Every finding on record at Eskridge Care and Rehab

Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria.Findings included:- During an initial tour of the kitchen on 04/20/26 at 07:41 AM, the following areas of concern were noted:1. The door handles of the oven had food debris.2. The can rack holding one-gallon cans had a build-up of food debris on the runners.3. The bottom shelf of the preparation table had a build-up of food debris.4. A three-drawered plastic storage container had a build-up of dried-on liquids and a white substance.5. The cart holding the facility ice chest had a scattered white substance and dried-on fluids.6. A one-half box of 12 X 12 dinner napkins (approximately 600 napkins) rested directly on the floor.7. A 25-pound (lb.) box of baking potatoes rested directly on the floor.8. A 20 lb. roll of ground beef was in a water bath of warm water thawing.On 04/21/26 at 10:31 AM, Dietary Staff BB confirmed the noted areas were in need of cleaning. The facility policy for Sanitation, effective 10/2025, included: The food service area shall be maintained in a clean and sanitary manner. The policy lacked instruction regarding the thawing of meat and items being stored directly on the floor.

Based on observation and interviews, the facility failed to provide a clean, home-like environment for the residents who resided in the facility.Findings included:- On 04/20/26 at 07:45 AM, a walkthrough of the facility revealed Resident (R) 1 had baseboard missing from the East wall of his room and R8 had baseboard missing from the [NAME] side wall of her room. Both rooms had exposed drywall, with broken drywall on the residents' floor. The gold-colored ceiling fan in the common area was covered with a lot of dust on all fan blades.On 04/22/26 at 08:50 AM, Administrative Staff A stated the facility had been remodeling in the 100 Halls. She stated there were rooms in which the baseboard was missing and said she would have the maintenance staff put the baseboard on. Administrative Staff A stated there were areas in the facility that needed work, but the facility had a budget so they worked in areas every month as they would get funds. She stated she did not realize the fan in the TV area had accumulated dust. She stated she would talk to housekeeping as housekeeping did have a deep cleaning schedule.The facility's Safe, Clean, Comfortable, Home like Environment, dated 10/25, documented residents had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Residents were encouraged to use their own belongings to the best extent possible, as such a homelike environment would be encouraged.

Based on observation, interview, and record review, the facility failed to provide Resident (R)5 with a dignified existence by not calling her by the name she wished to be called.Findings included:- R5's Electronic Medical Record (EMR) documented a diagnosis of schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) disorder.R5's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. She had hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) during the assessment period.R5's Behavioral Symptoms Care Area Assessment (CAA), dated 10/27/25, documented she had the potential for behaviors related to mental health diagnosis of schizoaffective disorder.R5's Quarterly MDS, dated [DATE], documented she had a BIMS score of 14, indicating intact cognition. She had hallucinations and delusions during the assessment period.R5's Care Plan, revised 03/31/26, instructed staff to use the resident's preferred name.On 04/20/26 at 08:44 AM, Dietary Staff CC approached R5 while she sat at the dining room table and greeted her by her legal name, not the name R5 preferred as listed on her plan of care. R5 informed Dietary Staff CC she wanted to be called by her preferred name (as listed on the care plan). Dietary Staff CC walked away from the table without using the resident's preferred name.On 04/21/26 at 08:31 AM, Certified Nurse Aide (CNA) M approached R5 while she sat at the dining room table and referred to R5 by her legal name. R5 stated she wanted to be called by her preferred name (as listed on the care plan). CNA M walked away from the table without using the resident's preferred name.On 04/21/26 at 07:11 AM, Dietary Staff CC stated staff call R5 by her legal name, but she preferred to be called by her chosen name (as listed on the care plan).On 04/21/26 at 08:07 AM, CNA M stated R5 preferred to be called by her preferred name (as listed on the care plan), but staff were directed to call her by her legal name.On 04/22/26 at 10:50 AM, CNA P stated R5's Care Plan instructed staff to refer to R5 by her preferred name and R5 was more cooperative with staff when they did use her preferred name, but most staff called R5 by her legal name. On 04/21/26 at 08:20 AM, Licensed Nurse (LN) G stated R5 had delusions such as not knowing her name. R5 would tell her staff her name was her preferred name (as listed on the care plan), which was not her legal name. LN G stated when the resident would not respond to her legal name, she would not use any name when communicating with her.On 04/22/26 at 11:07 AM, LN H stated she used R5's legal name when she spoke to R5. LN H confirmed R5's Care Plan instructed staff to use her preferred name.On 04/22/26 at 11:19 AM, Administrative Nurse D stated she referred to R5 by her legal name due to forgetting R5 used her preferred name (as listed on the care plan).The facility policy for Resident Rights, effective 11/2025, included: Our facility will make every effort to assist each resident in exercising his/her rights to ensure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview and record review the facility failed to provide adequate activity of daily living (ADL) assistance for Resident (R) 40, regarding appropriate positioning while in her wheelchair, and R 50 for failure to assist with urinary incontinence.Findings included:1. R40's Electronic Medical Record (EMR) documented a diagnosis of autism (a developmental and neurological condition that affects how individuals interact, communicate, learn, and behave).R40's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. R40 was dependent on staff for wheelchair mobility.R40's Activity of Daily Living (ADL) Care Area Assessment, dated 06/12/25, did not trigger.R40's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. R40 was dependent on staff for wheelchair mobility.R40's Care Plan, revised 03/24/26, documented the resident was dependent on staff for all ADLs related to severe cognitive impairment.R40's EMR under the Task tab, from 03/23/26 to 04/20/26 (28 days), documented R40 was dependent on staff for mobility in her wheelchair.On 04/20/26 at 08:39 AM, R40 sat in her wheelchair at the dining room table. Her bilateral feet dangled several inches above the floor. The wheelchair lacked footrests.On 04/20/26 at 12:41 PM, R40 sat in her wheelchair at the dining room table. Her bilateral feet dangled several inches above the floor. The wheelchair lacked footrests.On 04/21/26 at 08:30 AM, R40 sat in her wheelchair at the dining room table. Her wheelchair had footrests in place, and her feet dangled approximately three inches above the footrests.On 04/21/26 at 08:41 AM, Certified Nurse Aide (CNA) N stated R40's feet did not reach the floor when she was in her wheelchair because the wheelchair was too tall for her. CNA N stated the footrests to the wheelchair were underneath R40's bed but staff did not use them.On 04/21/26 at 08:41 AM, CNA M confirmed the resident's feet did not reach the floor when in her wheelchair because the cushion in her wheelchair was too thick.On 04/21/26 at 08:20 AM, Licensed Nurse (LN) G stated staff did not use footrests on the resident's wheelchair because staff will ambulate with R40 at times.On 04/22/26 at 11:07 AM, LN H stated the staff should have footrests on R40's wheelchair when they propel her.On 04/22/26 at 11:19 AM, Administrative Nurse D stated R40's feet did not reach the footrests of her wheelchair because the footrests legs were too long and did not work well for R40. Administrative Nurse D confirmed R40's feet dangled above the footrests when she was in her wheelchair.2. R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of repeated falls, dementia (a progressive mental disorder characterized by failing memory and confusion), abnormalities of gait and mobility, difficulty walking, muscle wasting and atrophy (wasting or decreasing in size of a part of the body), need for assistance with personal care, and lack of coordination.The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R50 had bilateral lower extremity limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R50 required substantial to maximum staff assistance for toileting and lower body dressing.R50's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 07/18/25, documented he had the potential for decline in the activities of daily living (ADLs). R50 also would have day-to-day fluctuation in the ability to perform his ADLs, and staff would assist him as needed. The CAA documented R50 had short term memory and staff were unable to educate him.R50's Care Plan, documented the following interventions:09/02/25, staff would cue and encourage him to allow assistance with ADLs, related to his decline. R50 required the assistance of one person for toileting.02/16/26, R50 required assistance for transfers.Staff would assist with applying incontinence chucks to the bed as allowed.Staff would encourage him to change after an incontinent episode, because he did not always realize when incontinent episode had occurred.03/31/26 staff would cue him to use the bathroom to reduce some incontinence episodes.On 04/20/2026 at 09:12 AM, R50 sat in his wheelchair in front of the nurse's desk with visibly wet navy pants and blue checkered. R50 asked several staff members for assistance with changing his soiled clothes. Several staff members walked by him and instructed R50 to wheel his wheelchair down to his room, and R50 asked staff what his room number was.On 04/22/26 at 10:50 AM, Certified Nurse Aide (CNA) P stated R50 would toilet himself most the time. CNA P stated he had incontinent pull ups located in his bathroom to put on after he had used the toilet if had an incontinent episode. CNA P stated R50 required assistance with toileting at times. CNA P stated the staff would be responsible to ensure R50 was wearing the correct incontinent product on was on correctly to prevent visibly incontinent episodes.On 04/22/26 at 11:00 AM, Licensed Nurse (LN) H stated she had heard R50 on 04/20/26 request assistance with changing his soiled clothes. LN H stated she had instructed him to wheel himself down to his room. LN H stated the direct care staff was responsible for assisting R50 with toileting and ensuring he was wearing the correct incontinent product.On 04/22/26 at 11:20 AM, Administrative Nurse D stated R50 was able at times to complete his own toileting task with cues from the staff. Administrative Nurse D stated she expected the staff to check on him to ensure his clothes were changed and he was wearing the correct incontinence product correctly to prevent soiled clothes.The facility's Quality of Life - Activities of Daily Living policy, dated 03/2026, documented the facility environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Residents who are unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interviews, observation, and record review, the facility failed to ensure staff implemented interventions per the plan of care for Resident (R) 50 to prevent further falls and possible injuries. Findings included:- R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of repeated falls, dementia (a progressive mental disorder characterized by failing memory and confusion), abnormalities of gait and mobility, difficulty walking, muscle wasting and atrophy (wasting or decreasing in size of a part of the body), need for assistance with personal care, and lack of coordination.The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R50 had bilateral lower extremity limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R50 required substantial to maximum staff assistance for toileting and lower body dressing. R50's Falls Care Area Assessment (CAA), dated 07/18/25, documented he was at risk for falls related to his diagnosis, use of high-risk medications, history of falls, and need for staff assistance with walking.R50's Care Plan, documented the following interventions:02/16/17, staff would determine and address causative factors of the fall. 10/24/19, staff would encourage R50 to ask for assistance when bending over to pick objects off the floor. 09/02/25, staff would ensure R50 was positioned correctly in the wheelchair.During morning rounds staff would encourage use of toilet and/or urinal.During the night staff would prompt him to use bathroom every three hours and asneeded throughout the night.01/23/26, a toilet riser was placed in the bathroom.A bolster was placed on the bed.The care plan lacked an intervention for an unwitnessed fall on 04/17/26.R50's EMR under the Progress Notes tab revealed a Nursing Note dated 04/17/26 at 03:00 AM, which revealed R50 was found leaning against his roommate's bed. R50 urinated on the floor and slipped. He stated he was attempting to get into his wheelchair.Review of the Facility's Fall Investigation provided by the facility, dated 04/17/26, revealed a note dated 04/20/26 which documented the root cause analysis, which was that R50 had urinated on the floor and slipped in the urine. Staff education would be provided to ensure R50 was wearing the appropriate incontinent product and wearing nonskid socks.On 04/20/2026 at 09:12 AM, R50 sat in his wheelchair in front of the nurse's desk with visibly wet navy pants and blue checkered. R50 asked several staff members for assistance with changing his soiled clothes. Several staff members walked by him and instructed R50 to wheel his wheelchair down to his room and R50 asked staff what his room number was.On 04/22/26 at 10:50 AM, Certified Nurse Aide (CNA) P stated she was able to find fall interventions on the resident's care plans. CNA P stated the nurses would communicate any new interventions to the staff.On 04/22/26 at 11:00 AM, Licensed Nurse (LN) H stated fall interventions could be found in the resident's care plans. LN H stated Administrative Nurse D was responsible to ensure an intervention would be placed on resident's care plan to prevent further falls.On 04/22/26 at 11:20 AM, Administrative Nurse D stated she was responsible for ensuring an intervention was placed on the resident's care plan after the root cause analysis was determined. Administrative Nurse D stated R50's dementia has progressed and R50 had difficulty remembering to call for assistance.The facility's Managing Falls and Fall Risk policy, dated 06/2025, documented based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).Findings included: - The PBJ Staffing Data Report CASPER Report 1705D provided by the Centers for Medicaid and Medicare (CMS) for Fiscal Year (FY) 2025 Quarter (Q)s 2, 3, and 4 and Fiscal Year 2026 Q1 documented excessively low weekend staffing.Review of the facility's actual working schedule sheets from 10/01/25 to 03/31/26 revealed the facility maintained and had the same number of staff scheduled and worked as during the week: One or two nurses for day shift and one nurse for evening and night shift; three to four nurse aides day shift and two nurse aides on evening and night shift; one medication aide on day and evening shift.The facility's Facility Assessment, revised on 11/20/25, documented the specific needs of each resident in the community were identified and staffing was adjusted as needed. The facility assessment included staffing for each shift. The direct care staff was to have one to two licensed nurses for day shift, and one licensed nurse for evening, and night shift; one medication aide on day and evenings; three to four nurse aids on days and two nurse aides on evening shift, and night shift; and one medication aide for day, and evening shift.On 04/21/26 at 08:06 AM, Administrative Staff A stated she was unsure why the facility showed extremely low weekend staffing on the PBJ. She stated she thought the PBJ triggered for low staffing due to the fact the facility had terminated a nurse and the facility had one nurse pass away. Administrative Nurse A stated those numbers reflected the facility's PBJ. She stated although the nurses were no longer working in the facility, the facility maintained staff as the facility assessment documented.The facility's Payroll Based Journal, dated 10/26, documented our community would submit payroll data in a uniform format to CMS, including staffing information for community, agency and contract staff. Direct Care Staff were defined as those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long-term care facility.

The facility had a census of 58 residents. The sample included 16 residents. Based on observation and interview, the facility failed to store, prepare, and serve food at the required serving temperature. This deficient practice placed the residents at risk of unpalatable food and food-borne illness. Findings included: - On 02/20/25 at 11:43 AM, Dietary Staff (DS) CC prepared to serve the noon meal. DS BB took the serving temperature check which revealed the pureed turkey temperature of 110 degrees Fahrenheit (F) and the pureed corn of 115 degrees F. DS CC reported he did not know what the holding/serving temperature of the hot food was. The surveyor brought the incorrect temperatures to the kitchen supervisor for the day Social Service Staff X prior to letting the pureed turkey and corn be served. Social Service Staff X, explained to DS CC the pureed turkey and corn had to be heated to the proper temperature before serving. DS BB placed the pureed turkey and corn back into the oven. Once the pureed turkey and corn reached 160 degrees F., they were placed on the steam table for serving. On 02/24/25 at 08:22 AM, DS BB reported DS CC was a fairly new employee, still learning the job and DS BB would educate DS CC on the proper safe serving temperatures. The facility's Food Safety Requirements policy, dated 10/2024, documented that foods shall be received and stored in a manner that complies with safe food handling practices. The policy lacked the holding/serving temperature. The facility failed to store, prepare, and serve food at the required temperature. This deficient practice placed the residents at risk of unpalatable food and food-borne illnesses.

The facility had a census of 58 residents. Based on record review and interview, the facility failed to retain evidence of the required Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) members attended meetings at least quarterly, which placed residents at risk of unidentified quality care services. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - Upon request, the facility failed to provide the facility's Quality Assurance Performance Improvement (QAPI) meeting attendance sheets for the past year. On 02/24/25 at 01:30 PM, Administrative Staff A stated the facility could not find QAA or QAPI meeting sign-in sheets from 2024. The facility's QAPI Committee policy, dated 10/2024, stated the primary goals of the QAA committee were to oversee facility systems and processes related to improving quality of care and services. The policy stated the required committee members included the Director of Nursing, the Medical Director or his/her designee, the Infection Preventionist, and at least three other staff. The policy stated the committee would meet monthly and would maintain records including the names of committee members present and absent. The facility failed to retain evidence the required QAA and QAPI members attended meetings at least quarterly. This deficient practice placed residents at risk of unidentified quality care services.

