Every finding on record at Hillside Village of de Soto Rehabilitation and Nur

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store and prepare food in a sanitary manner for the residents who reside in the facility and receive meals from the facility kitchenette. Findings included: - On 01/05/26 at 12:30 PM, during lunch meal service observation of the facility's kitchenette revealed a two-door refrigerator/freezer which had storage of one box of frozen vanilla Magic Cup (nutritional supplement that contained additional calories and protein), four ounces (pack of 48) with an expiration date of 10/16/25. Further observation revealed four Magic Cups had been removed from the box. On 01/06/26 at 12:35 PM, Dietary Staff BB verified the expiration date of 10/16/25. Dietary Staff BB stated the distributor had delivered the box to the facility on [DATE] and verified the date stamped on the side of the box, which indicated the date the product was shipped from the distributor. Dietary Staff BB verified the product had expired and should be discarded, and further verified staff should look at the expiration date when the product was stocked in the kitchenette. On 01/07/26 at 11:30 AM, during a tour of the medication room, observation revealed in the refrigerator 95 vanilla Magic cups, four ounces, with an expiration date of 10/11/25. On 01/07/26 at 11:40 AM, Administrative Nurse D verified the expiration date of 10/11/25 and stated they would discard the expired cups. The facility's General Food Handling/Storage/Preparation policy, dated 2021, documented the facility would provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors The facility procures food from sources approved or considered satisfactory by federal, state or local authorities, which includes the storage, preparation, distribution, and serving food in accordance with professional standards for food safety. Effective food safety systems involved for identifying hazards at specific points during food handling and preparation, and identifying how hazards can be prevented, reduced, or eliminated. It is important to focus attention on the risks that are associated with foodborne illnesses by identifying critical control points in the food preparation process that, if not controlled, might result in food safety hazards are thawing, cooking, cooling, handling, and reheating of foods, and employee hygiene practices. Facility staff would follow applicable State and local laws or regulations with respect to obtaining food items directly from local producers. The facility would purchase food from approved vendors, inspect all products on delivery, cover, label, and date refrigerated items, and indicate an expiration date for all items.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain a Quality Assessment and Assurance Committee (QA&A) that had the required membership in attendance. Findings included: - Upon review of the facility's QA&A committee attendance signed roster for the monthly meetings held 01/27/25 through 12/17/25, the roster of attendance lacked the signature of the Medical Director, except for 08/29/25. On 01/06/25 at 11:31 AM, Administrative Staff A reported the Medical Director had only signed one of the monthly meeting rosters. Administrator Staff A stated they would be working on scheduling QA&A meetings quarterly with the Medical Director present. The facility's Quality Assurance and Performance Improvement policy, dated 04/2025, documented the facility would establish and implement a Quality /assessment and assurance/committee, develop a written Quality Assurance and Performance Improvement Plan, which would be used to continually assess the facility's performance using a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality. The QAA committee would include the Director of Nursing, Medical Director, Administrator, Infection Preventionist, and at least two other members. The committee would meet at least quarterly or more often as the facility deemed necessary.

The facility had a census of 43 residents. The sample included 12 residents. Based on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of Resident (R) 1, R3, R20, and R45's facility-initiated discharge to the hospital. Findings included: - R1's Electronic Medical Record (EMR) included diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (rapid, irregular heartbeat), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), paranoid schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), sleep disorder, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R1's Minimum Data Set (MDS) dated [DATE] and 10/02/25, documented that R1 had been discharged and return anticipated. R1's Quarterly MDS dated 12/18/25 documented the resident had moderately impaired cognition, used a wheelchair for mobility, was dependent on staff for toileting hygiene, lower body dressing, and required partial to moderate assistance with personal hygiene, rolling in bed, and transfers. The MDS further documented that R1 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), antiplatelet (a class of medication that prevents blood from clumping and clotting), and anticonvulsant (medications used to prevent convulsions-seizure (violent involuntary series of contractions of a group of muscles). The Progress Note dated 09/06/25 at 02:00 PM documented at 12:10 PM, R1 had complained about not feeling well, had difficulty sitting on the edge of the bed, was nauseated, and was diaphoretic (sweating heavily). R1 had drowsiness but open eyes to verbal and tactile stimulation. The provider was notified and ordered to send R1 to the hospital for evaluation. The Progress Note dated 09/16/25 at 02:00 PM documented that R1 had returned from the hospital after having a decreased mental status. The Progress Note dated 10/02/25 at 02:58 PM documented that R1 had a seizure (violent, involuntary series of contractions of a group of muscles). The staff notified the practitioner and obtained orders to send R1 to the hospital. The Progress Note dated 10/08/25 at 11:49 AM documented that R1 had returned from the hospital. On 01/06/26 at 07:45 AM, R1 was sitting in the dining room in a wheelchair, waiting for breakfast. R1 was dressed and groomed appropriately for the day. On 01/06/25 at 01:30 PM, Social Services X reported the information pulled from the monthly discharges to notify the Ombudsman State Agency lacked R1's discharges to the hospital. On 01/06/25 at 03:45 PM, Administrative Nurse D stated she was uncertain of the requirements of the Ombudsman notification and that Social Services was responsible for this. The facility's Criteria for Transfer and Discharge policy, dated 04/2025, documented that when the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility shall send information of notice of discharge to the State Long-Term Care Ombudsman. - R3's Electronic Medical Record (EMR) included diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) with foot ulcer, acquired absence of right leg above the knee, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), non-pressure chronic ulcer of left foot with necrosis (localized tissue death that occurred in a group of cells in response to disease or injury) of muscle, major depressive disorder (major mood disorder that causes persistent feelings of sadness), and atherosclerotic heart disease (plaque buildup in artery walls). R3's Minimum Data Sheet (MDS) dated [DATE] recorded a discharge return anticipated. The Quarterly MDS dated 11/11/25 documented R3 had mild cognitive impairment, required substantial to maximal assistance with upper body dressing, showering, rolling in bed, and was dependent on staff for lower body dressing and transfers. The MDS further documented that R3 had a diabetic foot ulcer, pressure reducing device for the chair, nutrition or hydration interventions to manage skin problems, and application of ointment/medication and dressing to the feet. R3's Care Plan dated 11/21/25 documented R3 had atherosclerotic heart disease and instructed staff to monitor for acute onset of shortness of breath, pleuritic (sharp stabbing chest pain with deep breathing) chest pain, cough, syncope (fainting or passing out), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Progress Note dated 09/07/25 at 05:59 PM documented that R3 continued to receive an antibiotic (class of medication to treat infections) for pneumonia (infection in the lungs). The Progress Note dated 09/10/25 at 03:43 PM documented R3 and the family wanted the resident to go to the hospital due to extreme fatigue and not feeling better. The staff notified the practitioner. The Progress Note dated 09/16/25 at 10:06 AM documented R3 and been admitted to the hospital on [DATE], due to pneumonia, and returned to the facility on [DATE]. On 01/06/26 at 08:03 AM, R3 self-propelled in her wheelchair to the dining room. On 01/06/25 at 01:30 PM, Social Services X reported that the information pulled from the monthly discharges to notify the Ombudsman State Agency lacked R3's discharges to the hospital. On 01/06/25 at 03:45 PM, Administrative Nurse D stated she was uncertain of the requirements of the Ombudsman notification and that Social Services was responsible for this. The facility's Criteria for Transfer and Discharge policy, dated 04/2025, documented that when the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving healthcare institution or provider. The facility shall send information of notice of discharge to the State Long-Term Care Ombudsman. - R20's Electronic Medical Record (EMR) revealed diagnoses of atherosclerotic heart disease (plaque buildup in and on arterial walls), chronic respiratory failure (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), and hypoxia (inadequate supply of oxygen). R20's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R20 had moderate cognitive impairment (problems with thinking, learning, remembering, and using judgment). The MDS recorded she required staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident required oxygen therapy and ambulated with a walker and wheelchair. The Care Area Assessment (CAA) dated 08/01/25 recorded R20 required staff assistance with ADLs due to impaired functional ability. The CAA documented the resident had cognitive loss. R20's Care Plan dated 12/31/25 recorded R20 required staff assistance with most ADL care. R20's Care Plan documented the resident required oxygen therapy due to respiratory failure. The care plan documented staff would monitor the resident for respiratory distress and report to the physician as needed, and monitor oxygen saturation as ordered. On 11/13/25 at 10:01 AM Nurse's Notes documented R20 had abnormal vital signs: blood pressure 89/52 (normal 120/80), pulse 52 (normal 60-100 beats per minute), respirations 16 normal (12-20 breaths per minute), and oxygen saturation 92% (normal 95-100 percent) with oxygen per nasal cannula. The nurse's note documented the resident had grayish-tinted skin, cool to the touch, unable to arouse, right side fascial drooping, and slurred speech. The nurse practitioner was notified and ordered to send R20 to the emergency room. On 11/13/25 at 02:50 PM Nurse's Notes documented the facility called the hospital and stated R20 was admitted to the hospital for stroke-like symptoms. On 11/15/25 at 06:54 PM Nurse's Notes documented the resident was admitted back to the facility at 04:50 PM, per medical transport in a wheelchair, accompanied by her relative. R20 had oxygen on per nasal cannula, could verbalize needs, and denied pain or discomfort. R20's clinical record lacked documentation staff notified the LTCO of R20's discharge from the facility. On 01/06/26 at 01:30 PM, Social Service X stated they send a notification of residents discharged from the facility to the Ombudsman regarding the location they discharged to monthly. Social Service X verified she did not send the R20's discharge to the Ombudsman's monthly discharge report due to her program did not identify Medicare residents to be on the report. Social Service X verified she was able to edit the computer program and record the Medicaid residents discharged , and would send the Ombudsman the past months discharges she had failed to send. The facility's Admission, Discharge, and Transfer policy, dated 04/2025, documented when the facility transfers and discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institute or provider. The policy documented the facility shall send a copy of the notice to the State Long Term Care Ombudsman. - R45's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), atrial fibrillation (rapid, irregular heartbeat), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), chronic kidney disease (long term where the kidneys cat filter blood [NAME], causing waste buildup, and lead to complications like heart disease, anemia, and potentially kidney failure), quadriplegic (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and weakness. R45's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R45 had intact cognition and required staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident ambulated with a wheelchair and received insulin (a hormone that lowers the level of glucose in the blood) and scheduled pain medication due to the spinal cord injury. The Care Area Assessment (CAA) dated 04/02/25 recorded R45 required staff assistance with ADLs due to recent hospitalization for a spinal cord injury and quadriplegia. R45's Care Plan dated 12/18/25 recorded R45 required staff assistance with ADL care. R45's Care Plan documented the resident required pain relief due to a recent spinal cord injury and was on antibiotics (medication that fights infections by killing bacteria or stopping them from multiplying) due to a lower leg wound infection. The Care Plan documented staff would monitor the resident for nausea, diarrhea, hypersensitivity, and allergic reaction from medications. On 12/28/25 at 11:59 AM Nurse's Notes documented R45's nurse practitioner requested to send the resident to the hospital due to recent abnormal labs to evaluate and treat. The nurse practitioner informed the resident of the possible outcome if he would not be treated for the abnormal lab values. On 12/28/25 hospital History and Physical documented R45 went to the hospital due to abnormal labs, hyponatremia (a dangerous condition where blood sodium levels drop below 135 milliequivalents per liter), cellulitis of the bilateral lower legs, and malaise (vague, uneasy feeling of body weakness, distress, or discomfort). On 12/30/25 at 04:00 PM Nurse's Notes documented the resident was admitted back to the facility, per medical transport. R45 was awake and sitting in a wheelchair in his room with the call light within reach. R45's clinical record lacked documentation staff notified the LTCO of R45's discharge from the facility. On 01/06/26 at 01:30 PM, Social Service X stated they sent notification of residents discharged from the facility to the Ombudsman regarding the location they discharged to monthly. Social Service X verified she did not send the R45's discharge to the Ombudsman's monthly discharge report due to her program did not identify Medicare residents to be on the report. Social Service X verified she was able to edit the computer program and record the Medicaid residents discharged , and would send the Ombudsman the past months' discharges she had failed to send. The facility's Admission, Discharge, and Transfer policy, dated 04/2025, documented when the facility transfers and discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institute or provider. The policy documented the facility shall send a copy of the notice to the State Long Term Care Ombudsman.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to administer Resident (R) 6's medication as prescribed and instructed. Findings included: - R6's Electronic Medical Record (EMR) included diagnoses of hypothyroidism (a condition characterized by decreased activity of the thyroid gland), gastroesophageal reflux disease (GERD- backflow of stomach contents to the esophagus), unspecified severe protein-calorie malnutrition, dysphagia (swallowing difficulty), muscle weakness, need for assistance with personal care, and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R6 had severe cognitive impairment, used a wheelchair for mobility, and required partial to moderate assistance with toileting, upper and lower body dressing, rolling in bed, and transfers. The MDS further documented that R6 received an antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), anticoagulant (a class of medications used to prevent the blood from clotting), and a diuretic (a medication to promote the formation and excretion of urine). R6's Care Plan dated 12/31/25 documented that R6 received anticoagulant, diuretic, antidepressant, antianxiety, and had a nutritional problem. The Care Plan directed staff to administer medications as ordered and to monitor for side effects. The Care Plan lacked instructions related to the use of medication for hypothyroidism, and gastroesophageal medication or conditions. The Physician Order dated 09/22/25 instructed staff to administer Levothyroxine (medication used to treat thyroid conditions) 100 milligrams (mcg) by mouth one time a day, on an empty stomach, for hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Physician Order dated 09/22/25 instructed staff to administer Omeprazole (medication used to treat gastric reflux conditions) 40 mg by mouth two times a day, for GERD. The Physician Order dated 12/29/25 instructed staff to administer Ferrous Sulfate (medication used to treat anemia) 325 mg by mouth in the morning for anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) and to not administer with Omeprazole or Levothyroxine. On 01/06/25 at 07:48 AM, Certified Medication Aide (CMA) R prepared medications for the administration of R6. CMA R reviewed the Electronic Medication Administration Record (EMAR). CMA R provided all the morning medications, including the Ferrous Sulfate, Levothyroxine, and Omeprazole, crushed together and mixed in yogurt, at the same time. R6 took them without difficulty. On 01/06/25 at 12:00 PM, CMA R reviewed the EMAR and verified the instructions directing staff not to administer the Ferrous Sulfate with Omeprazole or Levothyroxine. CMA R verified that she gave all the medications at the same time, but had overlooked the instructions when she administered R6's medications earlier that morning. On 01/06/25 at 02:35 PM, Administrative Nurse D verified CMA R should have followed the physician's order for R6 and should not have administered the Ferrous Sulfate with Omeprazole and Levothyroxine. The facility's Medication Administration General Guidelines policy, dated 08/2014, documented medications were administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. Medications were administered in accordance with written orders of the prescriber.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to implement acceptable infection control practices when staff failed to properly store Resident (R) 14's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) in a sanitary manner. Findings include: - On 01/05/26 at 10:45 AM, observation revealed R14's unbagged oxygen tubing and nasal cannula draped over the handle of her wheelchair, attached to the oxygen cannister behind the wheelchair. On 01/06/26 at 07:45 AM, observation revealed R14's unbagged oxygen tubing and nasal cannula draped over the handle of her wheelchair, attached to the oxygen cannister behind the wheelchair, and the nasal cannula was approximately 10 inches from the floor. On 01/06/26 at 04:10 PM, Administrative Nurse D stated the oxygen tubing and cannulas should be stored in a bag when not in use, and she would have an in-service to remind the staff of appropriate storage. The facility's Oxygen Storage policy, dated 01/2022, documented the facility would maintain all oxygen equipment in a clean and sanitary manner and to ensure humidifiers, tubing, masks, and cannulas for residents receiving oxygen. The equipment would be discarded after use by the resident, and the facility would maintain clam tanks, connectors, and concentrators. The policy documented when masks or cannulas were temporarily not being used, they would be stored in a plastic bag.

