Every finding on record at Hoeger House

The facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety and failed to consistently document dish machine temperatures. This placed the resident at risk for foodborne illnesses. Findings included: - On 05/12/25 at 07:45 AM, during the initial kitchen tour, the two-door refrigerator had dried food particles all across the bottom shelf, and the handles to the refrigerator had dried food on them. The two-door freezer beside the refrigerator had a large, approximately 36 inches in diameter, round milky white frozen substance on the bottom shelf. The ninja blender had brown, crusty, dried food debris around the top of the base of the blender, the microwave was dirty on the outside and had dried red substance all on the walls inside. The toaster had dried food on the front of the toaster and the knobs of it. The second two-door silver refrigerator by the steam table had dried food particles inside it. On 05/12/25 at 08:30 AM, Dietary BB was asked for the daily meal temperature logs, Dietary BB was unable to produce any of the logs for April 2025 or the first 11 days of May. Dietary BB stated he was the interim Dietary Manager (DM) and stated Dietary CC knew the procedures of cleaning the kitchen and how to take the food temperatures prior to meal service. On 05/12/25 at 09:00 AM, Administrative Nurse D stated she could not find any food temperature logs. Administrative Nurse D stated that the Registered Dietician (RD) came to the facility weekly and reviewed the logs, but the previous DM had not left on good terms. Administrative Nurse D was unsure where the logs could be and could not prove that the meal temperatures were taken. On 05/12/25 at 11:55 AM, during the noon meal service, a review of the Dish Machine Temperature and Thermal Sanitizing sheet for March 2025 lacked documentation. The temperature was not taken during the following days: 03/20/25 03/21/25 03/22/25 03/24/25 03/25/25 03/26/25 03/26/25 03/27/25 03/28/25 03/29/25 03/30/25 03/31/25 A review of the Dish Machine Temperature and Thermal Sanitizing sheet for April 2025 lacked documentation. The temperature was not taken during the following days: 04/08/25 04/09/25 04/10/25 04/11/25 04/15/25 04/16/25 04/17/25 04/23/25 04/24/25 04/29/25 04/30/25 A review of the Dish Machine Temperature and Thermal Sanitizing sheet for May 2025 lacked documentation. The temperature was not taken during the following days: 05/01/25 05/02/25 05/03/25 05/04/25 05/05/25 05/06/25 05/07/25 05/08/25 05/09/25 On 05/12/25 at 12:15 PM, Dietary CC stated he did not know where the April 2025 food temperature log was and verified that he had not taken breakfast temperatures that day. He stated he had taken them in the past, but did not know where the paperwork was. Dietary CC further stated his coworker, who works opposite of him, did not clean the kitchen, so he did not feel like he needed to clean either. Dietary CC stated he did not know when the kitchen was last cleaned. The facility's Food Temperature Monitoring-Food and Nutrition Services policy, dated 12/16/24, documented that food temperatures were taken and recorded before each meal service. Periodically, temperatures were taken at other times during or at the end of meal service to ensure temperatures were held within acceptable ranges. Food was served at proper serving temperatures. The facility's General Sanitation-Food and Nutrition policy, dated 06/25/24, documented that the facility stored, prepared, distributed, and served food under sanitary conditions at all times. The policy documented cleaning and sanitizing equipment surfaces was a two-step process, surfaces are cleaned and rinsed before being sanitized. The policy documented that all food contact surfaces would be washed, rinsed, and sanitized. When cleaning fixed/immobile equipment such as mixers and slicers, removable parts are washed and sanitized, while non-removable parts are cleaned with detergent and hot water, rinsed, air-dried, and sprayed with sanitizing solution at an effective concentration. If any food contact surfaces are contaminated during reassembly, re-sanitize. The staff were to wipe down equipment and food spills.

The facility had a census of 28 residents. The sample included 12 residents, with one reviewed for re-hospitalization. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of Resident (R) 16's discharge from the facility. This deficient practice placed R16 at risk for impaired resident rights. Findings include: - R16's Electronic Medical Record (EMR) documented diagnoses of fracture of left lower leg, atrial fibrillation (rapid irregular heartbeat), end-stage renal disease with dialysis (a procedure where impurities or wastes were removed from the blood), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and thrombosis (a clot that developed within a blood vessel) of deep veins of both lower extremities. R16's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R16 required assistance with set up for eating and dressing and was dependent on staff for transfers, toileting, and lower body dressing. The MDS documented R16 received antibiotics and blood thinner drugs. R16's Care Plan, dated 04/06/25, directed staff to report to the health care provider, as needed, any signs or symptoms of infection or pneumonia (inflammation of the lungs). R16's EMR documented she was hospitalized from [DATE] to 03/27/25 for fluid overload. R16's EMR documented she was hospitalized from [DATE] to 04/05/25 for thrombosis (clot that developed within a blood vessel) of the deep veins of the lower extremities. The facility lacked documentation that the state LTCO was notified of the discharge and transfers to the hospital for both hospitalizations. On 05/12/25 at 09:09 AM, R16 was in her wheelchair in her room and reported no concerns with staff care and services. On 05/13/25 at 02:55 PM, Administrative Nurse D and Social Services Staff X stated neither one had notified the ombudsman of discharges. They were unaware they were required to. The facility's Discharge and Transfer policy, dated 03/28/2025, stated when a resident was temporarily transferred on an emergency basis to an acute care center, a notice of transfer must be provided to the resident and their representative as soon as practicable, and a copy of the notice must be sent to the ombudsman.

The facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and glove use during high contact care) were used for Resident (R) 23, who had a surgical incision (a surgical cut made in the skin). The deficient practice placed residents in the facility at risk of infectious disease processes. Findings included: -On 05/13/25 at 03:35 PM, R23's room door had an EBP sign. R23 propelled herself into the bathroom, she had an elastic bandage wrapped from her foot to her knee around her left ankle and started to try to transfer herself onto the toilet. Further observation revealed Licensed Nurse (LN) G went into the bathroom and shut the door. After a short time, LN G came out and sanitized her hands. LN G stated that R23 was on EBP due to her surgical incision and stated that R23's Person Protective Equipment (PPE) of gowns and gloves were in the cabinet beside her room. LN G stated that R23 had a surgical incision, and staff were to wear PPE when they provided wound care, but she has not had to do that yet. LN G stated she had assisted R23 on and off the toilet, but R23 was able to do her own personal care. On 05/13/25 at 12:26 PM, Certified Nurse Aide (CNA) M went into R23's room, put a gait belt around R23's waist, and maneuvered her wheelchair to the side of the bed. CNA M grabbed the gait belt and transferred R23 into R23's wheelchair. CNA M wheeled R23 to the recliner and transferred R23 into it. Further observation revealed CNA M grabbed the footrest of the recliner and lifted it so that R23 could elevate her legs. CNA M gave R23 her call light, fixed the covers on R23's bed, and walked out of the room. CNA M had not donned a gown or gloves and had not sanitized her hands after she left the room. R23 stated staff only had to wear a gown and gloves when staff assisted R23 with toileting. CNA M stated the facility had monthly skills checks and CNA M was reeducated about EBP and infection control monthly. On 05/13/25 at 01:00 PM, Administrative Nurse E stated staff were reeducated monthly about EBP and infection control. Administrative Nurse E further stated staff were to wear PPE while performing high contact care, especially with transfers and personal care. Administrative Nurse E stated that LN G asked her about when to wear PPE with R23, and Administrative Nurse E reeducated LN G that LN G should have worn a gown and gloves when LN G assisted R23. Administrative Nurse E stated CNA M should have worn a gown and gloves and should have sanitized her hands after she assisted R23. On 05/14/25 at 10:30 AM, Administrative Nurse D stated that staff received education about EBP and PPE monthly, and as needed. Administrative Nurse D stated that staff were to wear PPE with high contact care like transfers and toileting, care of any kind. The facility's Standard, Enhanced Barrier and Transmission Based Precautions policy, dated 04/05/25, documented Enhanced Barrier Precautions (EBP) that expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated. EBP is used for residents who are infected or colonized with a CDC (Centers for Disease Control)- targeted MDRO (Multidrug-Resistant Organism), or an epidemiologically important MDRO (per facility discretion), when contact precautions do not otherwise apply. The policy documented high-contact resident care activities included transfers, dressing, toileting, and bathing. Staff were to also wear PPE when changing linens, devices, wound care, and during therapy. The policy further documented, that residents on EBP would have clear signage posted on the door or wall outside of the resident's room, indicating the type of precautions and required PPE.