The facility had a census of 58 residents. Based on record review and interview, the facility failed to ensure the staff member designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 02/20/25 at 10:00 AM, Administrative Nurse D stated she was responsible for the Infection Prevention and Control Program but lacked certification as an Infection Preventionist. Administrative Nurse D stated an Infection Preventionist was starting at the facility in a week, but presently she assumed the job and lacked certification. The Infection Preventionist policy dated 08/2024, documented the Infection Control Preventionist was responsible for assessing, implementing, developing, and monitoring the infection prevention and control program, coordinating the implementation and updating of the established infection control policies and practices. The Infection Preventionist would develop and monitor the facility's established infection control policies and practices. The Infection Preventionist would report information related to compliance with the facility's established infection control policies and practices to the Administrator and Quality Assurance and Assessment Committee. The Infection Preventionist would keep abreast of changes in infection control guidelines and regulations to maintain and update the facility's protocols, as needed, and remain current and aid in the prevention and control of the spread of infections. The Infection Preventionist would collect, analyze, and provide infection data and trends to nursing staff and health care practitioners. The Infection Preventionist would consult on infection risk assessment and prevention control strategies, and collaborate with the Administrator, Medical Director, Consulting Pharmacist, and Nursing Leadership for all things Infection Prevention, including the Antibiotic Stewardship Program. The Infection Preventionist would provide education and training and implement evidenced-based infection control practices. The Infection Control Preventionist is recommended to have a background in nursing, medical technology, microbiology, epidemiology, or another related field. The facility failed to ensure the person designated as the Infection Preventionist completed the required certification. This deficient practice placed the residents at risk for lack of identification and treatment of infections.

The facility had a census of 58 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the required annual performance review was completed for two of the five staff reviewed. This deficient practice placed the residents at risk of receiving impaired care. Findings included: - A review of the facility nurse aide performance evaluation revealed two Certified Nurse Aides (CNA) M and CNA N who had been employed for over a year lacked an annual review. On 02/20/25 at 02:51 PM, Administrative Nurse D reported two of the five staff randomly selected staff for review lacked annual performance evaluation. The facility's Staff Competency policy, dated 06/2024, documented nursing staff would demonstrate competency in skills and techniques necessary to care for the resident's needs, as identified through resident assessments and resulting in plans of care. The premises of the competency-based program included an evaluation of a current program to identify needs and opportunities. The facility failed to ensure a nurse aide performance review related to the special needs of the resident population as identified from the facility assessment based on the outcome of the review. This deficient practice placed the residents at risk of receiving impaired care.

The facility had a census of 58 residents. Based on record review and interview the facility failed to provide two of three sampled residents, Resident (R)9 and R111 (or their representative) the CMS (Center for Medicaid/Medicare Services) approved Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055. The facility failed to provide R9 and R111 the contact phone numbers on the Notice of Medicare Non-Coverage (NOMNC) Form-10123 which informed the beneficiary of the right to an expedited review by a Quality Improvement Organization (QIO). This placed the residents at risk of uninformed decisions about their skilled services. Findings included: - Review of the Notice of Medicare Non-Coverage (NOMNC) document on Form CMS 10123-NOMNC informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included directions for the beneficiary (resident or resident representative) to contact the QIO for questions regarding appeals. Review of R9's NOMNC revealed Medicare Part A skilled services ended on 01/12/25. The facility provided CMS Form 10123 which lacked QIO name and contact number information for R9. The ABN form was completed but not the CMS approved form 10055. Review of R111's NOMNC revealed Medicare Part A skilled services ended on 01/21/25. The facility provided CMS Form 10123 which lacked QIO name and contact number information for R111. The ABN form was completed but not the CMS approved form 10055. On 02/20/25 at 10:24 AM, Administrative Nurse E verified she had not written the QIO phone number on the 10123 form and had not used the 10055 ABN form for R9 and R111's Part A discharge. The facility's Beneficiary Notice policy, dated 08/2024, stated a Medicare beneficiary had the right to have Medicare make the decision to determine if skilled services would be covered by Medicare. The facility must give notice to the beneficiary at least three days prior to termination of all Part A covered services when the beneficiary still has days left in the benefit period. The Notice of Medicare Non-Coverage, form 10123, informs the beneficiary how to request an expedited redetermination from QIO (Quality Improvement Organization) and provided the phone contact number. The policy directed staff to prepare and issue CMS form 10055 (Advanced Beneficiary Notice) to the resident. The facility failed to provide R9 and R111 the QIO contact number for appealing Medicare Part A decisions and the CMS approved 10055 ABN form. This placed R9 and R111 at risk of uninformed decisions about their skilled services.

The facility had a census of 58 residents. The sample included 16 residents, with two reviewed for discharge from the facility to an acute care hospital. Based on observation, interview, and record review the facility failed to notify the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) of the discharges for Resident(R) 26 and R111. This placed the two residents at risk for uninformed care choices. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of bipolar type (episodes of severe high and low moods) schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), chronic tension-type headache, and posttraumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). R26's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R26 required staff set up for all activities of daily living (ADL), had frequent, moderate pain, and used tobacco products. R26's EMR documented she was hospitalized from [DATE] to 12/31/24. The facility lacked proof they had sent a notice to the ombudsman regarding R26's discharge to the hospital. On 02/24/25 at 10:20 AM, R26 walked past other residents and staff and stated she was not fine, and wanted to get out of here. On 02/24/25 at 10:45 AM, Social Services Staff X stated the facility only sent a Continuation of Stay form to the KDADS offices monthly, listing all residents and if they were still in the facility or had moved somewhere else. She stated the facility did not have an ombudsman and did not send information to them regarding hospitalizations. The facility's Transfer or Discharge policy, dated 08/2024, stated the resident or their representative would be provided a written notice with the reason for the discharge or transfer and sent a copy of the notice to the office of the LTCO. The facility failed to send a notice to the LTCO office regarding R26's discharge to the hospital, placing R26 at risk for uninformed decision making. - R111's Electronic Medical Record (EMR) documented diagnoses of Schizoaffective Disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and Chronic Obstructive Pulmonary Disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R111 had long-term memory problems, moderately impaired decision-making skills, and an acute mental status change. The MDS documented R111 had delusions, abnormal behaviors, and was dependent on staff for all activities of daily living. R111's EMR documented she was hospitalized from [DATE] to 02/19/25. On 02/19/25 at 02:25 PM, Emergency Medical Services (EMS) brought the resident back to the facility to her room. R111's family accompanied her, and Licensed Nurse (LN) G assessed R111. On 02/24/25 at 10:45 AM, Social Services Staff X stated the facility only sent a Continuation of Stay form to the KDADS offices monthly, listing all residents and if they were still in the facility or had moved somewhere else. She stated the facility did not have an ombudsman and did not send information to them regarding hospitalizations. The facility's Transfer or Discharge policy, dated 08/2024, stated the resident or their representative would be provided a written notice with the reason for the discharge or transfer and sent a copy of the notice to the office of the LTCO. The facility failed to send a notice to the LTCO office regarding R111's discharge to the hospital, placing R111 at risk for uninformed decision making.

The facility had a census of 58 residents, and the sample included 16 residents. Based on observation, record review, and interview, the facility failed to assess and maintain urine continence for Resident (R) 51. This deficient practice placed R51 at risk of embarrassment and complications from incontinence. Findings included: - R51 ' s Electronic Medical Record (EMR) included diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar type (a major mental illness that causes people to have episodes of severe high and low moods), autistic (a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication) disorder, insomnia (inability to sleep) due to other mental disorders, extrapyramidal (movement disorders as a result of taking certain medications) and movement disorder, constipation (difficulty passing stools), and encopresis (repeated passing of stool usually involuntary into clothing) not due to a substance or known physiological condition. The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R51 had intact cognition, fluctuating inattention, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and no exhibited behaviors. R51 required setup or clean-up assistance with toileting, showering, upper and lower body dressing, and mobility. The MDS further documented that R51 was always continent of urine and bowels. The Quarterly MDS, dated [DATE], documented R51 had intact cognition, fluctuated disorganized thinking, delusions, and other behavioral symptoms not directed toward others which occurred one to three days of the seven-day look-back period. R51 required setup or clean-up assistance with toileting, showering, upper and lower body dressing, and mobility. The MDS further documented that R51 was occasionally incontinent of urine with no trial of a toileting program or current toileting, and always continent of bowel. The admission Urinary Incontinence Care Area Assessment (CAA), dated 03/15/24, documented R51 had the potential for a decline in toileting hygiene. The resident is encouraged to be as independent as possible. The CAA further documented R51 was up ad lib (as desired) with a steady gait. R51 ' s Care Plan dated 02/20/24, documented R51 had a diagnosis of encopresis related to constipation related to psychotropic (alters mood or thought) medication use. The care plan instructed staff to observe patterns of incontinence and initiate a toileting schedule if indicated, offer the use of briefs, and provide peri-care items for cleaning himself up following incontinent episodes. The Quarterly Nursing Evaluation Progress Note dated 11/21/24 at 03:03 PM, documented no new urinary incontinence. A 30-day (01/23/25 to 02/22/25) bladder continency review revealed R51 had incontinence 18 days during a 30-day look-back period. On 02/19/24 at 08:30 AM, R51 carried a large clear plastic bag of linens down the hall. R51 ' s bed had a large wet area in the center of the bed. On 02/24/25 at 07:52 AM, Certified Nurse Aide (CNA) O reported R51 had some incontinence, and staff at times told him he needed to change his clothes. CNA O stated that R51 would ask staff for linens. On 02/24/24 at 12:12 PM, Administrative Nurse E reported the nurse aides observed for incontinence and documented in the EMR which populated the MDS. Administrative Nurse E stated R51 ' s incontinence was usually nocturnal and would have the physician review medication to see if that may be causation due to sleeping through the urge or the need to void. Administrative Nurse E stated staff should have the resident on a night toilet regimen. On 02/24/25 at 02:15 PM, Administrative Nurse D stated that R51 ' s incontinence should be assessed to determine possible causation factors. The facility ' s Urinary Continence and Incontinence Assessment and Management policy, dated 10/2024, documented the facility must ensure that a resident who is continent of bladder and bowel on admission receives care and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. The facility failed to assess causation factors and maintain R51 ' s urinary incontinence. This deficient practice placed the resident at risk for continued embarrassment and complications of urinary incontinence.

The facility had a census of 58 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to address Resident (R) 51's food preferences and dislikes with continued weight loss resulting in a significant weight loss of 11.3 percent (%) in six months. Findings included: - R51's Electronic Medical Record (EMR) included diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar type (a major mental illness that causes people to have episodes of severe high and low moods), autistic (a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication) disorder, insomnia (inability to sleep) due to other mental disorders, extrapyramidal (movement disorders as a result of taking certain medications) and movement disorder, constipation (difficulty passing stools), and encopresis (repeated passing of stool usually involuntary into clothing) not due to a substance or known physiological condition. The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R51 had intact cognition, fluctuating inattention, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and no exhibited behaviors. R51 required setup or clean-up assistance with toileting, showering, upper and lower body dressing, and mobility. The MDS further documented R51 weighed 165 pounds (lbs.), had weight loss, and not on a prescribed weight loss regimen. R51 had no swallowing disorder and received a mechanically altered diet. The Quarterly MDS, dated [DATE], documented R51 had intact cognition, fluctuated disorganized thinking, delusions, and other behavioral symptoms not directed toward others which occurred one to three days of the seven-day look back period. R51 required setup or clean-up assistance with toileting, showering, upper and lower body dressing, and mobility. The MDS further documented that R51 weighed 159 lbs, had unknown weight loss or gain, no swallowing disorder and lacked nutritional approaches. The Admission Nutrition Status Care Area Assessment (CAA), dated 03/15/24, documented R51 had the potential for nutritional problems related to low body mass index (BMI), recent weight loss since admission. The resident was edentulous, received a mechanical soft diet, and reported being a picky eater at times. The CAA further documented R51 was offered snacks between lunch and dinner and evening snack prior to bed. The assessment lacked food likes and dislikes. R51's Care Plan dated 12/18/24, documented R51 at risk for altered nutritional/hydration status related to decreased fluid need due to hyponatremia, edentulous, inadequate intake, and weight loss. The care plan directed staff to honor food preferences and update as needed. R51 was a very picky eater and to remind him about the alternative meal, but to respect his right to refuse. The care plan further documented R51 receive a magic cup (frozen nutritional supplement) one time a day at lunch most generally, please offer it to the resident after he eaten his meal. R51 liked to sleep in and would sometimes refuse breakfast. The staff were to monitor and record meal intake, offer snacks between meals and as desired, and the Registered Dietician (RD) would evaluate and make recommendations and to weigh R51 monthly. The care plan lacked specific food preferences. Record Review of R51 weights revealed: On 02/08/24 admission weighed of 176.0 lbs. On 03/04/24 weighed 165.0 lbs. (a significant weight loss of 6.25% in a 30 day review from 02/08/24 to 03/04/24). On 06/03/24 weighed 162.8 lbs On 08/05/24 weighed 165.0 lbs. On 10/07/24 weighted 158.6 lbs. On 01/07/25 weighed 158.2 lbs. On 02/19/25 weighed 153.0 lbs. R51's EMR 30 day (01/22/25 to 02/20/25) meal intake review revealed R51 had refused the breakfast meal 17 times and the lunch meal three times and the supper meal once. The Progress Note dated 03/04/24 at 10:39 AM, documented a five percent weight loss variance over 30 days. The Progress Note dated 04/10/24 at 05:43 PM, documented R51 was a patient at risk related to weight loss. Both dietary and nursing contributing factor of weight loss due to R51 stated he does not want to eat some of the food. R51 preferred peanut butter and jelly sandwich most meals. The Progress Note dated 05/01/24 at 09:49 PM, documented R51's physician ordered twice a week weight related to weight loss. R51 was to receive his preferences at mealtime to reduce further weight loss. The Progress Note dated 05/07/24 at 08:53 AM, documented a nutrition review was completed for R51. R51 diet order is fortified foods, mechanical soft, ground meat texture. The meal intakes were fair ranging 51 to 75% intake in the last eleven days. R51 was currently receiving supplements. The Progress Note dated 05/14/24 at 11:01 AM, documented staff talked to R51 about weight loss and food intake. R51 stated he does not feel that the food was appealing to him but agreed to have a med pass at 10:00 AM and 2:00 PM for a nutrition supplement. Staff educated reason risks and benefits of proper nutrition. The Progress Note dated 06/05/24 at 11:09 AM, documented a nutritional assessment had been completed. R51 had gradual weight loss of the past six month. R51 received fortified foods, snacks, and magic cup. R51's current intake was not adequate to maintain his estimated needs. The note documented recommendation to discontinue fortified foods and magic cup, and instead would offer six ounces of Med Pass supplement if R51 refused a meal. The Progress Note dated 08/03/24 at 02:56 AM, documented R51 had a swallow study and received new order for a regular diet. The Progress Note dated 10/11/24 at 03:31 PM, documented a nutritional assessment was completed. The RD spoke with R51 and informed him of his weight loss and dropped below weight goal. R51 agreed to Magic Cup three times a day with meals. New goal weight of 158 lbs. The Progress Note dated 12/02/24 at 01:37 PM, documented R51 received a therapeutic regular diet, meal intake was fair averaging 51 to 75%. R51 received supplements and was on a fluid restriction. The Progress Note dated 02/06/25 at 02:07 PM, documented a nutritional review. R51 had not had a significant weight loss in the last month or last six months. On 02/19/25 at 03:25 PM, R51 came to the facility's conference room, drinking a supplement drink while talking with the survey team. R51 talked in a very quiet voice. R51 reported he had not gotten many of the supplement drinks but liked them and voiced he needed to put on weight. On 02/24/25 at 07:52 AM, Certified Nurse Aide (CNA) O reported R51 slept late and sometimes he ate a whole meal and other times would just eat a few bites. On 02/24/25 at 08:38 AM, Dietary Staff (DS) BB reported she was unsure of R51's total weight loss and would have to review the clinical record to determine if it was significant. DS BB stated when a resident admitted to the facility a food preference was completed on admission. DS BB stated she had not talked to R51 on food preferences. Upon record review preferences were not found. DS BB reported R51 got chicken broth with lunch and a magic cup daily, he could not sit for long periods of time in the dining room and got up and would throw away his meal, but then come back later and ask for dessert or a magic cup. On 02/24/25 at 09:50 AM, R51 stated he was aware of weight loss since admission. He reported being a picky eater but liked pizza, hot dogs, hamburgers, and tacos. He reported he did not like chicken due to past experience of working on a chicken farm when a roof collapsed and killed thousands of chickens that he had to clean up, therefor that turned him off of chicken. 02/24/25 at 02:15 PM, Administrative Nurse D stated she would expect someone on staff to have talked to R51 about his weight loss and food preferences to prevent further weight loss. The facility's Nutritional Assessment policy, dated 10/2024, documented a nutritional assessment including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Nursing and the Interdisciplinary Team (IDT) to include food preferences and dislikes. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's prognosis and personal preference. The facility failed to assess R51's preferences of diet to address continued weight loss. This deficient practice placed R51 at risk for continued significant weight loss.