The facility had a census of 41 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - CNA N, hired 09/30/22, no yearly performance evaluations were provided upon request. CNA O, hired 08/21/22, no yearly performance evaluations were provided upon request. CNA P, hired 04/16/22, no yearly performance evaluations were provided upon request. CNA Q, hired 11/18/21, no yearly performance evaluations were provided upon request. CNA MM, hired 02/15/21, no yearly performance evaluations were provided upon request. On 02/20/24 at 09:57 AM Administrative Nurse D stated the facility did not complete yearly performance evaluations for their staff. Administrative Nurse D stated she relied on other nursing staff to provide education to their peers on the spot when issues would arise. Administrative Nurse D further stated if an issue required more intervention, the nurses would have notified her, and further intervention or education would have been provided at that time. Administrative Nurse D stated that issues would have been addressed when they arose instead of waiting until a yearly evaluation was done. The facility policy Required Training, Performance Evaluation and In-Service of Staff documented performance is evaluated each day through communication with staff leaders and leadership team members. Any performance issues are addressed with staff members and followed up by any additional training needed. The facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 41 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings Included: - A review of the information provided by the facility on the facility's Water Management program revealed the program lacked text and diagrams specific to the building's water flow system. The program did not identify building-specific areas at risk for Legionella or identify specific points within the system checked by the water management program team. On 02/20/24 at 10:23 AM Administrative Staff A stated he was unable to locate the facility's water flow system diagram but would contact the maintenance director. On 02/20/24 at 10:35 Maintenance Staff U stated the facility did not have a diagramed flow chart of the facility water system. He stated the team does monitor high-risk areas and ensures areas of standing water are flushed out frequently. A review of the facility's Water Management policy (undated) indicated the facility would provide the appropriate precautions for the control of legionella including identifying areas of growth, completing risk assessments, and implementing precautions to provide regular inspections. The policy indicated microbial monitoring, temperature checks, and system flushing. The facility to ensure proper infection control standards were followed related to implementation of procedures to monitor and prevent Legionella disease or other opportunistic waterborne pathogens. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility had a census of 41 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education including the required topics per year. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's in-service records revealed the following: CNA N hired 09/30/22: The documentation provided lacked evidence that CNA N completed 12 hours of in-service/education hours in the past 12 months. CNA O hired 08/21/22: The documentation provided lacked evidence that CNA O had completed 12 hours of in-service/education hours in the past 12 months. CNA P hired 04/16/22: The documentation provided lacked evidence that CNA P had completed 12 hours of in-service/education hours in the past 12 months. CNA Q hired 11/18/21: The documentation provided lacked evidence that CNA Q had completed 12 hours of in-service/education hours in the past 12 months. CNA MM hired 02/15/21: The documentation provided lacked evidence that CNA MM had completed 12 hours of in-service/education hours in the past 12 months. On 02/20/24 at 09:12 AM Administrative Nurse D stated the facility provided education for staff; however, the facility did not have a way to track the hours of education provided for the year. Administrative Nurse D further stated Administrative Staff B assisted her in tracking post-tests for the education that was provided for staff; however, Administrative Nurse D stated she was typically the one responsible for ensuring staff met education requirements. The updated facility policy Required Training, Performance Evaluation and In-Service of Staff documented all direct care staff are required to attend 12 hours of continuing education and demonstrate competency annually. The facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education including the required topics per year. This placed the residents at risk for inadequate care.

The facility had a census of 41 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had a stop date for the use of as-needed (PRN) lorazepam (an antianxiety medication that calms and relaxes people). This placed the resident at risk of receiving unnecessary psychotropic (alters mood or thoughts) medications. Findings included: - R30's Electronic Medical Record (EMR) listed diagnoses of generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and dementia (progressive mental disorder characterized by failing memory, and confusion). R30's Quarterly Minimum Data Set (MDS) dated [DATE] documented R30 had a Brief interview for Mental Status score of four which indicated severe cognitive impairment. The MDS documented R30 had no behaviors. R30 received antianxiety medications, antidepressant (medication used to treat mood disorders), opioids (narcotic medication used to treat pain), and antiplatelet (medication to inhibit blood clotting) medication during the observation period. R30's Care Plan dated 07/20/23 documented R30 was at risk for adverse side effects due to medications with Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R30's Care Plan documented R30 had impaired cognitive function related to her dementia (08/04/23). The plan directed staff to provide approaches that maximized R30's involvement in daily decision making such as limiting choices, using cueing, task segmentation, written lists, and instructions. R30's EMR documented a Physician's Order dated 11/23/23 for lorazepam oral tablet, 0.5 milligrams (mg) by mouth every afternoon for anxiety. R30's EMR documented a Physician's Order dated 12/30/23 for lorazepam oral tablet, 0.5 mg by mouth every six hours as needed for tremors (uncontrolled shaking or trembling). The order lacked a stop date. A Behavior Note dated 12/30/23 at 10:16 AM recorded refused her medications and reported she did not want to take the medication because they were the wrong medications. Staff attempted redirection but it was ineffective. R30 tossed the pills in the trash and reported These pills make me shake. Staff notified R30's representative who attempted to calm the resident. At the time of the note, R30 sat in her recliner with her call light within reach. Staff provided R30 personal space for her to recollect herself, and noted if that was ineffective staff would administer PRN Ativan (lorazepam). A review of R30's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed R30 received the PRN lorazepam twice on 12/30/23, on 10 occasions in January 2023, and twice in February 2024 thus far. R30's EMR lacked a 14-day stop order or specified duration with a physician-documented rationale for the extended use of R30's PRN lorazepam. On 02/21/24 at 07:21 AM Certified Medication Aid (CMA) S prepared R30's morning medications. R30 sat at the medication cart. CMA S asked R30 if she would like to have her medication in her room or at the medication cart. R30 took her medication without behaviors or concerns. R30's PRN Ativan was not administered during this medication pass due to no anxiety or behaviors displayed. On 02/20/24 at 09:20 AM Licensed Nurse (LN) G stated PRN Ativan medication should include a 14-day stop date unless the medical provider reorders the medications. She stated the medical provider would document the continued use duration on a progress note or order. She stated the pharmacist completed monthly reviews of the medication and reported to Administrative Nurse D. On 02/20/24 at 09:35 AM Administrative Nurse D stated R30's PRN Ativan medication had been ordered for the intended use but was unable to provide a specified duration for the medications PRN use. She stated the pharmacy should have identified the lack of duration on the monthly reviews and reported the concern. A review of the facility's Psychotropic Medication Use policy revised 11/2017 indicated the facility will provide ongoing psychotropic (alters mood or thoughts) medication monitoring and ensure correct indication of use and appropriate duration. The facility failed to ensure R30 had a stop date for the use of PRN lorazepam. This placed the resident at risk of receiving unnecessary psychotropic (alters mood or thoughts) medications.