The facility documented a census of 28 residents. The sample included 13 residents with three reviewed for falls. Based on record review and interview, the facility failed to ensure a safe environment free from preventable accidents when staff failed to ensure Resident (R) 67 had foot pedals on her wheelchair before staff propelled the resident down the hallway to her room. The resident was unable to hold her legs up and placed her foot on the floor which caused the resident to fall forward out of the wheelchair. The fall resulted in a broken left femur (thigh bone). Findings included: - R67's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, altered mental status (change in mental function that stems from illnesses, disorders and injuries affecting your brain), and generalized muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R67 required limited assistance of one staff for many of her activities of daily living and transfers. The Cognitive Loss /Dementia Care Area Assessment (CAA), dated 07/11/23, documented R67 had impaired memory and a BIMS of 12. The Falls CAA dated 07/11/23, documented R67 had impaired gait and balance and required staff assistance with mobility. R67's Care Plan recorded an intervention dated 06/29/23, which documented R67 had bilateral lower extremity weakness and needed assistance with bed mobility, transfers, dressing, toilet use, and bathing. An Incident Note dated 07/11/23, documented R67 propelled herself to her room in her wheelchair. The note documented R67 stopped Certified Medication Aide (CMA) R and asked if CMA R could push her to her room. The note documented Licensed Nurse (LN) J heard her name being yelled and came around the corner and found R67 on the floor, on her right side, with CMA R next to her. The note documented CMA R stated R67 put her foot down, which caused her to tip out of the wheelchair. The note further documented R67 complained of left knee pain and had a skin tear to her right elbow. The note documented that the skin tear was bandaged, and R67 was assisted back into her wheelchair by staff with the use of a Hoyer lift (total body mechanical lift used to transfer residents). A Complaint Investigation Witness Statement dated 07/11/23, documented CMA R was walking to the kitchen when R67 asked CMA R to push her back to her room, in the wheelchair. The statement documented that CMA R asked R67 to put her feet up before pushing R67 toward her room. The statement further documented R67's feet fell , which caused her to tumble out of the wheelchair. The Investigation Report documented R67 propelled herself in her wheelchair when she asked CMA R to help push her back to her room. The report documented CMA R requested R67 pick her feet up before she transported her down the hallway. As CMA R transported R67 down the hallway, R67's feet dropped to the floor, which caused R67 to fall forward out of the wheelchair with her arms out in front of her and she rolled to her right side after she had landed. The report further documented R67 complained of left knee pain and had a skin tear to her right upper extremity, which was dressed, and staff assisted R67 back into her wheelchair with use of the Hoyer lift. The report documented R67 received an X-Ray, for her left knee, on 07/11/23 with no acute fracture or negative findings. R67 continued to complain of bilateral knee pain, she continued on a pain regimen, and planned to discharge home with her daughter. The report documented R67 was sent to the hospital for further evaluation and was found to have a left femur fracture. On 08/31/23 at 09:50 AM CMA R stated if there were no foot pedals on a resident's wheelchair, and the resident asked to be pushed by staff, staff would have to get the foot pedals and put them on the wheelchair first. She stated staff were never supposed to push residents without having the pedals in place. On 08/31/23 at 09:54 AM LN K stated staff must make sure residents have foot pedals on their wheelchairs before pushing them. She stated if there were no foot pedals then staff could not push the residents in the wheelchairs. On 08/31/23 at 12:22 PM Administrative Nurse D stated staff were expected to have footrests in place before pushing residents in their wheelchairs. She further stated if there were no foot pedals on the resident's wheelchair, and the resident wanted to be pushed by staff, then staff were expected to find the foot pedals and put them on, or the resident can self-propel. She stated the foot pedals were normally stored in a bag on the back of the wheelchair. She stated all staff had received education and signed off that they will not push residents without foot pedal on the wheelchairs. The facility policy Fall Prevention and Management revised 03/29/23, documented the risk of falling for residents in long-term care locations substantially increases due to decreased mobility, frailty, muscle weakness, gait disturbance and disease progression. The facility failed to ensure a safe environment free from preventable accidents when staff failed to ensure R67 had foot pedals on her wheelchair before staff propelled the resident down the hallway to her room. The resident was unable to hold her legs up and placed her foot on the floor which caused the resident to fall forward out of the wheelchair. The fall resulted in a broken left femur for R67. On 07/21/23 the facility completed corrective actions, which included education to all staff regarding wheelchair safety and ensuring footrests were in place prior to transporting residents. Footrest bags were placed on the back of each wheelchair for footrest placement when not in use to ensure availability when needed. Staff audits were conducted, and the issue was reviewed by the Quality Assurance and Performance Improvement committee. All corrective measures were completed prior to the onsite survey therefore the citation was issued as past noncompliance which existed at a G to represent the isolated, actual harm for R67.

The facility identified a census of 28 residents with one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to sanitary food and equipment storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 08/29/23 at 07:05AM a walkthrough of the facility's kitchen was completed. An inspection of the facility's freezer unit revealed opened but undated/unlabeled bags of potato wedges, breaded meat patties, and sliced strawberries. An inspection of the equipment storage rack revealed a large pasta strainer on the top shelf stored upward (not inverted) towards the ceiling. An inspection of the facility's deep fryer station revealed a sheet pan covering the fryer unit. Large amounts of old food particles floated in the oil at the top of the deep fryer unit. An inspection of the preparation area revealed dust/debris covering the spice bottles on the rack. On 08/29/23 at 08:30AM a walkthrough of the facility kitchenette was completed. An inspection of the kitchenette's microwave revealed old food particles inside the cooking unit. An inspection of the kitchenette's refrigerator/ top freezer unit revealed three upon and undated one-gallon ice cream containers. The upper freezer unit also contained a frost covered black grocery bag with unknown contents inside. The lower refrigerator unit contained opened condiments and an unlabeled jar of salsa. On 08/31/23 at 09:02AM Dietary Staff BB indicated staff were expected to clean each kitchen area daily and in between services. He stated kitchen staff would clean the ovens and deep fryer daily after use and filter out the oil daily. He stated a deep clean of the kitchen was to be completed once weekly including a checking the food products for refrigerator labels and dates. He stated all open food should be labeled with the open date and rotated out before expiration. He stated the kitchenette was cleaned weekly and staff should not be leaving personal food in it. A review of the facility's Food and Equipment Storage revised 05/2023 policy noted that all food preparation areas and equipment will be maintained in a clean serviceable manner. The policy noted all equipment used in the handling of food shall be cleaned, sanitized, and handled in a manner that prevents contamination. The facility failed to maintain sanitary dietary standards related to food and equipment storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

The facility identified a census of 28 residents. The sample included 13 residents. Based on record review, observations, and interviews, the facility failed to track and analyze infectious organisms related to its infection surveillance. The facility also failed to follow transmission-based precautions during wound care for Resident (R)169. This deficient practice placed the residents at risk related to infectious diseases. Findings included: - Review of the facility Antibiotic Stewardship Surveillance Logbook from July 2022 to July 2023 revealed that the contributing organism was not being tracked with trends noted on the surveillance log. On 08/31/23 at 09:25 AM Administrative Nurse E stated she was the Infection Preventionist since September 2022 and was certified since December 2022. Administrative Nurse E stated she had not been told that the causative organism or bacteria needed to be listed or tracked. Administrative Nurse E stated she was taught that only the antibiotic needed to be listed with the start date and resolution date. The Infection Prevention and Control Program policy last revised 02/15/22 documented: The infection prevention and control program will attempt to meet federal and state regulations for infection control where applicable. The program included infection prevention, control and education. The infection preventionist and the Quality Assurance and Performance Improvement (QAPI) committee would direct the functions of the infection and prevention and control program. The system of identifying, reporting, investigating, and controlling infections and communicable diseases for all residents will be tracked where possible on the Infection and Antimicrobial Tracing Tool and reviewed by the who will keep a record of any corrective action taken. The facility failed to track and analyze organisms for infection surveillance. This deficient practice placed the residents at risk related to infectious diseases. 45668 - The Medical Diagnosis section within R169's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), neuralgia (severe nerve pain), insomnia (inability to sleep), fracture of left humerus (break in upper arm bone), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia (progressive mental disorder characterized by failing memory, confusion). A review of the EMR indicated R169 admitted on [DATE]. No Minimum Data Set (MDS) or Care Area Assessments were completed yet for R169. R169's EMR under Physician's Orders revealed an active order dated 08/28/23 indicating Enhanced Barrier Precautions (precautions that required staff to complete hand hygiene, don gloves, and wear gowns while high contact cares activities were provided to residents with wounds, indwelling medical devices, or had multidrug resistant organism infections) were implemented related to a Methicillin-resistant Staphylococcus aureus (MRSA - a type of bacteria resistant to many antibiotics) infection on his right shoulder. The order indicated a sign was placed on his door to alert staff to apply the proper personal protective equipment (PPE) during high contact cares on all shifts. R169's EMR revealed a Wound Culture completed on 08/24/23. The culture indicated he tested positive for heavy growth of MRSA on his right chest and neck. On 08/29/23 at 07:43AM an inspection of R169's room revealed an Enhanced Barrier Precaution sign on R169's entry door. The sign indicated all entrants must complete hand hygiene when entering and exiting the room. The sign indicated staff were required to wear protective gloves and gowns when high contact care activities were provided. On 08/29/23 at 03:20PM, R169's Enhanced Barrier Precaution sign was not posted on his door. On 08/30/23 at 09:13AM, R169's Enhanced Barrier Precaution sign was not posted on his door. On 08/30/23 at 03:35PM, Licensed Nurse (LN) H and Consultant HH prepared outside R169's room for wound care. LN H reviewed R169's orders before entering the room. R169's door had no enhanced barrier precautions signage posted at the time of entry. LN H completed hand hygiene and donned gloves. LN H assisted R169 to sit onf the side of the bed and removed R169's shirt. LN H completed hand hygiene and changed her gloves. Consultant HH assessed R169's right side shoulder wound and instructed LN H to clean the wound, but said it would not require a dressing to cover due to the healing stage. LN H cleansed the wound with a saline solution and placed a clean shirt on R169. Both staff completed hand hygiene and exited the room. Neither staff wore a gown during the encounter. On 08/31/23 at 10:03AM an Enhanced Barrier Precautions sign was again on R169's door. On 08/31/23 at 09:14AM, Certified Nurses Aid (CNA) M stated she was assigned to care for R169 but was not sure if he was still on enhanced barrier precautions. She stated the nurse instructed staff which residents were on precautions, or the signs would be placed on the door. She stated staff were to complete hand hygiene, don gloves, and wear gowns for residents on enhanced barrier precautions. She stated she would ask the nurse. On 08/31/23 at 09:21AM, LN G stated residents on enhanced barrier precautions should have an order in the EMR or a sign on their door. She stated she was not sure if R169 was still on precautions but would check his orders. On 08/31/23 at 12:24PM, Administrative Nurse D stated all residents on enhanced barrier precautions would have signs on the door indicating the required personal protective equipment (PPE) required to perform cares. She stated staff were expected to completed hand hygiene and were gloves/gowns for all cares. She stated the resident's physician orders should also have reflected if the resident required the precautions. A review of the facility's Transmission Based Precautions revised 12/2021 indicated special precautions were meant to reduce the transmission of contagious organism between residents and lower the risks of healthcare associate illness and infections that lead to hospitalization s and death A review of the facility's Multi-drug Resistant Organisms policy revised 02/2022 indicated enhanced barrier precautions expanded the use of PPE beyond situations in which exposure to blood and body fluids was anticipated and referred to the use of gown and gloves during high-contact care activities. The facility failed to ensure transmission based precautions were followed during R169's wound care. This deficient practice placed R169 and other residents at risk related to the spread of infectious diseases.