The facility had a census of 58 residents. The sample included 16 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) 7 and R1. This placed the residents at risk for accident or injury due to unidentified risks associated with side rail use. Findings included: - R7's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and tremors. R7's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. The MDS documented R7 required substantial to maximum assistance with bed mobility and transfers. The MDS lacked documentation the resident had side rails. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/27/24, recorded R7 had trouble finding words and expressing herself, and recognized her surroundings, but could be forgetful. The Activities of Daily Living (ADL) CAA, dated 06/27/24, recorded staff transferred R7 per total body left and had a non-weight bearing status. R7's Care Plan, dated 12/03/24, documented R7 required extensive assistance with daily needs and propelled herself in a wheelchair around the facility. The care plan documented the resident utilized grab bars on the bed for safety and mobility. The care plan documented the resident used the grab bars for rolling from side to side while in bed, slide herself up and down in the bed, and support herself. R7's EMR recorded a Side Rail Evaluation completed on 01/28/25 documenting the resident used the rails to pull or push herself for mobility. The assessment documented alternatives to bed rails attempted were roll guards, a low bed to the floor, a concave mattress, and the alternatives had failed. On 02/20/25 at 08:25 AM, observation revealed a half-circle side rail on the upper right and left side of R7's bed with an opening approximately 13 inches wide by 20 inches high. Continued observation and examination revealed the side rail had a piece of canvas material covering 1/2 of the height of the rail, however, it was torn and easily movable to allow for a larger opening. The rail was unstable, able to be moved up and down, and back and forth a few inches with slight pressure on the rail. On 02/24/25 at 10:00 AM, Administrative Nurse D verified the bed rails on R7's bed had too large of an opening, and the rails were not stable and were able to be moved easily. Administrative Nurse E verified the facility lacked any further assessment for the use of the side rail. The Bed Safety-Bed Rails policy, dated 10/2024, documented the facility strived to provide a safe sleeping environment for the resident. Upon admission, evaluate the current status of the resident for any type of bed rail. Prior to applying any type of rail, attempt an alternative such as a roll guard, foam bumper, concave mattress, or lower the bed to the floor. The policy documented after attempted alternatives failed to complete the bed rail evaluation, including risk, upon admission, quarterly, and change of need or condition. Prior to applying the bed rail, obtain consent to include, the medical need for the rails, the benefit for use of the bed rails, how the risk would be mitigated, alternatives attempted but failed to meet the resident's needs, and alternatives considered but not attempted that were considered inappropriate. Staff would obtain a physician's order for the use of the bed rails. The bed rails would be used if assessment and consultation with the Attending Physician had determined they were needed to help manage a medical symptom or condition or to help the resident reposition, move in bed, and transfer, and no other reasonable alternative could be identified. The bed rails would be applied per manufacturer instructions and specifications for compatibility with the bed frame and mattress requirements. The facility was directed to confirm the rails are installed with the appropriate size and weight of the resident and to inspect regularly. The policy documented that staff would add the type of bed rails to the resident's care plan, including what type of specific direct monitoring and supervision would be provided during the use of the bed rails and where it would be documented. The policy directed identification of how needs would be met during the use of the side rail, such as turning and repositioning, and how often the use of the rails would be assessed, including evaluation if they need to be discontinued. Ongoing evaluation and risks, and any additional interventions to address residual effects of the bed rail use. The facility failed to adequately assess R7's actual rail in use to ensure safe openings and failed to assess for the safe use of a side rail prior to placing the side rail on R7's bed. This placed her at risk for accident or injury due to unidentified risks associated with side rail use. - R1's Electronic Medical Record (EMR) recorded diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) dementia (a progressive mental disorder characterized by failing memory and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented R1 required substantial to maximum assistance with bed mobility and transfers. The MDS lacked documentation the resident had side rails. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/07/24, recorded R1 had the potential for a decline in her cognition due to the diagnosis of dementia and potential further memory loss. The CAA documented the resident could be confused and forgetful. The Activities of Daily Living (ADL) CAA, dated 10/07/24, recorded R1 documented the resident had the potential for falls due to weakness, unsteady gait, and history of falls. The CAA documented the resident utilized a wheelchair for mobility and was able to self-propel. The CAA documented that the resident utilized grab bars on the bed to stand and pivot transfer. R1's Care Plan, dated 12/12/24, documented R1 was full weight bearing on both legs as tolerated, however chooses to use a wheelchair for mobility. The resident is at risk for falls secondary to Parkinson's, unsteady gait, and a history of falls. Staff assisted the resident with transfers due to a non-injury fall on 03/26/24 and placed a grab bar on the resident's bed. The care plan documented the resident had a fall out of bed on 12/13/24 and sustained a bruise to her right shoulder. R1's EMR recorded a Side Rail Evaluation completed on 01/28/25 documented the resident used the rails to pull or push R1's self for mobility. The assessment documented no alternatives to bed rails had been attempted and the bed rails potential risks were addressed with a representative including dignity and isolation. On 02/20/25 at 08:25 AM, observation revealed a half-circle side rail on the upper left side of R1's bed with an opening approximately 13 inches wide and 20 inches high. Continued observation and examination revealed the side rail had a piece of canvas material covering 1/2 of the height of the rail, was easily movable to allow for a larger opening, and the rail was unstable and able to be moved up and down and back and forth a few inches with pressure exerted on the rail. On 02/24/25 at 10:00 AM, Administrative Nurse E verified the bed rail on R1's bed had too large of an opening, and the rail was not stable. Administrative Nurse E verified the facility lacked any further assessment for the use of the side rail. The Bed Safety-Bed Rails policy, dated 10/2024, documented the facility strived to provide a safe sleeping environment for the resident. Upon admission, evaluate the current status of the resident for any type of bed rail. Prior to applying any type of rail, attempt an alternative such as a roll guard, foam bumper, concave mattress, or lower the bed to the floor. The policy was documented after attempted alternatives failed to complete the bed rail evaluation, including risk, upon admission, quarterly, and change of need or condition. Prior to applying the bed rail, obtain consent to include, the medical need of the rails, the benefit of use of the bed rails, how the risk would be mitigated, alternatives attempted but failed to meet the resident's needs, and alternatives considered but not attempted that were considered inappropriate. Staff would obtain a physician's order for the use of the bed rails. The bed rails would be used if assessment and consultation with the Attending Physician had determined they were needed to help manage a medical symptom or condition or to help the resident reposition, move in bed, and transfer, and no other reasonable alternative could be identified. The bed rails would be applied per manufacturer instructions and specifications for compatibility with the bed frame and mattress requirements. The facility was directed to confirm the rails are installed with the appropriate size and weight of the resident and to inspect regularly. The policy documented that staff would add the type of bed rails to the resident's care plan, including what type of specific direct monitoring and supervision would be provided during the use of the bed rails and where it would be documented. The policy directed identification of how needs would be met during the use of the side rail, such as turning and repositioning, and how often the use of the rails would be assessed, including evaluation if they need to be discontinued. Ongoing evaluation and risks, and any additional interventions to address residual effects of the bed rail use. The facility failed to adequately assess R1's actual rail in use to ensure safe openings and failed to assess for safe use of a side rail prior to placing on R1's bed. This deficient practice placed her at risk for accident or injury due to unidentified risks associated with side rail use.

The facility had a census of 58 residents. The sample included 16 residents. Based on observation and interview, the facility failed to ensure the correct use of a subcutaneous (beneath the skin) injection of insulin (a hormone that lowers the level of glucose in the blood) during the observation of administration. This placed the resident at risk of receiving less than the ordered dose. Findings included: - On 02/24/25 at 11:48 AM, Licensed Nurse (LN) H pulled Resident (R) 7 into the quiet room for the administration of subcutaneous insulin. LN H had dialed the Novolog insulin pen to five units. LN H then injected the insulin into R7's lower left abdomen. LN H stated she usually primed the insulin with two units of waste insulin before administration but was nervous and failed to at this time. On 02/24/25 at 02:15 PM, Administrative Nurse D stated she had expected LN H to prime the insulin needle with waste insulin before administering the dose. The facility's Insulin Administration policy, dated 10/2024, documented the nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) before their use. The facility failed to ensure the correct use of subcutaneous injection of insulin which placed the resident at risk of receiving less than ordered insulin.

The facility had a census of 58 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 7, R12, and R23s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with the date opened and the discard date on the two nurse medication carts. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:50 AM, observation of the facility's treatment cart revealed the following: R7's Novolog (rapid-acting insulin) flex pen was not labeled with an open or expired date. R12's Basaglar (long-acting insulin) flex pen was not labeled with an open or expired date. R23's Basaglar flex pen was not labeled with an open or expired date. On [DATE] at 09:00 AM, License Nurse (LN) G verified the nurses should label and date the insulin flex pens with the date opened and the expiration date. On [DATE] at 01:30 PM, Administrative Nurse D verified the nurses should label and date the flex pens with the date opened and the expiration date. Medlineplus.gov directs open, unrefrigerated Lantus (Novolog and Basaglar) can be used within 28 days; after that time, they must be discarded. The facility's Storage of Medication policy, dated [DATE], documented the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The facility would not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility failed to date the insulin flex pens when opened and the expiration date. This deficient practice placed the residents at risk for ineffective medication.

The facility identified a census of 57 residents, with three residents reviewed for food allergies. Based on record review, observation, and interview, the facility failed to accommodate R1's known food allergy to mushrooms which caused anaphylactic (severe life-threatening allergic reaction) allergic reaction. The facility failed to follow R1's dietary care plan, when staff served R1 facility food (oriental vegetables) for lunch, that contained mushrooms. R1 advised Certified Nurse Aide (CNA) M her mouth and throat were itching, and she was severely allergic to mushrooms. R1 required administration of diphenhydramine (antihistamine), administration of an epinephrine (adrenaline use to treat anaphylaxis) pen, and transfer by Emergency Medical Services (EMS) to the Emergency Department (ED) for evaluation and treatment. This deficient practice placed R1 in immediate jeopardy. Findings included: - The signed Physician Order Sheet (POS) for R1, dated 01/31/24, documented the facility admitted the resident on 03/24/22, with the following diagnoses: conversion disorder (a mental condition in which a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by illness or injury), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required supervision with eating. The Nutritional Status Care Area Assessment (CAA), dated 03/23/23, documented R1 could feed herself during meals and staff were to encourage the resident to eat healthy foods and snacks. The 01/27/24 Quarterly MDS documented the resident had a BIMS of 15 and required supervision with eating. The residents Altered Nutritional Status Care Plan, dated 12/30/22, included R1 had allergies to mushrooms, which were listed on her tray card. The revised care plan, dated 02/21/24, directed staff to review allergies when ordering her food tray. Review of the Registered Dietician's Annual Assessment, dated 12/21/23, documented R1 was on regular diet and had an allergy to mushrooms. Review of a Nursing Note revealed on 02/16/24 at 12:53 PM the resident was eating lunch when she noticed there were mushrooms in the food, and alerted staff to her allergy of mushrooms. The resident advised staff her throat and body began to itch. Review of a Nursing Note revealed on 02/16/24 at 12:53 PM the nursing staff notified R1's Healthcare Provider (HCP) of the resident's allergies to mushrooms and she was served mushrooms at lunch. The HCP provider ordered diphenhydramine, 50 milligrams (mg), by mouth, now, and 25 mg as needed (PRN), by mouth, every four hours. Review of a Nursing Note on 02/16/24 at 12:53 PM documented nursing staff observed R1's tongue began to swell and the resident reported her throat was swelling. Nursing staff then administered an epinephrine pen solution, 0.3 milligrams/0.3 milliliters (ML), to R1's right thigh. The staff notified R1's HCP and staff received an order to transport the resident to the Emergency Department (ED) by Emergency Medical Services (EMS). On 02/22/24 at 12:13 PM, the resident sat at the dining room tablet eating lunch. On 02/22/24 at 10:12 AM, Licensed Nurse (LN) G reported the resident complained her body and throat were itching after she consumed some of her meal that contained mushrooms. Staff notified the HCP and received an order for diphenhydramine. LN G administered the diphenhydramine, which was ineffective. The resident advised LN G that her tongue and throat began to swell, and LN G administered the epinephrine. Staff notified the HCP again and received an order to transport the resident to the Emergency Department (ED) by Emergency Medical Services (EMS). On 02/22/24 at 09:28 AM, Administrative Nurse D reported that Dietary Staff BB knew R1 had an allergy to mushrooms and did not check the ingredient label of the oriental vegetables, which contained mushrooms. On 02/22/24 at 10:17 AM, Dietary BB reported on 02/16/24, staff served sweet and sour chicken with oriental vegetables for the noon meal. Dietary BB reported she was asked by nursing staff if mushrooms were in the meal. After checking the oriental vegetable bag, Dietary BB found small mushrooms in it, which she did not notice when she prepared the meal. Dietary BB stated she did not check the label prior to preparing R1's plate or offering R1 an alternate meal. Dietary BB said R1 had an allergy to mushrooms and the allergy was identified on R1's green card. The facility's Food Allergies and Intolerance Policy, revised 10/2022, documented the facility should ensure steps to prevent resident exposure to allergens. On 02/24/24 at 03:22 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified the facility failed to follow R1's dietary care plan, which noted R1 had an allergy to mushrooms, to prevent an avoidable allergic reaction when staff served R1 facility food containing mushrooms, placed R1 in immediate jeopardy. The facility identified and implemented the following corrective actions immediately in response to the allergic reaction to R1, completed on 02/16/24: On 02/16/24 at 01:35 PM, immediately re-educated staff on identifying allergens: ingredients checked for allergens and immediate medical intervention for the affected resident. On 02/16/24 at 03:00 PM, all residents with food allergies were identified and tray cards were updated so the allergens were more easily visualized. Dietary Manager reviewed all food supplies in the Kitchen to identify any food allergens, Dietary Manager reviewed all recipes to identify food allergens. On 02/16/24 at 04:30 PM, Quality Assurance and Performance Improvement (QAPI) meeting held. Due to the corrective actions implemented prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J score and severity.

The facility identified a census of 56 residents. Based on observations and interviews, the facility failed to store & prepare food to prevent the spread of food borne illness to the residents of the facility. Findings included: - The kitchen environment tour observations, on 09/25/23, at 02:36 PM, revealed the following areas of concern: 1. The stove contained excessive brown residue around the three burners. 2. There was excessive food and dirt under the white freezer across from the dishwashing area, a commercial freezer, the preparation table, and the refrigerator. 3. The freezer contained food crumbs, one red and one orange frozen popsicle lying on the bottom shelf, clear container with red lid, unlabeled, with the lid opened, and unlabeled, undated large blue bag with broccoli. 4. The refrigerator contained clear container with blue lid, with diced peaches, unlabeled and undated. 5. The refrigerator contained a box with ten red tomatoes; three tomato's with white substance at the stem and soft areas, seven tomato's with soft areas, and one tomato leaking white substance. 6. The refrigerator contained a bag of 18 green peppers; five green peppers contained excessive amount of white and black substance, the five peppers were open and soggy. 7. Lying on the preparation table were two six-pound sealed packages of pork sausage thawing. On 09/25/23 at 03:00 PM, Dietary BB reported that she did not inspect the produce daily to ensure the produce or fruit did not contain mold or soft areas She reported that she did not check the freezers or refrigerators daily to ensure food items sealed, labeled, dated or cleanliness. She reported that the floors under the freezers and refrigerators are pulled out once a week to be swept and mopped. She verified that thawing out meat directly on the preparation table was not appropriate due to cross contamination. She verified the concerns were not acceptable and should be addressed immediately. On 09/25/23 at 09:40 AM, Administrative Staff A reported that she agreed the above listed concerns should be addressed and corrected. On 9/26/23 at 11:26 AM, Consultant GG verified that the freezer and refrigerators should be glanced through daily but did not feel that the produce would not need to be inspected daily because produce could go bad in one day. Consultant GG reported that pork sausage should not be left to thaw at room temperature. The facility failed to provide a policy for Safe, Clean, and Sanitary Environment in the Kitchen. The facility the facility failed to maintain a Safe, Clean, and Sanitary Environment in the Kitchen for the residents in the facility.