The facility had a census of 41 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of the required stop date for Resident (R) 30's as-needed (PRN) lorazepam (antianxiety-class of medications that calm and relax people). This placed the resident at risk of receiving unnecessary psychotropic (alters mood or thoughts) medications. Findings included: - R30's Electronic Medical Record (EMR) listed diagnoses of generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and dementia (progressive mental disorder characterized by failing memory, and confusion). R30's Quarterly Minimum Data Set (MDS) dated [DATE] documented R30 had a Brief interview for Mental Status score of four which indicated severe cognitive impairment. The MDS documented R30 had no behaviors. R30 received antianxiety medications, antidepressant (medication used to treat mood disorders), opioids (narcotic medication used to treat pain), and antiplatelet (medication to inhibit blood clotting) medication during the observation period. R30's Care Plan dated 07/20/23 documented R30 was at risk for adverse side effects due to medications with Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R30's Care Plan documented R30 had impaired cognitive function related to her dementia (08/04/23). The plan directed staff to provide approaches that maximized R30's involvement in daily decision making such as limiting choices, using cueing, task segmentation, written lists, and instructions. R30's EMR documented a Physician's Order dated 11/23/23 for lorazepam oral tablet, 0.5 milligrams (mg) by mouth every afternoon for anxiety. R30's EMR documented a Physician's Order dated 12/30/23 for lorazepam oral tablet, 0.5 mg by mouth every six hours as needed for tremors (uncontrolled shaking or trembling). The order lacked a stop date. A Behavior Note dated 12/30/23 at 10:16 AM recorded refused her medications and reported she did not want to take the medication because they were the wrong medications. Staff attempted redirection but it was ineffective. R30 tossed the pills in the trash and reported These pills make me shake. Staff notified R30's representative who attempted to calm the resident. At the time of the note, R30 sat in her recliner with her call light within reach. Staff provided R30 personal space for her to recollect herself, and noted if that was ineffective staff would administer PRN Ativan (lorazepam). A review of R30's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed R30 received the PRN lorazepam twice on 12/30/23, on 10 occasions in January 2023, and twice in February 2024 thus far. R30's EMR lacked a 14-day stop order or specified duration with a physician-documented rationale for the extended use of R30's PRN lorazepam. The facility was unable to provide this documentation as requested on 02/20/24. The CP's Monthly Medication Review for February 2024 documented no irregularities were noted and lacked evidence the CP identified the lack of a stop date for R30's PRN lorazepam. On 02/21/24 at 07:21 AM Certified Medication Aid (CMA) S prepared R30's morning medications. R30 sat at the medication cart. CMA S asked R30 if she would like to have her medication in her room or at the medication cart. R30 took her medication without behaviors or concerns. R30's PRN Ativan was not administered during this medication pass due to no anxiety or behaviors displayed. On 02/20/24 at 09:20 AM Licensed Nurse (LN) G stated PRN Ativan medication should include a 14-day stop date unless the medical provider reorders the medications. She stated the medical provider would document the continued use duration on a progress note or order. She stated the pharmacist completed monthly reviews of the medication and reported to Administrative Nurse D. On 02/20/24 at 09:35 AM Administrative Nurse D stated R30's PRN Ativan medication had been ordered for the intended use but was unable to provide a specified duration for the medications PRN use. She stated the pharmacy should have identified the lack of duration on the monthly reviews and reported the concern. The Consultant Pharmacist (CP) was not available for interview on 02//20/24 and 02/21/24. The facility's Pharmacy Review policy revised 11/2017 noted the CP will review all residents' records monthly and provide recommendations for clinical guidelines. The policy indicated the medical provider and Director of Nursing would be provided input on recommendations made. The facility failed to ensure the CP identified and reported the lack of the required stop date for R30's PRN lorazepam. This placed the resident at risk of receiving unnecessary psychotropic medications.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in a sanitary condition for 43 residents who received meals from the kitchen, and ate in the dining room placing them at risk for food borne illness. Findings included: - On 08/01/22 at 11:23 AM during the kitchen inspection, observation revealed the testing sanitizing solution lacked documentation for the month of July 2022. The sanitizing test strips were found without an expiration date, and the ventilation vent cover above the cooking surface in the kitchenette attached to the dining room in the long-term care area, was covered with thick dust like debris. The dining room had numerous chairs found to have dried food particles on the seat, arms, and back of chairs. The chairs also had dark liquid spill stains on the seats. On 08/02/22 at 08:30 AM, Dietary Staff (DS) CC verified the testing strips did not have a expire date on them and no logs for sanitizing solution were found. DS CC verified the vent above the cook stove should be cleaned. On 08/02/22 at 11:25 AM, Administrative Staff A verified the dining room chairs had dried food debris and dark liquid type stains on the seats. He reported it was the responsibility of all staff to maintain a clean environment for the residents. The facility's undated General Cleaning and Maintenance of Resident Environment policy, documented Environmental Service and Custodial staff will keep furnishings and equipment safe and in good repair and will maintain a safe and functional dining environment. The policy further documented the staff will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, functional and comfortable interior. The facility did not provide a policy for testing and maintaining record of sanitizing solution logs. The facility failed to store, prepare, and serve food in a sanitary condition for 43 resident who resided in the facility and received meals from the kitchen and dining room, placing them at risk for food borne illness.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed ensure the resident council was able to meet regularly, which placed the residents at risk for unmet concerns related to life in the facility. Findings included: - Record review of the Resident Council Meeting revealed the facility had no minutes or meetings for the months of August 2021, September 2021, January 2022, and April 2022. On 08/01/22 at 01:03 PM Social Services X reported the meetings were scheduled monthly. Social Services X stated she could not remember why no meeting was conducted in August 2021. The September meeting had been canceled due to staffing issues. The January 2022 meeting was canceled due to a Covid (highly contagious, potentially life-threatening respiratory infection) outbreak in the assisted living building. The April 2022 meeting was canceled due to staffing issues. Social Services X verified she had not rescheduled the meeting during the previously noted months. On 08/02/22 at 11:53 AM, Administrative Staff A verified the resident council meetings should be allowed to meet at least monthly monthly and should have been rescheduled to facilitate the meetings. The facility's undated Resident and Family Group policy documented the facility is committed to consideration of views of the resident group and will act promptly upon grievances and recommendation of the group concerns issues of resident care and life in the facility, and meeting will be included on the monthly activity calendar. The facility failed to ensure the resident council was able to meet at least monthly placing the residents at risk for unmet concerns.

The facility had a census of 43 residents. The sample included 12 residents of which six where reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to update interventions on the care plans to prevent falls and hot beverage spill for Resident (R) 6, R34, R14, and 32. This deficient practice placed the residents at risk for injuries and accidents due to uncommunicated care needs. Findings included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, required supervision to limited assistance with activities of daily living, was not steady, but was able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet, and surface to surface transfers. R6 was not steady and only able to stabilize with staff assistance with turning around and facing the opposite direction when walking. The MDS further documented R6 had no trial of a toileting program, was frequently incontinent of urine and bowel, and had two or more falls with no injury and one fall with injury since last assessment. The Fall Care Area Assessment (CAA), dated 01/18/22, documented R6 had been admitted following hospitalization after a fall in which had resulted in subdural hematoma. The Fall Care Plan, revised on 02/07/22, documented R6 was at risk for falls related to impaired balance, gait, and poor safety awareness. The care plan directed staff to ensure R6 wore appropriate footwear when ambulating, transferring or mobilizing in her wheelchair. Staff were to anticipate R6's needs, check frequently, ensure touch call light pad within reach with encouragement and remind R6 to use it for assistance, and to respond for requested assistance. The care plan further directed staff to keep floor free from spills and clutter, use of glare free light, bed in low position at night, handrails on walls in the bathroom, and keep personal items within reach. The Fall Care Plan, revised on 04/21/22, directed staff to toilet R6 between 02:00 AM to 03:00 AM and ensure a nightlight was kept on in the bathroom to reduce chance of early morning falls. The care plan lacked intervention related to falls on 02/02/22, 02/16/22, 02/27/22, 03/04/22, 03/25/22, 05/31/22, 06/08/22, 06/26/22, 06/30/22, 07/16/22, and 07/26/22. The Physician Order, dated 01/10/22, documented the admission of R6 to the facility due to a fall resulting in a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to back of head. The facility's Fall Risk assessment dated [DATE], documented R6 was at moderate risk for falls. The facility's Fall Risk Assessment, dated 04/14/22 and 07/14/22 documented R6 scored at high risk for falls. The Progress Notes recorded the following falls: 02/02/22 at 02:47 PM, fell in bathroom reaching for incontinent pad and received a skin tear to right hand. 02/16/22 at 05:10 AM, found on floor by her recliner, incontinent of urine, and had cut to right eyebrow, bruise to right cheek bone, and hematoma to back of right hand. 02/27/22 at 12:52 AM, resident on floor of room. R6 reported she fell in the bathroom changing her incontinent product. 03/04/22 at 03:00 AM, resident on floor of her bathroom, incontinent of urine; she reported she hit her head on the wall. 03/25/22 at 08:52 AM, found lying on her back next to her bed, holding transfer bar, had golf ball size hematoma to left side frontal lobe (forehead) with three skin tears to left hand. R6 reported she had backed up to the chair and fell to the side. 04/18/22 at 03:00 AM, found on floor of bathroom, incontinent of urine, reported reaching for incontinent product and slid to floor. Skin tear to right elbow. 05/31/22 at 10:57 AM, fell while making her way to the bathroom, holding lip stick in one hand and reaching for the doorknob with the other hand. 06/08/22 at 01:53 AM, found on floor of bathroom, reported trying to sit on toilet and lost balance, hitting back of her head. 06/26/22 at 05:47 AM, found on floor, reported she tried to pick up her shoe and landed on her face. She had some signs of bruising and small skin tear. 06/30/22 at 01:15 PM, R6 pulled out a chair in the dining room and lost her balance. 07/16/22 at 01:00 PM, R6 returned from outing with a family member, her walker caught on carpet in the entry way. Family member tried to catch her, and the resident fell on to the family member. 07/26/22 at 02:45 AM, found sitting on bathroom floor, incontinent of urine. On 08/01/22 at 09:30 AM, observation revealed R6 sat in her room in her recliner with her eyes closed. She was dressed for the day and wore tennis shoes. R6 reported her call light was on her bed and she should use it when going to the bathroom. On 08/01/22 at 08:57 AM, Certified Medication Aide (CMA) R reported if a resident fell , staff were to immediately notify the charge nurse, to assess the resident. The staff were alerted the resident had fallen in the communication system of the electronic record. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell , the staff alert the charge nurse to assess the resident; a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at the time of the fall, and the care plan should be updated with the intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified R6's care plan had not been updated with interventions to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Care Plan Revision/Updates policy documented each resident will have a care plan developed to meet their individual needs and cares. All resident care plans are reviewed quarterly, annually, and with any significant change in status. The facility failed to identify and implement interventions to the care plan to prevent falls for R6 who had multiple falls. This deficient practice placed R6 at increased risk for further falls and injury. - R34's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), date 07/01/22, documented R34 had intact cognition, required supervision to limited assistance of one staff for activities of daily living. R34 was not steady but able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet and surface to surface transfer, walking, and turning around and face the opposite direction while walking. The MDS further documented R34 had no trial of toileting program, was frequently incontinent of urine, always continent of bowel, and had pain. R34 had two or more falls with injury. The Fall Care Plan, revised on 02/18/22, documented R34 at risk for falls related to impaired balance, strength, and safety awareness. The care plan further documented to encourage and remind R34 to use the call light, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility. The care plan directed staff to ensure R34's wheelchair was next to the bed and the brakes were locked, to wear appropriate footwear, keep safe environment free from spills and clutter, use glare free lights, reachable call light, bed in low position at night, handrails in bathroom and keep personal items within reach. The care plan further documented R34 attempted to get up unassisted and needed frequent checks to anticipate needs. The care plan lacked intervention for falls on 06/11/22 and 06/25/22. The Progress Note, dated 06/11/22 at 06:30 PM, R34 was found sitting upright on the floor, incontinent of urine and reported she was looking for her TV remote. The Progress Note, dated 06/25/22, documented around 11:40 PM the resident was found on the floor by the wall. R34 stated she was going to the bathroom, lost her balance, and fell hitting her right shoulder against the wall. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/28/22 at 12:26 PM observation revealed R34 left the dining room independently with her walker. On 08/01/22 at 12:18 PM, Certified Medication Aide (CMA) R reported R34 was a standby for assistance with toileting as an intervention to prevent falls. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell , the staff alert the charge nurse to assess the resident, a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at time of fall, and the care plan should be updated with intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified R34's care plan had not been updated with interventions to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Care Plan Revision/Updates policy documented each resident will have a care plan developed to meet their individual needs and cares. All resident care plans are reviewed quarterly, annually, and with any significant change in status. The facility failed to identify and update interventions on the care plan to prevent falls placing R34 at risk for further falls and injury. - The Electronic Medical Record (EMR) for R14 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition and had only transferred with one staff two or fewer times, did not ambulate, had unsteady balance, and had no functional impairment. The MDS further documented R14 had two or more non injury falls since prior assessment. The Fall Risk Assessment, dated 05/03/22, documented the resident a high risk for falls. The Care Plan, dated 05/09/22, initiated on 11/14/21, directed staff to use two staff to assist with transfers on and off of the shower chair, and provide and serve her diet as ordered. The care plan documented R14 was able to feed herself but occasionally required reminders and cuing during meals. The care plan lacked documentation R14 required lids on her hot and cold drinks. The Nurse's Note, dated 04/13/22 at 09:04 AM, documented R14 spilled hot coffee down the left side of her chest and abdomen, had slight redness, no blisters or [CONDITION(S)] present, and improved after five minutes. The Nurse's Note, dated 06/26/22 at 03:45 PM, documented R14 spilled warm coffee on her left abdomen and upper thigh earlier that morning. The note documented R14 was sleepy upon rising from bed at 07:00 AM, had no redness or injury. The Investigation Report, dated 07/09/22, documented R14 spilled her hot coffee onto her chest after a dietary aide had given it to her without a lid. The report further documented R14's had scattered redness to the front of her lower chest, lower abdomen and very slightly to the front of her thighs. The area of redness to the left chest measured 9 centimeters (cm) x 4 cm, redness to abdomen measured 5 cm x 1.7 cm x 0.7 cm in three different spots. The coffee had a temperature of 161.8 and directed dietary staff to ensure the temperature of hot beverages were within acceptable range when serving. The report documented R14 was on a list to have cooled coffee with a cup and lid and staff would receive further training regarding hot liquids. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse's Note, dated 07/10/22, documented no redness or blistering noted in relation to R14's coffee spill. The Weekly Skin Assessment, dated 07/14/22, documented R14 had faint red markings on the center of her abdomen. The Investigation Report, dated 07/14/22, documented a Certified Nurse Aide (CNA) had to bear hug a resident to hold her up in the shower so another CNA could provide pericare after R14 had a bowel movement (bm). The report documented R14's feet slid due to the floor was wet and the CNA had to lower the resident onto the floor. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The report further documented R14 should have been properly positioned in the shower chair and should have been transferred with two staff. On 08/01/22 at 10:47 AM, observation revealed CNA M placed a gait belt around R14's waist, had her lean forward, count to three, and CNA M and Licensed Nurse (LN) I tried to stand the resident up straight. Further observation revealed R14 sat back down and CNA M counted to three again, and the resident was able to partially stand up and pivot to the wheelchair. R14 sat crooked in her wheelchair and CNA M took the back of her pants and pulled up to reposition the resident into the wheelchair. CNA M pushed R14 into the dining room, without foot pedals, into the dining room. On 07/28/22 at 08:47 AM, CNA M stated she did not know if R14 had any falls and would need to ask her nurse. CNA M further stated R14 required cups with lids so she did not spill on herself. On 08/02/22 at 10:05 AM, LN I stated R14 was a two- person transfer and had a recent fall in the shower room. R14 stated staff should use foot pedals on the wheelchairs when transporting residents. On 08/02/22 at 08:30 AM, Administrative Nurse D stated R14 was on a list for resident's who required lids on their cups and that was not communicated to the dietary staff member. Administrative Nurse D stated the resident required two staff to transfers and should not have been transferred by one staff in the shower room. Administrative Nurse D stated she was responsible to update the care plan after a fall or incident and verified she had not done so. The facility's Care Plan Revision/Updates policy, undated, documented each resident would have a care plan developed to meet their individual needs and cares and would be reviewed and changed with each significant change of status. The facility failed to revise R14's care plan with interventions to prevent further falls and accident hazards, placing the resident at risk for further falls and injury. - The Electronic Medical Record (EMR), documented for R32 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition and required extensive assistance of one staff for bed mobility and supervision and one staff for transfers. The MDS further documented R32 had unsteady balance, no functional impairment, and no falls. The Fall Risk Assessments, dated 09/23/21 and 12/24/21 documented R32 a high risk for falls and 06/28/22 a moderate risk for falls. The Care Plan, dated 07/07/22, initiated on 10/08/21, directed staff to ensure the call light was within reach and remind the resident to use it, ensure resident wore appropriate footwear when ambulating or transferring, and required one person assist for safe transfers. The care plan lacked interventions to prevent further falls. The Fall Investigation, dated 12/07/21 at 02:29 PM, documented R32 fell while straightening the sheet on her bed, had soreness to bilateral knees, and denied hitting her head. The investigation further documented R32 reported she was messing with the edge of her sheet before getting into bed for a nap, slipped and fell to her knees. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/05/22 at 03:29 PM, documented at approximately 11:15 AM, R32 was observed on the floor in her room and the resident was seated in the upright position facing the hallway with her back against her nightstand. The resident stated she lost her balance while she tried to make her bed. R32 stated she did not hit her head and denied pain. The investigation documented R32 had poor safety awareness and would continue to monitor the resident. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/07/22 at 09:45 PM, documented R32 was observed lying on her right side, on the floor, in her room with her legs stretched out in front of her. The investigation documented R32 had reached over her head to pick up colored pencils she had dropped on the floor and fell . The investigation further documented R32 did not sustain any injuries and was shown her call light and educated to push the red button for assistance. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. On 08/01/22 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) M place a gait belt around R32's waist, had the resident reach with her right hand to the right armrest of her wheelchair, stand, and then sit down into her wheelchair. On 08/01/22 at 11:20 AM, CNA M stated R32 required reminders to use her call light because she was forgetful. CNA M was unsure of any recent falls for R32. On 08/02/22 at 09:56 AM, Licensed Nurse (LN) I stated R32 often tried to get up unassisted and they reeducate her to use her call light. LN I further stated staff keep R32's bed in the lowest position and make sure the resident used her wheelchair because she had poor balance. On 08/02/22 at 12:38 PM, Administrative Nurse D verified the care plan lacked interventions for the falls and stated R32's cognition changed daily and staff should assist the resident to make her bed or let the resident assist the staff so she did not feel she needed to do it by herself. The facility's Care Plan Revision/Updates policy, undated, documented each resident would have a care plan developed to meet their individual needs and cares and would be reviewed and changed with each significant change of status. The facility failed to revise R32's care plan with meaningful, resident centered interventions for cognitively impaired R32, who had falls, placing the resident at risk for further falls.

