazards when on 07/15/24 at approximately 10:15 AM, cognitively impaired R1 left the facility, without staff knowledge and unsupervised, through an unsecured gate in the west courtyard. R1 remained unsupervised until Law Enforcement Officers (LEO) contacted R1 outside a local business, located approximately 2.8 miles away, at 11:10 AM (55 minutes after R1 left the facility). R1 did not return to the facility until approximately 11:25 AM (one hour and 10 minutes after R1 left the facility). This deficient practice had the potential to lead to serious bodily harm to R1 and placed R1 in immediate jeopardy. On 09/05/24 at 03:20 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) Template for the failure of the facility to provide an environment free of accident hazards for R1. The facility immediately implemented corrective measures following R1's return to the facility with Administrative Staff A on 07/15/24 at approximately 11:25 AM. The facility's corrective measures included the following which were verified by the surveyor on-site during the investigation: 1. The facility initiated 1:1 supervision of R1 and continued until 07/26/24 at 03:40 PM. 2. The facility changed the locks on the gates to require keys that only Administrative Staff A and Maintenance Director F carry completed 07/15/24. 3. The facility informed lawn care contractors that in order to enter or exit the courtyard that staff must be present to allow access and/or egress completed 07/15/24. 4. The facility immediately initiated a facility wide re-education related to elopement of all staff and no staff that were off duty were allowed to return to work without completing the education and was completed on 07/16/24 at approximately 02:00 PM 5. The facility initiated daily lock checks on all locked gates which was an ongoing intervention. 6. The facility performed new admission elopement evaluations on all newly admitted residents, which was an ongoing intervention. 7. The facility initiated weekly elopement drills every shift for one month, then every shift monthly for three months and then reevaluate in with the quality assurance process improvement (QAPI) meetings, which was an ongoing process/intervention. 8. The facility addressed elopement in QAPI and audited/updated elopement evaluations on all existing residents which was completed 07/15/24. 9. The facility assessed and updated R1's care plan to include checking of WanderGuard every shift and updating photo in elopement book and was completed 07/15/24. 10. The facility requested a psychological evaluation to be completed by psych provider to rule out any additional underlying causes for elopement and exit-seeking behavior and was completed on 07/24/24. 11. The facility requested a medication regimen review (MRR) requested from pharmacist and was completed 07/25/24. 12. The elopement policy was reviewed by Administrative Staff A and corporate staff on 07/15/24 to ensure that no updates were required. All corrections were completed prior to the onsite survey, therefore the deficient practice was cited as past noncompliance and remained at a scope and severity of a J.

The facility reported a census of 57 residents. The facility had one main kitchen where food was stored and prepared serving one dining room. Based on observation, interview, and record review the facility failed to properly store food in the main kitchen refrigerators and freezers due to boxes placed directly on the floor and foods left uncovered; failed to discard expired foods and failed to store opened food products in accordance with professional standards for food service safety, to prevent food borne illness to the residents. Findings included: - During the brief initial tour of the kitchen, on [DATE] at 07:46 AM, the following items were discovered: 1. The walk-in refrigerator had a sheet pan with shredded potatoes spread on it and a sheet pan with five cups of fruit on it open to air without a cover on either of them. 2. The walk-on freezer had approximately 10 various food boxes sitting directly on the floor with 30 boxes stacked on them. 3. The walk-in refrigerator had a box of lettuce open to air and wilted and not dated. 4. The bread rack contained one loaf of bread with a use by date of [DATE]. 5. The kitchen had two large storage bins with dark scratches covering most of the lid of each of them (making them uncleanable). On [DATE] at 07:46 AM, Dietary Staff CC stated she would date and seal any unused food products. She stated they should not be left open in the refrigerator or freezer. She confirmed the food boxes should not be sitting on the floor of either walk-in. Dietary Staff CC confirmed the expired bread. On [DATE] at 02:22 PM, Dietary Manager (DM) BB confirmed boxes should not be directly on the floor in either of the walk-ins. DM BB confirmed the expired bread should have been discarded. DM BB stated she would have to investigate replacing the lids to the bins. The facility's policy Food Storage dated [DATE] documented all items will be stored on shelves at least six inches above the floor. All packaged food items will be properly sealed. Storage areas will be neat, arranged for easy identification, and date marked. The facility failed to properly store food in the main kitchen refrigerators and freezers due to the boxes being directly on the floor and the open food items, also the lack of food items dated, labeled, and not resealed for food service safety for the residents.

The facility census totaled 57 residents with 17 sampled, including six residents for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure adequate monitoring for six of the six residents reviewed, by not following up timely on pharmacy consultant recommendations for Resident (R)15, R 14, R 21, R 25, R 41, and R 29. These failures placed the residents at risk for adverse effects related to medication use. Findings included: - R 15's signed physician orders dated 03/01/23 revealed the following diagnoses: hypertension (elevated blood pressure) atherosclerotic heart disease (where the arteries become narrowed and hardened due to buildup of plaque [fats] in the artery wall), pain, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hypokalemia (low level of potassium in the blood), sexual dysfunction, hyperlipidemia (condition of elevated blood lipid levels), delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), gastro-esophageal reflux disease (backflow of stomach contents to the esophagus),mild intellectual disabilities, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. The resident had no behaviors and received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications. Review of the quarterly MDS dated [DATE], revealed no significant changes in condition or medications. The Care Area Assessment (CAA) dated 10/07/22 revealed: Psychotropic Drug Use: Psychotropic Drug Use CAA triggered secondary to use of psychotropic medication to manage psychiatric illness/condition. A licensed nurse monitors for side effects every shift, and the physician is to be notified of any abnormal findings. A pharmacist consultant will review medications monthly and the PCP will review medications with each visit. Contributing factors include current history of depression/psychosis/bipolar. Review of the Consulting Pharmacist Medication Regimen Review (MRR) identified the following concerns: On 05/20/22, the records lacked a Pharmacist Medication Regimen Review. On 12/14/20 a physician order instructed nurses to monitor pulse and blood pressure weekly for antihypertensive medication (Lasix & lisinopril). notify MD if systolic blood pressure is less than 90 or greater than 200 or pulse less than 50 beats per minute. On 08/16/22, R 15 had pulse documented as 46 on 08/08/22, but no physician notification. On 09/27/22, R15's physician notified of low pulse on 08/08/22, a total of 51 days later. The records lacked a Pharmacist Medication Regimen Review for September 2022. On 12/21/22, pharmacist recommendation to consider a trial gradual drug reduction (GDR) for Provera (female hormone) 5 milligram (mg) in the evening, for sexual dysfunction. The physician followed up with Must discuss with psychiatrist, a total of 43 days later. This was not followed up by the facility, and on 02/23/23, the pharmacist made an additional comment to please ensure the recommendation is forwarded to appropriate provider. As of 03/28/23 no record was provided by Administrative Nurse D to indicate the recommendation had been sent to appropriate provider. On 03/23/23 at 08:12 AM, observation revealed the resident was happy and smiling with no behaviors. On 03/23/23 at 11:37 AM, CNA S reported the resident would yell at times but was pleasant most of time. On 03/27/23 at 01:20 PM, CNA T reported the resident sometimes yells but not often. She is often distracted by what is going on around her. On 03/27/23 at 12:44 PM, Administrative Nurse D reported the provider should look at the MRR in seven days. Sometimes staff send the pharmacy consultant reviews out three or four times. It's difficult to get them back from the provider. They are faxed every Monday, and a sticky note is placed on a folder, and if no response received back in the last week, she would re-fax the recommendation back to the provider. Sometimes it takes a while to get them fixed. On 03/29/23 at 10:52 AM, consultant HH stated he had no issues since the new director of nurses' (DON) came on board. Prior to that, he had to send the recommendations multiple times. He now sends one to the facility and one to the provider. He confirmed he had trouble with the providers responding to his recommendations, and the facility failed to follow-up on the recommendations. The facility's Medication Regimen Review policy dated 11/28/16, documented the center would encourage the provider receiving the MRR to act upon the recommendations contained in the MRR. The provider would document the identified irregularity had been reviewed and what, if any, action had been taken. The center would maintain readily available copies of the MRR's on file in the center as part of the resident's permanent health record. The facility failed to ensure adequate monitoring for R 15 by not following up timely on pharmacy consultant recommendations. These failures placed R 15 at risk for adverse effects related to medication use. - R 41's signed physician orders dated 02/27/23 revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), psychosis (any major mental disorder characterized by a gross impairment in reality testing), atrial fibrillation (rapid, irregular pulse), liver disease (chronic degenerative disease of the liver), chronic obstructive pulmonary disease (COPD is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and congestive heart failure (CHF is a condition with low heart output and the body becomes congested with fluid). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The resident did not have behaviors. The resident received antipsychotic, antidepressant, anticoagulant and opioid pain medications. Review of the Quarterly MDS dated [DATE] revealed the resident had a decline in cognition. The resident had no other significant changes. The Mood state Care Area Assessment (CAA) dated 07/18/23 revealed the Psychosocial CAA triggered secondary to feelings of trouble falling asleep, feeling tired and trouble concentrating. Contributing factors included the diagnoses of insomnia (difficulty sleeping) and anxiety. Risk factors included decreased socialization, worsening insomnia and anxiety. The Care Plan dated 02/16/2022 revealed the facility would have a monthly medication regimen review. The physician orders dated 05/24/22 revealed amiodarone, 200 mg, give 1 tablet by mouth in morning and one table in evening, for atrial fibrillation. Review of the consulting Pharmacist Monthly Medication Review revealed the following: On 04/25/22, the pharmacist medication review included the resident received amiodarone 200 mg twice a day. Recommendation for a thyroid function test (blood work) at base line and then a follow-up thyroid stimulating hormone (TSH) concentration (blood tests to monitor the thyroid function), monitor hepatic function (blood to monitor the liver function) at baseline every six months. Monitor pulmonary function tests at baseline then periodically based on symptoms, Obtain a chest x-ray at baseline and at least annually. Obtain electrocardiogram (ECG monitors the heart's health) at baseline and at least annually. Monitor Ophthalmologic function using funduscopic exam at baseline with unanticipated visual changes and annually. Monitor blood pressure and apical pulse weekly. The facility failed to follow-up with the pharmacist recommendation. On 03/28/23, the physician lacked response to the recommendation. On 04/25/22 the pharmacist documented to please consider decreasing amiodarone to 200 milligrams (mg) daily for atrial fibrillation (rapid, irregular heartbeat). The facility failed to follow-up with the pharmacist recommendation. On 03/28/23 the physician lacked response to the recommendation. On 08/16/22, the pharmacist