The facility reported a census of 58 residents with 17 residents sampled. Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for the residents of the facility. Findings included: - During an environmental tour of the 200 hallway, on 05/11/23 at 10:30 AM, with Administration Staff A and Housekeeping/Maintenance Staff U, revealed the following areas of concern: 1. One shared resident room had two built-in drawers, which would not properly push into the wall to close them. One of the four handles of the drawers was broken. There was a build-up of dirt around the floor parameter of the room. 2. The bathroom of one shared resident room had dirty towels lying directly on the bathroom floor. The toilet seat riser had rust on four of the four supportive legs. The toilet paper holder was broken. The bathroom had a build-up of dirt around the parameter of the bathroom floor. 3. One shared resident room had cove base separating from the wall in several various areas. Three of the eight, built-in drawers, would not properly push into the wall to close. There was a build-up of dirt around the floor parameter of the room. 4. One shared resident room had two of six built-in drawers, which would not properly push into the wall to close. There was a build-up of dirt around the floor parameter of the room. 5. One shared resident bathroom had a build-up of dirt around the floor parameter. On 05/11/23 at 10:30 AM, Administrator A confirmed the areas of concern required attention with housekeeping/maintenance services. The facility lacked a policy for the upkeep of housekeeping and maintenance issues. The facility failed to provide a safe, clean, comfortable and homelike environment for the residents of the facility.

The facility reported a census of 57 residents and reported handling personal funds accounts for all residents of the facility. Based on record review and interview the facility failed to protect at least 54 residents (50 residents' individual envelopes of cash found and four individual discharged residents' envelopes found with cash , Residents (R)10, R11, R12, and R13), from misappropriation of their money. This happened when Activity Director (AD) Z, the alleged perpetrator (AP), kept resident funds entrusted to her, under the understanding she would use the funds to purchase personal items for residents, from at least [DATE] (with stimulus money obtained) through [DATE]. AD Z accumulated approximately $13,000 in cash that she kept at her home without the residents' knowledge. The facility also failed to ensure the AP accurately provided accounting for the residents' purchases according to their policy, which included accounting with receipts for such purchases. This exploitation had the potential to leave the residents feeling angry, fearful, and betrayed by the staff member entrusted with their personal funds. These actions placed all 57 residents of the facility, as they all had personal funds accounts available with the facility, in immediate jeopardy. Findings included: - On [DATE] at 09:40 AM, an interview with Administrative Staff A and Administrative Nurse Staff D revealed she was the actual person who first found the incident of Activity Director (AD) Z/Alleged Perpetrator (AP) having large sums of money in envelopes for various residents. The staff agreed that Staff D could explain the facility response and actions of the incident day by day as follows: On [DATE], later in the afternoon on Friday, R1 reported to Administrative Nurse Staff D that she gave AD Z a large sum of money to buy her clothes and a television and the AP did not provide R1 with the items or receipts. Administrative Nurse D informed the resident they would talk with AD Z on [DATE], upon her return to work and see where they were with obtaining R1's requested items. Administrative Nurse D's continued interview included, On [DATE] at approximately 09:30 AM, Administrative Nurse D and the administrator talked with AD Z and asked about her purchasing the requested items for R1 and let her know they needed an update on the progress for the resident. AD Z explained the resident and herself shopped online and had not ordered anything yet because of internet problems during the prior week. Upon questioning about the television for the resident, AD Z explained she ordered a television on [DATE] and it had not arrived. Administrative Nurse D then asked AD Z if she had any other resident's money on her and she stated yes, the money was in her office. AD Z went to her office and retrieved several envelopes with resident names on them. Administrative Nurse D told her to bring all of the envelopes into Administrator A's office so they could review the contents. AD Z lacked any system to track the numerous receipts and residents' money in the various envelopes. This led Administrative Staff A and Administrative Nurse D to further investigate. AD Z explained she lacked organization of the receipts because she was behind. AD Z explained she took the receipt book to her home with other residents' receipts to try to catch up. Administrative Staff A asked AD Z to retrieve all of the residents' envelopes with money and any receipts from her home and bring them all back to the facility. When AD Z returned to the facility with a large container, she took the container to the activity room where Administrative Nurse D found her sitting on the floor rearranging money/receipts in multiple envelopes. Administrative Nurse D took AD Z and the large container to Administrative Staff A's office and informed Administrative Staff A of the large number of receipts/envelopes with money in them. Administrative Staff A suspended AD Z at that time until they could investigate further. The administrator notified local law enforcement. Administrative Nurse D's continued interview included, Administrative Staff A and Administrative Nurse D then spent most of the night counting the money, sorting receipts, and accounting for the money found in the numerous envelopes. The large container contained a smaller box with more envelopes, which contained anywhere from $2.00 to $950.00, some with receipts and some without. Some of the envelopes also contained gift cards. Administrative Staff A and Administrative Nurse D put each resident's information including the totals of cash, gift cards, and receipts on a spreadsheet. The staff also found four envelopes for residents that previously expired or discharged from the facility. Administrative Nurse D's continued interview included, on the next morning ([DATE]) Administrative Staff A made a bank deposit of approximately $13,000.00 into the resident funds account from the envelopes found. This was money from the residents' personal funds account which was found in various envelopes without an accounting system which AD Z previously removed from the facility and had in her possession without resident knowledge. Administrative Nurse D's continued interview included, on [DATE], Administrative Staff A and Administrative Nurse D continued with interviewing residents to ask if they had problems with obtaining requested items from AD Z when she shopped for them or the process. On [DATE], the facility reviewed the completed resident interviews and identified seven residents (R22, R8, R23, R1, R44, R25, and R26) that had concerns related to items they did not receive, no change back from the purchases, and receipts they never received. Administrative Nurse D's continued interview included, on [DATE] at 01:30 PM, Administrative Staff A and Administrative Nurse D conducted a meeting on the computer with AD Z. They asked her questions to clarify items of clothing found and so forth. AD Z again reported the retail store did not deliver R1's television and she did not have it as of [DATE]. They also asked AD Z to look around in her house and try to find any other residents' money, envelopes, or receipts to help ensure correct accounting for the residents. Later in the day, AD Z brought 10 more residents' envelopes with money and receipts to the facility administrator. These 10 residents' envelopes contained total cash in the amount of $1,330.00, which the facility also deposited into the resident funds account. This was additional money that AD Z had at her personal home without any resident knowledge and no accounting for the receipts. Administrative Nurse D's continued interview included, on [DATE] in the morning, Administrative Staff A called the retail store to question the delivery of R1's television set. The retail store staff reported there were two televisions ordered online on [DATE], both ordered in the name of AD Z and delivered to AD Z's personal home address on [DATE] at 02:02 PM. (Administrative Staff A found out the other television ordered belonged to R3, a non-interviewable resident.) At that time, Administrative Staff A notified the sheriff who went to AD Z's home. When AD Z failed to answer the door, the sheriff found the two televisions sitting on the back porch of the home, and Law Enforcement returned them to the facility to the residents. Administrative Nurse D's continued interview included, further explanation that she was responsible to oversee the Activity Director, but was not responsible to oversee the residents' money or the shopping by AD Z. The person responsible for the residents' personal funds account was Business Office Manager (BOM) B, who completed a Money Pass daily for the residents and had each resident sign a receipt for the amount of money she gave to them. On [DATE] at 10:40 AM, interview with BOM B revealed she was responsible for the residents' personal funds accounts. She would conduct a Money Pass each day and on the weekends, the manager on duty was responsible to conduct a resident Money Pass. She would have each resident sign out receipts for the money they wanted. Some residents' guardians had set daily limits on how much that resident could take out each day. The residents may take out money and then redeposit it later. Larger sums may have to wait a day or two as that would come from the bank upon request. BOM B explained some of the residents had the large sums of money because they received stimulus checks around [DATE]. BOM B and AD Z went through the resident's accounts and identified eight residents who were over their Medicaid limit and needed to spend down their money. Upon request, BOM B provided a list of the eight residents: (R2, R3, R4, R5, R6, R7, R8, and R9) with withdrawn amounts for each one. The total amount withdrawn for these eight residents was $13,092.00. These amounts varied from $500.00 to $2,377.00 in each resident envelope. BOM B explained she put the cash in envelopes for each resident and gave those envelopes to AD Z to shop for the residents. BOM B further stated these were withdrawn from the residents' accounts with verbal authorization and that AD Z took care of those. BOM B verified she did not get receipts back for any items that AD Z bought for the residents and did not know she was supposed to until the administrator had just read the facility policy for resident's personal funds accounts, and it said she was to get receipts back to account for the money. Review on [DATE], of the undated facility spreadsheet, revealed Administrative Staff A and Administrative Nurse D completed the spreadsheet to account for each of the 54 residents' envelopes found. This review revealed the following: A total of 66 individual residents' envelopes found with cash, gift cards, and receipts, belonging to 50 different residents (some residents had 2 different envelopes with their names on them), and four residents (R10, R11, R12, and R13) who previously expired/discharged from the facility. The total cash was $16,764.44 and the total gift cards was $882.07, for a total of cash/gift cards of $17,646.51. This was the amount of cash/gift cards that AD Z had in her possession in her personal home, with no accounting system to reconcile the residents' money. On [DATE] at 9:30 AM, interview with R27, revealed he could give a shopping list to AD Z and she would get them things he needed. He stated he always signed out for his money at money pass for whatever he was wanting. He did not think that AD Z had him sign any type of receipt when she gave him his things. He did not really remember if he got a receipt back with his things he ordered. He trusted AD Z and felt she would get him whatever he wanted. On [DATE] at 10:15 AM, R28 explained the routine for getting things she needed from the store. The residents could give a shopping list to AD Z two time per month and she would get their things unless it was not available. AD Z did not give the resident back her change lately but had in the past. She would always sign a receipt to get the money out she needed from money pass. R28 further explained she asked the administrator the other day how much money she had and was told she had $155. R28 further stated that her roommate R1, had more money than she did because she just got a new television. A small thin television sat on the floor against the wall. On [DATE] at 2:00 PM, interview with R29, he did put shopping list orders in with AD Z and she got him what he wanted. He did not get a receipt or change back, but he would always give her money with his order. He did not think about change or a receipt. He just felt this is how it had to be, since this Covid thing hit, it's the only way we can get things now. On [DATE] at 2:15 PM, interview with R8, revealed he had not been in the facility long, but he used AD Z for a shopping list, but only a couple of times. The first time he felt he should have gotten a receipt back because you just never know if they are out to take you. The last time I didn't worry about it because I felt like she was on my side and it would be okay. He did report he did not get change back, but he had given her $25 and ordered cereal, chips and other snack items. On [DATE] at 2:45 PM, interview with R1, revealed she did give AD Z money to buy her a television and some clothes. She did not get anything back from AD Z in quite a while and she told the Director of Nursing. She was happy now because she had her new television in her room, and it would be connected as soon as the maintenance staff could do that. She said that she also talked with AD Z about buying clothes and they were going to do that but could not yet. The facility failed to protect at least 54 residents (50 of the current residents with money in individual envelopes found and the four discharged residents (R)10, R11, R12, and R13), with money and gift cards totaling $17,646.51, found in the individual residents' envelopes, from misappropriation of their money. This deficient practice was cited as past non-compliance as of [DATE] when the facility completed the following actions: 1. The facility educated staff responsible for management of resident funds as of [DATE] at 09:00 PM. 2. On [DATE] at 03:00 PM, the facility held a resident council and discussed changes to resident shopping and money pass. Signatures were received from all applicable residents of understanding. 3. The facility held a Quality Assurance meeting with all disciplines, including the medical director on [DATE] at 09:30 AM, to develop a plan for auditing the resident funds to prevent further deficient practice . 4. On [DATE] at 09:00 PM, the facility reviewed the resident interviews and identified the eight resident that had concerns related to items they did not receive, change back they did receive not from the purchases, and receipts they never received. The facility took appropriate corrective actions to as accurately as possible correct the residents' concerns related to their money and account. 5. On [DATE] at 09:30 AM, the facility made the final deposit of all money found in the residents' individual envelopes into the bank in the residents' personal funds account. 6. On [DATE] at 03:00 PM, the sheriff department found returned the two televisions to the facility for the two residents they belonged to.

The facility reported a census of 59 residents. The sample consisted of 16 residents, including 3 reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure 1 of the 3 sampled residents (#11), received care in a dignified manner, when facility staff assisted the resident to walk nude from the waist down, to and from the bathroom/bed, in full view of his/her alert roommate; and failed to offer an incontinence brief or clothing to the lower body while in bed, as a reasonable person would expect. The resident expressed that he/she experienced emotional distress with embarrassment, heavy breathing, a red face and also became teary eyed, following these incidents. Findings included: - Resident #11's signed physician's orders [REDACTED]. The significant change MDS (minimum data set), dated 1/14/18, assessed the resident as having short and long-term memory problems and severely impaired decision making ability. The resident could not recall the current season, but could recall the location of his/her room, staff names and faces, and that he/she lived in a nursing facility. The resident required extensive assistance from one to two staff members to complete his/her ADLs (activities of daily living) and experienced frequent episodes of urinary incontinence. The CAAS (care area assessment) for urinary incontinence, dated 1/30/18, documented the resident experienced occasional episodes of urinary incontinence, and required extensive assistance with toileting. The resident's care plan, reviewed 10/26/18, documented that the resident experienced a self care deficit related to his/her diagnoses. The resident was at risk for skin breakdown due to his/her urinary incontinence, and staff must encourage the resident to wear briefs at all times. On 1/14/19 at 1:57 PM, the resident lay on the top of his/her bed, uncovered, nude from the waist down and with the door to the room open. The resident's privacy curtain obstructed the direct view of the resident from the hallway. The resident's alert roommate sat in his/her recliner and looking around the room. The privacy curtain between the roommate's recliner and resident's bed was not pulled, leaving the resident fully exposed to his/her roommate. At 2:04 PM, direct care staff F entered the resident's room, to assist him/her with toileting. Staff F failed to pull the resident's privacy curtain between the roommate's recliner and the resident's bed. Staff F then assisted the resident to stand, using a gait belt, and then assisted the resident to walk to his/her bathroom, directly in front of his/her roommate, who had an unobstructed view of the resident, nude from the waist down. Staff F assisted the resident to sit on the toilet, and stated that he/she would return in a moment, with clean linens for the resident's bed. Staff F then exited the room, failing to close the bathroom door. Staff F returned with clean linens, made the resident's bed, then assisted the resident with cares in the bathroom. Staff F failed to offer the resident a clean incontinence brief after care. Staff F then assisted the resident to stand, and assisted the resident with ambulating back to his/her bed, nude from the waist down, in full view of the resident's alert roommate. Staff F assisted the resident to lay down on his/her bed, without an incontinence brief or other clothing, and covered him/her up with a blanket. Staff F then left the room. At 2:15 PM, the resident stated that laying in bed naked made him/her feel bad, and embarrassed. While discussing his/her feelings, the resident's face turned red, he/she began breathing heavily, and his/her eyes teared up. On 1/14/19 at 3:05 PM, direct care staff J performed an incontinence check for the resident, and noted that the resident experienced an episode of urinary incontinence. Staff J requested assistance from direct care staff I to help position the resident during incontinence care. Staff J opened the resident's bottom dresser drawer, which contained incontinence briefs, and then failed to take one, instead taking a disposable absorbent bed pad from the middle dresser drawer. Staff J and staff I then removed the soiled disposable absorbent bed pad from underneath the resident, put the new one down, and repositioned the resident in his/her bed. Both staff J and staff I failed to offer an incontinence brief to the resident. On 1/14/19 at 3:16 PM, direct care staff F confirmed that he/she failed to offer the resident an incontinence brief, because he/she thought that the disposable absorbent bed pad was a sufficient replacement. Staff F confirmed that he/she assisted the resident with ambulation while the resident was partially nude, from the waist down. On 1/14/19 at 4:17 PM, direct care staff I explained that the resident was incontinent of bladder, but that staff failed to offer an incontinence brief to him/her because the disposable absorbent bed pad was a sufficient replacement. Staff I explained that staff were not to ambulate a resident, if that resident was partially nude, in front of their roommate. On 1/15/19 at 12:55 PM, licensed nursing staff B confirmed that ambulating a resident, who was partially nude, in front of his/her roommate would compromise that resident's dignity. Staff B explained that some residents were left 'open to air' in bed, on top of a disposable absorbent bed pad and without an incontinence brief, if the resident wished to do so. Staff B stated that this was done if the resident could request it, and that all residents would be asked their preference before doing so. Staff B confirmed that resident #11 could make his/her wishes known, and should have been offered an incontinence brief. On 1/15/19 at 1:00 PM, administrative nursing staff A stated that his/her expectation of staff would be that they would be covered while ambulating, and that an incontinence brief or other undergarment would be offered when getting into bed. The facility policy, dated 05/2017, for dignity, documented that facility staff would treat all residents with respect and dignity, and would provide care for each resident in a manner and in an environment that maintained or enhanced each resident's quality of life. Staff would dress each resident according to their preference, and must maintain each resident's privacy. The facility failed to ensure that this dependent resident received cares in a dignified manner, without emotional distress, when the facility staff assisted the resident, nude from the waist down, in ambulating to his/her bathroom to the toilet, in full view of his/her alert roommate; and failed to offer an incontinence brief to the resident after toileting, again assisting the resident to ambulate across his/her room, nude from the waist down, in full view of his/her alert roommate, and placed the resident in bed, failing to offer any kind of incontinence brief or clothing, as a reasonable person would expect. The resident expressed that he/she experienced emotional distress with embarrassment, heavy breathing, a red face and also became teary eyed, following these incidents.