- The Electronic Medical Record (EMR) for R14 documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition and had only transferred with one staff two or fewer times, did not ambulate, had unsteady balance, and had no functional impairment. The MDS further documented R14 had two or more non injury falls since prior assessment. The Fall Risk Assessment, dated 05/03/22, documented the resident a high risk for falls. The Care Plan, dated 05/09/22, initiated on 11/14/21, directed staff to use two staff to assist with transfers on and off of the shower chair, provide and serve her diet as ordered. The care plan documented R14 was able to feed herself but occasionally required reminders and cuing during meals. The care plan lacked documentation R14 required lids on her hot and cold drinks. The Nurse's Note, dated 04/13/22 at 09:04 AM, documented R14 spilled hot coffee down the left side of her chest and abdomen, had slight redness, no blisters or [CONDITION(S)] present, and improved after five minutes. The Nurse's Note, dated 06/26/22 at 03:45 PM, documented R14 spilled warm coffee on her left abdomen and upper thigh earlier that morning. The note documented R14 was sleepy upon rising from bed at 07:00 AM, had no redness or injury. The Investigation Report, dated 07/09/22, documented R14 spilled her hot coffee onto her chest after a dietary aide had given it to her without a lid. The report further documented R14's had scattered redness to the front of her lower chest, lower abdomen and very slightly to the front of her thighs. The area of redness to the left chest measured 9 centimeters (cm) x 4 cm, redness to abdomen measured 5 cm x 1.7 cm x 0.7 cm in three different spots. The coffee had a temperature of 161.8 and directed dietary staff to ensure the temperature of hot beverages were within acceptable range when serving. The report documented R14 was on a list to have cooled coffee with a cup and lid and staff would receive further training regarding hot liquids. The Physician's Order, dated 07/09/22, directed staff to apply [MEDICATION(S)] cream 1% (an antibiotic cream used to treat [CONDITION(S)]) apply to left chest, abdomen, and thighs topically, twice a day for seven days. The Nurse's Note, dated 07/10/22, documented no redness or blistering noted in relation to R14's coffee spill. The Weekly Skin Assessment, dated 07/14/22, documented R14 had faint red markings on the center of her abdomen. The Investigation Report, dated 07/14/22, documented a Certified Nurse Aide (CNA) had to bear hug a resident to hold her up in the shower so another CNA could provide pericare after R14 had a bowel movement (bm). The report documented R14's feet slid due to the floor was wet and the CNA had to lower the resident onto the floor. The resident was assessed without injury and due to the resident unable to bear weight, staff used the hoyer (mechanical lift) to assist the resident off of the floor and into her wheelchair. The report further documented R14 should have been properly positioned in the shower chair and should have been transferred with two staff. On 08/01/22 at 10:47 AM, observation revealed CNA M placed a gait belt around R14's waist, had her lean forward, count to three, and CNA M and Licensed Nurse (LN) I tried to stand the resident up straight. Further observation revealed R14 sat back down and CNA M counted to three again, and the resident was able to partially stand up and pivot to the wheelchair. R14 sat crooked in her wheelchair and CNA M took the back of her pants and pulled up to reposition the resident into the wheelchair. CNA M pushed R14 into the dining room, without foot pedals, into the dining room. On 07/28/22 at 08:47 AM, CNA M stated she did not know if R14 had any falls and would need to ask her nurse. CNA M further stated R14 required cups with lids so she did not spill on herself. On 08/02/22 at 10:05 AM, LN I stated R14 was a two- person transfer and had a recent fall in the shower room. R14 stated staff should use foot pedals on the wheelchairs when transporting residents. On 08/02/22 at 08:30 AM, Administrative Nurse D stated R14 was on a list for resident's who required lids on their cups and that was not communicated to the dietary staff member. Administrative Nurse D stated the resident required two staff to transfers and should not have been transferred by one staff in the shower room. Administrative Nurse D stated she was responsible to update the care plan after a fall and verified she had not done so. The facility's Fall Prevention Protocol, policy, undated, documented each senior who resided at the facility would be provided services and care that ensured an environment to prevent accidents. The policy documented all staff members would be educated on the fall reduction program annually through the mandated safety inservice and more often based on needed. The facility's Accident Prevention/Hazards policy, undated, documented all staff members of the facility would ensure that each senior's environment remained as free from accident hazards as possible. Each senior was assisted with activities of daily living, based on his/her needs including bathing, dressing, eating, oral hygiene, ambulation, and toileting activities. Clinical staff would ensure each senior was as safe from accidents as he/she received restorative services as possible. The facility failed to prevent coffee spills for cognitively impaired R14, which resulted in a mild burn, and failed to follow R14's care plan which resulted in a fall in the shower. These deficient practices placed the resident at increased risk for further injury. - The Electronic Medical Record (EMR), documented for R32 diagnoses of [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition and required extensive assistance of one staff for bed mobility and supervision and one staff for transfers. The MDS further documented R32 had unsteady balance, no functional impairment, and no falls. The Fall Risk Assessments, dated 09/23/21 and 12/24/21 documented R32 a high risk for falls and 06/28/22 a moderate risk for falls. The Care Plan, dated 07/07/22, initiated on 10/08/21, directed staff to ensure the call light was within reach and remind the resident to use it, ensure resident wore appropriate footwear when ambulating or transferring, and required one person assist for safe transfers. The care plan lacked interventions to prevent further falls. The Fall Investigation, dated 12/07/21 at 02:29 PM, documented R32 fell while straightening the sheet on her bed, had soreness to bilateral knees, and denied hitting her head. The investigation further documented R32 reported she was messing with the edge of her sheet before getting into bed for a nap, slipped and fell to her knees. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/05/22 at 03:29 PM, documented at approximately 11:15 AM, R32 was observed on the floor in her room and the resident was seated in the upright position facing the hallway with her back against her nightstand. The resident stated she lost her balance while she tried to make her bed. R32 stated she did not hit her head and denied pain. The investigation documented R32 had poor safety awareness and would continue to monitor the resident. The clinical record lacked evidence f a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/07/22 at 09:45 PM, documented R14 was observed lying on her right side, on the floor, in her room with her legs stretched out in front of her. The investigation documented R32 had reached over her head to pick up colored pencils she had dropped on the floor and fell . The investigation further documented R32 did not sustain any injuries and was shown her call light and educated to push the red button for assistance. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. On 08/01/22 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) M place a gait belt around R32's waist, had the resident reach with her right hand to the right armrest of her wheelchair, stand, and then sit down into her wheelchair. On 08/01/22 at 11:20 AM, CNA M stated R32 required reminders to use her call light because she was forgetful. CNA M said she was unsure of any recent falls R32. On 08/02/22 at 09:56 AM, Licensed Nurse (LN) I stated R32 often tried to get up unassisted and they reeducate her to use her call light. LN I further stated staff keep R32's bed in the lowest position and make sure the resident used her wheelchair because she had poor balance. On 08/02/22 at 12:38 PM, Administrative Nurse D verified the care plan lacked interventions for the falls and stated R32's cognition changed daily and staff should assist the resident to make her bed or let the resident assist the staff so she did not feel she needed to do it by herself. The facility's Fall Prevention Protocol, policy, undated, documented each senior who resided at the facility would be provided services and care that ensured an environment to prevent accidents. The policy documented all staff members would be educated on the fall reduction program annually through the mandated safety in-service and more often based on needed. The facility failed to implement meaningful, resident centered interventions for cognitively impaired R32, who had falls, placing the resident at risk for further falls. - The Electronic Medical Record (EMR) for R38 documented diagnoses of hypertension (high blood pressure), heart failure (a condition when the heart does not pump enough blood for the body's needs), and [CONDITION(S)] accident (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R38 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, and did not ambulate. The MDS further documented R38 had unsteady balance, no functional impairment, and had a fall with injury. The Fall Risk Assessment, dated 06/21/22 documented R38 was a high risk for falls. The Care Plan, dated 07/29/22, initiated on 08/27/21, directed staff to ensure R38 wore appropriate footwear when in wheelchair, ensure foot pedals were on the wheelchair when pushing him to and from his room; ensure his call light was within reach. The Fall Investigation, dated 06/15/22 at 05:50 PM, documented R38 had a witnessed fall in the dining room. Staff pushed the resident in his wheelchair out of the dining room without feet pedals and the resident's feet went under the wheelchair which caused him to fall forward out of the wheelchair. The investigation documented R38 yelled out in pain and stated his back hurt. Staff contacted the physician and were directed to send the resident to the emergency room (ER) for treatment. The investigation documented the ambulance arrived and R38 denied back pain. The facility contacted R38's family and it was decided not to send the resident to the ER. On 08/01/22 at 11:45 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N assisted R38 from his bed and into his Broda chair (repositioning chair) . With the sling for the lift (mechanical lift) already underneath the resident, CNA M attached the sling to the lift, raised R38 up and lowered him into the chair. On 08/01/22 at 11:45 AM, CNA N stated she did not think R38 had any recent falls and stated he used to be in a regular wheelchair but he was recently placed on hospice and the Broda chair was better for him. On 08/02/22 at 10:11 AM, Licensed Nurse I stated R38 fell in the dining room and should have had the foot pedals on the wheelchair before he was pushed anywhere. On 08/02/22 at 12:54 PN, Administrative Nurse D stated R38 had been in a regular wheelchair and should have had wheelchair pedals on before he was ever pushed into the dining room. Administrative Nurse D verified the care plan was not followed. The facility's Fall Prevention Protocol, policy, undated, documented each senior who resided at the facility would be provided services and care that ensured an environment to prevent accidents. The policy documented all staff members would be educated on the fall reduction program annually through the mandated safety in-service and more often based on needed. The facility failed to follow R38's care plan to make sure he had wheelchair pedals on his wheelchair before he was pushed to and from his room which resulted in a fall. The facility had a census of 43 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to identify and/or implement interventions to prevent falls for Resident (R)6, R34, R14, R32 and R38. which placed the residents at increased risk for ongoing falls and injuries. Findings included: -The Medical Diagnosis section within R6's Electronic Medical Record (EMR) included diagnoses of unspecified fall, hypertension (elevated blood pressure), traumatic subdural hemorrhage (collection of blood on the surface of the brain ) without loss of consciousness, and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, required supervision to limited assistance with activities of daily living, was not steady, but was able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet, and surface to surface transfers. R6 was not steady and only able to stabilize with staff assistance with turning around and facing the opposite direction when walking. The MDS further documented R6 had no trial of a toileting program, was frequently incontinent of urine and bowel, and had two or more falls with no injury and one fall with injury since last assessment. The Fall Care Area Assessment (CAA), dated 01/18/22, documented R6 had been admitted following hospitalization after a fall in which had resulted in subdural hematoma. The Fall Care Plan, revised on 02/07/22, documented R6 at risk for falls related to impaired balance, gait, and poor safety awareness. The care plan directed staff to ensure R6 wore appropriate footwear when ambulating, transferring or mobilizing in her wheelchair. Staff were to anticipate R6's needs, check frequently, ensure touch call light pad within reach with encouragement and remind R6 to use it for assistance, and to respond for requested assistance. The care plan further directed staff to keep floor free from spills and clutter, use of glare free light, bed in low position at night, handrails on walls in the bathroom, and keep personal items within reach. The Fall Care Plan, revised on 04/21/22, documented staff to toilet R6 between 02:00 AM to 03:00 AM and ensure a nightlight was kept on in the bathroom, to reduce chance of early morning falls. The Physician Order, dated 01/10/22, documented the admission of R6 to the facility due to a fall resulting in a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to back of head. The facility's Fall Risk assessment dated [DATE], documented R6 was at moderate risk for falls. The facility's Fall Risk Assessment, dated 04/14/22 and 07/14/22 documented R6 scored at high risk for falls. The facility's Bowel and Bladder Program Screener, dated 01/11/22, 04/14/22, and 07/14/22, scored R6 a good candidate for retraining. The Progress Notes recorded the following falls: 02/02/22 at 02:47 PM, fell in bathroom reaching for incontinent pad and received a skin tear to right hand. 02/16/22 at 05:10 AM, found on floor by her recliner, incontinent of urine, and had cut to right eyebrow, bruise to right cheek bone, and hematoma to back of right hand. 02/27/22 at 12:52 AM, resident on floor of room. R6 reported she fell in the bathroom changing her incontinent product. 03/04/22 at 03:00 AM, resident on floor of her bathroom, incontinent of urine; she reported she hit her head on the wall. 03/25/22 at 08:52 AM, found lying on her back next to her bed, holding transfer bar, had golf ball size hematoma to left side frontal lobe (forehead) with three skin tears to left hand. R6 reported she had backed up to the chair and fell to the side. 04/18/22 at 03:00 AM, found on floor of bathroom, incontinent of urine, reported reaching for incontinent product and slid to floor. Skin tear to right elbow. 05/31/22 at 10:57 AM, fell while making her way to the bathroom, holding lip stick in one hand and reaching for the doorknob with the other hand. 06/08/22 at 01:53 AM, found on floor of bathroom, reported trying to sit on toilet and lost balance, hitting back of her head. 06/26/22 at 05:47 AM, found on floor, reported she tried to pick up her shoe and landed on her face. She had some signs of bruising and small skin tear. 06/30/22 at 01:15 PM, R6 pulled out a chair in the dining room and lost her balance. 07/16/22 at 01:00 PM, R6 returned from outing with a family member, her walker caught on carpet in the entry way. Family member tried to catch her, and the resident fell on to the family member. 07/26/22 at 02:45 AM, found sitting on bathroom floor, incontinent of urine. On 08/01/22 at 08:57 AM, Certified Medication Aide (CMA) R reported if a resident fell , staff were to immediately notify the charge nurse, to assess the resident. The staff was alerted that the resident had fallen in the communication system of the electronic record. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell , the staff alert the charge nurse to assess the resident; a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at the time of the fall, and the care plan should be updated with the intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified no new interventions had been developed and implemented for R6 to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Fall Prevention Protocol, documented the effectiveness of fall reduction activities, including assessment, causal factors, interventions, and education will be evaluated by the Interdisciplinary Care Plan team at time of each comprehensive assessment. The effectiveness of the facility fall reduction activities will be evaluated on a monthly basis by Quality Assurance Performance Improvement (QAPI) committee. Outcome indicators include the number f falls, and the severity of fall-related injuries, and effectiveness of implemented care plan interventions. The facility failed to identify and implement interventions to prevent falls for R6 who had multiple falls. This deficient practice placed R6 at increased risk for further falls and injury. - R34's Medical Diagnosis section within the Electronic Medical Record (EMR) included diagnosis of age-related physical debility, difficulty in walking, hypertension (elevated blood pressure), major depressive (major mood disorder ) disorder recurrent, severe with psychotic (any major mental disorder characterized by a gross impairment in reality testing)symptoms, spinal stenosis ([CONDITION(S)] condition of the spine that could cause weakness and loss of use of extremities), [CONDITION(S)] (rapid, irregular heart beat), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, right shoulder pain, anterograde amnesia (a type of memory loss that occurs when person cannot form new memories), and alcoholic [CONDITION(S)] (chronic [CONDITION(S)] disease of the liver) of liver with ascites (the accumulation of fluid in the abdominal cavity, causing swelling). The Quarterly Minimum Data Set (MDS), date 07/01/22, documented R34 had intact cognition, required supervision to limited assistance of one staff for activities of daily living. R34 was not steady but able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet and surface to surface transfer, walking, and turning around and face the opposite direction while walking. The MDS further documented R34 had no trial of toileting program, was frequently incontinent of urine and always continent of bowel, had pain. R34 had two or more falls with injury. The Fall Care Plan, revised on 02/18/22, documented R34 at risk for falls related to impaired balance, strength, and safety awareness. The care plan further documented to encourage and remind R34 to use the call light, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility. The care plan directed staff to ensure R34's wheelchair was next to the bed and the brakes were locked, to wear appropriate footwear, keep safe environment free from spills and clutter, use glare free lights, reachable call light, bed in low position at night, handrails in bathroom and keep personal items within reach. The care plan further documented R 34 attempted to get up unassisted and needed frequent checks to anticipate needs. The Progress Note, dated 06/11/22 at 06:30 PM, R34 was found sitting upright on the floor, incontinent of urine and reported she was looking for her TV remote. The Progress Note, dated 06/25/22, documented around 11:40 PM the resident was found on the floor by the wall. R34 stated she was going to the bathroom, lost her balance, and fell hitting her right shoulder against the wall. On 07/28/22 at 12:26 PM observation revealed R34 left the dining room independently with her walker. On 08/01/22 at 12:18 PM, Certified Medication Aide (CMA) R reported R34 was a standby for assistance with toileting as an intervention to prevent falls. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell , the staff alert the charge nurse to assess the resident, a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at time of fall, and the care plan should be updated with intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified new interventions had not developened or implemented for R34 to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Fall Prevention Protocol, documented the effectiveness of fall reduction activities, including assessment, causal factors, interventions, and education will be evaluated by the Interdisciplinary Care Plan team at time of each comprehensive assessment. The effectiveness of the facility fall reduction activities will be evaluated on a monthly basis by Quality Assurance Performance Improvement (QAPI) committee. Outcome indicators include the number of falls, and the severity of fall-related injuries, and effectiveness of implemented care plan interventions. The facility failed to identify and implement interventions to prevent falls placing R34 at risk for further falls and injury.