consultant documented the resident received acetaminophen containing medications without a documented maximum daily dose. The records lacked a response to the recommendation. On 08/16/22, the pharmacist documented the recommendation from 06/29/22 had not been acted upon. The record lacked follow-up from the recommendation from 06/29/22. On 10/31/22 the pharmacist documented that the pharmacy recommendations for 09/28/22 had not been acted upon. Review of the resident record lacked recommendations from 09/28/22. Review of the resident record had no consulting pharmacist recommendations for November 2022. On 03/23/23 at 08:00 AM, the resident propelled his wheelchair to the dining room for breakfast. The resident was alert but quiet. Observation on 03/27/23 at 04:30 PM, revealed the resident propelled his wheelchair towards the dining room. The resident was pleasant to the staff but only answered questions asked of him. He did not initiate conversation. On 03/27/23 at 12:44 PM, Administrative Nurse D reported the provider should look at the MRR in seven days. Sometimes staff have to send the pharmacy consultant reviews out three or four times. It's difficult to get them back from the provider. They are faxed every Monday, and a sticky note is placed on a folder, and if no response received back in the last week, she would re-fax the recommendation back to the provider. Sometimes it takes a while to get them fixed. On 03/29/23 at 10:52 AM, consultant HH stated he had no issues since the new director of nurses' (DON) came on board. Prior to that, he had to send the recommendations multiple times. He now sends one to the facility and one to the provider. He confirmed he had trouble with the providers responding to his recommendations, and the facility failed to follow-up on the recommendations. The facility's Medication Regimen Review policy dated 11/28/16 documented the center would encourage the provider receiving the MRR to act upon the recommendations contained in the MRR. The provider would document the identified irregularity had been reviewed and what, if any, action had been taken. The center would maintain readily available copies of the MRR's on file in the center as part of the resident's permanent health record. The facility failed to ensure adequate monitoring for R 41 by not following up timely on pharmacy consultant recommendations. These failures placed R 41 at risk for adverse effects related to medication use. 41302 - R21's 03/23/23 Electronic Health Record (EHR) documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness) and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The 12/23/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The assessment documented the use of an anticoagulant (a class of medications that inhibit the coagulation of the blood) and an antidepressant medication daily for R 21. The Physicians Orders documented an order dated 04/15/22 for primidone (a medication used to treat seizures), 50 milligrams, (mg) three times a day, that the physician changed to 100 mg three times daily, on 06/13/22. On 09/19/22 the changed the primidone order to 150 mg three times a day, that changed to 200 mg three times a day on 01/04/23 until 03/24/23. The physician ordered on 09/12/22 diclofenac gel topically to the left shoulder every 12 hours as needed (the order lacked a dosage amount). Review of the Lab Results obtained since 05/19/22, revealed the lack of any trough concentration results. Review of the monthly Pharmacy Medication Record Review (MRR) for April 2022 through January 2023, revealed they documented several months recommendation to the facility to monitor the resident's primidone and phenobarbital trough concentrations on the next convenient lab day, one week after the dose changed, every six months, and as clinically indicated. Recommendations also included to monitor labs of complete blood count (CBC) and complete metabolic profile (CMP) at baseline and every six months. Rationale for recommendation: Primidone use is associated with agranulocytosis (A serious condition that occurs when there is an extremely low number of granulocytes (a type of white blood cell) in the blood) and megaloblastic anemia (a form of anemia characterized by very large red blood cells and a decrease in the number of those cells). A phenobarbital concentration is recommended as primidone is metabolized to phenobarbital. A recommendation on 01/26/23 for a dosage for the diclofenac gel which was signed in agreement on 02/01/23 with no dose noted on the Medication Administration Record as of 03/22/23 (a total of 50 days after the physician signed the order). On 03/27/23 at 09:09 AM, Certified Medication Aide (CMA) KK confirmed R 21 received primidone daily. CMA KK could not remember using the diclofenac gel for R 21. On 03/27/23 at 02:53 PM, Administrative Nurse D confirmed she was responsible for completion of the MRR's and that the recommendations for R 21 had not been processed appropriately. She stated the provider should respond to the MRR within seven days, they fax them back if they are not in the building to sign them. The licensed nurses can complete them if they are returned via fax and placed in the medical records box to be processed and taken off her list. On 03/29/23 at 10:52 AM, consultant HH stated he had no issues since the new director of nurses' (DON) came on board. Prior to that, he had to send the recommendations multiple times, he now sends one to the facility and one to the provider. He confirmed he had trouble with the providers responding to his recommendations. The facility's Medication Regimen Review policy dated 11/28/16, documented the center would encourage the provider receiving the MRR to act upon the recommendations contained in the MRR. The provider would document the identified irregularity had been reviewed and what, if any, action had been taken. The center would maintain readily available copies of the MRR's on file in the center as part of the resident's permanent health record. The facility failed to adequately monitor medication use for R 21, by the failure to obtain the recommended labs and document the dosage of the diclofenac gel. - R29's 03/23/23 Electronic Health Record (EHR) documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The 01/02/23 Annual Minimum Data Set (MDS) documented an interview with staff indicating severely impaired cognition. The assessment documented the use of an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication six days of the seven-day look back, one day out of the seven-day look back received an antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication. R29 received an opioid, an antibiotic, and a diuretic (medication to promote the formation and excretion of urine) medication four out of the seven-day look back. The 10/12/22 Quarterly MDS documented a brief interview for mental status (BIMS) of one, indicating severely impaired cognition. R29 received an antipsychotic, an antidepressant, an anticoagulant, and a diuretic medications daily in the seven-day look back. R29 received an antianxiety medication one of the seven-day look back. The Physicians Orders documented an order dated 04/18/22, for alprazolam (a medication used to treat anxiety), 0.25 milligrams, (mg) every eight hours as needed (PRN) for anxiety. Review of the Medication Administration Record (MAR) from May 2022 through December 2022 documented R29 received the PRN alprazolam seven additional times past the 14-day limit. Review of the monthly Pharmacy Medication Record Review (MRR) for April 2022 through January 2023, documented the pharmacist consultant recommended: On 04/25/22 a recommendation to the facility that the center for Medicaid and Medicare services (CMS) requires that as needed (PRN) orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time, and the duration for the PRN order. No physician response noted. On 08/16/22 the same recommendation, with no physician response noted. On 10/31/22 the same recommendation, with no physician response noted. And again on 11/29/22 the same recommendation, with a physician response noted on 12/07/22 that documented to use for anxiety, for an additional year, and there was a continued need. On 03/27/23 at 09:09 AM, Certified Medication Aide (CMA) R stated CMAs were unable to administer alprazolam, as it would be the nurse responsibility. On 03/23/23 at 07:55 AM Licensed Nurse (LN) H confirmed only the LN could administer alprazolam and he could not remember the last time he administered the PRN to the resident. On 03/27/23 at 02:53 PM, Administrative Nurse D confirmed she was responsible for completion of the MRR's and that the recommendations for R29 had not been processed appropriately. She stated the provider should respond to the MRR within seven days, they fax them back if they are not in the building to sign them. The licensed nurses can complete them if they are returned via fax and placed in the medical records box to be processed and taken off her list. On 03/29/23 at 10:52 AM, consultant HH stated he had no issues since the new director of nurses' (DON) came on board. Prior to that, he had to send the recommendations multiple times, he now sends one to the facility and one to the provider. The facility's Medication Regimen Review policy dated 11/28/16, documented the center would encourage the provider receiving the MRR to act upon the recommendations contained in the MRR. The provider would document the identified irregularity had been reviewed and what, if any, action had been taken. The center would maintain readily available copies of the MRR's on file in the center as part of the resident's permanent health record. The facility failed to follow-up on the pharmacist recommendation in a timely manner for this resident that had an order for a PRN antianxiety medication past the 14 days, as required. 46960 - R25's pertinent diagnoses from the Electronic Health Record (EHR) documented schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Review of 25's annual Minimum Data Set (MDS), dated [DATE] documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication and an antidepressant medication seven out of seven days in the look-back period. Review of 25's quarterly MDS, dated [DATE] documented a BIMS of 13, indicating intact cognition. The resident received antipsychotic and antidepressant medications seven out of seven days in the look-back period. The EHR Physician Orders documented: 1. Zyprexa (olanzapine) 5 milligrams (mg), to be given by mouth (orally) in the morning, related to schizoaffective disorder, dated 04/22/22. 2. Zoloft (sertraline) 50 mg, to be given orally in the morning, related to schizoaffective disorder, dated 02/09/23. Review of consultant pharmacist monthly medication regimen review (MRR) documents provided by the facility included: 1. A MRR dated 09/28/22, revealed the pharmacist requested a gradual dose reduction (GDR) for Zoloft (sertraline) and Zyprexa (olanzapine). However, the documents lacked a physician signature and lacked follow-up documentation from the facility. 2. A MRR dated 11/29/22, revealed the pharmacist requested staff to follow up with an outstanding pharmacy recommendation dated 09/28/22 for GDR for Zoloft (sertraline) and Zyprexa (olanzapine). The document signed by Administrative Nurse D, dated 12/19/22. This was 83 days after the initial recommendation from the consultant pharmacist, and 21 days after the second recommendation/reminder from the consultant pharmacist. The facility was unable to provide additional documentation for this MRR. 5. A MRR dated 12/21/22, revealed the consultant pharmacist again requested staff to follow up on the outstanding pharmacist recommendation originally dated 08/28/22 for GDR for Zoloft (sertraline) and Zyprexa (olanzapine). The Physician documentation of must discuss with psychiatry dated 02/01/23. This was 127 days after the initial recommendation. The facility did not provide any additional documentation for this MRR/GDR. On 03/22/23 at 11:23 AM, R 25 observed to have pill-rolling motion isolated to the right hand. On 03/27/23 at 12:44 PM, Administrative Nurse D reported she faxes the MRR to providers when she receives them from the pharmacist. Additionally, she stated that providers should review the MRR within seven days and reported difficulty with getting physicians to respond. Administrative Nurse D stated that every Monday, if she hasn't heard back from the physician, she re-faxes it to providers. Further states that the expectation is for nursing staff to act upon the return faxes from the physician on the day it is received. On 03/29/23 at 10:52 AM, consultant HH stated he had no issues since the new director of nurses' (DON) came on board. Prior to that, he had to send the recommendations multiple times, he now sends one to the facility and one to the provider. He confirmed he had trouble with the providers responding to his recommendations for follow-up. The facility's Medication Regimen Review policy dated 11/28/16 documented the center would encourage the provider receiving the MRR to act upon the