The facility identified a census of 28 residents. The sample included 13 residents with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure reducing measures according to the plan of care were implemented for Resident (R) 69's bilateral lower extremities and a cushion in the wheelchair to prevent worsening of pressure ulcers. This placed R69 at increased risk for pressure ulcer development and worsening of right heel pressure ulcer. Findings included: - R69's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance for personal care, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), epilepsy (brain disorder characterized by repeated seizures), and embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of lower extremities. The Admission Minimum Data Set (MDS) was in progress. R69's Care Area Assessment (CAA) was not completed. R69's Care Plan dated 08/20/23 documented staff would provide a pressure relieving/reducing device on the bed and in wheelchair. The Care Plan dated 08/23/23 documented staff would float R69's heels when in bed. Review of the EMR under Orders tab revealed the following physician orders: Wound order: skin prep to bilateral heels, float heels every day and night shift dated 08/19/23. Review of EMR under Assessment tab revealed a Wound assessment dated [DATE] which documented a stage one (pressure are with red, non-blanchable skin but not open) pressure ulcer on R69's right heel. On 08/29/23 at 12:18 PM R69 sat upright on his bed, with his left arm in a sling, and his bilateral heels rested directly on the mattress. R69's wheelchair sat next to the bed and lacked a cushion. On 08/30/23 at 07:24 AM R69 was asleep on the bed, with left arm in a sling, and his bilateral heels rested directly on the mattress. R69's wheelchair was next to the bed and lacked a cushion. On 08/30/23 09:34 AM R69 was asleep on his bed, with a sling on his left arm, and his bilateral heel rested directly on the mattress. Licensed Nurse (LN) I entered the room to apply skin prep (liquid skin barrier) to R69's bilateral heels. LN I applied skin prep to the left heel, then placed R69's left foot back on the bed. LN I opened second package of skin prep, removed R69's right sock to his toes, applied skin prep to right heel, then placed right foot back onto mattress. LN I pulled left sock back onto R69's foot and then pulled his right sock back onto his right foot and placed heels directly onto the mattress. LN I doffed gloves and removed R69's breakfast tray from room. On 08/30/23 at 12:30 PM R69 sat in his wheelchair in the dining room with out a wheelchair cushion. On 08/31/23 at 08:14 AM R69 propelled self into the hallway to talk with nursing staff, no cushion was on the seat of the wheelchair. On 08/31/23 at 10:55 AM Certified Medication Aide (CMA) R stated she was not sure if R69's heels should be floated. CMA R stated she would find that information on the Kardex (a medical information system used by nursing staff as a way to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change). CMA R stated a pressure reducing cushion should be in the wheelchair most of the time. On 08/31/23 at 11:05 AM LN I stated she did not float R69's heels after his treatment because he moved his feet a lot. LN I stated every wheelchair should have a pressure reducing cushion in the wheelchair. LN I stated it was everyone's responsibility to ensure the wheelchair had a cushion. On 08/31/23 at 12:22 PM Administrative Nurse D stated all the mattresses at the facility were pressure reducing. Administrative Nurse D stated every wheelchair needed a pressure reducing cushion and R69's heels should be floated when he was in bed. Administrative Nurse D stated heels were floated on a pillow. The facility's Skin Assessment Pressure Ulcer Prevention and documentation Requirements-Rehabilitation/Skilled policy last reviewed 04/26/23 documented the purpose was to systematically assess residents regarding risk of skin breakdown, to accurately document observations and assessments of residents, and to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. Residents who were unable to reposition themselves independently, as indicated on the clinical assessment, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule was required for those residents unable to position themselves and was based on nutrition, hydration, incontinence, diagnoses, mobility, and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation was a required tool that is used to determine an individualized repositioning plan. The positioning schedule would be communicated to the nursing assistants using the Kardex. Any resident at risk would be placed on a pressure redistribution surface as determined appropriate. The facility failed to implement the pressure reducing measures according to the plan of care for R69, who had a pressure ulcer on his right heel and was at risk for pressure injuries. This placed R69 at increased risk for worsening pressure ulcers and pressure/skin injuries.

The facility identified a census of 28 residents. The sample included 13 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized interventions to improve Resident (R)167's bladder incontinence or prevent further loss. This deficient practice placed R167 at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R167's Electronic Medical Records (EMR) included diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), repeated falls, chronic obstructive pulmonary disorder (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), neuralgia (severe nerve pain), and insomnia (inability to sleep). A review of the EMR indicated R167 admitted on [DATE]. No Minimum Data Set (MDS) or Care Area Assessments were completed for R167. R167's Care Plan initiated 08/23/23 indicated he required extensive assistance from one staff for toileting. The plan noted he required a gait belt and limited assistance from one staff for transfers between surfaces. The plan indicated he had bladder incontinence and used incontinence briefs. The plan indicated he had a history of falling related to significant changes in his safety awareness, gait, and mobility. The plan did not mention a portable urinal. The plan lacked individualized interventions or toileting program to maintain and promote R167's highest level of functioning related to incontinence. A Bladder Evaluation for R167 completed on 08/27/23 indicated he had daily incontinence in both day and nighttime. The evaluation indicated he used incontinence products. The evaluation noted obesity and mobility as factors related to his incontinence. The evaluation noted he used the toilet but not a bedpan or portable urinal. The evaluation recommended he be provided a toileting program and staff were to provide check/change. R167's clinical record lacked evidence staff developed and implemented a toileting program. On 08/29/23 at 10:00AM R167 sat on his bed with his bedside table pulled to him for breakfast. R167 wore only his underwear as he ate his breakfast. R167's room smelled heavily of urine and a half-full portable urinal sat next to the resident's breakfast tray. R167 stated staff had not emptied the urinal in the morning. He stated he had urinary incontinence but he was not sure if the facility had implemented a program for it. On 08/30/23 at 07:09AM a full urinal sat on R167's bedside table as he slept in his bed. On 08/31/23 at 08:23AM Certified Nurse's Aide (CNA) M stated she was not sure if R167 had a toileting program. She stated he utilized a portable urinal and staff would empty it. On 08/31/23 at 09:05AM Licensed Nurse (LN) G stated R167 was not on a toileting plan. She stated he did have urinary incontinence and wore incontinence products but was not aware if any individualized interventions were in place to maintain his bladder function. On 08/31/23 at 12:23PM Administrative Nurse D stated residents were screened for incontinence upon admission. She stated staff were expected to provide toileting and peri-care to prevent skin breakdown. She stated the interventions listed on the evaluations would be implemented and available for staff to review on the Kardex. A review of the facility's Bowel and Bladder policy revised 04/2023 stated that resident will be evaluated for bowel and bladder incontinence management. The policy noted that residents noted without irreversible causes will be evaluated for potential bowel and bladder management. The policy noted that pattern evaluations will be provided to residents for individualized continence management programs. The policy indicated implemented interventions would have included prompted toileting, bladder training, and dietary monitoring. The facility failed to implement individualized toileting program related to urinary incontinence for R167. This deficient practice placed R167 at risk for complications related to incontinence.

The facility reported a census of 28. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility failed to implement monitoring for behaviors and side effects associated with Residents (R)9's psychotropic medications (class of medications that chemically alter the brain to effect mood, perception, and behaviors). This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects. Findings included: - The Medical Diagnosis section within R9's Electronic Medical Records (EMR) included diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), hallucinations (sensing things while awake that appear to be real, but the mind created), and obstructive sleep apnea (absence of breathing). R9's Quarterly Minimum Data Set (MDS) completed 08/04/23 noted a Brief Interview for Mental Status (BIMS) score 15 indicating intact cognition. The MDS noted no behaviors. The MDS noted he had antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) and antidepressant medications (class of medications used to treat mood disorders and relieve symptoms of depression). R9's Psychotropic Medication Care Area Assessment (CAA) completed 03/14/23 indicated he was being treated for mood disorder and took alprazolam (antianxiety medication). The CAA also indicated he took escitalopram (antidepressant medication). R9's Psychosocial Well-being CAA completed 03/14/23 indicated he had little desire to participate in his favorite activities. A review of R9's Care Plan initiated 03/13/23 indicated he took antianxiety medication. The plan indicated staff were to monitor and document the medications side effects and effectiveness. The plan instructed staff to monitor R9's condition based on clinical practice guidelines or clinical standards of practice related to the alprazolam. The plan noted he took antidepressant medication. The plan instructed staff to monitor R9's condition based on clinical practice guidelines or clinical standards of practice related to the escitalopram (antidepressant medication). R9's EMR indicated under Physician's Orders he received alprazolam (0.25 milligrams (mg)) two times a day for mood started 04/27/23. R9's EMR indicated under Physician's Orders he received escitalopram (10mg) one time daily for mood. A review of R9's EMR revealed no documentation showing staff consistently monitored the alprazolam and escitalopram's side effects or behaviors for the medication efefctiveness and continued use. On 08/31/23 at 09:54AM, Licensed Nurse (LN) K stated staff should be documenting side effects and behaviors in the progress notes as they occurred. She stated she was not sure of any other place it could be documented in the EMR. She stated the direct cares staff would any behaviors observed to the nurse for documenting. On 08/31/23 at 12:24PM Administrative Nurse D stated behaviors were not documented on an everyday basis; they were put in the EMR as needed. She stated staff would put in progress notes if behaviors occurred or might also be listed in tasks section or in an assessment. She stated behaviors usually were more stable due to the facility being short stay and the residents were more adjusted to their medications. She stated if the residents had behaviors social services would assess and report what behaviors needed to be monitored. A review of the facility's Psychotropic Medications revised 12/2022 indicated the facility must provide documentation of psychotropic medications side effects and behavioral monitoring for residents on the medications. The Policy indicated documentation would include mood, behavior changes, sleep disturbances, restlessness, dizziness, nausea, or any adverse reactions associated with the class of medications. The facility failed to implement monitoring for behaviors and side effects associated with R9's alprazolam and escitalopram medications. This deficient practice placed the residents at risk for ineffective treatment and unnecessary medication side effects