The facility had a census of 43 residents. The sample included 12 residents. The facility idneitfied two staff members currently positive for COVID-19 (highly contagious, potentially life-threatening respiratory virus). Based on observation, record review, and interview, the facility failed to follow the core principles of infection control for resident surveillance of signs/symptoms of COVID-19 when they failed to complete a respiratory assessment and temperature at least daily for 12 sampled residents, Resident (R) 5, R6, R14, R16, R23, R25, R28, R31, R32, R34, R38, and R142. This deficient practice placed the residents at increased risk for transmission and/or development of COVID-19. Findings included: - The Electronic Medical Record (EMR) for R5 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R6 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R14 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R16 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R23 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R25 from 03/02/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R28 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R31 from 06/12/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R32 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R34 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R38 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R142 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. On 07/28/22 at 12:26 PM observation revealed R34 left the dining room independently with her walker. Observation on 08/01/22 at 09:16 AM R28 sat in the dining room with supplemental oxygen supplied by tank attached to her wheelchair. On 08/01/22 at 12:20 PM, observation revealed R25, in her room, asleep in her chair. On 07/27/22 at 11:19 AM, Administrative Nurse D stated they had not been screening the residents' respiratory status for a few months because she had talked to her local health department who stated the facility did not need to screen residents daily. Administrative Nurse D further stated her medical director also told them they did not need to. Administrative Nurse D stated they were told to assess the resident if they were exhibiting symptoms. The Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance dated 04/02/20 recommended: Long-term care facilities should immediately implement symptom screening for all. In accordance with previous (CMS) guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked, Facilities should limit access points and ensure that all accessible entrances have a screening station. In accordance with previous CDC guidance, every resident should be assessed for symptoms and have their temperature checked every day. The facility failed to follow the guidelines set by the CDC and CMS for monitoring and assessing residents' respiratory status and temperatures at least daily, which placed the residents at risk for transmission and/or development of COVID-19.

The facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report no blood sugar parameters for Resident (R) 25, who received insulin (hormone used to control blood sugar levels). The facilty further failed to ensure the CP identified and reported the lack of a stop date for Resident (R) 28's as needed (PRN) [MEDICATION(S)] (a sedative used to treat anxiety). This placed R25 at risk for hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes and R28 at risk for side effects from [CONDITION(S)] (alters mood or thought) medication. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory and confusion), [CONDITION(S)] (low blood pressure), [CONDITION(S)] (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and chronic diastolic heart failure (when the left heart ventricle has decreased blood flow). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had intact cognition and required supervision and one staff assistance with bed mobility, transfers, toileting and personal hygiene. The MDS documented the resident received insulin (a hormone produced in the pancreas by the cells in the pancreas), an antidepressant (a class of medication that used to treat mood disorders and relieve symptoms of depression), and a diuretic (medication to help the body get rid of extra fluids) during the look back period. The Diabetes Mellitus Care Plan, dated 03/18/22, documented staff obtain accu-checks (a system which measures blood glucose in the body) before meals, at bedtime, and at 03:00 AM. It directed staff to observe for signs and symptoms of [CONDITION(S)] and [CONDITION(S)]. The Physician's Order, dated 07/26/21, directed staff to obtain accu-checks before meals and at bedtime. The order lacked blood sugar parameters for the resident. The Physician's Order, dated 12/31/21, directed staff to obtain accu-checks at 03:00AM. The order lacked blood sugar parameters for the resident. A Physician's Order dated 7/13/22 directed [MEDICATION(S)] (long acting insulin) [MEDICATION(S)] pen inject 28 units twice daily for type 2 DM. A Physician's Order dated 7/13/22 directed [MEDICATION(S)] (fast acting insulin) flex pen inject 16 units three times daily for type 2 DM. The Medication Regimen Review, dated 04/06/22, 05/05/22, 06/13/22, and 07/07/22 lacked documentation the CP identified and reported R25 lacked blood sugar parameters. On 08/01/22 at 12:20 PM, observation revealed R25, in her room, asleep in her chair. On 07/28/22 at 01:20 PM, Licensed Nurse (LN) G stated they did not have any blood sugar parameters from the physician. LN G stated she used her nursing judgement to determine when to call the physician. On 08/02/22 at 12:38 PM, Administrative Nurse D stated the resident should have blood sugar parameters and the pharmacist should have recognized this. On 08/03/22 at 10:38 AM, Consultant Pharmacist GG stated that although she looked at the resident's blood sugars, she did not look to see if the resident had blood sugar parameters. The facility's Consultant Pharmacist policy, undated, documented the pharmacist consultant reviewed the drug regimen review of each resident in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review and findings in the resident's clinical record. The pharmacist would communicate potential or actual problems detected related medication therapy orders to the responsible physician and the Director of Nursing. The facility's Consultant Pharmacist failed to identify and report to the Director of Nursing, physician, and medical director R25 lacked blood sugar parameter's, placing the resident at risk for hyperglycemic or hypoglycemic episodes. -The Medical Diagnosis section withing R28's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), retention of urine, hypertension (elevated blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear (disorder, heart failure and chronic obstructive pulmonary disease ([CONDITION(S)] - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition, had verbal and other behavioral symptoms not directed toward other one to three days of the look back period, required extensive assistance of one staff for activities of daily living, and frequently incontinent of urine and bowel. The MDS further documented R28 received an antianxiety medication on a routine basis. The Care Plan, dated 06/28/22, documented R28 was at risk for adverse side effects related to [CONDITION(S)] medication. The care plan directed staff to give medications ordered by physician, document side effects and effectiveness, to provide education about risks and benefits and the side effect of [MEDICATION(S)] ([MEDICATION(S)]). The care plan further documented a Registered Pharmacist to review drug regimen monthly. The Physician Order, dated 10/28/19, directed staff to administer [MEDICATION(S)] 0.5 milligrams (mg) by mouth every 24 hours as needed for anxiety. The ordered did not have a stop date. Record review revealed R28 received PRN [MEDICATION(S)] on May 1, 5, 11, 12, 16, 24, and 30 2022. June 3, 6, 13, 26, and 28 2022, and July 1, 8, 26, 2022. On 08/02/22 at 09:03 AM, Administrative Nurse D verified the PRN [MEDICATION(S)] did not have a stop date and would have expected the pharmacist to have reviewed the order and brought it to the attention of the facility and physician. On 08/03/22 at 10:29 AM, Consultant GG stated during the pharmacy monthly review the as needed [CONDITION(S)] medications are reviewed and would notify the facility and physician to obtain a stop date. Consultant GG reported the resident had been hospitalized in January 2022 and had returned with the as needed [MEDICATION(S)] which she had not realized and had not sent a request to the facility and physician for a stop date. The facility's Consultant Pharmacist Services Provider Requirements, dated 09/18/17, documented review the medication regimen(drug regimen review of each resident in health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review of findings in the resident's clinical record. Communicating to the responsible physician and the facility Director of Nursing potential or actual problems detected and other findings related to medication therapy orders. Communicating recommendations for changes in medication therapy and monitoring of medication therapy. The facility failed to ensure the CP identified and reported the lack of a stop date on R28's as needed [MEDICATION(S)]. This placed the resident at risk for adverse side effects related to [CONDITION(S)] medication.

The facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain, from the physician, blood sugar parameters for Resident (R) 25, who received insulin (hormone used to control blood sugar levels) and had her blood sugar taken five times per day. This placed the resident at risk for hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had intact cognition and required supervision and one staff assistance with bed mobility, transfers, toileting and personal hygiene. The MDS documented the resident received insulin (a hormone produced in the pancreas by the cells in the pancreas), an antidepressant (a class of medication that used to treat mood disorders and relieve symptoms of depression), and a diuretic (medication to help the body get rid of extra fluids) during the look back period. The Diabetes Mellitus Care Plan, dated 03/18/22, documented staff obtain accu-checks (a system which measures blood glucose in the body) before meals, at bedtime, and at 03:00 AM. It directed staff to observe for signs and symptoms of [CONDITION(S)] and [CONDITION(S)]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order lacked blood sugar parameters for the resident. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order lacked blood sugar parameters for the resident. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/01/22 at 12:20 PM, observation revealed R25, in her room, asleep in her chair. On 07/28/22 at 01:20 PM, Licensed Nurse (LN) G stated they did not have any blood sugar parameters from the physician. LN G stated she used her nursing judgement to determine when to call the physician. On 08/02/22 at 12:38 PM, Administrative Nurse D stated the resident should have blood sugar parameters. The facility's Blood Sugar Parameter policy, undated, documented the facility had the responsibility to care for the resident who received accu-check test and medication either oral or insulin for [CONDITION(S)] and [CONDITION(S)] and unless specific parameters are ordered by the physician, the standing orders would be used. The facility failed to obtain, from the physician, blood sugar parameters for R25 who had accu-checks five times per day. This placed the resident at risk for hyperglycemic or hypoglycemic episodes.

The facility had a census of 43 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure Resident (R) 28's as needed [MEDICATION(S)] (an antianxiety medication) had a stop date as required, placing the resident at risk for adverse side effects related to [CONDITION(S)] (altering mood or mind) medication use. Findings included: -The Medical Diagnosis section withing R28's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), retention of urine, hypertension (elevated blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear (disorder, heart failure and [CONDITION(S)] ([CONDITION(S)] - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition, had verbal and other behavioral symptoms not directed toward other one to three days of the look back period, required extensive assistance of one staff for activities of daily living, and frequently incontinent of urine and bowel. The MDS further documented R28 received an antianxiety medication on a routine basis. The Care Plan, dated 06/28/22, documented R28 was at risk for adverse side effects related to [CONDITION(S)] medication. The care plan directed staff to give medications ordered by physician, document side effects and effectiveness, to provide education about risks and benefits and the side effect of [MEDICATION(S)]. The care plan further documented a Registered Pharmacist to review drug regimen monthly. The Physician Order, dated 10/28/19, directed staff to administer [MEDICATION(S)] 0.5 milligrams (mg) by mouth every 24 hours as needed for anxiety. The ordered did not have a stop date. Record review revealed R28 received as needed [MEDICATION(S)] on May 1, 5, 11, 12, 16, 24, and 30 2022. June 3, 6, 13, 26, and 28 2022, and July 1, 8, 26, 2022. Observation on 08/01/22 at 09:16 AM R28 sat in the dining room with supplemental oxygen supplied by tank attached to her wheelchair. On 08/02/22 at 09:03 AM, Administrative Nurse D verified the as needed [MEDICATION(S)] did not have a stop date as required. The facility's Consultant Pharmacist Services Provider Requirements, dated 09/18/17, documented review the medication regimen (drug regimen review of each resident in health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review of findings in the resident's clinical record. Communicating to the responsible physician and the facility Director of Nursing potential or actual problems detected and other findings related to medication therapy orders. Communicating recommendations for changes in medication therapy and monitoring of medication therapy. The facility failed to ensure R28 as needed [MEDICATION(S)] had a stop date as required, placing the resident at risk for adverse side effects related to [CONDITION(S)] medication.

The facility had a census of 41 residents. Based on observation and interview, the facility failed to store food in a safe and sanitary manner for the 41 residents, that resided in the facility, and received food from the facility kitchen. Findings Included: - On 04/19/21 at 08:30 AM, during initial kitchen tour, observation of the silver double door refrigerator in the kitchen revealed no documentation of daily temperature logs for April 1-19, 2021. Further observation revealed no documentation of daily temperature logs for this refrigerator since April 2020. Observation of the refrigerator revealed storage of condiments, 4 gallons of milk, eggs, yogurt cups, and prepared chili mix to be served on 04/20/21. On 04/19/21 at 08:35 AM, Dietary Staff (DS) BB verified the refrigerator temperature had not been documented, and stated the facility use to have a sheet on the front of the door, but it was currently not there. DS BB verified the lack of temperature log documentation for the last year. On 04/26/21 at 03:15 PM, Administrative Staff A verified staff should document the refrigerator and freezer temperatures twice daily and keep a record of the temperatures for at least three months. Administrative Staff A verified the lack of temperature log documentation for the last year. The undated facility Refrigerator and Freezer Temperature policy, documented dining services would be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift. The facility failed to log daily refrigerator temperatures, and store food in a safe and sanitary manner for the residents that resided in the facility, placing the residents at risk for food borne illness.

The facility identified a census of 42 residents. The sample included one resident reviewed for hospice services. Based on observation, interview and record review the facility failed to provide a physician ordered breathing treatment for [REDACTED]. Findings included: - Review of the electronic medical record (EMR) revealed resident #33 had a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. Resident received oxygen therapy while a resident. Resident #33 required extensive assistance with 2 staff members for activities of daily living (ADLs). The care area assessment for activities of daily living revealed resident #33 requires staff assistance with activities of daily living due to muscle weakness, impaired balance and coordination. Review of the EMR revealed resident #33 had a physician's orders [REDACTED]. If oxygen saturation is 90 percent or less give an as needed (PRN) [MEDICATION NAME] treatment ([MEDICATION NAME][MEDICATION NAME] that relax muscles in the airways and increase air flow to the lungs). The electronic medical record lacked evidence that nursing staff administered the PRN [MEDICATION NAME] treatment for [REDACTED]. In June, on the evening shift, [MEDICATION NAME] treatment was not administered per physician order [REDACTED]. During an interview on 07/25/19 at 10:18 AM, Administrative Nurse D stated if there was a blank in the Medication Administration Record [REDACTED]. The facility policy dated (MONTH) (YEAR) stated all medications will be administered as ordered by a health care professional authorized by the state to order medications. The facility failed to follow physician orders [REDACTED].

The facility had a census of 55 residents. The sample included 27 residents. Based upon observation, record review and staff interview the facility failed to implement interventions to prevent accidents for 1 (#15) of five residents sampled for accidents and preventative safety equipment in the 2 out 2 shower rooms. Findings included: - Resident #15's annual Minimum Data Set ((MDS) dated [DATE] identified the Brief Interview for Mental Status (BIMS) score was 9, which indicated mild cognitive impairment, required limited assistance for bed transfer, dressing, eating, toileting, personal hygiene and the resident had experienced two or more falls since admission. The quarterly MDS dated [DATE] indicated the resident experienced two or more falls since the prior assessment, and one fall resulted in injury. The 9/15/11 annual Care Area Assessment indicated staff would address falls in the care plan. The resident's care plan dated 9/20/11 noted a non-injury fall, resident slept in a recliner and tried to get up without putting the foot rest down. The care plan dated 9/21/11 noted the resident had frequent falls. The 9/30/11 care plan noted the resident lost his/her balance and fell to one side and bumped the whirlpool tub seat, was at risk for falls, keep room free of obstacles, keep call light in reach, and apply non-skid strips on the floor beside the bed. The 4/7/12 care plan indicated staff to take the resident to the toilet after each meal. The 6/2/12 care plan noted the resident received a high/low bed. The 8/7/12 care plan noted staff placed a fall mat beside the bed, and staff to keep the high low bed in the lowest position. The 8/27/12 care plan noted the resident required a two person assist or use of a mechanical lift for transfers. A nursing progress note dated 2/27/2012 at 6:55 P.M. noted staff found the resident sitting on the bathroom floor. The resident stated that he/she tried to toilet him/herself, stumbled and fell on to his/her bottom. A nursing progress note dated 3/26/2012 at 11:21 P.M. indicated staff found the resident on the floor flat on his/her back with his/her feet next to the bed, his/her head at the bathroom door, his/her feet tangled in the blankets and the bed alarm was sounding at 9:00 P.M. The resident stated he/she tried to go to the bathroom. A nursing progress note dated 3/28/2012 at 11:52 A.M. noted staff found the resident on the floor on his/her back, with his/her head at the door to the hallway and feet towards the window. The intervention included re-education of staff to lock the wheelchair brakes with the wheelchair close to the bed while the resident was in bed. A nursing progress noted dated 4/10/2012 at 5:46 P.M. noted the staff found the resident sitting on the floor next to his/her bed. A nursing progress noted dated 4/11/2012 at 2:06 A.M. noted the resident fell in his/her room. He/she attempted to self transfer from the wheelchair to the bed. A nursing progress note dated 4/12/2012 at 2:13 P.M. noted the staff found the resident on the floor next to his/her bed. The resident stated that he/she hit his/her head. A nursing progress note dated 4/15/12 at 7:15 A.M. noted the staff found the resident at 11:20 P.M. on his/her back in his/her bedroom floor. Resident stated that he/she was going to the bathroom and slipped. The bed alarm was off. A nursing progress noted dated 5/27/2012 at 6:17 P.M. noted at approximately 4:50 P.M. staff entered the resident's room on the floor on his/her left hip on the floor with his/her head resting on the night stand. A nursing progress note dated 6/2/12 at 5:00 A.M. indicated staff gave the resident Ativan at 3:00 A.M. for restlessness and had attempted to kick staff. At 3:15 A.M. staff found the resident in a sitting position at the side of his/her bed. A social services progress note dated 6/2/2012 at 9:57 A.M. noted staff explained to the resident's family that staff changed his/her parent's bed to a hi/low bed due to increased falls, and the resident was impulsive and tried to transfer his/herself, and nursing staff continued to remind the resident to push his/her call light when he/she wanted to get in or out of bed. A nursing progress note dated 6/7/2012 at 7:56 A.M. noted the staff found the resident sitting on the floor beside his/her bed with his/her legs out in front of him/her, the blankets and sheets were wrapped around him/her and it appeared that he/she slid out of the low bed, and onto the fall mat. The resident complained of left lower leg pain. A nursing progress note dated 7/17/2012 at 9:28 P.M. noted at 7:30 P.M. staff reported the resident was on the floor, in his/her room, on the floor pad with his/her back leaning against the bed, legs extended, and facing the bathroom door. An incident note dated 8/25/2012 at 7:30 A.M. noted the staff found the resident sitting on the floor beside his/her bed at 7:30 A.M., the call light was in reach, the bed alarm sounding, and the fall mat tucked under the bed. A nursing progress note dated 9/3/2012 at 10:39 P.M. noted at 5:00 P.M. the resident slid out of his/her bed with the lower half of his/her body on the floor mat beside his/her bed. The resident had a low bed and a mat beside it as he/she frequently turned and/or slid out of bed. An observation on 8/30/12 at 2:30 P.M. noted the resident laid in the bed in the low position, fall mat and bed cane were in place. An observation on 9/4/12 at 7:30 A.M. noted the resident rested quietly with eyes closed with the bed in low position, alarm on, fall mat at side of bed, and bed cane in place. An observation on 9/4/12 at 9:40 A.M. noted the resident resident rested quietly with eyes closed with the bed in low position, alarm on, fall mat at side of bed, and bed cane in place. An interview with licensed nursing staff D on 9/5/12 at 12:20 P.M. indicated the resident experienced several falls and that staff had initiated a bed alarm, fall mat, and placed the bed in the low position. The undated facility Incident/Accident Reporting policy noted that all residents of the facility were considered at risk for falls/accidents and that if a fall occurred, the licensed nurses were to follow the Fall Guideline Checklist which included the following post-fall interventions: bed in low position, call light within reach, non-skid shoes or slippers when the resident was up, night light, personal alarm in bed or chair, referral to therapy/restorative program, system assessment, laboratory evaluation, ensure a safe environment, toileting program as appropriate, bedside commode, medication regimen review, increase activity participation, appropriate positioning, evaluation of sensory stimuli, assess staffing (family, 1:1), light snack or fluids offered, and rearrange furniture if needed and less restrictive. The facility failed to provide timely and effective interventions for this cognitively impaired, dependent resident with a history of falls. - On 9/5/12 at approximately 3:00 P.M. during the environmental tour, observation revealed 2 of 2 shower rooms lacked non-skid strips on the floor in front of the entrance to the shower stall and in front of the toilet. On 9/5/12 at 3:04 P.M. maintance staff M acknowledged the lack of non-skid strips in the shower rooms. The facility failed to have non-skid strips on the floor in the facility's shower rooms.