recommendations contained in the MRR. The provider would document the identified irregularity had been reviewed and what, if any, action had been taken. The center would maintain readily available copies of the MRR's on file in the center as part of the resident's permanent health record. The facility failed to ensure adequate monitoring for 25's by not following up timely or acting upon the pharmacy consultant recommendations. These failures placed 25's at risk for adverse effects related to medication use. - Review of R14's pertinent diagnoses from the Electronic Health Record (EHR) documented bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), post-traumatic stress disorder (PTSD - psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture), systemic lupus erythematosus (SLE - an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs) and rheumatoid arthritis (RA - a long-term autoimmune disorder that primarily affects joints and other organ systems, causing warm, swollen and painful joints). Review of R14's significant change Minimum Data Set (MDS), dated [DATE] documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication and an antidepressant medication seven out of seven days in the look-back period. Review of the Psychotropic Drug Use Care Area Assessment (CAA), dated 05/12/22 documented use of psychotropic medication usage due to psychiatric illness/condition. Further documented licensed nurse to monitor for side effects. Review of R14's quarterly MDS, dated [DATE] documented a BIMS of 12, indicating moderate cognitive impairment. The resident received antipsychotic medication and antidepressant medication seven out of seven days in the look-back period. The care plan documented: 1. Dated 06/06/19, use of medications that have a black box warning [Prozac (fluoxetine - an antidepressant) and Abilify (aripiprazole - an antipsychotic)] and instructed staff to monitor for and document signs and symptoms of side effects and notify the physician if present. 2. Dated 06/06/19, use of antidepressant medications [Prozac (fluoxetine)] and instructed staff to monitor, document and report adverse reactions such as behavior changes. 3. Dated 06/06/19, use of psychotropic mediations [Abilify (aripiprazole)] and instructed staff to monitor, document and report adverse reactions such as behavior changes. The EHR Physician Orders included: 1. Abilify (aripiprazole) 10 milligrams (mg), to be given by mouth (orally) at bedtime, related to bipolar disorder, dated 02/06/23. 2. Prozac (fluoxetine) 20 mg, 4 capsules (80 mg total) to be given orally in the morning, related to major depressive disorder, dated 09/10/22. 3. Doxycycline (an antibiotic) 100 mg, to be given orally one time per day, for antibiotic therapy, dated 02/25/23. The physician order for doxycycline, dated 4/14/22 was revised/reordered on 02/24/23 changing indication for use from for knee wound to for antibiotic therapy. Review of the consultant pharmacist monthly medication regimen review (MRR) documents provided by the facility included: 1. A MRR dated 03/30/22, revealed the pharmacist requested an abnormal involuntary movement scale (AIMS is an assessment tool) be performed and repeated at least every six months related to Abilify (aripiprazole) use. However, the document lacked signature from the facility and lacked follow-up from the facility. 2. A MRR dated 05/20/22, revealed the pharmacist requested a stop date for doxycycline or rationale if doxycycline could not be discontinued. However, the document lacked a physician signature and lacked follow-up from the facility. 3. A MRR dated 05/20/22, revealed the pharmacist requested an AIMS assessment be performed and repeated at least every six months related to Abilify (aripiprazole) use. However, the document lacked signature from the facility and lacked follow-up documentation from the facility. 4. A MRR dated 07/23/22, revealed the pharmacist requested a stop date for doxycycline or rationale if doxycycline could not be discontinued. However, the document lacked a physician signature but noted that R14 was a patient of a different physician. The document lacked follow-up from the facility. 5. A MRR dated 08/16/22, revealed the pharmacist requested follow up for outstanding recommendations that were dated 07/23/22. The document signed by Administrative Nurse D, dated 09/27/22. This was 67 days after the initial recommendation from the consultant pharmacist, and 43 days after the second recommendation/reminder from the consultant pharmacist. The facility was unable to provide additional documentation for this MRR. 6. A MRR dated 10/31/22, revealed the pharmacist requested an abnormal involuntary movement scale (AIMS is an assessment tool) be performed and repeated at least every six months related to Abilify (aripiprazole) use. However, the document lacked signature from facility and lacked follow-up documentation from the facility. 7. A MRR dated 11/29/22, revealed the pharmacist requested a stop date for doxycycline or rationale if doxycycline could not be discontinued. However, the document lacked a physician signature and lacked follow-up documentation from the facility. 8. A MRR dated 12/21/22, revealed the pharmacist requested an abnormal involuntary movement scale (AIMS is an assessment tool) be performed and repeated at least every six months related to Abilify (aripiprazole) use. The document signed by Administrative Nurse D, dated 01/24/23. This is 301 days after the initial recommendation from the consultant pharmacist and 35 days after the recommendation/reminder from the consultant pharmacist. The facility was unable to provide additional documentation for this MRR. 9. A MRR dated 01/26/23, revealed the pharmacist requested follow up for outstanding recommendations that were dated 11/29/22. The document signed by Administrative Nurse D, dated 02/16/22. This was 80 days after the initial recommendation from the consultant pharmacist, and 22 days after the second recommendation/reminder from the consultant pharmacist. The facility was unable to provide additional documentation for this MRR. On 03/27/23 at 12:44 PM, Administrative Nurse D reported she faxes the MRR to providers when she receives them from the pharmacist. Additionally, she stated that providers should review the MRR within seven days and reported difficulty with getting physicians to respond. Administrative Nurse D stated that every Monday, if she hasn't heard back from the physician, she re-faxes it to providers. Further states that the expectation is for nursing staff to act upon the return faxes from the physician on the day it is received. On 03/29/23 at 10:52 AM, consultant HH stated he had no issues since the new director of nurses' (DON) came on board. Prior to that, he had to send the recommendations multiple times, he now sends one to the facility and one to the provider. He confirmed he had trouble with the providers responding to his recommendations for follow-up. The facility's Medication Regimen Review policy dated 11/28/16 documented the center would encourage the provider receiving the MRR to act upon the recommendations contained in the MRR. The provider would document the identified irregularity had been reviewed and what, if any, action had been taken. The center would maintain readily available copies of the MRR's on file in the center as part of the resident's permanent health record. The facility failed to follow-up on the consultant pharmacist medication recommendations related to required assessments due to psychotropic medications and antibiotic use. These failures placed R14 at risk for adverse effects related to medication use.

The facility census totaled 57 residents residing on four halls in the facility. Based on observation, record review, and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment by the failure to repair walls where they were scuffed into the dry wall and paint missing on three out of four halls and elevated noise levels on the two south halls that were unacceptable to residents voicing complaints about noise levels. Findings included: - Observation, on 03/22/23 10:21 AM, revealed large gouges in a wall by the head of the bed in a room on the 100 hall. Several areas where walls have been hit and paint was gone noted on the south halls. On 03/28/23 at 11:00 AM, a tour of the facility with Maintenance Staff U revealed several areas on the south two halls where paint and plaster were scuffed off on the walls. The wall in a resident room on a north hall revealed a large deep gouge approximately 10 inches in diameter on the wall by the head of the bed. The area had paint and plaster missing. Interview, on 03/22/23 at 11:30 AM, with Maintenance Staff U reported he did a preventative checklist for the more mechanical things in the facility on his TELS (preventative maintenance) program. When it came to fixing holes in walls in resident rooms and halls, he relied on staff to turn in work orders for repair and he had no work order for the resident's wall. He also said as residents leave (discharged ), he will check the room to make sure it is in good repair before another resident moved in. Review of the Policy for the TELS program, dated 2015, provided a work order tab for team members to submit work orders for repairs needed to the facility. The facility failed to provide a safe, clean, comfortable, and homelike environment by the failure to repair walls where they were scuffed into the dry wall and paint missing on three out of four halls. - On 03/22/23 at 11:20 AM, an unidentified resident voiced concern related to too much noise coming from the hallways. While discussing the concern with the resident, the surveyor was able to hear clearly staff talking in the hallway through the closed door. On 03/23/23 at 12:35 AM, during a staff interview in the hallway, the surveyor observed an unidentified CNA conversing with a resident in the hallway, loud enough to be heard with approximately 50 feet between them. On 03/27/23 at 02:55 PM, the survey team members sat in a room off the hallway, all team members were able to clearly hear staff conversing in the hallway to include periods of loud laughter. On 03/28/23 at 07:45 AM, the surveyor sat in a room off the south hallway and was able to clearly hear staff conversing in the hallway to include periods of loud laughter. On 03/28/23 at 10:30 AM, Administrative Staff A made aware of the resident concerns with the loud noise levels in the halls. Administrative Staff A reported there would be education of staff and monitoring on all hallways to assure the noise levels would be acceptable to all the residents. The facility was unable to provide a policy related to noise control. The facility failed to provide a comfortable and homelike environment by the failure to monitor elevated noise levels on the two south halls that were unacceptable to residents voicing complaints about the loud noise levels.

The facility reported a census of 57 residents, with 17 sampled, including six residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to adequately monitor three of the six residents reviewed, that included R 21 for laboratory tests to monitor effective medication use, R15 related to monitoring of vital signs, and R14 related to adequate indication/rationale for R14. Findings included: - R 21's 03/23/23 Electronic Health Record (EHR) documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness) and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The 12/23/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The assessment documented the use of an anticoagulant (a class of medications that inhibit the coagulation of the blood) and an antidepressant medication daily for R 21. The Physicians Orders documented an order dated 04/15/22 for primidone (a medication used to treat seizures), 50 milligrams, (mg) three times a day, that the physician changed to 100 mg three times daily, on 06/13/22. On 09/19/22 the physician changed the primidone order to 150 mg three times a day, that changed to 200 mg three times a day on 01/04/23 until 03/24/23. The physician ordered on 09/12/22 diclofenac gel topically to the left shoulder every 12 hours as needed (the order lacked a dosage amount). Review of the April 2022 through February 2023 Medication Regimen Review documented multiple recommendations for labs to be completed to monitor this medication. Review of the Lab Results obtained since 05/19/22, revealed the lack of any trough concentration results. On 03/27/23 at 09:09 AM, Certified Medication Aide (CMA) KK confirmed R 21 received primidone daily. CMA KK could not remember using the diclofenac gel for R 21. On 03/27/23 at 02:53 PM, Administrative Nurse D confirmed R 21 had not had the labs drawn that were requested. The facility failed to produce a policy for unnecessary medications as requested on 03/28/23. The facility failed to adequately monitor for unnecessary medication use with the use of the primidone and also failed to clarify a documented dosage for the diclofenac gel. 31078 - R 15's signed physician orders dated 03/01/23 revealed the following