The facility reported a census of 60 residents. The sample of 16 residents included 1 resident sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide pressure ulcer monitoring and implement timely and appropriate interventions to prevent and promote healing of pressure ulcers for 1 (#49) sampled resident. Findings included: - The signed physician orders, dated 11/8/17, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 10/11/17, revealed the resident's memory was intact, and he/she had modified independence in decision making, with difficulty in new situations only. The resident was at risk for a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) development, with no unhealed pressure ulcers at the time of the assessment. The resident required pressure relieving devices for the bed and the chair. The pressure ulcer CAA (care area assessment) dated 11/24/17, documented the resident required extensive assistance with bed mobility, and he/she was at risk for development of pressure ulcers. The resident did not have pressure ulcers, and had a preventative treatment, and bandages in place. Review of the Braden scale for predicting pressure sore risk, dated 3/16/17, documented the resident scored 17, revealing a low risk for developing pressure ulcers. The clinical record lacked an updated assessment for development of pressure ulcers. Review of the nutrition assessment , dated 11/17/17, documented no pressure ulcers present at the time of the assessment. The care plan, dated 9/8/17, documented the resident had a potential for skin breakdown, secondary to decreased mobility, and he/she was wheelchair bound due to double amputation (absence of legs). Instructions included to provide the resident with a pressure-reduction mattress, on-going assessment of skin conditioning during his/her routine care, and provide a pressure reduction cushion in the resident's wheelchair. The resident was not compliant with re-positioning, and he/she could transfer him/herself independently initiated on 8/16/17. Wound care appointment as needed, dated 11/26/17. Wound care for the left stump, left lateral buttock, left medial buttocks, right buttock, and right stump. Wash areas with soap and water. Apply skin prep. Apply Venelex (an ointment to promote wound healing). Cover areas with a foam border, dated 12/2/17. Staff should remind the resident to use the wheelchair cushion, dated 12/11/17. Review of the nurse's notes, from 9/5/17 to 12/17/17, documented: On 10/6 /17, the resident reported his/her bottom hurt, and staff administered prn (as needed) pain medication. However, the clinical record lacked evidence of an actual assessment of the resident's buttocks. On 10/8/17, staff changed the dressings on both buttocks, and documented the areas looked well. The resident required hospitalized from [DATE] to 10/20/17, related [MEDICAL CONDITION] (a life-threatening complication of an infection), cause undetermined. Review of the admission/readmission nursing evaluation, dated 10/20/17, documented the resident had dressings on his/her right and left buttock to prevent skin breakdown. In addition, the left (front) stump had a scabbed area. The clinical record lacked measurements. On 10/28/17, the resident required hospitalization , and returned to the facility on [DATE], for decreased level of consciousness. Review of the admission nursing evaluation, dated 11/1/17, documented the resident had skin break down on left buttock and right buttock. However, the documentation lacked pressure ulcer assessment/monitoring. On 11/10/17, staff identified an open area on left stump, however, the clinical record lacked size, depth, odor, drainage, or periwound (tissue surrounding a wound) description of the decubitus (pressure ulcer). In addition, the clinical record lacked documentation of the pressure areas to the buttocks. Review of the first measurements of skin/wound documentation, dated 11/22/17, documented the resident had 2 open areas on his/her left buttocks that measured 2.5 cm (centimeters) by 2.5 cm, and 2.5 cm by 1 by 0.1 cm. The physician ordered wound care clinic for evaluation of the open areas on the resident's stumps and buttocks. Review of the wound care consultation, dated 11/30/17, documented the resident had multiple stage 2 pressure ulcers. The left stump may require additional amputation and bone removal related to the amount of the pressure in that area. The wound consultation measured the following wound areas: 1.) The left lateral buttock wound measured 3.5 cm by 8 cm by 0.1 cm. 2.) The left medial buttock wound measured 0.6 cm by 3.3 by 0.1 cm. 3.) The right buttock wound measured 1.1 cm by 1 cm. 4.) The left stump wound measured 4.1 cm by 4.5 cm by 0.1 cm. The documentation lacked the right stump measurements, however, the physician's orders [REDACTED]. Review of the nurse's notes, on 12/8/17, documented the following open wound areas: 1.) The left lateral (towards the outside of the middle of the body) buttocks, measured 4.3 cm by 1.4 cm by 0.3 cm. 2.) The left medial (towards the middle of the body) buttocks, measured 4.1 cm by 3 cm by 0.5 cm. 3.) The right medial buttocks, measured 2 cm by 1.4 cm by 0.2 cm. 4.) The right lateral buttocks, measured 4 cm by 2.5 cm by 0.1 cm. 5.) The left stump, that measured 4.1 cm by 4.5 cm by 0.1 cm. The clinical records lacked evidence of documentation of a right stump wound. Review of the facility's equipment invoice, dated 12/8/17, revealed staff ordered a mosaic cushion (pressure relieving cushion) for the resident's wheelchair. The clinical record lacked documentation of a risk/ benefit statement, however, staff reported the resident was non-compliant with repositioning him/herself. Observation on 12/11/17 at 3:01 pm, the resident sat in his/her wheelchair, in the bedroom. The resident had a thick seat cushion in the wheelchair. Observation on 12/12/17, from 8:35 am to 10:27 am, revealed the resident remained in his/her wheelchair, and repeatedly propelled him/herself from the hallway to the living room, and then outside to smoke a cigarette. Observation revealed staff failed to encourage the resident to reposition. On 12/12/17 at 10:36 am, upon surveyor request, licensed nursing staff J measured the pressure ulcers as the following: 1.) The left lateral buttocks measured 4.5 cm by 2 cm. The periwound (tissue around the wound) was slightly reddened. 2.) The left medial buttocks measured 3.5 cm by 2.5 cm. The periwound had slight redness, and the wound had granulation. 3.) The right medial buttocks measured 0.9 cm by 1 cm. The wound bed had slough (dead tissue, usually cream or yellow in color). The periwound was pink. 4.) The right lateral buttocks measured 5.7 cm by 4 cm. The wound bed was pink. The periwound had scarred tissue, without redness. 5.) The left stump measured 4.5 cm by 5 cm. The wound bed was pink, and the periwound had slight maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, feces, or wounds for extended periods). 6.) The right stump measured 2 cm by 2 cm. On 12/11/17 at 3:52 pm, direct care staff F, reported the wounds were present for at least 3 months. The resident was able to reposition him/herself by wiggling a little in the wheelchair. The resident does not get out of the wheelchair, and into his/her bed nightly until around 9:30 pm, and the resident knows he/she has sores, but staff are not going to push him/her into laying down. On 12/12/17 at 11:26 am, licensed nursing staff J, reported the resident will be referred to a surgeon because of his/her pressure ulcers. Before the resident admitted to the hospital, the resident's bottom was always red, and staff placed a protective dressing on his/her buttocks as a preventative treatment. The resident preferred to transfer him/herself, instead of using a mechanical lift, and when the resident gets onto the bed, he/she wriggles and rubs the stumps against the sheet, and caused friction to the stumps. Staff do not ask the resident if he/she needs to toilet or reposition, because the resident can do this without staff assistance. On 12/12/17 at 1:39 pm, direct care staff O, reported the resident laid down whenever he/she wanted, because it was his/her choice. The resident had the stump dressings for a few months. On 12/12/17 at 3:13 pm, administrative nursing staff B, verified the resident complained of his/her bottom hurting,and staff should have assessed the resident's bottom when he/she complained of discomfort. He/she reported staff should encourage the resident to reposition or lay down to get off his/her buttocks. Administrative nursing staff B verified staff failed to adequately assess or monitor the resident's pressure ulcers. On 12/13/17 at 9:04 am, administrative nursing staff H, reported staff should have done a better job at monitoring the resident's wounds. The resident had the same cushion in the wheelchair when he/she admitted to the facility. When the resident returned from the hospital on [DATE], therapy recommended a new cushion for his/her wheelchair, but a month later, the cushion still had not arrived. On 12/13/17 at 12:40 pm, physician K, reported staff should have monitored the resident's skin and reported to the physician before the wounds required a wound care clinic consult. He/she reported being notified of the stump wounds when the facility staff called and requested a venous study, but because the resident had double amputations, the venous study was unnecessary, so a wound consultation visit ordered. Physician K verified he/she was unaware of any pressure ulcers on the resident's buttocks. If staff monitored the wounds effectively, the wounds may not have gotten as large. He/she reported the stump ulcers could have occurred when the resident rubbed the areas on the linens from self transfers. On 12/14/17 at 12:23 pm, nursing staff L, verified staff do not complete a skin assessment tool when a resident returned from the hospital, or if a resident developed a new pressure ulcer. The facility's undated wound care dressings policy, instructed to document on decubitus weekly for size, depth, odor, drainage, skin condition and progress of decubitus. The facility failed to assess, monitor, develop and implement timely and appropriate interventions to promote healing of an existing pressure ulcers for this resident with decreased mobility due to amputations of both legs.

The facility reported a census of 60 residents. The sample included 3 residents reviewed for elopement (when a cognitively impaired resident leaves the facility grounds unattended and without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent elopement after staff identified the resident as a low risk for elopement. Resident #1 exited the facility on 5/21/17 at approximately 2:30 P.M. without staff knowledge, walked approximately 0.2 miles (264 feet), and was found by resident #2 approximately 2 blocks from the facility. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The May 2017 physician's orders [REDACTED].#1 included a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with moderately impaired cognition, poor safety awareness, had a tendency to wander, had episodic hallucinations (seeing things that are not really there) and delusions (seeing things differently than they are in reality). The resident did not require staff assistance for walking and did not use assistive devices. The Care Area Assessment (CAA) dated 2/23/17 for cognition lacked a detail narrative of the resident's strengths and limitations. The CAA for communication recorded the resident had a hearing deficit and was able to hear well enough to communicate his/her needs. The CAA for psychotropic medications (medications used for diagnosed mental disorders) documented he/she received medications for a chronic mental illness. The elopement risk assessment dated [DATE] documented the resident scored a 9, which indicated he/she was a low risk for elopement. The care plan, revised in February 2017, documented the resident's safety may be at risk due to behaviors of trying to go outside to get to his/her car (no longer had a car) or trying to go home. He/she would hold the alarm down until it sounded and can be aggressive with staff when they tried to respond to alarms triggered by the resident's wander guard (a bracelet worn with an electronic signaling device alerting staff when an at risk resident neared an exit). The care plan directed staff to assess his/her elopement risk status per the facility policy, to encourage family to bring in personal possessions, to introduce him/her to other residents at the facility, to involve him/her in preferred activities, and to involve him/her in decision making regarding daily choices. The nurse's note dated 5/21/17 at 5:41 P.M. documented a person from outside of the facility called the facility after resident #2 reported there was a resident downtown who should not have been by him/herself. Resident #2 stayed with resident #1. Staff immediately went downtown to get resident #1, and brought him/her back to facility. According to the facility's investigation, staff did not observe the resident leave the facility. The investigation lacked documentation of what time the resident left the facility and through what door, how long he/she was gone, where and when staff found the resident, and what activity he/she was doing at that time. According to Google maps, the resident walked 284 feet from the facility, approximately 2 to 3 blocks. Observation of the area the resident would have traveled revealed a rural area with paved roads with 25 miles per hour (MPH) speed limit, and included nearby hazards of railroad tracks, uneven surfaces, and overgrown weeds. According to wunderground.com, the outside temperature on 5/21/17 at 5:53 P.M. was 72 degrees Fahrenheit. The winds were light and the sky was clear. On 5/25/17 at 3:10 P.M. the resident lay in bed and wore a wander guard bracelet on his/her left wrist. On 5/25/17 at 3:56 P.M. the resident ambulated in the hall, sat down at the dining room table, raised his/her arms over his/her head, and spoke to an unseen person(s). On 5/25/17 at 3:10 P.M. the resident stated he/she had not been to the bank and/or gone for a walk recently, but added he/she went outside every day. He/she stated his/her bracelet (wander guard device) was for Morse code (an electronic code consisting of short and long (dots and dashes) transmissions), and sent messages to the people with the remote for the doors, so he/she could exit the facility. On 5/25/17 at 3:51 P.M. direct care staff O stated he/she was passing ice water on the opposite hall and denied seeing and/or hearing the resident leave the facility on 5/23/17. Staff O stated another staff member reported to him/her the resident was downtown and staff brought him/her back to the facility. Direct care staff O denied knowledge of which door the resident might have exited and/or if it alarmed. Direct care staff O stated only one resident in the facility wore a wander guard device, hesitated, and then added there were two residents, as he/she forgot {resident #1} wore one also. On 5/25/17 at 3:23 P.M. administrative nursing staff D stated the resident was last seen by facility staff at approximately 2:30 P.M. on 5/21/17. Staff D further stated the facility was notified at approximately 2:50 P.M. on 5/21/17 (20 minutes) the resident was downtown near the grocery store. Administrative nursing staff D stated the facility checked all door alarms and wander guard alarms and they appeared to be functioning at that time. Nurse D explained the lock door alarms and wander guard alarms were wired in to the same keypad. The recommendation from the alarm company was for these two systems to be wired to different keypads. Administrative nurse D stated on 5/21/17, when a resident returned to the building from outside, they deactivated the keypad for the lock door alarm upon his/her return. Because of how the alarms were wired, this also deactivated the wander guard alarm, which allowed resident #1 to exit the building without an alarm sounding. The facility's Elopement Prevention policy, revised on 2/14/14, directed staff to develop individualized interventions which may include, but were not limited to electronic/monitoring/alarm systems, protected list of names and photographs of those at risk for elopement, and assess the security potential internal environmental risk factors including exit doors, and maintain door alarms and wander control systems in proper working order. The facility failed to ensure this resident received adequate supervision and appropriate interventions to prevent an elopement after staff identified the resident as an elopement risk. This cognitively impaired resident exited the facility on 5/21/17 without staff knowledge, was gone approximately 20 minutes and was found approximately 2 blocks from the facility. This deficient practice placed resident #1 in immediate jeopardy. This deficient practice was determined to be past non-compliance when the facility placed elopement risk residents on one on one monitoring, rewired the door alarm system and wander guard system separately, and provided in-service training to staff on 5/22/17.