The facility had a census of 28 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)218's insulin (hormone which allows cells throughout the body to uptake glucose) pen with the date opened and discard date and failed store his medications securely. This placed R218 at risk for ineffective or diverted medications. Findings included: - On 08/29/23 at 07:10 AM an observation in the cabinet outside of R218's room revealed an unlocked medication storage drawer that contained the following: R218's Humalog (fast-acting insulin) pen. The pen lacked a date opened, and discard date. R218's Lantus (long-acting insulin) pen. The pen lacked a date opened, and discard date. Seven cards that contained various prescription medications. The inside of the cabinet door revealed a sign that documented insulin expired 28 days after opening. On 08/29/23at 07:23 AM Licensed Nurse (LN) I stated medication drawers should be locked if not being used. She stated that the insulin pens were R218's home medications, and she was not sure when they were opened. She further stated insulins were no longer good if opened for longer than 28 days. On 08/31/23 at 12:22 PM Administrative Nurse D stated medication drawers should always be locked if no one was present. She stated that on average, most insulins expired 28 days after they were opened. She stated there were some exceptions, with certain insulins that lasted longer than 28 days and that had been discussed with their pharmacy consultant; however, she was unsure if the policy had been updated to reflect those changes. The facility policy Medications: Acquisition Receiving Dispensing and Storage revised 03/02/23, documented medications will be stored in a locked medication cart, drawer, or cupboard. Only the person passing medication and the director of nursing services and/or designees will be permitted to have access to the keys to the medication storage areas. The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. The facility failed to label R218's insulin pens with the dates opened and discard dates and failed to store his medications securely. This placed R218 at risk for ineffective or diverted medications.

The facility reported a census of 27 residents. The sample included four residents reviewed for elopement (when a cognitively impaired resident leaves the facility without staff knowledge and supervision). Based on record review, observation, and interview, the facility failed to ensure staff identified Resident (R)1's risk for elopement an failed to provide adequate supervision to prevent an elopement when R1 exited through an alarmed door after activating the required door release. This placed R1 at risk for injury related to elopement. Findings included: - The Electronic Medical Record (EMR) recorded R1 admitted to the facility on [DATE]. The EMR under the Diagnosis tab, listed diagnoses of: cerebral infarction (stroke- a disruption of blood flow to the brain), [CONDITION(S)] (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), and [CONDITION(S)] ([CONDITION(S)] or passing out). The Admission Minimum Data Set (MDS) dated [DATE] recorded R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated the resident's cognition was severely impaired. R1 had no wandering behaviors during the assessment period. R1 required limited assistance of one staff member with most activities of daily living (ADL's), and ambulated with the use of a rolling walker. R1's initial Elopement Risk assessment dated [DATE] documented R1 was recently admitted to the facility, had increased confusion and forgetfulness, and had a diagnosis of dementia. The assessment recorded the resident was not at risk for elopement. The resident's initial Care Plan dated 05/06/22 documented R1 had an ADL self-care performance deficit related to cognitive status and weakness. The care plan directed staff to provide limited assistance for ambulation of one staff member with use of a gait belt and rolling walker. The 05/06/22 Care Plan for behaviors recorded the resident had a diagnosis of dementia and directed staff to attempt non-pharmacological interventions when R1 looked for his spouse. R1's Care Plan, updated on 05/07/22, acknowledged the resident was at risk for elopement, due to a diagnosis of dementia. A Health Status Note note, under the Notes tab dated 05/09/2022 at 06:34 AM recorded R1 was in the hallway early in the shift, looking for the parking lot. R1 was redirected easily. R1 did not wander the rest of the shift. A Progress Note dated 05/09/22 at 8:25 P.M. recorded a Certified Medication Aide (CMA) reported a dietary employee brought R1 to the nurse and stated R1 was in the parking lot. Staff assesses no new skin issues were noted. R1's vital signs were within normal limits. R1 denied any complaint of pain or discomfort; staff notified Administrative Nurse D, Consultant GG and R1's emergency contact immediately. A Witness Statement from Licensed Nurse (LN) J on 05/09/22 documented she dropped off medications to the medication room and observed R1 outside his room. LN J stated she asked R1 if he needed help and R1 said no. LN J went to the back of the building and assisted a different resident. LN J recorded she did not hear the alarm sound. A Witness Statement from Licensed Nurse (LN) K on 05/09/22 recorded she prepared medications and then assisted a resident in the bathroom. LN K documented she was not aware the alarm sounded until she exited the resident's room and entered the hallway. LN K stated she went to the door that was alarming and opened it, went outside and looked around each side of the building and in the parking lot and did not see anyone. LN K documented she went back in the building and back to a resident's room. She stated she went to the laundry room to get linens and then to the restroom. While in the restroom LN K heard the door alarming. Dietary Staff (DS) BB notified LN K R1 was found in the parking lot. LN K stated she was not aware R1 left the building and had not seen R1 that shift. LN K recorded she received information in shift report which indicated R1 was an elopement risk. A Witness Statement from Certified Medication Assistant (CMA) R on 05/09/22 documented CMA R passed medications in the back of the building. CMA R recorded DS BB approached her and said R1 was in the parking lot. CMA R stated she walked with DS BB to the front of the building where R1 sat outside his room. CMA R recorded she altered the other staff. A Witness Statement received from DS BB on 05/09/22 recorded at approximately 08:10 AM on 05/09/22 DS BB observed R1 exit the side door. DS BB stated he thought R1 was a visitor.DS BB stated he went to his vehicle and waited for a friend to arrive. DS BB recorded R1 ambulated to the parking lot. DS BB pulled his car around to the front of the parking lot at approximately 08:15 PM and R1 approached him and asked for a ride. DS BB documented he then realized R1 was not a visitor and escorted R1 back into the facility. DS BB directed R1 to sit in a chair by R1's room while DS BB obtained nursing staff to assess R1. Review of camera footage for 05/09/2022 at 08:10 PM revealed R1 pushed on east exit door emergency release for 15 seconds and the door opened. At 08:13 PM a staff member exited the door then reentered after approximately one minute. At 08:20 PM a dietary staff member returned with R1. On 05/12/22 at 12:15 PM R1 propelled his wheelchair towards the dining room. Staff accompanied R1. On 5/12/22 at 12:22 PM R1 stated he came to the facility after a hospital stay. Interviewed on 05/12/22 at 12:10 PM Licensed Nurse I (LN I) stated R1 had no elopement attempts during the time LN I worked. LN I stated R1 did ambulate in hall on occasion. LN I said R1 was easily redirected and was just confused about where to go and what to do. Interviewed on 05/12/22 at 12:10 PM Certified Nurse's Aide (CNA) N stated she did not typically work with R1. CNA N stated R1 had not had any elopement behaviors prior to the elopement on 05/09/22. Interviewed on 05/12/22 at 2:20 P.M. Administrative Nurse D acknowledged R1's initial elopement risk assessment was inaccurate and stated immediate training would be conducted with nursing staff. The facility's Elopement/Rehab/Skilled policy revised on January 01/12/2022 documented: All residents would be assessed for elopement through the preadmission and/or admission process and as needed, Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan . The facility failed to identify R1's elopement risk and failed to provide adequate supervision to prevent an elopement. This placed R1 at risk for injuries related to elopement.