diagnoses- hypertension (elevated blood pressure) atherosclerotic heart disease (where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall.), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The resident had no behaviors and received antipsychotic and antidepressant medications. The Care Area Assessment (CAA) dated 10/07/22 revealed: Cognitive Loss CAA triggered secondary to orientation, memory, and recall deficits noted during BIMS interview. Contributing factors include dementia. Risk factors include self-care deficits, falls and injuries, incontinence, decreased socialization, skin breakdown, weight loss, and fluid imbalance. The Care Plan dated 08/19/19 revealed the resident had a diagnosis of hypertension and instructed staff to administer medications per the provider's orders. Avoid taking the blood pressure reading after physical activity or emotional distress. Initiated on 08/19/2019. Give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (tachycardia) and effectiveness. Initiated on 08/19/2019. Monitor and record use and side effects of antihypertensive medications. Report to the physician as necessary. Initiated on 08/19/2019. Obtain blood pressure readings as indicated. Take blood pressure readings under the same conditions each time. Initiated on 08/19/2019. On 12/14/20 a physician order instructed nurses to monitor the resident's pulse and blood pressure weekly for antihypertensive medication (Lasix & lisinopril) and to notify the physician if systolic blood pressure is less than 90 or greater than 200 or pulse less than 50 beats per minute (bpm). On 08/08/22, R 15 had a pulse documented as 46, but no physician notification until 09/27/22, a total of 51 days later. On 03/23/23 at 08:12 AM observation revealed the resident was happy and smiling with no behaviors. On 03/27/23 at 01:20 PM CNA T reported the resident was often distracted by what was going on around her. On 03/27/23 at 12:44 PM Administrative Nurse D reported she expected the resident to be monitored per physician orders and the physician notified at that time and note any new orders received. The facility lacked a policy for medication administration. The facility failed to ensure adequate monitoring for R 15 by not following up timely on physician ordered vital signs. These failures placed R 15 at risk for adverse effects related to medication use. 46960 - Review of R14's pertinent diagnoses from the Electronic Health Record (EHR) documented systemic lupus erythematosus (SLE - an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs) and rheumatoid arthritis (RA - a long-term autoimmune disorder that primarily affects joints and other organ systems, causing warm, swollen and painful joints). Review of R14's significant change Minimum Data Set (MDS), dated [DATE] documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident received an antibiotic seven out of seven days in the look-back period. Review of the Care Area Assessment (CAA), dated 05/12/22 lacked documentation related to antibiotic use. Review of R14's quarterly MDS, dated [DATE] documented a BIMS of 12, indicating moderate cognitive impairment. The resident received antibiotics seven out of seven days in the look-back period. The care plan dated 10/20/19, use of antibiotics and instructed staff to monitor for and document signs and symptoms of side effects as well as secondary infections related to antibiotic use and notify the physician if present. The EHR Physician Orders included: 1. Doxycycline (an antibiotic) 100 milligrams (mg), to be given orally one time per day, for antibiotic therapy, dated 02/25/23. The physician order for doxycycline, dated 4/14/22 was revised/reordered on 02/24/23 changing indication for use to antibiotic therapy from for knee wound. Review of the consultant pharmacist monthly medication regimen review (MRR) documents provided by the facility included: 1. A MRR dated 05/20/22, revealed the pharmacist requested a stop date for doxycycline or rationale if doxycycline could not be discontinued. However, the document lacked a physician signature and lacked follow-up from the facility. 2. A MRR dated 07/23/22, revealed the pharmacist requested a stop date for doxycycline or rationale if doxycycline could not be discontinued. However, the document lacked a physician signature but noted that R14 was a patient of a different physician. The document lacked follow-up from the facility. 3. A MRR dated 08/16/22, revealed the pharmacist requested follow up for outstanding recommendations that were dated 07/23/22. The document signed by Administrative Nurse D, dated 09/27/22. This was 67 days after the initial recommendation from the consultant pharmacist, and 43 days after the second recommendation/reminder from the consultant pharmacist. The facility was unable to provide additional documentation for this MRR. 4. A MRR dated 11/29/22, revealed the pharmacist requested a stop date for doxycycline or rationale if doxycycline could not be discontinued. However, the document lacked a physician signature and lacked follow-up documentation from the facility. 5. A MRR dated 01/26/23, revealed the pharmacist requested follow up for outstanding recommendations that were dated 11/29/22. The document signed by Administrative Nurse D, dated 02/16/22. This was 80 days after the initial recommendation from the consultant pharmacist, and 22 days after the second recommendation/reminder from the consultant pharmacist. The facility was unable to provide additional documentation for this MRR. On 03/27/23 at 12:44 PM, Administrative Nurse D reported she faxes the MRR to providers when she receives them from the pharmacist. Additionally, she stated that providers should review the MRR within seven days and reported difficulty with getting physicians to respond. Administrative Nurse D stated that every Monday, if she hasn't heard back from the physician, she re-faxes it to providers. Further states that the expectation is for nursing staff to act upon the return faxes from the physician on the day it is received. On 03/29/23 at 10:52 AM, consultant HH stated he had no issues since the new director of nurses (DON) came on board. Prior to that, he had to send the recommendations multiple times, he now sends one to the facility and one to the provider. He confirmed he had trouble with the providers responding to his recommendations for follow-up. The facility's Medication Regimen Review policy dated 11/28/16 documented the center would encourage the provider receiving the MRR to act upon the recommendations contained in the MRR. The provider would document the identified irregularity had been reviewed and what, if any, action had been taken. The center would maintain readily available copies of the MRR's on file in the center as part of the resident's permanent health record. The facility failed to obtain adequate indication or rationale for this resident's antibiotic therapy, as required.

The facility reported a census of 57 residents, with 17 sampled, including two residents sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide care consistent with standard of practice for Resident (R) 165 and R 163 to maintain good grooming and personal hygiene. - The 03/23/23 Electronic Health Record (EHR) documented R 163 had the following diagnosis of orthopedic aftercare (aftercare following a joint replacement). The 02/14/23 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, indicating intact cognition. The assessment noted that it was very important for R 163 to choose what to wear and to choose between a shower or a bath. R 163 required extensive assistance of one staff for all ADL. R 163 was totally dependent on one staff for bathing. The 02/14/23 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R 163 needed extensive assistance with all ADL. The 03/03/23 Care Plan lacked documentation regarding bathing preferences for R 163. The Progress Notes January 2023 through March 2023 lacked documentation of refusals of showers/baths by R 163. The Tasks document in the last 30 days, eight scheduled opportunities, R 163 received four showers with no refusals noted. On 03/23/23 at 02:11 PM, R 163 observed lying in her bed. On 03/23/23 at 02:11 PM, R 163 revealed she wiped herself down every day and that she only received showers from staff when she asked for one. On 03/23/23 at 08:51 AM, Certified Nurse Aide (CNA) O revealed she was the bath aide on this date, but that the CNA on the northwest hall would give R 163 her showers. On 03/23/23 at 08:55 AM, CNA JJ revealed she was on the northwest hall, but that the shower aide would give the baths/showers. She stated she did not usually work on the hall that the resident resided in. On 03/23/23 at 09:04 AM, LN G revealed staff should document showers in the electronic record as well as on shower sheets that the nurse would sign and place in the medical records box. On 03/27/23 at 02:53 PM, Administrative Nurse D revealed she expected her staff to provide bathing as per the residents' preference, to document it in the electronic record, on a shower sheet, and the nurse to make a progress note. The facility did not provide a policy related to bathing. The facility failed to provide care consistent with professional standard of practice, for R 163 to maintain good grooming, and personal hygiene. - The 03/23/23 Electronic Health Record (EHR) documented R165 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type II. The 11/02/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of seven, indicating severely impaired cognition. R165 required limited assistance of one staff for all activities of daily living (ADL). The assessment noted that bathing did not occur. The 11/02/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R165 needed assistance with all ADL. The assessment noted that bathing did not occur. The 02/02/23 Quarterly MDS documented a BIMS of nine, indicating moderately impaired cognition. R165 required supervision to set up of one staff for all ADL. The 02/17/23 Care Plan lacked documentation regarding bathing preferences or staff required to assist R165 with bathing. The Progress Notes January 2023 through March 2023 lacked documentation of refusals of showers/baths by R165. The Tasks document in the last 30 days, eight scheduled opportunities, R165 received two showers. R165 had refusals noted on 03/19/23, 03/20/23, 3/22/23, and 03/23/23. On 03/22/23 at 09:15 AM, Certified Nurse Aide (CNA) Q assisted R165 to prepare for the day and provided physical assistance with his ADL. CNA Q assisted R165 to change his clothing. On 03/23/23 at 08:48 AM, R165 observed sitting up in his wheelchair and staff had set up his morning meal and he was eating. On 03/23/23 at 08:51 AM, CNA O stated she was the bath aide, but that the CNA on the evening shift would give R165 his showers. She stated staff should document bathing in the electronic record, on a paper shower sheet, and given to the nurse after completion of the resident's bathing. On 03/23/23 at 09:04 AM, LN G revealed staff should document showers in the electronic record as well as on shower sheets that the nurse would sign and place in the medical records box. On 03/27/23 at 02:53 PM, Administrative Nurse D revealed she expected her staff to provide bathing as per the residents' preference, to document it in the electronic record, on a shower sheet, and the nurse to make a progress note. The facility did not provide a policy related to bathing. The facility failed to provide care consistent with professional standard of practice, for R165 to maintain good grooming, and personal hygiene.

The facility reported a census of 57 residents with 17 selected for review, including two residents for participation in care planning. Based on interview and record review, the facility failed to include Residents (R)14 and 49 in their care planning. Findings included: - On 03/22/23 at 10:02 AM, R14 stated that she was unable to recall having been to a care plan meeting in a long time but was unable to specify how long. On 03/22/23 at 11:42 AM, R49 stated that he did not recall ever having attended a care plan meeting since his admission to the facility in 08/2022. On 03/23/23 at 03:52 PM, Certified Nurse Aide (CNA) M revealed care plan meetings happened on first shift, and she had never been invited to attend. On 03/23/23 at 04:18 PM, Licensed Nurse (LN) I revealed care plan meetings happened every three months. On 03/27/23 at 12:06 PM, Social Services X revealed she was only employed in her current role for a few months. She stated prior to her employment, care plan meetings had not been done for reasons that were unknown to her. She was able to produce an attendance roster for 02/18/22 for R49 and 02/09/22 for R14. Further, she stated she was unable to provide documentation for any care plan meetings for all of 2022. On 03/27/23 at 11:25 AM, Administrative Nurse D revealed care plan meetings were scheduled quarterly and were coordinated by Social Services X and activities staff. The facility lacked a policy related to care plan meetings and failed to include R14 and R49 in the planning of their care.