The facility identified a census of 60 residents. The sample included 6 residents. Based on observation, record review, and interview, the facility failed to provide medication as ordered by the physician for 5 residents (#5, #1, #2, #3, #4,) sampled. Residents #5 and #1 experienced serious side effects from not receiving there [MEDICATION NAME] ([MEDICATION NAME]-an antipsychotic medication used to treat mental illness and/or mood instability), which resulted in hospitalization . This deficient practice placed these 5 residents in immediate jeopardy. Findings included: - Resident #5's physician's orders [REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had hallucinations (a false perception, seeing something not there, smelling something not there, etcetera), and delusions (false beliefs, distortions of reality), and no rejection of cares. The resident was independent with all activities of daily living (ADLs) such as ambulation, dressing and toilet use. The resident received antipsychotic medications (medication for mental disorders). The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident had hallucinations and delusions, and no rejection of cares. The resident was independent with all activities of daily living (ADLs) and the resident received antipsychotic medications. The Care Area Assessment (CAA) dated 11/16/16 documented the resident had a long history of mental illness, had a [DIAGNOSES REDACTED]. The medication CAA documented the resident's mood had been stable and the pharmacist reviewed his/her medications monthly. The care plan dated 2/13/17 documented the resident received the antipsychotic medication [MEDICATION NAME] (medication used to treat mental and mood disorders) and did not want to experience any adverse effects related to that medication. The care plan documented the resident would be free of [MEDICAL CONDITION] drug (any medication that affects the mind, emotions, and behavior) related complications and a monthly pharmacy review of the medication regimen would be completed. The physician order [REDACTED]. The physician order [REDACTED]. The February 2017 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The pharmacy automated dispensing unit (ADU) report documented [MEDICATION NAME] was not dispensed from the ADU for the resident from 2/3/17 through 2/21/17 for a total of 19 missed doses (This information conflicts with the MAR indicated [REDACTED] The nurse's progress note dated 2/22/17 at 9:41 PM documented the nurse found the resident on the floor of his/her bedroom at approximately 8:55 PM. The resident showed jerking activity and had difficulty breathing. Staff placed the resident on his/her side to keep the airway open. Emergency Medical Services (EMS) arrived at approximately 9:15 PM and left the facility with the resident at 9:25 PM. The hospital discharge summary dated 2/25/17 documented the resident's discharge [DIAGNOSES REDACTED]. According to the Food and Drug Administration (FDA.com), the prescribing information for [MEDICATION NAME] documented the starting dose at 12.5 mg once or twice daily with gradual increased divided dosages in order to minimize the risks of orthostatic [MEDICAL CONDITION] (a drop in blood pressure with position changes), [MEDICAL CONDITION] (slow heart rate), and [MEDICAL CONDITION] (dizziness). The most commonly reported signs and symptoms associated with [MEDICATION NAME] overdose (ingestion of a drug in quantities greater than recommended) included aspiration pneumonia, cardiac arrhythmias (irregular heart beat), and [MEDICAL CONDITION] (changes in the brains electrical activity). On 3/22/17 at 5:24 PM, the resident sat in the main dining area and ate dinner. On 3/22/17 at 11:15 AM, licensed nursing staff H stated the resident was sent to the hospital with respiratory distress in February. He/she stated there was a change in the way the medications were packaged, that the [MEDICATION NAME] used to come on cards, but now was dispensed by the automated dispensing unit (ADU). He/she stated this transition may have occurred around the time of the disruption in [MEDICATION NAME]. He/she stated that several residents went without their [MEDICATION NAME] for several days during that time. He/she stated outside provider E ordered the [MEDICATION NAME] and volunteered to be on the registry ([MEDICATION NAME] is a medication that requires providers and prescribers to be enrolled in a national registry) prior to the changes in registry guidelines. He/she stated medical consultant S did not volunteer to join the registry, because he/she was not good with technology and the registry was an online process. He/she stated facility administration had been trying to get another physician and/or designee from the facility to be on the registry, but it had not happened yet. Nurse H stated medical consultant S was not authorized (on the registry) to prescribe the medication, but he/she had an APRN (nurse practitioner) who was able to, but the APRN left. He/she stated after outside provider E left employment of the facility, medical consultant S ordered the [MEDICATION NAME]. The nurses made sure the labs were done and the results faxed to the pharmacy. Everything worked well until February when the pharmacy called and said the [MEDICATION NAME] could not be filled until there was someone certified with the registry to order the medication. On 3/22/17 at 11:30 AM, direct care staff O stated the medications were in the ADU for dispensing, but fractioned doses had to be pre-packaged on the cards. On 3/22/17 at 11:36 AM, medical consultant S stated he/she was aware of a disruption in the ordering, receiving and administration of the [MEDICATION NAME] for several residents. He/she stated outside provider E used to order it before he/she left employment, because he/she was certified with the registry. He/she stated when the facility did not have anyone to order the [MEDICATION NAME], he/she agreed to order it for a short time. He/she stated some people have a dangerous drop in the number of white blood cells, so the manufacturer of the drug required a registry to ensure prescribers were aware of the medication side effects and what was required for monitoring the medication. Consultant S stated he/she had been permitted to order the [MEDICATION NAME] until February 2017, when the pharmacy did not allow it anymore. He/she then took the test to get on the registry, so the pharmacy could release the medication to the residents. On 3/22/16 at 12:00 PM, consultant pharmacist JJ stated he/she had told licensed nursing staff I (who was the director of nursing at the time) in November 2016 about the revised guidelines required by the registry and sent an email with this information. Consultant pharmacist JJ explained to licensed nursing staff I at the time what the registry was and that it was a federal guideline that had to be followed. On 3/22/17 at 3:10 PM, licensed nursing staff I stated he/she was aware of the requirement change for the [MEDICATION NAME] registry, but thought medical consultant S was on the registry. He/she was made aware that medical consultant S was not on the registry in January 2017. On 3/23/17 at 9:45 AM consultant pharmacist JJ stated because of the increased potential of very serious side effects, [MEDICATION NAME] was not used unless necessary. He/she stated when starting or stopping the medication, a titration method was used, usually over several weeks. Consultant pharmacist JJ stated the only justification for abruptly discontinuing the medication would be a resident's abnormal lab work (blood count) and it was not safe to continue, but stated even then, they would probably give half the dose first instead of just stopping it. Consultant pharmacist JJ stated delusions could be a possible expected side effect of discontinuing the medication quickly. He/she stated the acute disruption (not getting the medicine for over 2 weeks) followed by a reintroduction at the resident's regular dose could have contributed to the resident's acute medical condition which required hospitalization in February 2017. On 3/23/17 at 2:48 PM, licensed nursing staff J stated the doctors write a medication order, which was sent to the pharmacy by fax, and then the order was transcribed by a nurse into the electronic medical record. Nursing staff J stated only the Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) can access the ADU and set up the medication cart each day. Licensed nursing staff J stated it was often not the same staff that pulled and passed the medications, because it occurred at different times. The routine medications were individually packaged and they all come out together in strips, and were then separated for each resident and placed in the medication carts for later administration. Licensed nursing staff J stated the facility had 2 medication carts, one for each hall. Licensed nursing staff J stated CMAs (certified medication aides) could give [MEDICATION NAME]. He/she stated someone from the pharmacy came at least 2 to 3 times a week and often canisters of medications arrived in advance of the pharmacy staff, so when the pharmacy staff arrived at the facility, they loaded the machine with the canisters. Licensed nursing staff J stated a check mark on the MAR indicated [REDACTED]. Licensed nursing staff J further stated if a medication was not given for some reason, there were corresponding codes, for example, if the resident was out of the building or in the hospital. On 03/23/17 at 3:41 PM, Pharmacy Consultant Staff KK stated the registry determined the supply restrictions for [MEDICATION NAME]. He/she added the pharmacy had been contacting the physicians who were not on the registry since 2015, to get them on the registry. Medical consultant S was one of the physicians on the list as not being on the registry. Pharmacy Consultant Staff KK further stated the pharmacy had also been in contact with the facility about the issue. The facility's Medication Administration Policy revised 5/1/11 lacked information to ensure residents' medications were readily available. The facility failed to administer medication as prescribed, which resulted in signs and symptoms of unwanted side effects and resulted in hospitalization for this cognitively aware resident with diagnosed mental illness. This deficient practice placed this resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 2/23/17 by implementing the following measures: All licensed staff was in-serviced on [MEDICATION NAME] ([MEDICATION NAME]), all orders were confirmed with the medical director, the medical director was enrolled in the registry, the director of nursing would monitor the [MEDICATION NAME] 5 times a week for 90 days and report compliance to the Quality Assurance Performance Initiative, and the facility sought a psychiatric physician to join the facility staff. - The electronic medical record (EMR) dated March 2017 for resident #1 included [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated intact cognition. He/she experienced delusions at times. The resident performed all activities of daily living independently, and received [MEDICAL CONDITION] medications (used to treat a variety of mental disorders). The quarterly MDS dated [DATE] documented no functional or cognitive changes with the resident. The care area assessment (CAA) dated 6/8/16 for medications lacked narrative summary documentation, but recorded staff would care plan the resident's medications. The March 2017 physician's orders [REDACTED]. The care plan dated 12/6/16 documented the resident was at risk for potential drug reactions related to the use of [MEDICATION NAME] and directed staff to monitor him/her for adverse drug reactions and report to the nurse practitioner and physician, and to see the Black Box Warning (a warning issued by the Food and Drug Administration for medications with potentially life threatening side effects). The February 2017 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The pharmacy automated dispensing unit (ADU) report documented [MEDICATION NAME] was not dispensed from the ADU for the resident on 2/14/17 (this information conflicts with the MAR indicated [REDACTED] The nurse's notes dated 2/9/17 through 2/23/17 documented the resident did not receive his/her [MEDICATION NAME] medication due to the medication was unavailable from the pharmacy. According to the Food and Drug administration (FDA.com), abrupt discontinuation of [MEDICATION NAME] could result in potentially life threatening physical and psychological side effects including rebound [MEDICAL CONDITION] (mental disorder including increased delusions). The change of condition report dated 2/23/17 at 12:35 P.M. documented at 9:00 A.M. the resident woke up and complained of not being able to see, unable to call staff by name, trouble standing on his/her own, difficulty breathing, aware of surroundings, but unable to state his/her name. The nurse's note dated 2/23/17 at 10:08 A.M. licensed nurse I documented at 9:20 A.M. the physician gave an order to transport the resident to the hospital for evaluation and treatment. The hospital history and physical dated 2/23/17 documented the resident admitted with altered mental status and [MEDICAL CONDITION] due to general medical condition. He/she went 13 days without his/her [MEDICATION NAME]. He/she did test positive for a urinary tract infection. In the emergency room , the resident had an episode of significant agitation while standing at the foot of the bed and screaming at his/her {family member} I will kill you. The family member stated this was not usual for him/her. The hospital discharge summary dated 2/25/17 documented on arrival (to the hospital), the resident was combative and demonstrated paranoid delusions, which were not normal according to nursing staff where he/she resided. Psychiatry was consulted and recommended admission to the hospital. [MEDICATION NAME] was reinstated at 100 mg nightly with plans for increased dosages as tolerated by the patient. On 3/22/17 at 10:40 A.M. the resident ambulated to the conference room without difficulty for an interview. He/she had no agitation or delusional behavior at that time. On 3/22/17 at 10:40 A.M. the resident stated he/she lived at the facility for 6 years and the past couple of weeks were very rocky. The resident stated his/her medications were being adjusted and it had been a fight getting his/her medications. The resident stated his/her family member was very good about making sure he/she received his/her medications. The resident stated his/her medications helped him/her and that he/she did not refuse medications. On 3/21/17 at 10:58 A.M. licensed nursing staff H stated there was a disruption for the residents that received [MEDICATION NAME] due to a change in personnel and the medical consultant S was not on the registry ([MEDICATION NAME] is a medication that requires providers and prescribers to be enrolled in a national registry), which was required for the pharmacy to dispense the medication. On 3/22/17 at 12:00 P.M. consultant pharmacist JJ stated the requirements (from the manufacture) for the dispensing of [MEDICATION NAME] increased in January 2017, which required the providers to be on a registry to prescribe the medication. Consultant JJ stated he/she informed licensed nursing staff I (nursing director at the time) of the requirements in November 2016. He/she stated the abrupt discontinuation of the [MEDICATION NAME] could have contributed to the resident's increased delusions, requiring his/her hospitalization . On 3/21/17 at 11:36 A.M. physician consultant S stated he/she was aware of the resident's disruption of [MEDICATION NAME] and when the facility did not have a physician to order the medication, he/she prescribed it for a short time. Physician consultant S stated he/she told the facility the residents could not go without their medications. Physician consultant S took a test and was currently on the registry and permitted to write the orders for the [MEDICATION NAME] at this time, but was not at the time of the incident. On 3/22/17 at 3:10 P.M. licensed nursing staff I stated he/she was aware of the requirement change for the medication [MEDICATION NAME], but he/she thought consultant physician S was on the registry at the time of the incident. The facility's Medication Administration policy, revised 5/1/2011, documented staff were to document the administration of medications on the MAR indicated [REDACTED]. The policy lacked documentation to ensure the residents medications were readily available. The facility failed to administer medication as ordered from 2/9/17 to 2/23/17, which resulted in a significant medication error and hospitalization for this resident with psychological impairment. This deficient practice placed this resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 2/23/17 by implementing the following measures: All licensed staff was in-serviced on [MEDICATION NAME] ([MEDICATION NAME]), all orders were confirmed with the medical director, the medical director was enrolled in the registry, the director of nursing would monitor the [MEDICATION NAME] 5 times a week for 90 days and report compliance to the Quality Assurance Performance Initiative, and the facility sought a psychiatric physician to join the facility staff. - The March 2017 physician's orders [REDACTED].#2 included the [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status Score (BIMS) score of 15, which indicated intact cognition. He/she experienced episodic delusions (seeing things that are not real). He/she was independent with all activities of daily living and received anti-psychotic medication (medication for mental disorders). The February 2017 physician's orders [REDACTED]. The care plan dated January 2017 documented the resident received [MEDICAL CONDITION] medications and included the Black box Warning (a warning issued by the Food and Drug administration listing medications with potentially life threatening side effects). The care plan lacked documentation of any specific information to related to the resident's use of [MEDICATION NAME]. According to FDA.com (food and drug administration), the prescribing information for [MEDICATION NAME] documented abrupt discontinuation could result in potentially life threatening physical and psychological side effects including rebound [MEDICAL CONDITION] (mental disorder including increased delusions). The February 2017 Medication Administration Record [REDACTED]. Reviewed automated dispensing unit (ADU) record dated February 2017 documented the medication was not dispensed from the machine during 2/1/17 to 2/23/17, which directly conflicted with the MAR indicated [REDACTED] Review of the nurse's progress notes from 2/1/17 through 2/23/17 lacked documentation of a physician's orders [REDACTED]. On 3/21/17 at 10:58 A.M. licensed nursing staff H stated there was a disruption for the residents that received [MEDICATION NAME] due to a change in personnel and the medical consultant S was not on the registry ([MEDICATION NAME] is a medication that requires providers and prescribers to be enrolled in a national registry), which was required for the pharmacy to dispense the medication. On 3/22/17 at 12:00 P.M. consultant pharmacist JJ stated the requirements (from the manufacture) for the dispensing of [MEDICATION NAME] increased in January 2017, which required the providers to be on a registry to prescribe the medication. Consultant JJ stated he/she informed licensed nursing staff I (nursing director at the time) of the requirements in November 2016. He/she stated the abrupt discontinuation of the [MEDICATION NAME] could have contributed to the resident's increased delusions, requiring his/her hospitalization . On 3/21/17 at 11:36 A.M. physician consultant S stated he/she was aware of the resident's disruption of [MEDICATION NAME] and when the facility did not have a physician to order the medication, he/she prescribed it for a short time. Physician consultant S stated he/she told the facility the residents could not go without their medications. Physician consultant S took a test and was currently on the registry and permitted to write the orders for the [MEDICATION NAME] at this time, but was not at the time of the incident. On 3/22/17 at 3:10 P.M. licensed nursing staff I stated he/she was aware of the requirement change for the medication [MEDICATION NAME], but he/she thought consultant physician S was on the registry at the time of the incident. The facility's Medication Administration policy, revised 5/1/2011, documented staff were to document the administration of medications on the MAR indicated [REDACTED]. The policy lacked documentation to ensure the residents medications were readily available. The facility failed to administer medication as ordered from 2/1/17 to 2/23/17, which resulted in a significant medication error and hospitalization for this resident with psychological impairment. This deficient practice placed this resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 2/23/17 by implementing the following measures: All licensed staff was in-serviced on [MEDICATION NAME] ([MEDICATION NAME]), all orders were confirmed with the medical director, the medical director was enrolled in the registry, the director of nursing would monitor the [MEDICATION NAME] 5 times a week for 90 days and report compliance to the Quality Assurance Performance Initiative, and the facility sought a psychiatric physician to join the facility staff. - The March 2017 physician's orders [REDACTED].#3 included the [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. He/she experienced delusions (seeing things that are not real) but had no behaviors toward others. He/she was independent with all activities of daily living and received anti-psychotic medication (medication for mental disorders). The 2/7/17 Care Area Assessment (CAA) for medications documented the resident's use of antipsychotic medications and noted the pharmacist reviewed the medications monthly. The February 2017 POS documented an order dated 11/21/15 for [MEDICATION NAME] 250 milligrams (mg) at bedtime for yelling and agitation related to [MEDICAL CONDITION]. The care plan dated February 2017 documented the resident's use of antipsychotic medications and the Black Box Warning (a warning issued by the Food and Drug administration listing medications with potentially life threatening side effects) for [MEDICATION NAME]. The care plan lacked documentation of any specific information to related to the resident's use of [MEDICATION NAME]. According to FDA.com, the prescribing information for [MEDICATION NAME] documented abrupt discontinuation of [MEDICATION NAME] could result in potentially life threatening physical and psychological side effects including rebound [MEDICAL CONDITION] (mental disorder including increased delusions). The February 2017 Medication Administration Record [REDACTED]. Review of the automated dispensing unit report confirmed these doses were not administered. Review of the nurse's progress notes dated from 2/5/17 through 2/21/17 lacked an order from the physician to hold the resident's medication. On 3/23/17 at 4:07 PM the resident sat in a loveseat in the day room and watched television. On 3/21/17 at 10:58 A.M. licensed nursing staff H stated there was a disruption for the residents that received [MEDICATION NAME] due to a change in personnel and the medical consultant S was not on the registry ([MEDICATION NAME] is a medication that requires providers and prescribers to be enrolled in a national registry), which was required for the pharmacy to dispense the medication. On 3/22/17 at 12:00 P.M. consultant pharmacist JJ stated the requirements (from the manufacture) for the dispensing of [MEDICATION NAME] increased in January 2017, which required the providers to be on a registry to prescribe the medication. Consultant JJ stated he/she informed licensed nursing staff I (nursing director at the time) of the requirements in November 2016. He/she stated the abrupt discontinuation of the [MEDICATION NAME] could have contributed to the resident's increased delusions, requiring his/her hospitalization . On 3/21/17 at 11:36 A.M. physician consultant S stated he/she was aware of the resident's disruption of [MEDICATION NAME] and when the facility did not have a physician to order the medication, he/she prescribed it for a short time. Physician consultant S stated he/she told the facility the residents could not go without their medications. Physician consultant S took a test and was currently on the registry and permitted to write the orders for the [MEDICATION NAME] at this time, but was not at the time of the incident. On 3/22/17 at 3:10 P.M. licensed nursing staff I stated he/she was aware of the requirement change for the medication [MEDICATION NAME], but he/she thought consultant physician S was on the registry at the time of the incident. The facility's Medication Administration policy, revised 5/1/2011, documented staff were to document the administration of medications on the MAR indicated [REDACTED]. The policy lacked documentation to ensure the residents medications were readily available. The facility failed to administer medication as ordered from 2/1/17 to 2/23/17, which resulted in a significant medication error and hospitalization for this resident with psychological impairment. This deficient practice placed this resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 2/23/17 by implementing the following measures: All licensed staff was in-serviced on [MEDICATION NAME] ([MEDICATION NAME]), all orders were confirmed with the medical director, the medical director was enrolled in the registry, the director of nursing would monitor the [MEDICATION NAME] 5 times a week for 90 days and report compliance to the Quality Assurance Performance Initiative, and the facility sought a psychiatric physician to join the facility staff. - The March 2014 physician's orders [REDACTED].#4 included the [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident did not complete the BIMS score. The resident had delusions, but not behaviors and/or rejection of cares. He/she was independent with activities of daily living and received anti-psychotic medications (medications for mental disorders). The Care Area Assessment (CAA) dated 2/7/17 for [MEDICAL CONDITION] medications documented the medications would be addressed in the residents care plan. The February 2017 POS documented an order dated 11/21/16 for [MEDICATION NAME] 100 milligrams (mg) by mouth at bedtime for [MEDICAL CONDITION] (mental illness) related to [MEDICAL CONDITION]. The resident's care plan dated February 2017 recorded the resident's use of anti-psychotic medications and Black Box Warning (a warning issued by the Food and Drug administration listing medications with potentially life threatening side effects). The care plan lacked documentation of any specific information to related to the resident's use of [MEDICATION NAME]. According to FDA. com (food and drug administration), the abrupt discontinuation of [MEDICATION NAME] could result in potentially life threatening physical and psychological side effects including rebound [MEDICAL CONDITION] (mental disorder including increased delusions). Review of the Medication Administration Record [REDACTED]. Review of the nurse's progress notes dated 2/5/17 through 2/19/17 lacked documentation of a physician's orders [REDACTED]. On 3/23/17 at 4:07 PM the resident sat in a loveseat in the day room and watched television. On 3/21/17 at 10:58 A.M. licensed nursing staff H stated there was a disruption for the residents that received [MEDICATION NAME] due to a change in personnel and the medical consultant S was not on the registry ([MEDICATION NAME] is a medication that requires providers and prescribers to be enrolled in a national registry), which was required for the pharmacy to dispense the medication. On 3/22/17 at 12:00 P.M. consultant pharmacist JJ stated the requirements (from the manufacture) for the dispensing of [MEDICATION NAME] increased in January 2017, which required the providers to be on a registry to prescribe the medication. Consultant JJ stated he/she informed licensed nursing staff I (nursing director at the time) of the requirements in November 2016. He/she stated the abrupt discontinuation of the [MEDICATION NAME] could have contributed to the resident's increased delusions, requiring his/her hospitalization . On 3/21/17 at 11:36 A.M. physician consultant S stated he/she was aware of the resident's disruption of [MEDICATION NAME] and when the facility did not have a physician to order the medication, he/she prescribed it for a short time. Physician consultant S stated he/she told the facility the residents could not go without their medications. Physician consultant S took a test and was currently on the registry and permitted to write the orders for the [MEDICATION NAME] at this time, but was not at the time of the incident. On 3/22/17 at 3:10 P.M. licensed nursing staff I stated he/she was aware of the requirement change for the medication [MEDICATION NAME], but he/she thought consultant physician S was on the registry at the time of the incident. The facility's Med