The facility identified a census of 21 residents. The sample included 15 residents with five residents reviewed for food services. Based on observations, record reviews, and interviews, the facility failed to serve food at an appetizing temperature to resident (R) 8, R11, R12, R13, and R123. This deficient practice placed the residents at risk for decreased nutrition and a delay in recovery. Findings Include: - The electronic medical record (EMR) documented the following diagnosis for R8: fracture of right tibia, [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain), acute [CONDITION(S)], [CONDITION(S)] (greater than normal amounts of cholesterol in the blood), major depressive disorder (major mood disorder), [CONDITION(S)] (inability to sleep), malaise (vague uneasy feeling of body weakness, distress or discomfort), hypoosmolality (decrease in the levels of electrolytes, chemicals, and other fluids in the blood required for adequate functioning), and [CONDITION(S)] (low sodium levels in the blood), and protein-calorie malnutrition ( body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function). A review of R8's Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R8's Nutrition Care Area Assessment (CAA) was triggered for monitoring related to her recent right tibia (leg bone) fracture. The assessment noted concern that R8 was forgetful but does not address the diagnoses listed in the resident's EMR. A review of R8's Care Plan indicated a cardiac diet and a high body mass index (BMI- a weight-to-height ratio) of 48.6. The Care Plan indicated R8 would express that her nutritional needs are being met and she would feel supported in dining decisions. On 01/25/22 at 10:05 AM R8 reported that every time the food arrived to her room, it arrived cold. She reported that she would have to ask staff to reheat it but most the time she just did not feel like eating it. On 01/26/22 at 12:20 PM R8 reported that her breakfast and lunch for the day were not very warm. An Inspection of the lunch plate indicated that the butter was not melting when she put it on her sweet potatoes. On 01/27/22 at 0750 An observation of the morning breakfast service was completed. Around 08:00AM the food was plated and loaded onto the transport carts. The food was served on glass plates with either a plastic or metal dome top covering the food. The food arrived in the resident hallway at 08:08 AM. The unit staff began taking trays to the resident's room around 08:10 AM. At 08:28 AM R8's breakfast tray was delivered to her room. At 08:33 AM R8 asked to have her food temperature tested for quality. The test revealed her food to be around 85 degrees Fahrenheit. R8 did not eat her breakfast and fell back asleep. A temperature inspection of the food on 01/26/22 at 11:13 AM revealed the food temperatures in the kitchen to be at or above the acceptable temperature range for dining service. On 01/27/22 at 10:20 AM interview with Dietary Staff CC stated that food temperature is checked for every service than loaded onto the carts to be delivered to the resident's room. He has not been notified of any complaints from the residents of the food being cold during service. An interview completed on 01/27/22 at 01:44 PM with Licensed Nurse (LN) G stated that she was aware that some of the residents complained that the food was cold but not very often. She reported that a microwave was available to reheat the food if a resident needed the food to be reheated. An interview with Administrative Nurse D on 01/27/22 at 01:50 PM reported that she was aware of some complaints about the food temperature and the facility recently acquired dome tops for the plates to help keep the food warm while being transported to the rooms. The facility failed to serve food at an appetizing temperature to resident R8. The deficient practice placed the resident at risk for decreased nutrition and a delay in recovery from rehabilitative services. - The electronic medical record (EMR) documented the following diagnosis for R11: hypertension (high blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), [CONDITION(S)] (condition characterized by decreased activity of the [CONDITION(S)]), Irritable bowel syndrome (abnormally increased motility of the small and large intestines), constipation (difficulty passing stools), malaise (vague uneasy feeling of body weakness, distress or discomfort), [CONDITION(S)] (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain), and aftercare for joint replacement surgery. A review of R11's Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. R11's Nutrition Care Area Assessment (CAA) was triggered for monitoring related to his recent right hip replacement. The DehydrationCAA also triggered related to his poor fluid intake and history of falls. A review of R11's Care Plan dated 01/20/22 revealed he was on a cardiac diet related to excessive calorie intake and a high body mass index (BMI- a weight-to-height ratio) of 34.5. The Care Plan indicated R11 was at risk for skin breakdown and dehydration. The intervention listed on the plan of care indicated monitoring nutritional intake, offer resident drinks of choice, and monitor resident. On 01/25/22 at 11:00 AM R11 reported that his food always arrives at his room cold to lukewarm. He stated that he felt it was because he was the last room being served and it took a long time for the other rooms to be served. He reported that for the first five days of his admission to the facility he did not receive drinks with his meals. He reported that every time he would order food from the kitchen, he would be missing items he ordered. He stated that he would have to ask multiple times until he either got what he needed or just gave up. A temperature inspection of the food on 01/26/22 at 11:13 AM revealed the food temperatures in the kitchen to be at or above the acceptable temperature range for dining service. On 01/27/22 at 10:20 AM interview with Dietary Staff CC stated that food temperature is checked for every service than loaded onto the carts to be delivered to the resident's room. He has not been notified of any complaints from the residents of the food being cold during service. An interview completed on 01/27/22 at 01:44 PM with Licensed Nurse (LN) G stated that she was aware the some of the residents complained that the food was cold but not very often. She reported that a microwave is available to reheat the food if a resident needs the food to be reheated. An interview with Administrative Nurse D on 01/27/22 at 01:50 PM reported that she was aware of some complaints about the food temperature and the facility recently acquired dome tops for the plates to help keep the food warm while being transported to the rooms. The facility failed to serve food at an appetizing temperature to resident R11. The deficient practice placed the resident at risk for decreased nutrition and a delay in recovery from rehabilitative services. - The electronic medical records (EMR) documented the following diagnosis for R12: congestive heart failure (a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), [CONDITION(S)] (low potassium levels in the blood), acute kidney failure, [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain), and chronic pain. A review of R12's Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. R12's Nutrition Care Area Assessment (CAA) triggered for monitoring related history of pressure injuries and forgetfulness . The Dehydration CAAalso triggered related use of diuretics. A review of R12's Care Plan dated 01/18/22 indicated a potential nutritional problem related to excessive calories evidenced by a body mass index (BMI- a weight-to-height ratio) of 32.9. R12 will express that her nutritional needs are being met, and she feels supported in dining decisions. The care plan indicated interventions of daily weights, and positive coping behaviors. On 01/25/22 at 09:00 AM R12 reported that the food served most of the time was between warm and cool. She reported that she didn't want to complain about it to make anyone mad or upset. R12 reported that her breakfast and coffee was cold. On 01/26/22 at 12:30 PM R12 reported that her breakfast was cold in the morning, but her lunch was hot. She reported that she was missing a cookie that she ordered with her lunch. On 01/27/22 at 07:50 AM observation of the morning breakfast service was completed. Around 08:00AM the food was plated and loaded onto the transport carts. The food was served on glass plates with either a plastic or metal dome top covering the food. The food arrived in the resident hallway at 08:08 AM. The unit staff began taking trays to the resident's room around 08:10 AM. R8's food tray was delivered to her room at 08:21 AM. R8 reported that the food and coffee were cool to the touch. She stated that it seems to get worse each day. A temperature inspection of the food on 01/26/22 at 11:13 AM revealed the food temperatures in the kitchen to be at or above the acceptable temperature range for dining service. On 01/27/22 at 10:20 AM interview with Dietary Staff CC stated that food temperature is checked for every service than loaded onto the carts to be delivered to the resident's room. He has not been notified of any complaints from the residents of the food being cold during service. An interview completed on 01/27/22 at 01:44 PM with Licensed Nurse (LN) G stated that she was aware the some of the residents complained that the food was cold but not very often. She reported that a microwave is available to reheat the food if a resident needs the food to be reheated. An interview with Administrative Nurse D on 01/27/22 at 01:50 PM reported that she was aware of some complaints about the food temperature and the facility recently acquired dome tops for the plates to help keep the food warm while being transported to the rooms. The facility failed to serve food at an appetizing temperature to resident R12. The deficient practice placed the resident at risk for decreased nutrition and a delay in recovery from rehabilitative services. - The electronic medical record (EMR) documented the following diagnosis for R13: [CONDITION(S)] (low blood pressure), localized [CONDITION(S)] (swelling resulting from an excessive accumulation of fluid in the body tissues), spinal stenosis ([CONDITION(S)] condition of the spine that could cause weakness and loss of use of extremities), acute kidney failure, hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain ), and malaise (vague uneasy feeling of body weakness, distress or discomfort). A review of R13's Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. R13's Nutrition Care Area Assessment (CAA) triggered related to her diagnosis of type two diabetes and the Dehydration CAA related to her use of diuretics. A review of R13's Care Plan dated 01/19/22 indicated she is on a controlled carbohydrate diet. The Care Plan stated R12 will express that her nutritional needs are being met and she feels supported in dining decisions. On 01/25/22 at 08:45 R13 reported that her only complaint about the facility is that the food always cold. She always had to ask staff to reheat it. It never arrived hot or even warm. She reported it tasted good but never hot. On 01/26/22 at 12:45 PM R13 stated that breakfast arrived cold for the morning, but lunch was a little better. On 01/27/22 at 07:50 AM observation of the morning breakfast service was completed. Around 08:00AM the food was plated and loaded onto the transport carts. The food was served on glass plates with either a plastic or metal dome top covering the food. The food arrived in the resident area at 08:08 AM. The unit staff began taking trays to the residents' room around 08:10 AM. R13's food tray was delivered to her room at 08:47 AM. The resident reported that the food was cold when she ate it. A temperature inspection of the food on 01/26/22 at 11:13 AM revealed the food temperatures in the kitchen to be at or above the acceptable temperature range for dining service. On 01/27/22 at 10:20 AM interview with Dietary Staff CC stated that food temperature is checked for every service than loaded onto the carts to be delivered to the resident's room. He has not been notified of any complaints from the residents of the food being cold during service. An interview completed on 01/27/22 at 01:44 PM with Licensed Nurse (LN) G stated that she was aware the some of the residents complained that the food was cold but not very often. She reported that a microwave is available to reheat the food if a resident needs the food to be reheated. An interview with Administrative Nurse D on 01/27/22 at 01:50 PM reported that she was aware of some complaints about the food temperature and the facility recently acquired dome tops for the plates to help keep the food warm while being transported to the rooms. The facility failed to serve food at an appetizing temperature to resident R13. The deficient practice placed the resident at risk for decreased nutrition and a delay in recovery from rehabilitative services. -The electronic medical record (EMR) documented the following diagnosis for R123: [CONDITION(S)] (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), irritable bowel syndrome (abnormally increased motility of the small and large intestines), [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), hypertension (high blood pressure), [CONDITION(S)] (condition characterized by decreased activity of the [CONDITION(S)]), and aftercare following joint replacement surgery. A review of R123's Medicare Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No Care Area Assessments (CAA) completed due to recent admission. R123's Care Plan dated 01/24/22 indicated she requires assistance from one staff at all times to complete activities for daily living related to transfers, ambulation, hygiene, and toileting. The care plan states that R123 will express that her nutritional needs are being met and she feels supported in dining decisions. The Care Plan noted that she is on a regular diet with no restrictions. On 01/25/22 at 10:05 AM R123 reported that every morning the food is either cold or missing items. She stated that items missing from her tray ranged from coffee creamer to being given the wrong foods. She reported her breakfast arrived cold and she did not want to eat it. On 01/26/22 at 12:05 PM she reported that her lunch was nice and hot but her breakfast was cold again. On 01/27/22 at 07:50 AM an observation of the morning breakfast service was completed. Around 08:00AM the food was plated and loaded onto the transport carts. The food was served on glass plates with either a plastic or metal dome top covering the food. The food arrived in the resident hallway at 08:08 AM. The unit staff began taking trays to the resident's room around 08:10 AM. At 08:48 AM R123's food tray arrived at her room. With permission of the resident the food was temperature tested for quality. The food on the resident's plate ranged between 75-80 degrees Fahrenheit. A temperature inspection of the food on 01/26/22 at 11:13 AM revealed the food temperatures in the kitchen to be at or above the acceptable temperature range for dining service. On 01/27/22 at 10:20 AM interview with Dietary Staff CC stated that food temperature is checked for every service than loaded onto the carts to be delivered to the resident's room. He has not been notified of any complaints from the residents of the food being cold during service. An interview completed on 01/27/22 at 01:44 PM with Licensed Nurse (LN) G stated that she was aware the some of the residents complained that the food was cold but not very often. She reported that a microwave is available to reheat the food if a resident needs the food to be reheated. An interview with Administrative Nurse D on 01/27/22 at 01:50 PM reported that she was aware of some complaints about the food temperature and the facility recently acquired dome tops for the plates to help keep the food warm while being transported to the rooms. The facility failed to serve food at an appetizing temperature to resident R123. The deficient practice placed the resident at risk for decreased nutrition and a delay in recovery from rehabilitative services.