The facility census totaled 57 residents with 17 included in the sample. Based on interview, record review the facility failed to revise the care plans for two residents by the failure to care plan injury and treatment to Resident (R11) shoulder injury and R 165's facility acquired pressure ulcer. Findings included: - R 11's signed physician orders dated 03/21/23 revealed the following diagnoses: hemiplegia and hemiparesis (paralyzed on one side of body) following cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting right dominant side and muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident required extensive assistance with transfers and toilet use. The resident used a walker or wheelchair for locomotion. The resident had impaired range of motion in his upper and lower extremities on one side, and the resident had no falls. The Care Area Assessment (CAA) dated 11/04/22 revealed: Activities of Daily Living (ADL) Function CAA triggered secondary to assistance required in ADLs, impaired balance and transition during transfers, and functional impairment in activity. Contributing factors included decreased safety awareness. Risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain. The Care Plan dated as revised on 11/29/22 revealed the resident had an ADL self-care performance deficit. The resident required assistance of one staff for bathing, transfers, and ambulation. The resident required physical help in part of the bathing activity with one-person physical assist with bathing and showering at least twice weekly and as necessary and requested. Revised on 01/10/22. The resident requires extensive assistance with two plus person physical assist to turn and reposition in bed. Revised on 04/20/21. The resident required extensive assistance with one-person physical assist for toileting. Revised on 04/20/21. The care plan lacked interventions for his injured shoulder that required a sling for stabilization and a decline in ADLs from the shoulder injury. It also lacked interventions for more assistance with eating, repositioning and transfers due to the injury to the shoulder. The physician's orders included: Hydrocodone (narcotic pain medication) 5-325 milligram (mg), 1 tab every 6 hours as needed (PRN) pain. Duration 5 days. Follow up with Orthopedic Physician in 2 weeks, dated 03/21/23. Occupational Therapy (OT) evaluate and treat the left shoulder, dated 03/23/23. Sling to the resident's left arm always except for bathing for Subluxation (incomplete or partial dislocation) of the resident's left shoulder joint, dated 03/23/23. On 03/18/23 at 02:12 AM, a nursing progress note revealed the resident complained of severe left shoulder and neck pain. The nurse administered the resident Tylenol 500 mg, two tablets as ordered for pain. Nursing staff repositioned the resident, but the resident decided to get into his wheelchair to sit at the nursing desk as he said he was keeping his roommate awake. Nurse assessed the resident's shoulder with range of motion normal for the resident. The resident denied a headache or any other areas of pain. The resident denied knowing of any recent injury, occurrence that could have strained his left extremity. On 03/20/23 at 09:50 AM, a nursing progress note revealed the resident resting in bed, and yelled out in pain, complained that his left shoulder hurt. The nurse assessed the shoulder and noted left shoulder to be swollen. The resident complained of pain with touch or any movement to the left shoulder. The nurse gave Tylenol 500 mg, two tablets at 09:05 AM for pain. Physician notified and to see physician on 03/20/23 at 02:20 PM. On 03/21/23 at 10:06 AM, a nursing progress note revealed the resident had an appointment with the physician with an x-ray of the left shoulder. The physician then sent the resident to hospital emergency department for evaluation of a dislocated left shoulder. On 03/21/23 at 03:02 AM, staff received a call from the hospital in relation to the resident's status. The resident admitted to orthopedic unit to have surgery in the morning for the dislocated left shoulder. On 03/21/23 at 01:05 PM, the resident returned to facility via facility van. An orthopedic physician reviewed the x-ray and reported the shoulder was not dislocated and did not need surgery. The resident was to always keep a sling on his left arm except for bathing. The resident required assistance for eating. The physician wrote an order for Hydrocodone 5-325 mg, one tab every six hours, as needed for pain for five days. Follow up with orthopedic physician in two weeks. The resident was assisted to bed via full lift. Resting quietly with eyes closed at this time. Observation on 03/23/23 at 08:00 AM revealed the resident was in his bed on his right side. He had a sling on his left arm and shoulder. Observation on 03/23/23 at 12:00 PM revealed the resident sat up in his bed and had his lunch tray on his over the bed table. Certified Nursing Assistant (CNA) S sat by the resident's bed assisting him with his lunch tray. The resident was eating well with water and juice for him to drink. Observation on 03/27/23 at 11:30 AM revealed Licensed Nurse (LN) H and CNA T as they transferred the resident to the wheelchair using a mechanical lift for lunch. The resident was alert and wanting to get out of bed for lunch. On 03/23/23 at 02:30 PM CNA/CMA Q reported she unaware how the resident injured his shoulder. The resident requires a sling on his arm and requires extensive assistance of two staff. Previously, he was able to transfer by himself. On 03/27/23 at 4:00 PM, CNA T reported the resident was one assist for eating and drinking though assistance of two for transfers. He should always wear that sling on his shoulder., staff need to feed the resident because the injury is his only good arm. On 03/28/23 at 9:30 AM, LN G reported the resident used that arm for everything. He would not call for help and try to do things like dressing himself with his one arm. He was always reaching for things he knew he could not reach such as on top of the refrigerator in the hall and overextending his arm. He also pulled on the turn bar on his bed hard, so she wasn't surprised when he hurt it but did not really know how it happened. She reported she did not update the care plans and did not know she was to do that. The assessment nurse was responsible to update the care plans. On 03/28/23 at 10:45 AM Administrative Nurse E reported when a resident returned from the hospital or had new orders, the nurse or herself should update (revise) the care plan with any changes. On 03/28/23 at 11:00 AM Administrative Nurse D reported she expected staff to revise the care plans to reflect the care the resident required. The facility failed to provide a policy related to revision of care plans. The facility failed to revise the care plan for R 11 to guide staff in the resident's cares when this resident's ADLs declined after the resident required a sling for his left shoulder injury. 41302 - The 03/23/23 Electronic Health Record (EHR) documented R165 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type II. The 11/02/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of seven, indicating severely impaired cognition. R165 required limited assistance of one staff for all activities of daily living (ADL). The 11/02/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R165 needed assistance with all ADL. The 02/02/23 Quarterly MDS documented a BIMS of nine, indicating moderately impaired cognition. R165 required supervision to set up of one staff for all ADL. The 02/17/23 Care Plan documented R165 had a self-care deficit, that staff were to make sure R165 had on comfortable shoes that were not slippery and that R165 required staff assistance to ambulate. The care plan lacked guidance to the staff related to the resident's pressure area identified on 03/22/23. Furthermore, the care plan also lacked shower preferences for R165. The 03/23/23 Progress Note documented the resident had an area to the right foot on the outer side of the bottom of the foot. The note documented the area as calloused, with a dark hard area in the center. The documentation lacked measurements. The Tasks document in the last 30 days, eight scheduled opportunities, R165 received two showers. R165 had refusals noted on 3/19/23, 3/20/23, 3/22/23, and 3/23/23. On 03/23/23 at 08:48 AM, R165 observed sitting up in his wheelchair and staff had set up his morning meal and he was eating. On 03/23/23 at 09:04 AM, LN G revealed she could update the care plan, but rarely did as the management team usually did that. On 03/27/23 at 02:53 PM, Administrative Nurse D revealed she expected her staff to keep care plans updated. On 03/28/23 at 10:45 AM Administrative Nurse E reported when a resident returned from the hospital or had new orders, the nurse or herself should update (revise) the care plan with any changes. The facility's Skin Care Guidelines policy, dated July 2018, documented staff were to update the care plan to address change in skin condition including interventions for each problem/risk factor. The facility failed to produce a bathing policy as requested on 03/28/23. The facility failed to update R165's care plan to guide staff related to this resident's pressure area. In addition, the facility failed to update the resident related to this resident's shower preferences.

The facility reported a census of 57 residents which included 17 selected for review. Based on interview and record review, the facility failed to accurately complete a comprehensive assessment on resident (R)33, related to the resident's cognition. Findings include: - Review of R33's diagnoses from the Electronic Health Record (EHR) documented history of falls, osteoporosis (a degenerative age-related condition of the bones which causes them to be brittle and susceptible to breaking) and fracture of upper end of the resident's [left] humerus (a broken upper arm bone). Review of the 09/16/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of not assessed indicating that R33's cognition was not assessed. Documented a total severity score of not assessed indicating that R33 was not assessed for depression symptoms. The Care area assessment dated [DATE], lacked documentation related to the resident's cognitive or mental status. The care plan, dated 03/23/23, lacked guidance related to the resident's cognition or mental status. On 03/28/23 at 10:08 AM, Administrative Nurse E stated that she was new to the position after the documentation in the 09/16/22 MDS and was unable to provide rationale as to why it was incomplete. Additionally stated that the person who documented the assessment was remotely (not physically in the building and assessing the resident) doing the assessment. Further stated that in the event of her absence, she should delegate the in-person assessments of the MDS to a licensed nurse in the building. On 03/28/23 at 10:52 AM, Administrative Nurse D stated that at the time of R33's admission, the regional transitional RNAC (Registered Nurse Assessment Coordinator) specialist dashed a lot of MDS's which indicated that the assessments were not completed. Administrative Nurse D stated that her expectation was that all assessment fields on the MDS should be completed and assessed. The facility's policy RAI Process Guideline, dated 09/2020 documented that the facility would ensure that the process included direct observation and communication with the residents. The facility failed to complete an accurate comprehensive admission assessment on the MDS and an analysis of findings on resident (R)33, related to the resident's cognition and mood score.

The facility reported a census of 57 residents with 17 selected for review. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident (R)33 and R14 when certified nurse aide (CNA) P, and Licensed Nurse (LN)H entered R33's room without knocking. Findings included: - On 03/22/23 at 09:00 AM, during interview with R33, a CNA P opened the door and entered the resident's room without knocking or announcing herself then promptly left. On 03/22/23 at 04:45 PM, R14, a resident with post-traumatic stress disorder (PTSD - psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture) stated that approximately three to four months prior, a staff member walked into her room without knocking or announcing themselves. R14 revealed that she was changing her clothes at the time, and the incident caused her emotional distress due to the intrusion into her personal privacy and dignity. On 03/23/23 at 12:04 PM, during an interview with R33, LN H opened the door and partially entered resident's room without knocking or announcing himself and asked her lunch preference then left the room. LN H identity revealed by Administrative Nurse F who was in the room with surveyor. On 03/22/23 at 02:12 PM, CNA P stated that upon entrance to a resident's room, staff are supposed to knock on the door and announce themselves before entering. On 03/23/23 at 04:18 PM, LN I stated that entrance to a resident's room should be after knocking and announcing self. For routine cares, staff were to wait for the resident to acknowledge staff before entering the resident's room. During staff rounds, if the resident did not answer their door, nursing personnel were allowed to briefly look in the room to assess if the resident was in distress. On 03/23/23 at 12:11 PM, Administrative Nurse F stated staff was expected to knock and announce their presence then wait for the resident to acknowledge them before entering a resident's room. She stated staff were allowed to stick their head in a resident's room if they were checking on them. She further stated that it was acceptable to enter a resident's room without knocking or announcing themselves if an emergency existed. The facility's Social Services Manual, dated 05/01/12 documented that staff should knock and request permission to enter a resident's room for every entry. Further documents that an exception to this practice was if a life-threatening situation existed or if the resident was unable to respond. The facility failed to protect the privacy and dignity of Resident (R)33 and R14 when staff entered resident rooms without knocking.