The facility identified a census of 55 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to prevent multiple injury falls for 1 (#22) of 4 residents reviewed for accidental hazards. Findings included: - The 10/12/14 significant change Minimum Data Set (MDS) for resident #22 revealed a Brief Interview for Mental Status score of 15, indicating no cognitive impairment but he/she did display potential indicators of psychosis (any major mental disorder characterized by a gross impairment in reality testing) as evidence by hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident required extensive assistance from 2 or more staff members for bed mobility, transfer, walking in his/her room and the corridor, locomotion on and off the unit, dressing, and toilet use. He/she was not steady and was only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet, and surface-to-surface transfers. The resident used a wheelchair or walker for ambulation and had range of motion impairment for one upper extremity and one lower extremity. He/she had a fall within one month of admission, had a fall within 2 to 6 months of admission, and had a fracture related to a fall within 6 months of admission. The 10/12/14 Care Area Assessment (CAA) regarding communication revealed the resident had mental illness, cognitive impairment, and delusions affecting his/her communication and thought process thus he/she got off topic and verbalized delusional thoughts. The 10/12/14 CAA regarding activities of daily living (ADLs) revealed the resident had a long history of cyclic mental illness with ongoing cognitive and communication impairment with hallucinations and delusions. He/she received therapy services through physical therapy and occupational therapy and used a wheelchair for safety during therapy. The 10/12/14 CAA regarding falls revealed he/she had several falls prior to a recent hospitalization . One of the falls resulted in a hip fracture and another fall resulted in fractures of fingers on his/her left hand. The fall risk assessment dated [DATE] revealed a score of 11 (score of 10 or higher indicated the resident was a t risk for falls). On 10/5/14 he/she scored 17 for fall risk and on 11/20/14 he/she scored 22 for fall risk. The care plan with a revision date of 12/3/14 revealed the resident had impaired self-care and required staff support to complete ADLs related to a long history of mental illness with impaired thought, impaired cognition, pain and a hip fracture. When the resident became over stimulated or delusional he/she sometimes had difficulty expressing his/her needs and wants. He/she continued to be delusional regarding his/her pain and was not consistent as to what hurt or where it hurt. The care plan also revealed the resident had a history of [REDACTED]. Staff observed for medication side effects, assisted to keep his/her environment well lit and free of clutter, kept his/her bed in a low position, provided nonskid footwear, reminded the resident to not transfer independently, and encouraged him/her to use his/her call light when he/she needed assistance. The nurse's note (NN) dated 10/31/14 at 3:04 P.M. revealed the resident sustained [REDACTED]. He/she stood from the chair he/she was sitting in, reached for his/her walker and fell on to his/her left side. During the fall the resident hit the right side of his/her head on the arm of the chair and then hit the left side of his/her head on the floor resulting in 3 centimeter lacerations on both sides of his/her head. Staff applied steri-strips to the lacerations and initiated neurological checks. The fall investigations provided by the facility revealed a fall on 10/31/14 with casual factors included a history of falls, shuffling and unsteady gait at times, psychotropic medication use, [DIAGNOSES REDACTED]. Recommendations and new interventions placed by staff included resident education on proper technique to get out of a chair, resident education on proper positioning of his/her walker when sitting in a chair, and request of the resident to ask for staff assistance when he/she needed help with ambulation. The NN dated 1/5/14 at 10:23 A.M. revealed the resident sustained [REDACTED].M. in his/her room that day resulting in 2 skin tears to his/her right forearm. The resident reported to staff he/she started leaning over and just fell . The fall investigation provided by the facility revealed a fall on 1/5/14 with causal factors including the resident was to use his/her walker for ambulation due to an unsteady gait, the resident had a shuffling gait, he/she had chronic mental illness with impaired decision making and impaired judgment. Recommendations and interventions placed by the staff included resident education on use of the call light for assistance when he/she was unsteady and to use his/her walker at all times. The NN dated 6/20/14 at 8:55 P.M. revealed the resident sustained [REDACTED]. The fall investigation provided by the facility revealed a fall on 6/20/14 with causal factors including staff observation of another resident assisting him/her, the resident's balance and gait were unsteady, and he/she had a long history of chronic mental illness with impaired decision making and judgment. Recommendations and interventions placed by staff included resident education to not ask other residents for assistance. The NN dated 7/7/14 at 12:55 P.M. revealed the resident sustained [REDACTED]. Staff heard the resident yell from the hallway outside the resident's room. Staff found the resident laying with his/her torso supine on the floor just inside the doorway to his/her room with his/her left arm along his/her side and his/her right arm above his/her head. The resident's legs were extended with knees slightly bent and "somewhat pointing to his/her right side." He/she responded to staff voice but answers were not appropriate. Assessment showed his/her pulse was rapid and thready but the pulse oximeter revealed a pulse of 92 beats per minute. The resident moaned, "ouch" upon palpation of his/her left rib/axilla area. He/she also moaned in response to touch on his/her left hand and visual displacement between his/her second and third knuckle was noted. He/she was lethargic. The resident was transported via ambulance to the hospital for evaluation. The NN dated 7/8/14 at 8:49 A.M. revealed x-ray results from the hospital indicated fractured ribs and fractured fingers. The fall investigation provided by the facility revealed a fall on 7/7/14 which was reported to the state and resulted in multiple fractures, 3 fingers on his/her left hand and 2 ribs on his/her upper ride side. Review showed the resident was attempting to ambulate to the bathroom without staff assistance. Causal factors included the resident had been recently readmitted from the hospital and had a weakened condition. Recommendations and interventions placed by staff included resident education on importance in asking for assistance when ambulating. The NN dated 7/8/14 at 2:09 P.M. revealed the resident sustained [REDACTED]. He/she showed some limitation in range of motion for his/her lower extremities and was transported to the hospital to rule out a hip fracture. The NN dated 7/8/14 at 7:30 P.M. revealed the resident returned to the facility with no new orders. The fall investigation provided by the facility revealed a fall on 7/8/14 with causal factors including a weakened condition related to illness, a previous fall with rib and finger fractures, and a history of chronic mental illness with impaired judgment and decision making. Recommendation and interventions placed by staff included the resident was transported to the hospital for evaluation and x-ray of his/her hip. The NN dated 7/23/14 at 11:19 A.M. revealed the resident sustained [REDACTED]. He/she was transported to the hospital for evaluation. The NN dated 7/23/14 at 6:00 P.M. revealed the resident returned to the facility with no new orders and no new injuries noted. The fall investigation provided by the facility revealed a fall on 7/23/14 with causal factors including he/she was in a weakened state and working with physical therapy (PT), was evaluated by PT on 7/22/14, he/she returned from the hospital on [DATE] and was in the process of gaining strength back to baseline, and had chronic mental illness with impaired judgment and decision making. Recommendations and interventions placed by staff included staff assessment of the resident and transportation to the emergency room for evaluation. The NN dated 9/27/14 at 11:57 P.M. revealed the resident sustained [REDACTED]. The CNA observed the resident hit the left side of his/her head and he/she lay on his/her back and complained of left hip pain. Staff noted the left side of the resident's face was swollen and he/she refused to extend his/her legs. Staff transferred the resident to the hospital for evaluation. The NN dated 9/28/14 at 9:25 A.M. revealed the resident was admitted to the hospital for the [DIAGNOSES REDACTED]. The NN dated 9/28/14 at 10:31 A.M. revealed the resident's guardian called the facility to notify them the resident was in surgery to have 2 pins placed in his/her hip. The NN dated 10/5/14 at 3:01 P.M. revealed the resident returned to the facility. The fall investigation provided by the facility revealed a fall on 9/27/14 was reported to the state. The reports showed he/she typically ambulated with a front wheeled walker, had a steady, shuffling gait and his/her care plan showed he/she was reluctant to ask for help, was to ask for assistance if needed, and staff encouraged him to perform independent tasks with minimal staff assistance. Casual factors included a long history of mental illness with impaired judgment and decision making ability, a BIMS score 12 (indicating moderate cognitive impairment), and a history of falls. Recommendations and interventions placed by staff included staff kept the resident comfortable until the ambulance was able to arrive after the fall, he/she was transported to the emergency room for evaluation, and he/she was later admitted to the hospital for a hairline fracture of the left hip. Observation on 12/3/14 at 2:22 P.M. revealed therapy staff H and direct care staff F assisted the resident to transfer from his/her wheelchair to his/her bed using a physical assistance, verbal cues, and a gait belt. The resident was able to follow verbal cues from staff and moderately participate physically in the transfer. Interview on 12/2/14 at 11:20 A.M. with the resident revealed he/she replied to the question, " how long have you lived here?, " with, " 1 teaspoon. " He/she also responded to the question, " What is the food like here?, " with, " 3/4 cup. " The resident was determined to be non-interviewable. Interview on 12/3/14 at 2:42 P.M. with direct care staff F revealed the resident was considered a fall risk but now that he/she was in a wheelchair he/she was no longer really a fall risk. Staff F reported he/she sometimes looked at the care plan but mainly found out about interventions through report from other staff members. Interview on 12/4/14 at 10:13 A.M. with direct care staff I revealed prior to the resident's injury falls staff tried to educate him/her on proper walking techniques and proper use of his/her walker. Direct care staff I reported he/she learned that information through staff report but believed it was also on the care plan. Interview on 12/4/14 at 11:03 A.M. with licensed nursing staff K revealed the staff provided a 1 or 2 person assist with transfers depending on the resident's willingness to participate in ADLs. Staff K reported prior to the hip fracture staff encouraged him/her to use the call light, kept his/her bed in a low position, and educated him/her on asking staff for assistance. Staff K felt the resident was able to remember to use his/her call light when staff reminded him/her. Staff K reported post fall staff reviewed the investigation and looked into new interventions to prevent future falls and updated the care plan accordingly. Interview on 12/14/14 at 2:17 P.M. with direct care staff J revealed he/she was not sure if the resident was a fall risk but he/she thought so. Staff J reported staff provided 2 person assist with a gait belt for transfers, ensured he/she wore nonskid footwear, and kept the bed in a low position. Interview on 12/4/14 at 2:52 P.M. with licensed nursing staff L revealed staff encouraged the resident to call for assistance. Staff L stated the resident was able to remember to use the call light "to a degree," and that was why staff frequently reminded him/her to do so. Interview on 12/4/14 at 3:18 P.M. with administrative nursing staff M revealed when a fall with injury occurred the charge nurse was responsible for initiating an immediate intervention based on the circumstances of that fall. Staff M reported when this resident had the fall with fractured fingers and ribs he/she was already receiving therapy to try to balance and strengthening, staff was using gait belts with transfers. He/she reported after that fall one of the biggest things staff did to reduce his/her risk for falls was to increase the use of his/her wheelchair due to his/her fractures fingers making it difficult to use a walker and initiate 2 person assist. Interview on 12/4/14 at 3:36 P.M. with administrative nursing staff B revealed the facility began to attempt to identify a resident at risk for falls immediately upon admission based on old records and the nurse's admission assessment. Those findings alerted the nurse to get a plan in place for fall prevention. If a resident was a new fall risk then the staff implemented an IPOC (immediate plan of care) to be able to get into the chart quickly so all staff would be aware. The IPOC was kept in the chart until staff completed the comprehensive care plan. Staff B reported this resident had an intermittent unsteady gait. He/she stated fall alarms were not successful at the facility due to the type of community (mental health) and tended to make the residents more anxious. For this resident staff implemented use of a wheelchair, a walker, toilet riser, kept the bed in a low position, and placed a mobility bar on the bed to assist with transfers. Staff also kept the resident in a room that was directly across the hall from the administrator's office so close supervision could be provided. Staff B acknowledged that at times the resident was not cognitively able to remember to use the call light due to mental illness. Staff B stated that at times the resident understood staff instructions and other times did not. He/she stated when the resident appeared to staff to be less coherent then they knew he/she needed more supervision so the staff monitored the resident more closely. Staff B reported the facility had a " stop and watch " program when a staff member noted a difference in a resident they would document it on that piece of paper. The policy provided by the facility with a reviewed date of 6/12/14 regarding fall management revealed the facility implemented a fall prevention and intervention program. The facility failed to develop and implement appropriate interventions to prevent multiple injury falls for this resident with known long history of mental illness with impaired cognitive skills and judgment.