The facility identified a census of 21 residents with one kitchen and one main dining room. Based on observation, interview, and record review, the facility failed to ensure sanitary food services and failed to document the daily cleaning and sanitation process. This deficient practice placed residents at risk for food borne illnesses and food safety concerns. Findings Include: - During the initial inspection of the kitchen on 01/25/22 at 07:15 AM the facility's dishwasher sanitation log was missing documentation in December of 2021 for 13 dates (12/13, 12/14,12/17, 12/18, 12/19, 12/21, 12/22, 12/24, 12/25, 12/26, 12/29, 12/30, and 12/31). An inspection of the main oven and fryer area revealed grease covering the top surfaces of the fryer and oven. Several old, cooked French fries sat in area between top burners and fryer. The inside of the oven was covered in a black grease residue with cooked food debris on floor of the oven. The spice rack on the rear wall had dust and spice particles covering the rack and spice bottles. The trash can lid in the oven area had a red sauce dried on it. Inspection of the rear sink area revealed a square pan of apples topped with cinnamon sat uncovered and unattended for more then 10 minutes. The main refrigerator revealed an orange marmalade bottle with no opened date indicating how long it had been opened. Inspection of the ice machine found the outside dirty with grease smudges around the opening. An interview with dietary staff CC on 01/27/22 at 10:00 AM stated that the kitchen staff should be cleaning daily the main areas of the kitchen and a deep cleaning once a week. Kitchen staff are responsible for checking the food stored in the kitchen for dates and expirations. The kitchen staff clean as they go and try not to leave messes behind for the next shift to clean up. The dishwasher should be cleaned twice daily and sanitized. It gets recorded on our daily log. A review the facility's Food Handling policy states that food should be handled in a manner that minimizes the risk of contamination. Food and nutrition employees ensure that food preparation equipment, dishes, and utensils are effectively cleaned, sanitized to destroy potential disease carrying organism and stored in a protective manner. The facility failed to ensure sanitary food services and failed to document the daily cleaning and sanitation process which placed residents at risk for food borne illnesses and food safety concerns.

The facility identified a census of 21 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to ensure that staff did appropriate hand hygiene in between cares for residents and proper disinfecting of equipment used in between resident cares. This deficient practice placed the residents at risked for increased infection and transmission of communicable disease. Findings included: - Observation on 01/26/22 07:43 AM Certified Medication Aid (CMA) S failed to do hand hygiene between rooms 21 to room [ROOM NUMBER] and she used the vital machine on room [ROOM NUMBER] and room [ROOM NUMBER] without disinfecting the blood pressure cuff or pulse oximeter after use. Observation on 01/27/22 08:08 AM unidentified facility direct care staff removed a Hoyer lift (a mechanical lift used to raise and aide in transferring residents from one place to another) from room [ROOM NUMBER] and placed into room [ROOM NUMBER] without disinfecting the equipment. On 01/27/22 at 01:25PM Certified Medication Aide (CMA) R stated that hand hygiene should be done anytime between residents, before and after you enter a resident's room, if your gloves get soiled. The equipment should be sanitized after used with each resident. On 01/27/22 Licensed Nurse (LN) G stated that hand hygiene should be done before entry into a resident's room, before any task with a patient, after any dirty tasks where gloves would get soiled, and when leaving a resident's room. All equipment should be wiped down/sanitized in between patients. On 01/27/21 at 02:18PM Administrative Nurse D stated she would expect staff to do hand hygiene any time the enter or exit a resident's room, before any cares, when gloves get soiled and after taking off gloves. Staff was to clean any equipment used for a resident before and after each resident. The facility policy Infection Prevention and Control Program revised 12/01/19 directed each Society maintained and infection prevention and control program and provided a safe, sanitary and comfortable environment for the residents and employees. The facility failed to ensure that staff demonstrated proper use of hand sanitizer/hand washing in between residents while providing services to residents, and failed to ensure staff properly sanitized shared equipment in between residents after use. These facility failures had the potential to increase the risk for infection and disease to the residents in the facility.

The facility identified a census of 21 residents. The sample included 15 residents with two residents reviewed for reasonable accommodation. Based on observations, record reviews, and interviews, the facility failed to provide Resident (R)12 an alternate method of summoning assistance which relayed directly to nursing staff during a call light system failure on 01/20/22. The deficient practice placed the resident at risk for a delay in care or assistance. Findings included: -The electronic medical records (EMR) documented the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R12's Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS recorded R12 required extensive assistance of two staff members for bed mobility, and transfers and extensive assistance of one staff member for toileting. R12's Nutrition Care Area Assessment (CAA) triggered for monitoring related history of pressure injuries and forgetfulness . The Dehydration CAA also triggered related use of diuretics. The Activities for Daily Living CAA triggered related to decline in strength, generalized weakness and history of pressure injuries. The Falls CAA triggered for impaired gait and weakness. R12's Care Plan states she had an activities of daily living (ADL'S) self-care deficit and she required one staff to assist her with transfers, bed mobility, hygiene, bathing, and toileting. On 01/25/22 at 09:00 AM R12 reported that on Thursday (1/20/22) she woke up and needed to use the restroom in the morning. She pushed her call light to signal the nurse and then waited 40 minutes for the nurse to come in and check on her. R12 reported when the nurse entered the room, she told R12 that the call light system was being worked on and the resident would have to wait on staff to complete rounds. R12 reported that she was given no other way to communicate with staff if an emergency did occur. R12 stated she had a room phone. R12 stated that she was not notified when the call light system went down or when it came back on. R12 stated that every time she does use the call light, it takes the staff 15-25 minute to respond. R12 reported that if she had a real emergency, it would be too late. An interview completed on 01/27/22 at 01:44 PM with Licensed Nurse (LN) G stated when the call light system went out the nurses continually went around and checked on each resident. In an interview with Administrative Nurse D on 01/27/22 at 01:50 PM, she reported that Thursday 01/20/22 the facility's call light system went down due to a bad battery. The residents should have been notified by the nursing staff about the outage. Staff completed continuous room checks until the system was fixed. Administrative Nurse D stated she had not heard any complaints or grievance about the issue. In an email communication dated 02/09/22 at 02:22 PM, Administrative Staff A wrote the call light system failed a little after 05:00 AM on 01/20/22 and remained out until approximately 09:00 AM She wrote when Administrative Nurse D arrived at the facility, she went into the residents' rooms and confirmed that each resident had been alerted to the outage. Administrative Staff A further wrote that review of the camera revealed the following timeline regarding R12 on the [NAME] of 01/20/22: Staff entered R12's room at 05:22 AM and exited 05:24 AM. One hour later, Administrative Nurse D entered R12's room at 06:24 AM, then exited at 06:28 AM. One hour later, staff entered R12's room at 07:30 AM for medication administration and exited at 07:34 AM. Staff reentered the room at 07:36 AM and exited 07:38 AM. Breakfast arrived at 07:52 AM and staff exited the room at 07:56 AM. Thirty-five minutes later, multiple staff entered R12's room at 08:31 AM, 08:32 AM and therapy staff entered at 08:33 AM. Staff left at 08:33 AM,and 08:34 AM, reentered at 08:35 AM and then exited again at 08:39 AM. Therapy staff exited at 09:08 AM. The facility failed to provide an alternate method, which relayed directly to nursing staff, for Resident (R)12 to summon staff for assistance during an call light system failure on 01/20/22. The deficient practice placed the resident at risk for a delay in care or assistance.