The facility reported a census of 57 residents, with 17 sampled, including two residents sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failure to perform skin assessments to identify a pressure area for Resident (R) 165, allowing an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured) pressure ulcer to develop. Findings included: - The 03/23/23 Electronic Health Record (EHR) documented R165 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type II. The 11/02/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of seven, indicating severely impaired cognition. R165 required limited assistance of one staff for all activities of daily living (ADL). The MDS noted R165 had no PU, no open lesions of the foot, no diabetic foot ulcers, and no skin issues. The 11/02/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R165 needed assistance with all ADL, and it was a contributing factor for skin breakdown. The care plan would be initiated/reviewed to decrease risk of PU for R165. The 11/02/22 Pressure Ulcer CAA, documented R165 admitted with the risk of development of PU. Licensed staff should perform a skin assessment weekly and staff would observe the resident's skin with cares. The 02/02/23 Quarterly MDS documented a BIMS of nine, indicating moderately impaired cognition. R165 had no PU documented. The 02/17/23 Care Plan documented staff were to perform daily skin checks of R165's feet. The Electronic Health Record (EHR) Physician Orders lacked documentation of daily skin assessments from 11/01/22 until an order dated 03/23/23, which instructed staff to monitor calloused area to the outer side bottom of the right foot for changes. On 03/17/23, the Progress Note documented R165 returned from a hospitalization stay in a wheelchair. A visual head to toe skin assessment completed and noted R165's skin was clean, dry, and intact. On 03/23/23, a Progress Note documented R165 had an area to the right foot on the outer side of the bottom of the foot. The noted documented the area as calloused, with a dark hard area in the center. The documentation lacked measurements or further description or staging of the area identified. The weekly Skin Assessments dated 02/16/23, 02/25/23, 03/04/23, and 03/17/23 each documented R165's skin was intact. On 03/24/23, (the day after a progress note indicated the callous area) noted R165's skin was intact. On 03/23/23 at 07:56 AM, R165 rested in his bed with his right foot resting directly on the mattress. No pressure relieving devices in place. On 03/27/23 at 08:45 AM, R165 stated that he was having pain and when asked where he stated that foot pointing to his right foot. An observation and interview on 03/22/23 at 09:15 AM, Certified Nurse Aide (CNA) Q assisted R165 to prepare for the day and when asked about the approximately 1.5 centimeter (cm) circular dark black area with unmeasurable depth and raised edges on R165's right bottom outer foot, she stated she had not seen that before. CNA Q stated she would get the nurse to assess the foot. On 03/23/23 at 08:42 AM, Certified Nurse Aide (CNA) N stated she was unaware of any skin issues for R165. On 03/22/23 at 09:15 AM, Licensed Nurse (LN) G assessed R165's right foot and stated it was the first time she had seen this circular dark area, and that it could have been a calloused area. On 03/23/23 at 09:04 AM, LN H revealed he was the wound nurse on this date. He confirmed he was unaware of any skin issues for R165. LN H confirmed as the wound nurse, he should be informed of any new skin issues. On 03/27/23 at 02:53 PM, Administrative Nurse D revealed she expected her staff to perform complete skin assessments at the time of return from the hospital after 10 day absence. Administrative Nurse D confirmed the area on R165's foot had not been noticed prior to her and LN G when asked to assess it on the morning of 03/22/23. At that time, LN G informed the provider and obtained orders to monitor the area. On 03/20/23 at 09:50 AM, call was returned by physician GG who revealed he had no note or knowledge of the pressure area for R165. The facility's Skin Care Guidelines policy, dated July 2018, documented the goal was to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for the care of changes/disruptions in skin integrity. All those admitted would be observed for baseline skin condition and evaluated for risk. The findings would be documented in the EHR. Residents would be observed by the nurse aide team members daily for changes in skin condition. These changes would be documented in the EHR. The facility failed to provide care consistent with professional standard of practice, to adequately assess and identify a newly developed unstageable pressure ulcer to R165

The facility reported a census of 57 residents with 17 selected for review which included one resident for accident hazards. Based on observation, interview and record review, the facility failed to provide a safe environment when staff placed a call light out of the reach of Resident (R)33. Findings include: - R33's diagnoses from the Electronic Health Record (EHR) documented history of falls, osteoporosis (a degenerative age-related condition of the bones which causes them to be brittle and susceptible to breaking) and a fracture of the upper end of (left) humerus (a broken upper arm bone). Review of R33's Admission Minimum Data Set (MDS), dated [DATE] lacked complete documentation for cognition (brief interview for mental status). Documented that the resident required limited assistance of one to two staff for all ADLs (activities of daily living). Further documented one fall without injury prior to admission. Review of R33's quarterly MDS, dated [DATE], documented a brief interview for mental status (BIMS) of 14, indicating intact cognition, and the resident required supervision and setup with transfers, ambulation in the room, and required limited assistance on one person with toileting. Further documented one fall without injury since admission/prior assessment. The Falls Care Area Assessment (CAA) dated 09/16/22, revealed that the resident was at increased risk for falls and injury due to impaired gait (manner of walking) and mobility, and level of assistance required with transfers. The resident had a fall before and after admission to the facility. The care plan, dated 03/23/23, revealed the resident had a risk of falls related to history of falls before admission that included an intervention to place the resident's call light within reach and to encourage R33 to utilize it for assistance. The Physician's orders lacked documentation of orders specific for fall prevention. Review of the resident's assessments revealed fall risk screening, dated 09/09/22 and 09/29/22, however the assessment lacked scoring to indicate the level of risk. On 03/23/23 at 11:59 AM, R33 observed to be sitting upright inside the bedroom in a recliner with a pillow behind her head. The call light clipped to the upper left corner of her pillow. R33 reported that she could not see the call light button. R33 attempted to reach the call light with her right arm but was unable due to pain reported to her fractured left arm. On 03/23/23 at 12:01 PM, Administrative Nurse F alerted to the call light out of reach of the resident. Administrative Nurse F placed the call light in reach of R33's right hand and stated that her expectation of staff was to place call lights within easy reach of all residents. The 09/01/14 facility's policy for Nurse Call System documented that the call light cord was to be visible and reachable by the resident. The facility failed to provide a safe environment when staff placed a call light out of the reach of resident (R)33. This deficient practice placed R33 at an increased risk of injury from falls.

The facility had a census of 59 residents. The sample included 3 residents. Based on record review and interview, the facility failed to adequately follow the physician's orders [REDACTED]. Physician orders [REDACTED]. The facility provided the resident with a regular diet peanut butter sandwich for a snack. The resident choked on the sandwich and died . The deficient practice placed the resident in immediate jeopardy. Findings included: - Review of resident #1 ' s signed physician's order [REDACTED]. Review of the significant change MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview for mental status) score of 7 indicating severe cognitive impairment. The resident required supervision of 1 staff for eating and received a mechanically altered diet (required change in texture of food or liquids such as pureed food, thickened liquids). The resident was edentulous (without teeth) and had no swallowing problems. He/she received speech therapy 2 days during the 7 day look back period. Review of the Nutritional status CAA (Care Area Assessment) dated [DATE] revealed fed him/herself with assistance from staff as needed related to tremors. He/she received a mechanical soft diet with honey thick liquids and currently worked with speech therapy. The resident was alert and oriented, able to make his/her needs known, and had an average meal intake of ,[DATE]%. Review of resident #1 ' s Quarterly MDS dated [DATE] revealed a BIMS score of 6 which indicated severe cognitive impairment. The resident required extensive assistance of 1 staff for eating, and received a mechanically altered diet. Review of the resident ' s nutrition care plan dated [DATE] revealed the resident had weight loss upon return from the hospital, continued to have difficulty with chewing and currently utilized speech therapy. The resident returned from the hospital with a mechanical soft diet and thickened liquids; and he/she asked the staff for help with eating at times. Review of the speech therapy discharge summary dated [DATE] revealed the resident currently received a mechanical soft diet with nectar thick liquids. The summary indicated the speech therapy staff downgraded the resident ' s diet to pureed texture with nectar thickened liquids. Review of the Nutritional Status review dated and signed by the Registered Dietician on [DATE] revealed a diet order of puree with nectar thickened liquids for a [DIAGNOSES REDACTED]. Review of the diet education binder located in the behavioral unit dated 2014, revealed education for the Dysphagia Puree (level 1) diet. The diet included foods to avoid such as peanut butter unless a part of a complete pureed recipe that was easy to swallow and regular breads or any non-pureed or non-slurried (mixed with liquids and blended) breads/starch foods. Review of a nurse note dated [DATE] at 8:45 PM revealed staff called licensed nurse to the dining room around 4 PM. Resident #1 was trying to cough with no sounds heard from him/her. Staff C asked the resident if he/she was choking and the resident nodded his/her head indicating he/she was choking. Staff C began the [MEDICATION NAME] maneuver (a technique used to dislodge food from the throat when a person is choking). During that time, 2 pieces of food came out of the resident ' s mouth. Staff C then performed a " finger swipe " in the oral cavity with no other food found at that time. Staff C reported the resident began to clear his/her throat and staff gave him/her a sip of water per his/her request. The report indicated the resident suddenly became unresponsive, and his/her skin coloring became cyanotic (bluish). Again staff C performed the [MEDICATION NAME]. Additional staff arrived to assist the resident. Staff placed the resident on the floor and he/she had no respirations or pulse. Facility staff initiated CPR (cardio [MEDICAL CONDITION] resuscitation -combines compressions of the chest with rescue breathing to keep blood flowing through the body and brain while delivering oxygen to the bloodstream). Another staff person notified EMS (emergency medical service) at 4:08 PM. CPR continued until EMS staff arrived and took over assisting the resident. At 4:30 PM, EMS personnel transported the resident from the facility to a local hospital. The nurse note indicated they received a call from the local hospital reporting the resident expired. Review of the EMS service report dated [DATE] revealed upon arrival to the facility, staff reported the resident had eaten a peanut butter sandwich and started to choke. Facility staff performed CPR at that time and the resident was not breathing and had no pulse. Upon assessment of resident #1 ' s airway, he/she had peanut butter in his/her airway. EMS staff provided required suctioning 2 times to remove the peanut butter from the airway. EMS staff intubated the resident (a tube placed down the throat and into the lung to provide oxygen to an unconscious person) and transported him/her to a local hospital. The EMS was unable to resuscitate the resident before transferring him/her to the hospital emergency room . During an interview on [DATE] at 2:22 PM direct care staff H reported he/she made snacks in the dining room for the residents. The snack was a peanut butter and jelly sandwich. Resident #1 requested a peanut butter and jelly sandwich and staff H made one and gave it to the resident. Staff H revealed he/she was aware the resident was prescribed a puree diet due to difficulty with swallowing but knew the resident had always liked peanut butter and jelly sandwiches and ate them regularly for snacks. Staff H reported he/she knew this was not a part of the puree diet and should not have given the resident the sandwich. Staff H revealed he/she left the dining room and another direct care staff took his/her place. Within a few minutes of returning to the dining room the resident had begun to choke, his/her facial skin color had changed from pink/normal to a blue/dusky color. Staff H alerted the nurse on the unit who immediately came to assist the resident During an interview on [DATE] at 2:51 PM licensed nurse C reported he/she was in the nurse office across the hall from the dining room around 4 PM when the aide came and told him/her to come to the dining room immediately. Upon arrival to the dining room, staff C assessed the resident was in distress and choking. Staff C reported he/she did the [MEDICATION NAME] and recovered 2 pieces of peanut butter and jelly sandwich the size of a cherry tomato came out of the resident ' s mouth. Staff C reported the food was not chewed very well. Staff C assessed the resident was still choking, looked into the mouth and saw no food, and then staff C performed a " finger sweep " of the mouth. Staff C asked