The facility had a census of 45 residents. The sample included 4 residents. Based upon observation, record review and interviews the facility failed to ensure that 1 (#1) of 3 residents sampled for pressure ulcers did not develop a pressure sore and failed to ensure the resident received the necessary treatment and services to promote healing. Findings included: - Review of resident #1's Physician order [REDACTED]. The POS included the resident received 100 milligrams of Zinc daily since 3/16/12, 60 cubic centimeters (cc's) of house supplement three times since 4/1/12, and weekly skin assessments. The POS included the resident received Hospice services. The resident's admission Minimum Data Set 3.0 with an assessment reference date (ARD) of 2/3/12: identified the resident scored a 12 (mild impaired cognition) on the Brief Interview for Mental Status (BIMS), did not exhibit any behaviors, totally dependent upon staff for bed mobility, transfers, toilet use, personal hygiene, did not walk in the room or corridor, and independent with eating. The MDS recorded the resident was always incontinent of urine, frequently incontinent of bowel and not on a toileting program for bowel or bladder. The MDS recorded the resident weighed 121 pounds, had not experienced a weight loss, was at risk for the development of pressure ulcers, and did not have unhealed pressure ulcers. The MDS included the resident was not on a turning/repositioning program, and did not utilize a pressure relieving device for the bed or chair. The resident's Prospective Payment System MDS with an ARD of 2/24/12 included the resident had (1) unstageable suspected deep tissue pressure ulcer that was not present upon admission. The resident's quarterly MDS with an ARD of 5/5/12 identified the resident scored 10 (mild impaired cognition) on the BIMS, did not exhibit any behaviors, totally dependent upon staff for bed mobility, dressing, required extensive staff assistance with transfers, walking in the room, and independent with eating. The MDS recorded the resident was frequently incontinent of urine, occasionally incontinent of bowel, and not on a toileting plan. The MDS recorded the resident had (1) Stage 3 pressure ulcer, not present upon admission, and measured 2 centimeters (cm) in length, 3 centimeters in width, depth of 2 centimeters with granulation tissue. The MDS identified the resident did not utilize a pressure relieving device for the chair and bed, and not on a turning/repositioning program. The resident's pressure ulcer care area assessment (CAAs) dated 2/3/12 documented the resident was incontinent of bowel and bladder, required staff assistance for bed mobility, and upon admission the resident's skin was dry and intact with a surgical wound to left leg. The CAA included the resident spent a lot of time in the bed or recliner which increased his/her risk for skin breakdown. The resident's care plan dated 2/13/12 addressed the resident had a potential for alteration in skin integrity due to incontinence and decreased mobility, staff turned and repositioned the resident every 2 hours, and checked the resident for incontinence at least every 2 hours. A handwritten entry dated 3/3/12 documented the resident had a Stage 2 pressure ulcer on his/her coccyx. A handwritten entry dated 3/20/12 included [MEDICATION NAME] to the Stage 2 worsening pressure ulcer. A handwritten entry dated 4/26/12 included for the facility to consult with the wound care center for the Stage 2 pressure ulcer on the resident's coccyx due to no improvement. The care plan included the resident received a mechanical soft diet and the facility made diet changes based upon the Registered Dietician evaluation and recommendations. A skin assessment dated [DATE] documented the resident did not have any skin issues. A health status note dated 2/23/12 and timed 2:54 P.M. documented the resident had a darkened area on his/her coccyx, the area purple in color, measured 1.4 centimeters (cm) by .4 centimeters, and no open areas observed. A skin/wound note dated 3/1/12 timed 2:37 P.M. documented staff observed a Stage 3 pressure ulcer on the resident's coccyx that measured 2.5 cm by 2.5 cm by 2 cm. A skin assessment dated [DATE] documented the resident had an open ulcer on his/her coccyx, [MEDICATION NAME] was in place, and the resident was going to the wound center for a consultation. A wound assessment dated [DATE] documented the resident had a Stage 3 pressure ulcer on his/her coccyx that measured 2.5 cm by 2.5 cm and with a depth of 2 cm. A wound assessment dated [DATE] 2.8 documented the resident had a Stage 3 pressure ulcer that measured 2.8 cm by 3.0 cm with a depth of .5 cm. The clinical record reviewed on 5/9/12 at approximately 3:30 P.M. lacked evidence the facility had measured the resident's Stage 3 coccyx pressure ulcer since 4/12/12. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the resident's clinical record lacked evidence the wound care clinic evaluated the Stage 3 pressure ulcer on the resident's coccyx. A laboratory report dated 3/16/12 recorded the resident's serum [MEDICATION NAME] level at 3.4 (low)grams/deciliter (g/dl), normal reference range 3.5-5.7 g/dl and the resident's [MEDICATION NAME] level at 9 (low) milligrams/deciliter (mg/dl) normal reference range of 17-34 mg/dl. A Registered Dietitian's note dated 2/24/12 documented the resident needed to consume 75 percent (%) at meals, the resident only consumed approximately 50%, and recommended for the resident to receive 60 cubic centimeters (cc's) of 2 Cal (a nutritional supplement) three times a day to meet his/her nutrient needs. A registered dietician's form dated 3/20/12 included the resident had a Stage 3 pressure ulcer on his/her coccyx, the resident received 60 cc's of Med Pass 2.0 (nutritional supplement) three times a day (TID) which was 15 grams of protein, and recommended to increase the Med Pass 2.0 to 120 cc's TID. Review of the form revealed the resident's physician agreed to the recommendation on 4/12/12 (13 days after the recommendation). Review of the resident's April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s physician agreed with the recommendation). A Registered Dietician form dated 4/14/12 included the dietitian recommended for the facility to increase the resident's house supplement to 120 cc's TID and to start the resident on 30 cc's of ProStat (protein supplement) twice a day. According to the form the resident's physician agreed with the recommendation on 4/14/12 and the resident received the 30 cc's of Pro Stat on 4/18/12. Observations on 5/8/12 at 9:30 A.M., 10:30 A.M., 11:00 A.M. , 11:30 A.M., 12:00 noon, 12:30 P.M., 1:30 P.M., 2:00 P.M., 3:00 P.M., and 3:30 P.M. revealed the resident sat in a wheelchair in his/her room, a bedside table in front of the resident and the resident "polishing" the bedside table. On 5/8/12 the resident continued to sit in the wheelchair at 3:45 P.M. and 4:00 P.M. At 4:00 P.M. interview with the resident revealed he/she had sat in the wheelchair for a while, his/her bottom hurt, and staff had informed him/her that he/she had an open area on his/her buttock. The resident continued to sit in the wheelchair at 4:15 P.M., 4:30 P.M., 4:45 P.M. , 5:00 P.M. , 5:15 P.M., 5:30 P.M. 5:45 P.M. and at 6:00 P.M. (duration of 2 and 1/2 hours). On 5/9/12 at 9:10 A.M. the resident sat in the wheelchair in his/her room, the resident ate the breakfast meal which consisted of eggs, toast, prune juice and hot tea. At 9:20 A.M. the resident sat in the wheelchair and ate the breakfast meal. At 9:30 A.M. the resident sat in the wheelchair and ate the breakfast meal. At 9:40 A.M. the resident sat in the wheelchair, and had consumed 100% of the breakfast meal. On 5/9/12 the resident continued to sit in the wheelchair with the bedside table in front of him/her at 10:00 A.M., 10:15 A.M., 10:30 A.M., and 11:00 A.M. On 5/9/12 the resident sat in the wheelchair at 12 noon, 12:10 P.M., 12:15 P.M., 12:20 P.M., 12:30 P.M., 12:45 P.M., 1:00 P.M., 1:15 P.M., and 1:30 P.M. On 5/9/12 at 1:30 P.M. direct care D and E transferred the resident from the wheelchair to the bed. Observation revealed the resident had a Stage 3 pressure ulcer that measured approximately 2 centimeters long by 2 cm wide with a depth of approximately 2 cm. The area surrounding the Stage 3 pressure area was reddened and non-blanchable. During interview with licensed nurse F at that time revealed the reddened area surrounding the pressure ulcer had decreased in circumference. During interview with licensed nurse F on 5/9/12 at approximately 1:25 P.M. the nurse stated the resident had not been to the wound clinic for an evaluation of his/her wound. Licensed nurse F stated on the date of the scheduled appointment the resident did not feel well and the facility decided not to send the resident and the appointment was rescheduled. Licensed nurse F stated the resident was on a repositioned program and staff should reposition the resident at least every 2 hours. During interview with direct care staff E on 5/9/12 at approximately 1:55 P.M. confirmed the resident spent the majority of the day in the wheelchair, and the resident was not incontinent of urine or bowel anymore. During interview with nursing administrative staff C on 5/9/12 at 3:20 P.M. confirmed the facility had not measured the resident's Stage 3 pressure ulcer since 4/12/12. Nursing administrative staff C stated the resident was scheduled to go to the wound clinic for an evaluation on 5/10/12 and the wound clinic would measure the resident's Stage 3 pressure ulcer. According to the Pressure Ulcer Prevention Quick Reference Guide developed by the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel: Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; high pressures over bony prominence's, for a short period of time, and low pressures over bony prominence's, for a long period of time, are equally damaging. In order to lessen the individual ' s risk of pressure ulcer development, it was important to reduce the time and the amount of pressure she/he was exposed to. Limit the time an individual spends seated in a chair without pressure relief, and when an individual was seated in a chair, the weight of the body caused the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases was relatively small, the pressure will would be high; therefore, without pressure relief, a pressure ulcer would occur very quickly. The facility's policy and procedure for the prevention of pressure ulcers revised March 2005 included pressure ulcers were usually formed when a resident remained in the same position for an extended period of time. The policy included the facility should have a system/procedure to assure assessments were timely and appropriate, reposition at least every 2 hours if the resident sat in a chair, and routinely assess and document the condition of the resident's skin per facility wound and skin care program. The facility failed to timely assess and provide timely interventions for the prevention and treatment of [REDACTED].