The facility identified a census of 21 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to implement a person-centered care plan that included the minimum information necessary to properly care for one resident (R), R14 who required off-site [CONDITION(S)] services, and failed to implement a baseline care plan for R18 who required the use of pressure reducing devices, which had the potential for R14 and R18 to have unmet care needs. Findings included: - R14's electronic medical record (EMR) documented under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R14 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. R14 required supervision to limited assistance of one staff for activities of daily living (ADLs). R14 also received [CONDITION(S)]. The Dehydration/Fluid Care Area Assessment (CAA) dated 01/20/22 documented that R14 required diuretic (a medication that promotes the production of urine) use and [CONDITION(S)]. The [CONDITION(S)] Baseline Care Plan initiated 01/10/22 for R14 documented: The resident needs [CONDITION(S)] related to renal failure; Work with resident to relieve discomfort for side effects of treatment, cramping, fatigue, headaches, itching; observe hydration status; observe for dry skin and apply lotion as needed. Under the Orders tab in the EMR the Order Summary report documented an active order dated 01/21/22 for [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays at 11:00 AM. On 01/27/22 at 01:18 PM Certified Medication Aide (CMA) R stated that the care plan or Kardex should have all the information about cares for the residents that need [CONDITION(S)] care. The nurses were responsible for the assessments for the residents on [CONDITION(S)]. On 01/27/22 at 01:44 PM Licensed Nurse (LN) G stated that the staff nurse that is admitting a resident usually initiated and input information into the baseline care plan and the care plan is updated with any new interventions or care areas as needed. On 01/27/22 at 02:18 PM Administrative Nurse D stated that the admitting nurse entered information into the EMR for a resident's baseline care plan. The baseline care plan should have information about when and where a resident went for [CONDITION(S)] services off-site as well as any special instructions, any monitoring, etc. that staff should need to do. The facility policy Care Plan-Rehab/Skilled revised 09/17/21 defined a baselien care plan includes instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. The policy further recorded a baseline care plan will be developed upon admission according to federal and state regulations. The facility failed to ensure that R14's baseline care plan included the minimum healthcare information necessary to properly care for the resident immediately upon her admission that addressed resident-specific goals and interventions (time, days, location of [CONDITION(S)]; monitoring weight, monitoring fluid intake, documentation pre and post [CONDITION(S)]) needed for [CONDITION(S)] services which placed resident R14 at risk for decline and possible unwarranted adverse side effect and ineffective [CONDITION(S)] treatment. - R18's electronic medical record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R18 required extensive assistance of two staff member for activities of daily living (ADL's). The MDS documented R18 was at risk for pressure ulcers and had no pressure areas noted on admission. R18's Pressure Ulcer Care Area Assessment (CAA) dated 01/21/22 documented she had impaired mobility, left side weakness, and required staff assistance with repositioning. R18's Care Plan dated 01/13/22 documented a pressure reducing mattress on her bed and cushion placed in wheelchair. The Care Plan documented R18 required assistance with being turned and repositioned at least every two hours. The Care Plan lacked documentation of the Bunny boot (pressure reducing device used to prevent and heal decubitus ulcers) and Prafo/Roylan boot (pressure ankle foot orthotic boot) to be worn by R18 when in bed. Review of the EMR under Orders documented physician orders: Skin prep (a solution when applied that forms a protective waterproof barrier on the skin) applied every shift to the back of left heel. If shoes or brace are rubbing on this area pad with foam or [MEDICATION(S)] (an absorbent, foam dressing used to treat wounds and pressure ulcers) every shift dated 01/21/2022. Bunny boot to right foot while in bed for skin protection dated 01/17/202. Prafo/Roylan boot to left ankle while in bed related to foot drop (inability or difficulty in moving the ankle and toes upward), apply every shift dated 01/13/2022. On 01/26/22 at 10:46 AM R18 laid in bed on her back, bilateral lower extremities (BLE) rested on the mattress with no boots observed. On 01/26/22 at 03:07 PM R18 laid in bed, head of bed was elevated and her BLE rested directly on the mattress with no boots observed. On 01/27/22 at 07:56 AM R18 was in bed and her BLE rested directly on the mattress. R18 did not wear any boots on either foot. On 01/27/22 at 09:00 AM R18 sat in her wheelchair. Her BLE rested on her foot pedals of her wheelchair. She did not have any boots on. Licensed Nurse (LN) H applied skin prep to R18's right heel. LN H removed R18's left foot socks and noted her left heel to have a reddened area. LN H placed a pillow behind R18's BLE, to prevent BLE resting on the foot pedals. On 01/27/22 at 01:18 PM in an interview, Certified Medication Aide (CMA) R stated the charge nurse prints a report sheet every day for the staff working on the floor. CMA R stated that on that report sheet has what special equipment each resident needed. On 01/27/22 at 01:44 PM in an interview, Licensed Nurse (LN) G stated the staff nurse that is admitting a resident usually initiated and input information into the baseline care plan and the care plan is updated with any new interventions or care areas as needed. LN H stated the staff working on the floor know what pressure reducing equipment and other measures in place for each resident from the kardex. LN G stated the kardex information is pulled from the care plan and if the information is not placed on the care plan it will not show up on the kardex. On 01/27/22 at 02:17 PM in an interview, Administrative Nurse D stated the admitting nurse entered information into the EMR for a resident's baseline care plan. The baseline care plan should have information about the pressure reducing devices and equipment for each resident's needed. Administrative nurse stated the staff working on the floor would know what special pressure reducing equipment and other devices in place from the kardex for R18. Administrative Nurse D stated everything on the care plans pull forward to the kardex. The facility policy Care Plan-Rehab/Skilled revised 09/17/21 defined a baselien care plan includes instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. The policy further recorded a baseline care plan will be developed upon admission according to federal and state regulations. The facility failed to develop a person centered baseline care plan that included pressure reducing devices ordered for R18, which placed her as risk of development and worsening pressure ulcers.

The facility identified a census of 21 residents. The sample included 15 residents, with one resident reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed ensure pressure reducing measures were placed on Resident (R) 18's bilateral lower extremities to prevent pressure ulcers. This placed R18 at increased risk for pressure ulcer development. Findings included: - R18's electronic medical record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R18 required extensive assistance of two staff member for activities of daily living (ADL's). The MDS documented R18 was at risk for pressure ulcers and had no pressure areas noted on admission. R18's Pressure Ulcer Care Area Assessment (CAA) dated 01/21/22 documented she had impaired mobility, left side weakness, and required staff assistance with repositioning. R18's Care Plan dated 01/13/22 documented a pressure reducing mattress on her bed and cushion placed in wheelchair. The Care Plan documented R18 required assistance with being turned and repositioned at least every two hours. Review of the EMR under Orders documented physician orders: Skin prep (a solution when applied that forms a protective waterproof barrier on the skin) applied every shift to the back of left heel. If shoes or brace are rubbing on this area pad with foam or [MEDICATION(S)] (an absorbent, foam dressing used to treat wounds and pressure ulcers) every shift dated 01/21/2022. Bunny boot (pressure reducing device used to prevent and heal decubitus ulcers) to right foot while in bed for skin protection dated 01/17/202. Prafo/Roylan boot (pressure ankle foot orthotic boot) to left ankle while in bed related to foot drop (inability or difficulty in moving the ankle and toes upward), apply every shift dated 01/13/2022. On 01/26/22 at 10:46 AM R18 laid in bed on her back, bilateral lower extremities (BLE) rested on the mattress with no boots observed. On 01/26/22 at 03:07 PM R18 laid in bed, head of bed was elevated and her BLE rested directly on the mattress with no boots observed. On 01/27/22 at 07:56 AM R18 was in bed and her BLE rested directly on the mattress. R18 did not wear any boots on either foot. On 01/27/22 at 09:00 AM R18 sat in her wheelchair. Her BLE rested on her foot pedals of her wheelchair. She did not have any boots on. Licensed Nurse (LN) H applied skin prep to R18's right heel. LN H removed R18's left foot socks and noted her left heel to have a reddened area. LN H placed a pillow behind R18's BLE, to prevent BLE resting on the foot pedals. On 01/27/22 at 01:18 PM in an interview, Certified Medication Aide (CMA) R stated the charge nurse prints a report sheet every day for the staff working on the floor. CMA R stated that on that report sheet has what special equipment each resident needed. CMA H stated the nurse would sign off for the pressure reducing equipment on the Treatment Administration Record (TAR). On 01/27/22 at 01:44 PM in an interview, Licensed Nurse (LN) G stated the staff working on the floor know what pressure reducing equipment and other measures in place for each resident from the kardex. LN G stated the kardex information is pulled from the care plan and if the information is not placed on the care plan it will not show up on the kardex. LN G stated the charge nurse does sign off on the TAR for the special pressure reducing equipment ordered for the resident on the TAR. On 01/27/22 at 02:17 PM in an interview, Administrative Nurse D stated the staff working on the floor know what special pressure reducing equipment and other devices in place from the kardex for R18. Administrative Nurse D stated everything on the care plans pull forward to the kardex. The facility Pressure Ulcers-Rehab/Skilled, Therapy and Rehab policy with reviewed/revised date of 02/10/21 documented to provide appropriate assessment and prevention of pressure ulcers, as well as treatment when necessary. The facility failed to implement pressure reducing measures for R18, who was at risk for pressure injuries. This placed R18 at increased risk for pressure/skin injuries.