the resident if he/she was ok and wanted a drink of water. Staff C reported the resident indicated he/she wanted the water so he/ she gave him/her a drink of thickened water. Staff C reported resident #1 ' c skin color turned blue around the eyes and lips and he/she suddenly collapsed with a fixed stare in his/her eyes. Staff C then attempted the [MEDICATION NAME] again while other facility staff entered the area to assist with the resident. Staff together moved the resident to the floor, assessed he/she had no respirations or pulse and initiated CPR. Staff C reported the EMS service came to the facility shortly after that assessed the resident and took him/her to the hospital via ambulance. Staff C reported he/she had recently began work at the facility and did not know the resident ' s well enough at the time to know what snack foods they were normally allowed to have. Staff C reported a peanut butter and jelly sandwich would not be considered appropriate food for a resident on a prescribed puree diet. Staff C reported he/she was not CPR certified during this time. During an interview on [DATE] at 3:18 PM licensed administrative staff B reported the resident had eaten a peanut butter and jelly sandwich. Staff B reported the resident had enjoyed the sandwiches for a long time but had swallow evaluations done through speech therapy and the physician ordered the resident was to receive a puree diet. Staff B reported the sandwich was not part of a puree diet and the direct care staff should not have given it to the resident. Staff B reported the majority of the facility ' s staff were CPR certified and the facility was in the process of scheduling a CPR trainer for a class to make sure all the staff were CPR certified. During an interview on [DATE] at 3:55 PM dietary manager D reported peanut butter was not considered a part of a puree diet unless it was baked into a type of food then pureed to the proper consistency. Staff D reported the resident ' s diet changed a while ago due to him/her pocketing his/her food in his/her mouth and then not swallowing very well. Staff D reported the resident complained it hurt when he/she swallowed. Staff D reported the resident should not have received the peanut butter and jelly sandwich due to swallowing issues. During an interview on [DATE] at 10:24 AM direct care staff F reported he/she reported he/she referred to a diet manual provided by the Registered Dietician for all staff. Staff looked through the manual that described the different diets and their specific consistencies. Staff F reported the manual was kept in the kitchen for staff to refer when they questioned whether a typed of food was allowed or not for the resident ' s diets. During an interview on [DATE] at 9:56 AM physician G confirmed the resident was on a pureed diet as of [DATE] due to difficulty with swallowing. Physician G reported a puree diet was ground up to a mush like consistency to make it easier to swallow. Physician G reported a peanut butter and jelly sandwich would not be considered a puree consistency food and would be unsafe to give to a resident on a puree diet. During an interview on [DATE] at 12:04 PM consultant I reported the resident had dementia and had trouble chewing and swallowing. Consultant I reported the peanut butter was not on a puree diet unless it was cooked into a cookie for instance then blended to the proper consistency. Consultant I expected the facility to follow the prescribed diet as ordered and give the resident foods blended with the appropriate consistency. During an interview on [DATE] at 1:17 PM consultant J reported if a resident was on a puree diet, no sandwiches were allowed unless they were puree consistency. Peanut butter was typically avoided on a puree diet due to being a sticky substance. The facility ' s undated Guidelines for Consistency Modifications of Foods and Liquids stated alterations to the consistency of foods and/or liquid presented to the individual are made in accordance with the recommendation of an occupational therapist or speech and language pathologist and implement according to the order of the person ' s primary care provider. This deficient practice placed the resident in immediate jeopardy. The facility implemented education to all nursing staff on resident appropriate diets, placed a listing of resident diet orders at each nursing station, on meal carts, and snack carts. Resident diet orders were added to the CNA (certified nurse aide) pocket guides for direct care. The Dietary Manager completed a diet order audit of charts, care plans, and meal carts. The facility reviewed and revised the Resident Nutrition Services policy. The facility provided education to all dietary staff on modified diets. The corporate nurse provided education to activity staff regarding diets and compensatory swallowing techniques. An all staff in-service was given by the Speech Therapist on [DATE] on Swallowing disorders, mechanically altered diets and swallo procedures. the immedicate jeopardy was abated on [DATE]. The facility added additional protocols and provided audits and additional education. This was completed on [DATE]. The Speech Therapist will screen residents on modified diets quarterly and as needed. Ongoing dining room audits of meal service for correct meals, fluids, etc. started on [DATE]. The resident diet list will be updated weekly and as needed. The facility ' s nurse consultant will conduct dining room/snack audits. The facility provided additional education on [DATE] on Diet/Snack Consistency, Modification of Food/Fluids, and Mechanically Altered Diets for staff that did not attend previous in-services. The deficient practice remains at a scope and severity of a G.

The facility had a census of 64 with 18 sampled residents. Of the 18 residents 3 were reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to provide consistent accurate placement of pressure relieving boots and the timely repositioning services to a dependent resident to prevent the development of an avoidable pressure ulcer for 1 of 3 residents. (#22) Findings included: - Review of the medical record for resident #22 revealed the resident admitted to the facility in 2008. On January 27, 2014, the resident was hospitalized for [REDACTED]. The resident returned to the facility on [DATE]. Upon the resident's return from the hospital, the resident had [DIAGNOSES REDACTED]. enough insulin made or the body can't respond to the insulin). Review of an admission MDS (minimum data set) dated 11/6/13 revealed the resident had a BIMS (brief interview for mental status) score of 15 (indicated little to no loss of cognition), required extensive assistance of at least two staff for bed mobility and was at risk for pressure ulcers. Review of the ADL (activities of daily living) CAA (care area assessment) dated 12/5/13 revealed the resident was bed fast at the time and required 4 plus staff assistance to move the resident in his/her bed. Review of the current pressure ulcer care plan dated 10/24/14 directed staff to place booties (large soft cushioned booties on the resident's feet) to relieve pressure on both heels and feet. The care plan indicated on 10/24/13 a nurse and a wound specialist educated the resident regarding the need to turn and reposition on a routine schedule to assist healing of the resident's current wounds. The resident went to the hospital on [DATE] for a planned surgical intervention to aide in the healing of a non-healing pressure ulcer and returned to the facility on [DATE]. The care plan lacked new revisions developed by staff to aide in the assist of the healing of the surgical wound on the resident's buttocks. Review of the physician's progress report dated 3/10/14 revealed the resident had 5 wounds. The note indicated the resident had a sacral (buttocks) surgical wound which was full thickness (exposed to the bone), a right lateral (on the outside) superior (upper) buttock surgical wound, a right medial (in the middle) surgical buttock wound, a left buttock surgical wound, and lateral (outside) ankle wound. Review of the Braden scale for prediction of pressure sore risk dated 3/6/14 revealed a risk score of 15 indicating mild risk. Review of a nurse's note dated 3/16/14 at 12:43 PM revealed licensed nurse P found the resident in bed with his/her right foot resting against the foot board. The documentation revealed Nurse P assessed the resident's feet and a red non-blanchable area (Stage I) was present to the plantar surface (area just below the toes) of the right foot measuring 1.0 cm (centimeters) x 0.4 cm and a second non-blanchable area on the lateral (on the outside) surface of the right foot that measured 2.0 cm x 1.7 cm. Nurse P documented the resident had no feeling in the right foot and 45 minutes later the discolored areas of the right foot continued to remain non-blanchable. The note failed to identify how long it had been since staff last repositioned the resident, or if the resident had been wearing the pressure relieving boots as planned. Review of physician progress notes [REDACTED]. One area the physician documented as located in the middle of the lateral area and assessed the area with acute, necrotic tissue (acute is newly developed, sudden onset and necrotic is dead tissue). The note identified the area as unstageable with the possibility of it being a deep tissue injury. The second area the physician documented as distal, or further down on the outside of the foot, and the physician's assessment identified the area with acute, necrotic tissue. The note identified the second area as unstageable and with the possibility of it being a deep tissue injury, also. The note ended with directions for staff to continue the boots. Observation on 3/18/14 at 11:09 AM revealed licensed nurse staff G, H, and I provided treatment and dressing changes to the resident's wounds. The resident lay in a bariatric bed (larger bed to accommodate residents with obesity) with a foot board at the end. The resident wore a soft padded boot on each foot. Observation revealed the pressure relieving boot on the right foot had not been placed on the resident's foot correctly. The boot had been placed so that the area on the right foot from the toes to down to the middle of the foot remained exposed. This placement left the areas of the resident's foot without pressure relief. Observation of the bottom of the resident's right foot revealed it contained a large, round red/purple bruise, the size of a small orange. Staff I observed the discolored area on the resident's right foot and pressed on the area to see if the discoloration faded when pressed (to determine if it was blanchable). The color did not change when nurse I pressed on it (indicating it was non-blanchable) and the nurse repositioned the boot so that it was on the resident's foot correctly. Interview with the resident on 3/19/14 at 8:18 AM revealed the resident had no feeling from the ankle down on the right foot and could not feel if his/her foot pressed against something. The resident reported his/her bed broke and he/she laid there until they fixed it. During an interview on 3/19/14 at 3:30 PM licensed nurse staff I reported the bed malfunctioned on 3/16/14. The head of the bed was elevated when the bed malfunctioned, and the resident sat in an upright position. The resident slid down in the bed exerting pressure on the right foot from the foot pressed against the bed's footboard. Staff I reported the resident had no feeling in the affected foot and could not feel it against the foot board. Staff I reported the resident sustained [REDACTED]. Staff I failed to address if the resident had been wearing the planned pressure relieving boots at the time, or if staff had placed them on the resident correctly. During an interview on 3/19/14 at 6:15 PM administrative nurse staff B revealed he/she expected staff to reposition the resident to relieve pressure to the right foot to avoid the development of a pressure ulcers. On 3/21/14 at 3:25 PM administrative staff B interviewed nurse HH, who found the resident during the incident. Staff B indicated staff HH was not available for interview during the survey. Staff B provided a written account from staff HH who reported he/she found the resident about 10:00 AM on 3/16/14 upon entering the room to provide treatment to the resident. Nurse HH noticed the little toe on the right foot was dark color and did not blanch. Staff HH reported the resident slid down in his/her bed and his/her foot rested on the footboard. Staff HH reported he/she and licensed nurse P readjusted the leg and provided pressure relief to the foot. Staff HH reported he/she then called maintenance staff to fix the bed. The statement did not address how long it had been since staff had assisted the resident with repositioning services. On 3/24/14 at 8:17 AM administrative staff B provided a signed statement from maintenance staff GG via fax machine. Staff GG's statement signed on 3/21/14 revealed he/she received a phone call approximately 10:30 AM on 3/16/14 from nurse HH who stated resident #22's bed would not function. Staff GG reported he/she arrived about 12:00 PM, found the resident still in his/her bed, jacked the bed up and repaired the pinched remote by 12:30 PM. Staff GG reported the resident's foot was propped on pillows and elevated above and past the footboard by maybe an inch or two. This statement did not address if the resident wore boots at that time. During an interview on 3/24/14 at 1:48 PM physician W reported the pressure ulcer to the right foot was caused from pressure on the foot pressed against the footboard when the resident's bed malfunctioned on 3/16/14. Physician W reported the area would take 1 to 2 hours of pressure to develop. Review of the undated policy for Prevention of Pressure Ulcers revealed pressure ulcers formed when a resident remained in the same position for an extended period of time causing increased pressure and subsequent destruction of tissue. The policy indicated preventive measures for a resident in bed, included a change of position at least every two hours or more frequently if needed and raise the head of the bed for a short time and only as necessary. The facility failed to ensure the consistent use and appropriate placement of pressure relieving boots and provide timely repositioning services for a dependent resident to prevent development of an avoidable pressure ulcers to the resident's right foot for resident #22.