The facility had a census of 45 residents. The sample included 4 residents. Based upon observation, record review and interview the facility failed to ensure that 1 (#4) of 3 sampled residents maintained acceptable parameters of nutritional status. Findings included: - Review of resident #4's Physician order [REDACTED]. The POS included the resident received Hospice services for a [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set 3.0 (MDS) with an assessment reference date (ARD) of 3/4/12 identified the resident scored 0 (severely impaired cognition) on the Brief Interview for Mental Status, did not exhibit any behaviors, required extensive staff assistance with transfers, totally dependent upon staff for eating, complaints of difficulty of pain when swallowing, and weighed 138 pounds (#'s). The MDS recorded the resident had experienced a weight loss of 5 percent (%) in 1 month or 10% in 6 months, was not on a prescribed physician weight loss regimen, and received a mechanical altered diet. The resident's significant change MDS with an ARD of 12/3/11 identified the resident had short and long term memory problems, moderately impaired cognition, and required extensive staff assistance with eating. The MDS recorded the resident weighed 157#'s and had not experienced a weight loss or weight gain. The resident's nutritional status Care Area Assessment (CAA) dated 12/3/11 documented the resident was at risk for nutritional decline related to dementia, dysphagia and received a mechanically altered diet. The CAA included the resident's intake had declined, and the resident required more assistance from staff during meals. The resident's care plan dated 3/8/12 included the resident received a pureed diet with honey thickened liquids, required staff assistance with meals, the facility offered the resident snacks between meals, and reported any significant weight changes to the resident's physician. The care plan included if the resident was lethargic and sleepy allow the resident to remain in bed and serve the resident an alternate meal when he/she awakened. The resident's care plan did not include the resident had experienced a significant weight loss nor had the resident's care plan been revised to include the resident no longer received thickened liquids. The resident's Vital Sign and Weight Flow Sheet documented the following weights: 09/09/11: 154#'s 11/10/11: 157#'s 01/05/12: 135#'s (a loss of 22#'s or 14% of his/her body weight in 2 months) 02/07/12: 136#'s 03/08/12: 126#'s (loss of 10#'s or 7.35% in 1 month, and a loss of 31#'s in 4 months or 19.74%) 04/13/12: 129#'s 05/09/12: 128#'s The resident's vital sign and weight flow sheets did not include a weight for the month of October or December of 2011. A Nutritional Risk Review signed by a Registered Dietician on 12/1/11 documented the resident had inadequate intake related to a recent [MEDICAL CONDITION], dysphagia and [MEDICAL CONDITION]. The note included for the facility to monitor the resident's laboratory results, weights, and meal intake. The Registered Dietician recommended for the resident to receive magic cups (a frozen product that provided 290 calories and 9 grams of protein) twice a day with meals. A dietary's recommendations form completed and signed by a Registered Dietician on 3/30/12 documented the resident weighed 126 pounds, and a decrease of 18% of the resident's body weight in 180 days. The dietician's recommendations included for the resident to receive milk three times a day (TID), supercereal, and 120 cubic centimeters (cc's) of Med Pass 2.0 (fortified nutrition to supplement calories and protein) twice a day. Review of the dietary recommendation form revealed the resident's physician signed the form on 4/12/12 (13 days after the recommendations) agreeing with the recommendations and the facility noted the recommendations on 4/18/12 (19 days after the recommendations and 6 days after the physician agreed with the recommendations). The resident's April 2012 MAR indicated [REDACTED] Review of the resident's clinical record lacked evidence the facility had followed up on the dietician's 12/1/11 recommendations for the resident to receive the magic cups twice a day with meals. Further review of the resident's clinical record did not support the resident received the magic cups. On 5/8/12 at 12:15 P.M. the resident sat in a wheelchair at the dining room table eating the lunch meal which included pureed steak, mashed potatoes and gravy, 4 ounces of juice and 8 ounces of water. Observation revealed the resident needed staff cueing with eating. At 1:00 P.M. the resident had finished with the lunch meal and consumed 100% of the potatoes, 75% of the steak, 100% of the juice and 75% of the water. The observation did not reveal the resident received a magic cup or milk. On 5/8/12 at 5:30 P.M. the resident received the supper meal which included pureed Philly steak, potatoes, 3 bean salad, 8 ounces of water and 4 ounces of juice. At 6:15 P.M. the resident had finished the supper meal and consumed 50% of all the solid foods, 100% of the juice and 50% of the water. The observation did not reveal the resident received the magic cup or milk. On 5/9/12 at 8:25 A.M., 9:10 A.M., 9:40 A.M., 10:00 A.M. and 10:10 A.M. the resident was in bed and appeared asleep. At 10:20 A.M. direct care staff D entered the resident's room, asked the resident if he/she was ready to get up and the resident responded yes, and direct care staff D proceeded to get the resident up. On 5/9/12 at 10:40 A.M. the resident sat in the wheelchair in the living room area. Observation did not reveal the resident was offered the breakfast meal or an alternate meal. On 5/9/12 at 11:55 A.M. the resident sat in the wheelchair at the dining room table, the resident's lunch meal in front of him/her which included pureed chicken enchiladas, beans, rice, gravy, 4 ounces of juice, 8 ounces of water, and 8 ounces of hot chocolate. The observation revealed the resident appeared tired, staff did not assist the resident with the lunch meal, and the resident did not consume any of the solid food or liquids. At 12:05 P.M. the resident had not consumed any of the food or liquids, and staff was not assisting the resident with the meal. At 12:20 P.M. the resident had not consumed any of the food or liquids and staff did not assist the resident. At 12:55 P.M. staff wheeled the resident from the dining room and the resident had not consumed any of the meal or liquids. Observation revealed staff did not offer the resident a magic cup. During interview with direct care staff D on 5/9/12 at 9:40 A.M. the staff reported the resident did not feel well, had not eaten breakfast, the facility prepared the resident a breakfast tray, and would offer the breakfast meal to the resident after the resident was up. During interview with direct care E on 5/9/12 at 9:52 A.M. the staff reported the resident had been up until 4 A.M., when he/she entered the resident's room earlier that morning to get the resident up for breakfast, the resident started hitting. Direct care staff E stated the resident often times did not go to bed until early A.M., and if the resident was up all night the resident would not eat breakfast on those days. During interview with dietary staff J on 5/9/12 at 10:41 A.M. dietary staff J stated the resident had not eaten breakfast, the facility did not prepare a breakfast tray for the resident nor was the resident offered an alternate meal. During interview with dietary staff K on 5/9/12 at 1:00 P.M. the staff stated the resident had experienced a weight loss and the resident often times did not eat breakfast if he/she had been up all night. Dietary staff K stated the dietary department would prepare an alternate meal for the resident when the resident awakened if nursing staff notified the dietary department. During interview with Administrative Staff A on 5/9/12 at approximately 3:45 P.M. the staff stated the resident had experienced a weight loss, the resident often times stayed up all night and did not receive breakfast meals if he/she was up all night. During interview with dietary staff K on 5/10/12 at 11:40 A.M. the staff stated he/she did not know if the resident received magic cups or not. Dietary staff K stated he/she was only aware of 1 resident receiving magic cups (not the resident), and nursing staff provided the magic cups to residents. During interview with licensed nurse F on 5/10/12 at approximately 11:45 P.M. the nurse stated if the resident received a magic cup, the facility would have obtained a physician's orders [REDACTED].[REDACTED]'s MAR indicated [REDACTED] At the time of this writing on 5/11/12 at 11:30 A.M., the facility had not provided the resident's meal intake sheets (including snacks offered) for the months of November 2011, December 2011, January and February 2012. The facility failed to follow up on the dietitian's recommendations regarding the magic cups, failed to timely follow up on the dietitian's recommendations dated 3/30/12, failed to offer the resident an alternate meal on the days the resident did not receive the breakfast meal, and failed to update the resident's care plan to include the significant weight loss for this resident that experienced a significant weight loss of 31 pounds or 19.75% decrease in his/her body weight in 3 months.

The facility identified a census of 40 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to maintain acceptable nutritional parameters to prevent unintended weight loss for 1 of 3 sampled residents (#32). Findings included: - Resident #32 ' s physicians order sheet dated, March 2010 documented the resident ' s [DIAGNOSES REDACTED]. The significant change Minimum Data Set 2.0 ((MDS) dated [DATE], documented the resident with short and long term memory impairment and moderately impaired decision making skills, easily distracted, episodes of disorganized speech, and varying mental function over the course of the day. The MDS recorded the resident required extensive to total assist assistance of one staff member for all activities of daily living (ADLs). This same assessment documented the resident had swallowing problems, received a mechanically altered therapeutic diet and used adaptive equipment with meals. The MDS further recorded a weight of 122 pounds. The MDS does not denote a planned weight change. The subsequent quarterly assessment dated [DATE] documented no significant cognitive and/or physical change with the resident, however weight of 126 pounds. The most recent quarterly assessment dated [DATE] documented the resident weight of 115 pounds, not on a planned weight change and no net weight gain or loss. Review of the Resident Assessment Protocol Summary (RAPS) dated 7/10/09, documented for nutrition, pureed diet, honey thick liquids and Sippy cup, consumes 80-100 percent. The physician order [REDACTED]. " The POS lacked documentation of a physicians order dated 12/22/09, for Magic Cup (a high protein caloric supplement). The most recent dietary assessment dated [DATE], documented the residents, " ...weight 117 pounds, the discontinuation double portions (started in December 2009) and resident placed on a fortified meal plan, weight loss may be unavoidable secondary to [DIAGNOSES REDACTED]. " Record review revealed a physicians telephone order dated, 12/22/09, for, " magic cup (a high protein caloric supplement) at lunch and dinner due to decreased weight, weekly weights, Review of the resident recent weight history revealed the following: October 2009= 129.5 pounds. November =122.0 pounds December 2009= 111.5 pounds January 2010= 114, pounds February 2010, 3rd week =117.5 pounds March 3rd week 117.2 pounds. Between October and December 2009 the resident had an 18 pound (13.89%) severe weight loss before any new interventions were initiated. The resident ' s care plan dated 1/14/10 documented the resident potential for weight loss, and advised staff to administer diet as ordered. The care plan documented handwritten notations, to " provide Magic Cup at lunch and dinner, dated 12/23/09 and gradual weight loss may be due to (responsible party) out of town, dated 2/18/10. " However, this care plan lacked documentation regarding the resident ' s actual weight loss or any corrective interventions. The record of this resident with significant weight loss lacked evidence of any recent [MEDICATION NAME] levels. At 6:59 A.M. on 3/24/10 observation revealed the resident up in Broda chair (a specialized wheelchair) seated in television viewing area. At 8:25 A M. the resident is seated in the dining room awaiting breakfast, calm, sleeping in chair, no drinks in front of him/her and wearing a clothing protector. At 8:30 A.M. licensed nurse D assisted resident with eating, pureed eggs, and oatmeal. At 8:35 the resident remains without any drinks. At this time licensed nurse D asked direct care staff C about drinks for the resident and the direct care staff member stated they would inquire in the kitchen. At 8:40 A.M. the resident was supplied drinks in Sippy cups, consumed both and ate 100 percent of meal. On 3/23/09 at 6/15 P.M. and on 3/24/10 at 12:00 observation revealed that the resident did not receive the physician ordered Magic Cup. Continued record review revealed the daily dietary intake record for the months of February and March 2010 was incomplete. The facility intake record for March 2010 posted one entry on 3/23/10 recording the resident ' s 100 percent intake at supper. This same record lacked documentation intake for 69 meal and snack opportunities. The facility policy entitled Weight Assessment and Intervention, revised 2001 documented: " The Multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. " This same document maintains that, " ... any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately, notify the dietician in writing ... " and " ...negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. " On 3/25/10 at 10:30 A.M. licensed nurse A revealed, " the residents (responsible party) leaves in the fall and returns in spring and that during this time the resident often becomes melancholy. When (responsible party) is out of town this happens and lately since (responsible party) is back (resident) is gaining. " Licensed nurse A also implied, " that (resident) has had less agitation, less flailing from disease process. " Licensed nurse A continued, " this has been kind of cyclical for the past three years, " and " the dietician reviews each resident, assesses functional level, starts a supplement, and/or Med Pass 2.0 or fortified meals, i.e. added sugar, calories, butter, I don ' t know exactly what the kitchen is doing, in the past it was double portions, but that is not really effective for the elderly so were trying to change it. " On 3/25/10 at 1:00 P.M. licensed nurse A stated that a restructuring was underway and that the newly hired dietician was scheduled to begin on Monday. The facility failed to maintain acceptable parameters of nutrition regarding the timely delivery of beverages with meals, encouragement with meals, giving supplements as ordered, the monitoring of weight changes and the clear communication of dietary intake for this dependent resident.