The facility identified a census of 58 residents. The sample included three residents. Based on record review, and staff and resident interviews, the facility failed to have systems in place to provide necessary services to one (#1) resident that had a significant change in health status resulting in his death. Findings included: - The [DATE] physician's orders [REDACTED]. The [DATE] Admission Minimum Data Set (MDS) noted the resident understood/understands; had unclear speech; the Brief Interview for Mental Status (BIMS) score was 11 which was mildly impaired cognitive status; had no symptoms of [MEDICAL CONDITION]; the resident was independent with Activity of Daily Living (ADL), but required supervision with eating; had depression, [MEDICAL CONDITION], borderline personality disorder, unspecified myalgia and myositis, extrapyramidal symptoms and an abnormal movement disorder; was on scheduled pain medication with an as needed (PRN) ordered; occasionally had moderate pain that made it hard to sleep at night and had shortness of breath; was on a daily antipsychotic and antidepressant medication. The [DATE] Resident Assessment Protocol (RAP) for Cognition noted behaviors of depression, anxiety, and sad mood/mood decline; had repetitive verbalizations not easily altered; he/she had demonstrated a cognitive decline and had moderate impairment for decision making skills; required supervision for safety during meals and with some transfers, and took daily antipsychotic and antidepressant medications. The [DATE] RAP for ADL noted the resident participated in facility activities and was comfortable initiating his/her own activity; was independent with ADL except for supervision with meals. The [DATE] RAP for Behavioral Symptoms and [MEDICAL CONDITION] Medications triggered due to cyclic symptomology from long term mental illness symptoms. The [DATE] Care plan for Cognitive Loss instructed the staff to involve the resident in activities of choice as listed; provide verbal cues to assist with daily function and ADL as needed; to discourage attention seeking behaviors by redirecting, and by providing attention at times when not strongly sought and not reacting to attention seeking behavior any more than necessary; and to encourage participation in group activity. The resident went on a facility van trip to see Christmas lights on Saturday [DATE] about 5:30 P.M. Facility van staff A and B reported that the resident complained of nausea and not feeling well about 8:00 P.M. while on the return trip, and they provided an emesis bag. Residents #4, #5 and #6, also on the bus trip, reported the resident complained of not feeling well and he/she did not eat as much as usual when they stopped for dinner prior to returning. (Interviews with staff A and B occurred on [DATE] at 11:47 A.M. and 11:57 A.M. Interviews with residents #4, #5 and #6 occurred on [DATE] at 10:31 A.M., 10:38 A.M., and`12:05 P.M.) When the group arrived at the facility, van staff A informed the charge nurse of the resident's complaints per interview on [DATE] at 11:47 A.M. Licensed nursing staff A asked the resident to sit out in the area by the nurse's station for observation on [DATE] after returning from the van trip at approximately 9:00 PM. The resident did sit for awhile and then went to his/her room. The resident did not vocalize any more complaints per licensed nursing staff A. The next day when the resident complained of the pain in his/her stomach, staff A said that he/she told the resident it was probably because of all the dry heaving the day before. (Per interview with staff A [DATE] at 2:41 P.M.) The clinical record lacked documentation of an assessment of the resident. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on [DATE]; an antacid Calcium [MEDICATION NAME] given on [DATE] at 12:45 P.M.; an [MEDICATION NAME] treatment at 4:00 P.M. on [DATE]; and [MEDICATION NAME] 10 mg for irritable bowel syndrome, given at 4:00 P.M. on [DATE]. The resident also received Tylenol 325 mg two tablets (650 mg) scheduled daily at bedtime. Night shift staff licensed nurse B reported he/she, "gave the resident a PRN [MEDICATION NAME] at 12:35 A.M. for anxiety, when the resident complained of his/her stomach hurting, because staff B thought the resident was attention seeking." (Interviewed on [DATE] at 6:41 A.M.) Direct care staff B reported the resident did not go to breakfast on [DATE] because the resident stated that he/she was sick and was up all night with breathing problems. Staff B said the resident stated he/she told the day shift nurse, that night shift gave him/her something for anxiety when the resident complained of not feeling well and being Short of Breath (SOB) even though the resident told night shift he/she was not anxious, but sick. (Interview on [DATE] at 1:35 P.M.) The clinical record lacked documentation regarding the resident's SOB. Licensed nursing staff C reported the resident did not come to get his/her medications on [DATE] during day shift and staff C went to the resident's room, gave the resident his/her medications and asked the resident to come to the nurse's station. "The resident looked miserable and was SOB." Staff C took his/her vital signs and they were within normal limits except the respirations were a little high and the resident complained of not feeling well. Staff C assessed the resident after a loose stool, found his/her abdomen tender, but with bowel sounds, and administered [MEDICATION NAME]. Licensed nursing staff C instructed the resident to report to the nurse if he/she had any more loose stools in addition to the three loose stools already reported. Staff C updated the evening shift licensed staff on [DATE] about 2:00 P.M. concerning the residents complaints of diarrhea and abdominal pain. Staff C stated he/she failed to write any progress notes for the [DATE] day shift. (Interview on [DATE] at 4:31 P.M.) Direct care staff C reported the resident used his/her call light continually on [DATE] starting at the beginning of evening shift at 2:00 P.M. The resident complained of pain and wanted to go to the hospital. Staff C reported this to the charge nurse, licensed nursing staff A. (Interview on [DATE] at 3:58 P.M.) Resident #7, a roommate of resident #1, "overheard a conversation on [DATE] after noon sometime, between the resident and the direct care staff. Resident #7 stated that resident #1 told staff he/she needed to be taken to the hospital because he/she did not feel well. They did not take him/her to the hospital and he/she died ." (interviewed [DATE] at 10:12 A.M.) The clinical record lacked documentation of the resident's complaints of pain and wanting to go to the hospital. Direct care staff A revealed the resident was on his/her call light continually between 2:30 and 3:30 P.M. on [DATE]. The first time staff A answered the light, the resident said, "I am hurting so bad" and motioned up and down his sternum. The resident said he/she "had been hurting all day and evening and the nurses had given him Tylenol and [MEDICATION NAME]." Staff A reported to licensed nursing staff A that the resident was complaining that his/her chest was hurting and licensed nursing staff A said "OK." The resident was probably on his/her light every ,[DATE] minutes or so for about ,[DATE] minutes. The second time he/she put the light on, licensed nursing staff A took him/her some medicine. The next time direct care staff A answered the resident's light, he/she said, " I want to go to the hospital " . Direct care staff A told licensed nursing staff A who said he/she thought the resident could be sore from all the dry heaving the night before, and to let the medicine work. The next time direct care staff A saw the resident he/she was breathing heavy. (Per the facility investigation notarized interview of [DATE]) Direct care staff D reported the resident called on his/her call light at the beginning of the evening shift on [DATE] and complained about pain in his/her chest/sternum. The nurse gave the resident some medicine. Staff D answered the call light again and the resident stated that he/she needed to go to the hospital. Staff D notified licensed nursing staff A who said to let the medicine do it's work. (Interview per facility investigation notarized interview [DATE]) The clinical record lacked documentation regarding the resident's chest pain and wanting to go to the hospital. Licensed nursing staff A revealed the day shift licensed nursing staff reported during change of shift that the resident had complaints of abdominal pain, the day shift licensed nursing staff C assessed the resident and heard bowel sounds and there was nothing to be concerned about. When direct care staff reported the resident complaints of his/her stomach hurting, licensed nursing staff A went to see the resident and told him/her the pain was probably from dry heaves the day before. Licensed nursing staff gave the resident [MEDICATION NAME] for irritable bowel syndrome on evening shift [DATE] at 4:00 P.M. and when the resident continued to put his/her light on, licensed nursing staff A told the direct care staff to give the medicine a chance to work. At 4:00 P.M., licensed nursing staff A gave the resident a nebulizer treatment and took his/her vital signs with his/her blood pressure ,[DATE], pulse 72, respirations of 28 and oxygen saturation of 92%. (Per facility investigation notarized interview dated [DATE]) Direct care staff E noticed the resident sweating in the dining room at dinnertime on evening shift. Staff E, "took the resident's temperature three times and it registered 94.6 Farenheit (F) each time. Direct care staff E, thinking that was awful cold, informed licensed nursing staff A." (Per facility investigation notarized interview of [DATE]) Direct care staff A reported the resident left the dining room on evening shift without eating. (Per facility investigation notarized interview on [DATE]) On [DATE] about 7:15 P.M., direct care staff C knocked on the resident's room door, saw the resident had a pillow lying on his/her face with the left arm holding the pillow and the right arm lying at the resident's side. Staff C went to remove the pillow and saw the resident was completely purple and getting blotchy spots on his/her skin, felt for a pulse and could not find one, did not see the resident breathing and went to get help. (Per facility notarized interview of [DATE]) Licensed nursing staff A reported direct care staff notified him/her on [DATE] at 7:20 P.M., that the resident's lips were blue and he/she was not breathing. Licensed staff A went to the resident's room, initiated cardiopulmonary resuscitation and asked staff to call 911. A physician working via telephone with the Emergency Medical Team pronounced the resident dead at 8:32 P.M. (Per facility notarized interview of [DATE]) Licensed nursing staff A stated during an interview on [DATE] at 2:41 P.M., when the resident came back from the van ride on [DATE] and complained of dry heaving, he/she thought it was because the resident ate too much. Staff A did not inquire of the van staff if the resident had eaten anything during the excursion. The next day when the resident complained of pain in his/her stomach, staff A thought it was from all the dry heaving the resident did the previous day. Licensed staff A reported the resident was always complaining about being too hot in his/her room in the summertime. Staff A was unable to remember any health complaints from the resident before [DATE]. During shift change they indicated the resident complained of pain in the stomach, had indigestion. When the direct care staff reported the resident had chest pain, staff A associated the pain with the [MEDICATION NAME] given earlier. Staff A remembered the staff telling him/her that the resident complained of chest pain and wanted to go to the hospital. Staff A did not mention the chest pain in his/her facility notarized statement or in the nurses progress notes as he/she was not specifically told by the resident that he/she was having chest pain. Licensed nursing staff A felt it was an attention seeking behavior on the part of the resident. Staff A had sent resident #2 to the hospital that evening and felt sure that this resident saw the ambulance and just wanted to go to the hospital too. Licensed nursing staff A reported on [DATE] at 2:41 P.M. that he/she would call the physician if a resident's vital signs were abnormal. When asked about the low temperatures of 94.6 F reported by direct care staff E...licensed nursing staff A stated the temperature monitoring equipment was not accurate. Staff A stated, "that if he/she thought that the resident was really ill, he/she would call the doctor and have sent the resident out. Staff A felt he/she addressed all of the resident's complaints. Licensed nursing staff A again reiterated that at no time did he/she think this resident was seriously ill. Staff A did not call the physician because he/she thought the resident was attention seeking." Licensed nursing staff B reported on [DATE] at 6:41 A.M., "the night shift staff saw this resident very seldom, he/she had a low profile at night. Staff B did not remember the resident putting the call light on but very, very rarely. During change of shift they mentioned that the resident went on the Christmas lights excursion that evening and they said they stopped and had burgers and that he/she complained of his/her stomach being upset. During night shift, he/she also complained of his/her stomach hurting. Staff B said he/she gave the resident a PRN [MEDICATION NAME]. Licensed nursing staff B stated the [MEDICATION NAME] was the resident's PRN medication for when he/she had mood problems, to help him/her calm down. Staff B felt the resident was a little anxious. Staff B stated he/she addressed the resident's anxiety rather than the stomach problems thinking that the anxiety made the resident's stomach upset. Staff B did not remember having any health problems or any other problems with this resident during night shift in the past. Staff B reported he/she may have given a PRN medication in the past, but nothing like this. Licensed nursing staff B did not think of giving the resident anything for his/her complaints of pain or for the upset stomach at that time. Staff B remembered the resident sat in bed with the head of the bed elevated and staff B did not take the resident's vital signs during that shift. Though staff B thought the resident manifested a behavior, he/she did not chart that behavior on the behavior flow sheet. During change of shift the next morning, licensed nursing staff B reported he/she gave the resident a [MEDICATION NAME] for anxiety and that the resident rested quietly after that. Staff B remembered the resident rang his/her call light one other time after that, shortly after staff B gave him/her the [MEDICATION NAME], and the resident said his/her stomach was upset. Staff B asked the resident to give the [MEDICATION NAME] a chance to work and said he/she would check the resident in 30 minutes. Staff B checked the resident in 30 minutes and he/she was resting quietly with his/her eyes closed. Licensed nursing staff B stated, normally in this facility if a resident complained of stomach upset, depending on the resident and how they appeared to staff would determine what staff gave the resident for their complaints. Licensed nursing staff B thought this resident was worked up, excited from the lights and what he/she had to eat. Staff B thought he/she was attention seeking. Staff B stated so much depends on who the resident was and how they presented themselves to him/her." The Preliminary Autopsy report dated [DATE] noted bilateral [MEDICAL CONDITION] congestion, bilateral black pigmentation of lungs, cardiomegaly, horseshoe shaped kidney, and a bloated intestine... The undated facility policy for Notification of Change in Resident Health Status noted: The facility will consult the resident's physician, nurse practitioner or physician assistant...when there is: Acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental, psychosocial status in either life-threatening conditions or clinical complications. ) Criteria: life threatening conditions are such things as a [MEDICAL CONDITION] or stroke. Appropriate notification time: immediate...Definition: Immediate: as soon as possible no longer than 24 hours. Nursing judgement is an integral part of the skilled care provided in this facility, therefore, such judgement must be applied in a case by case basis in keeping with acceptable nursing practice. The facility policy for Notification of Change failed to give specific directions, timeline or parameters to notify physicians. The facility failed to assess and treat this resident with complaints of chest pain and wanting to go to the hospital. The resident expired on [DATE] in the facility. The facility abated the immediate jeopardy on [DATE] when they inserviced licensed staff on the new policies and procedures on assessing, documenting and notifying the physician. The scope and severity remains at a "G" level.