The facility census totaled 64 with 9 residents included in the sample Three residents were reviewed for pressure ulcers. Based on observation, interview and record review the facility failed to follow wound treatment orders to prevent the worsening of a resident's stage IV pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear resulting in full thickness tissue loss with exposed bone, tendon or muscle) for resident #39. Findings included: - Review of resident #39's signed physician consult dated 5/21/14 revealed the resident had [DIAGNOSES REDACTED]. Review of the annual MDS (minimum data set) dated 1/10/14 revealed a BIMS (brief interview for mental status) score of 15, indicating no cognitive impairment. The resident required extensive assistance of two or more people for bed mobility. The resident only transferred once or twice during the look back period and required assistance of two or more staff. The resident required extensive assistance of one staff with toileting and supervision with one assist for personal hygiene. The resident had an increased risk for pressure ulcers as determined by a formal assessment tool and clinical assessment. The resident did not have any pressure ulcers and had a turning/repositioning program in place, pressure reducing device to the chair, and medications/ointments to the body other than feet. Review of the Pressure Ulcer CAA (care area assessment) dated 1/23/14 revealed the resident had a risk for pressure ulcers and needed extensive assistance with bed mobility. The Braden score (scale used to identify risk for pressure ulcer) of 15 put the resident at risk because he/she always laid in bed and only got up for showers and appointments. He/she was able to reposition his/her upper body for the most part, but usually needed extensive assist to make major changes in lower body positioning. He/she spent most of his time prone and up on his/her elbows causing trauma to the elbows. The resident had a history of [REDACTED]. Therapy tried multiple interventions to relieve the pressure he/she put on his/her elbows. He/she had a history of [REDACTED]. Nursing needed to enforce interventions for prevention and treatments and to watch for signs/symptoms of skin breakdown. Review of the quarterly MDS (minimum data set) dated 4/12/14 revealed a BIMS (brief interview for mental status) score of 15, indicating no cognitive impairment. The resident needed only supervision with one assist for bed mobility, had total dependence for toileting on two or more staff, and required supervision of one staff for personal hygiene. There resident was at risk for developing a pressure ulcer determined by clinical assessment and a formal assessment tool, and the resident had a stage I (intact skin with non blanchable redness of a localized area usually over a bony prominence) or greater pressure ulcer. The resident had one stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough or an intact or open/ruptured date of development being 4/4/2004 and the wound bed had granulation tissue. Staff used a pressure relieving device in the bed and chair, turning/repositioning program, ulcer care, nonsurgical dressings, and ointments/medications other than to the resident's feet. Review of the resident's care plan for Pressure Ulcers, reviewed 1/16/13, revealed the resident had a risk for skin breakdown related to [MEDICAL CONDITION], impaired mobility and [MEDICAL CONDITION]. The care plan alerted staff the resident had the following skin conditions: 1/15/14 there was an open area noted to the right elbow 2/11/14 an open area to the right ischium crease (part of the hip bone) that healed 3/3/14. 2/11/14 Fluid filled blister right ischium. Healed on 3/3/14 Care plan interventions directed staff to: 2/16/12 to have a licensed nurse check skin upon admit and weekly noting any abnormal findings and notifying physician as needed. 11/14/12 the resident was to have a bariatric air bed related to [MEDICAL CONDITION]. Daily skin checks direct care staff/Nurse. Notify Nurse of any abnormal findings. 11/28/12 apply Spenco boots (soft boots to protect heels while lying in bed) to both feet, to wear elbow protectors to both elbows. Note: the protectors would slide down and he/she did not always pull them back into place. Wound Nurse encouraged Resident to call staff when he/she was unable to pull them back into place for staff to assist him/her. 1/16/13 staff encouraged repositioning, resident laid on stomach and propped up on elbows when he/she did anything: eating, on computer, reading. Resident encouraged to use off-loading pillows to elbows for pressure relieving, and pillows to off load feet from bed. 2/1/14 to apply [MEDICATION NAME] Cream to left foot twice a day. 2/11/14 to apply moisture barrier to buttock and right ischium crease 3/24/14 to apply Aqua cell AG (a type of dressing) to right elbow and change Wednesday through Friday and Mondays at the wound clinic 3/25/14 to apply [MEDICATION NAME] (a type of dressing) to blisters on buttock 4/29/14 an ORDER TO Discontinue AIR MATTRESS received DUE TO RESIDENT REFUSAL. Review of the wound care notes revealed the following measurements: Nurse's note dated 5/5/14 revealed the right elbow wound was debrided Nurse's note dated 5/7/14 revealed the right elbow wound measured 2.4 cm (centimeters) x 3.1 cm x 2.0 cm deep. Nurse's note dated 5/14/14 revealed the right elbow wound measured 1.7 cm x 2.5 cm x 0.5 cm Nurse's note dated 5/21/14 revealed the right elbow wound measured 1.3 cm x 3.4 cm x 0.6 cm Nurse's note dated 5/28/14 reveled the right elbow wound measured 1.9 cm x 2.4 cm x 2.3 cm depth. This showed decline from measurements on 5/7/14. Review of an infectious disease consultant noted dated 5/21/14 revealed the resident [MEDICAL CONDITION] (a drug resistant infection) in his/her right elbow. There were plans for one more surgery of the elbow and then an amputation if the surgery failed. Review of a wound care physician noted dated 4/28/14 revealed the larger ulceration to the right elbow was slightly smaller, but still over 2 cm deep in the center of the ulcer. Will continue Aqua cell Silver (AG) but it needs to be packed into the deep central section at each dressing change. Review of an infectious disease physician progress notes [REDACTED]. The resident seen at wound care on 5/5/14 for further debridement. Review of a patient instruction form dated 5/12/14 from the wound care center revealed directions from the wound care center included the resident to use his/her arm splint, cover dressings: barrier cream, 4 x 4 dressing, Kerlix wrap and foam cushion. Total non-weight bearing for right elbow. Review of a physician progress notes [REDACTED]. continue dressing changes on Wednesday, Friday and Sunday with Aqua cell Silver, wound barrier and cushioned dressing and continued to use splint. "NOTE!!! The Aqua-cell Silver needs to be packed INTO the depths of this wound at each dressing change-there are currently 2 pieces of Aqua-cell Silver packed into the wound today." Review of a physician progress notes [REDACTED]. Pack Silver into the sound. Dressing changes until next appointment on Wed, Fri, and Sundays. Next appointment-June 2nd. Ulcer of right elbow persisted. Surgical excision scheduled by Physician M in about one month. Review of the nurse's notes from 4/25/14-5/7/14 revealed no measurements were obtained. Review of the resident's physician progress notes [REDACTED]. Review of the May 2014 TAR (treatment administration record) revealed the head to toe skin assessment on 5/11/14, 5/18/14 and 5/25/14 was not initialed as completed. The TAR did indicated staff was to document findings on a progress note and initial the TAR. The TAR entry dated 5/7/14 indicated to pack Aqua-cell AG into the depths of the wound and over the surface, apply barrier cream gauze and roll gauze three times weekly. The TAR not initialed as completed on 5/23/14. TAR entry dated 3/31/14 Aqua-cell AG to elbow, cover with barrier cream, foam wrap with Kerlix three times weekly. (Discontinued see new treatment order 5/5/14). An observation on 5/27/14 at 1:42 p.m. revealed the resident lay in bed on his/her right side with a pillow under his/her right elbow and a [MEDICATION NAME] in place. At 1:59 p.m., the resident remained in the same position. At 2:15 p.m., the resident's right elbow did not lay on the pillow, but the resident's body remained in the same position. No elbow pads noted in place. An observation on 5/27/14 at 2:40 p.m. revealed the resident had rolled over onto his/her stomach and his/her right elbow remained bend and did not touch any surfaces. No elbow pads noted. An observation on 5/28/14 at 9:18 a.m. revealed staff lay the resident in bed on his/her stomach with his/her right elbow bent and pointing up towards the ceiling and booties on his/her feet. At 9:32 a.m., the resident lay on his/her right side with his/her elbow on a pillow, booties on his/her feet. At 9:47 a.m., the resident lay back on his/her stomach with a pillow under his/her right elbow and booties on his/her feet. At 10:06 a.m., the resident remained in the same position. No elbow pads. Observation on 5/28/14 at 10:07 a.m. revealed licensed nursing staff K went in and put on a precautions gown, washed his/her hands, put on gloves, took off the [MEDICATION NAME], cut off gauze and removed gel pad. Staff K reported the dressing was supposed to have Aqua cell Silver but he/she did not see any. Staff K confirmed no Aqua cell in place in the old dressing. Light tan drainage noted to the surface of the dressing. Staff K measured the wound 1.9 cm x 2.4 cm. He/she used a Q-tip to measure depth of 2.3 cm. Staff K reported dressing changes were done Wednesday, Friday, and Sunday and measured weekly on Wednesdays. The resident went to the wound care clinic on Monday, but it was not open this Monday for Memorial Day. Staff K put Periguard skin protectant around the outside of the wound, put Aqua cell pad over the hole, put on about four 4 x 4 gauze pads and wrapped with gauze roll. Staff K put gel pad on elbow and wrapped with gauze roll. Staff used [MEDICATION NAME] tape to secure gauze. Dated and initialed the dressing, pulled [MEDICATION NAME] up over the dressing. No elbow pads in place. Staff did not pack the Aqua cell AG into the wound. An interview with the resident on 5/27/14 at 1:42 p.m. revealed he/she had a pressure sore on his/her right elbow and it had been there for about 3 months. The resident reported he/she could reposition him/herself and the staff did not remind him/her. The resident reported he/she went to the wound clinic every week and the facility staff changed the dressings per the doctor's orders three times a week (he/she thought). The resident reported it had gotten infected [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph aureous, a drug resistant infection) and some other things and the doctor was supposed to surgically close the wound next month. An interview on 5/28/14 at 10:27 a.m. with the resident revealed he/she had elbow protectors and usually wore them, but they drove him/her nuts, so he/she took them off for a while. An interview with direct care staff I on 6/2/14 at 10:48 a.m. revealed the resident had some kind of guards and sleeves to wear and was usually compliant, if reminded, but could be stubborn. An interview with licensed nursing staff K on 5/28/14 at 10:27 a.m. revealed the area looks a lot better. He/she had been doing the wound care lately. Staff K reported the staff tried to keep the resident off of the wound. He/she had a brace he/she used to help protect the elbows when he/she used his/her computer. The resident did have elbow protectors. Interview with licensed nursing staff K on 5/28/14 at 10:37 a.m. revealed he/she had not been trained on wound staging, but if he/she had to say, he/she would stage the pressure ulcers on the resident's elbow a stage 4. Staff K revealed at 3:22 p.m. there was not a wound book that tracked measurements or anywhere to track measurements. An interview with licensed nursing staff K on 6/2/14 at 8:28 a.m. revealed the resident had been seen by a wound care physician who measured the wounds. Staff L reported he/she measured the wound weekly, if the physician did not come weekly, the it was the nurse's responsibility to measure the wound. Review of the facility's policy for Prevention of Pressure Ulcers last revised 2/2014, revealed that for a resident in bed, position should be changed at least every 2 hours or more frequently if needed. Determine if the resident needed a special mattress per the Braden Score (a scale used to identify pressure ulcer risk), routinely assess and document the condition of the resident's skin per weekly skin integrity form for any signs and symptoms of irritation or breakdown, protect bony prominences as needed. The policy also identified the need to float heels (keep heels off of the bed), when in bed, by placing a pillow from the knee to the ankle or with other devices as recommended by clinical staff or by the physician. The facility failed to perform wound care per the physician orders [REDACTED].