The facility identified a census of 21 residents. The sample included 15 residents. One resident (R) was sampled for [CONDITION(S)] (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review and interview, the facility failed to ensure there was ongoing communication and collaboration with the [CONDITION(S)] facility regarding [CONDITION(S)] care and services, and failed to monitor R14's [CONDITION(S)] access port (a vascular access to the bloodstream) daily, which had the potential for unwarranted and unidentified physical complications related to [CONDITION(S)]. Findings included: - R14's electronic medical record (EMR) documented under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R14 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. R14 required supervision to limited assistance of one staff for activities of daily living (ADLs). R14 also received [CONDITION(S)]. The Dehydration/Fluid Care Area Assessment (CAA) dated 01/20/22 documented that R14 required diuretic (a medication that promotes the production of urine) use and [CONDITION(S)]. The [CONDITION(S)] Care Plan initiated 01/10/22 documented that R14 needs [CONDITION(S)] related to renal failure and to monitor [CONDITION(S)] site in right chest for signs and symptoms of infection. Under the Orders tab the Order Summary documented an order dated 01/21/22 for [CONDITION(S)] on Tuesdays, Thursdays and Saturdays at 11:00AM. The Treatment Administration Record lacked any documentation for monitoring R14's right chest port area for signs and symptoms of infection. The facility provided two [CONDITION(S)] Communication Sheet that were reviewed from R14's visits one was dated 01/18/22 and signed by facility staff and the [CONDITION(S)] clinic staff. The other communication sheet was not dated nor was it signed by any staff member or [CONDITION(S)] staff. The following were [CONDITION(S)] dates that R14 attended but the facility was unable to provide a communication sheet on 01/11/22, 01/13/22, 01/15/22, 01/20/22, 01/22/22, and 01/25/22. The Treatment Administration Record lacked any documentation for monitoring R14's right chest port area for signs and symptoms of infection. On 01/26/22 at 01:15PM R14 sat in her wheelchair in her room watching television, her bedside table in front of her, her call light was in reach. On 01/27/22 at 01:18PM Certified Medication Aide (CMA) R stated that on the days that a resident goes to [CONDITION(S)] the aide would get the weight and vital signs for the resident, and the nurse assessed the resident. On 01/27/22 at 01:58 PM Licensed Nurse (LN) D stated when the facility admits a resident who required [CONDITION(S)], staff would get a referral and case management from the hospital would notify facility management. Facility management would then set up transportation, get the resident scheduled for [CONDITION(S)] according to the orders that were received. The night shift nurse typically prepared all the paperwork for any appointments for the next day, including the [CONDITION(S)] Communication Sheet. The staff nurse assessed the resident prior to going to [CONDITION(S)] and would enter any new information received when the resident returned from [CONDITION(S)]. She further stated that the facility did not always get the communication sheets back when a resident returned from their appointment. On 01/27/22 at 02:18PM Administrative Nurse D stated that they have been trying to get the [CONDITION(S)] clinic to do a better job at making sure that the communication sheet is sent back with resident when a resident is finished at the appointment. The facility typically does not call the [CONDITION(S)] clinic to request them to send them the form unless the resident had and issued upon returning to the facility. The night shift nurse was responsible for preparing any paperwork for the next day appointments. The day shift nurse would obtain the resident's vital signs and get their weights prior to the [CONDITION(S)] appointment, then would send the packet with the paperwork along with the resident and the driver. Upon return to the facility if the paperwork was returned the resident would be assessed again, and any paperwork would be entered into the resident EMR in a communication note. The facility has been working to improve on the communication with the [CONDITION(S)] facility. The facility policy [CONDITION(S)] Services-Rehab/Skilled revised 09/17/21 documented: Locations caring for residents receiving [CONDITION(S)] services must have an agreement in place with the provider of the service. Residents who require [CONDITION(S)] services may have those services provided at an outside [CONDITION(S)] service or by a contract [CONDITION(S)] company which assist with the provision of [CONDITION(S)] services at the location. The Clinical Monitoring-[CONDITION(S)] UDA is available in Point Click Care (PCC) for use in monitoring the resident receiving [CONDITION(S)] The facility failed to retain [CONDITION(S)] communication sheets, and failed to monitor R14's [CONDITION(S)] access port daily, which had the potential for adverse outcomes and unwarranted physical complications related to [CONDITION(S)].

The facility identified a census of 21 residents. The sample included 15 residents, which five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure antihypertensive medications (class of medication used to treat high blood pressure) were administered as ordered and physician notification for blood sugar outside ordered parameters for Resident (R) 120. This placed R120 at risk for unnecessary medication use and unwarranted side effects. Findings included: - R120's electronic medical record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) was in progress. R120's Care Area Assessment (CAA) was in progress. R120's Care Plan dated 01/15/22 documented he would be free from any signs or symptoms of [CONDITION(S)]. The Care Plan documented he would be free from discomfort or preventable adverse reactions related to medication. Review of the EMR under the Orders tab revealed physician orders: [MEDICATION(S)] (antihypertensive) tablet extended release (ER) 24 hour, give 25 milligrams (mg) by mouth one time a day for hypertension, hold for systolic (relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) blood pressure (SBP) less than (<) 110 millimeters of mercury (mmHg) or heart rate (HR) <60 beats dated 01/18/2022. Blood sugars before meals and at bedtime, notify physician of blood sugars greater than (>) 350 or < 60 dated 01/14/2022. Review of the EMR under Reports under Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R120s' clinical record and EMR lacked documentation of physician notification of blood sugar on 01/22/22 of 398. On 01/26/22 at 12:00 PM R120 sat on the side of his bed, consumed 100% of his lunch without assistance. On 01/27/22 at 01:44 PM in an interview, Licensed Nurse (LN) G stated the Certified Medication Aides (CMA) would notify the charge nurse of and vital signs obtained that were outside the physician ordered parameters. LN G stated the charge nurse would complete an assessment and notify the physician if needed. LN G stated the charge nurse would document in the EMR under the progress notes and new orders, assessments or physician notification. On 01/27/22 at 02:17 PM in an interview, Administrative Nurse D stated the charge nurse would complete an assessment of the resident if any vital signs or blood sugar was outside the physician ordered parameters. Administrative Nurse D stated she had been unable to locate the documentation that the physician was notified on 01/22/22 of the blood sugar of 398. The facility Medication-Drug Regimen Review-Rehab/Skilled policy with a reviewed/revised date of 01/25/22 documented the purpose is to prevent medication errors that could cause harm to a resident or result in hospitalization and to identify the potential for adverse reaction. The facility Notification of Change-Rehab/Skilled policy with a reviewed/revised date of 05/27/21 documented the facility must immediately notify the physician when a need to alter treatment significantly- a need to discontinue or change an existing form of treatment or to commence a new form of treatment. The facility failed to ensure that the physician was notified when blood sugar was > 350 and failed to ensure antihypertensive medication was held as ordered for R120. This deficient practice had the potential for unnecessary medication use and possible unwarranted side effects.

The facility identified a census of 21 residents. The sample included 15 residents with one resident reviewed for food preferences. Based on observations, record reviews, and interviews, the facility failed to provide R11 with food ordered on his dietary menu and did not notify of changes or substitutions to his meal. This deficient practice placed the resident at risk for malnutrition and impaired quality of life. Findings included: -The electronic medical record (EMR) documented the following diagnosis for R11: hypertension (high blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), [CONDITION(S)] (condition characterized by decreased activity of the [CONDITION(S)]), Irritable bowel syndrome (abnormally increased motility of the small and large intestines), constipation (difficulty passing stools), malaise (vague uneasy feeling of body weakness, distress or discomfort), [CONDITION(S)] (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain), and aftercare for joint replacement surgery. A review of R11's Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. R11's Nutrition Care Area Assessment (CAA) was triggered for monitoring related to his recent right hip replacement. The Dehydration CAA also triggered related to his poor fluid intake and history of falls. A review of R11's Care Plan dated 01/20/22 revealed he was on a cardiac diet related to excessive calorie intake and a high body mass index (BMI- a weight-to-height ratio) of 34.5. The Care Plan indicated R11 was at risk for skin breakdown and dehydration. The intervention listed on the plan of care indicated monitoring nutritional intake, offer resident drinks of choice, and monitor resident. On 01/25/22 at 11:00 AM R11 reported that every time he would order food from the kitchen, he would be missing items he ordered. He would order coffee and no milk or sugar. He stated that he would have to ask multiple times until he either got what he needed or just gave up. R11 stated the dietary department would not tell him if they were running low or out of something. He stated that he is not notified if something on his chosen menu was being substituted. On 01/27/22 at 10:20 AM interview with Dietary Staff CC stated that the resident's meals are prepared based on the dietary tickets the residents complete. If a resident is on a special diet, we cannot give them certain food that may be restricted due to health concerns. If an item is not available, we can offer a choice of a substitute item. I have not received any complaints about missing items or resident meal concerns. An interview completed on 01/27/22 at 01:44 PM with Licensed Nurse (LN) G stated that she was aware the some of the residents complained about residents missing things they order or getting things they didn't order. If a resident has a concern or issue staff can easily fix the issue by contacting the kitchen. An interview with Administrative Nurse D on 01/27/22 at 01:50 PM reported that she was aware of some complaints about the resident's food orders and have talked to the dietary department about looking at the tickets before the food is taken to the resident. The facility failed to provide R11 with food ordered on the dietary menu and did not notify of changes or substitutions to his meal. This deficient practice placed the resident at risk for malnutrition and impaired quality of life.

The facility reported a census of 27 residents. The sample included 6 residents. Based on observation, record review and interviews the facility failed to ensure one resident was free from neglect when staff failed to provide necessary assistance and assistive devices to Resident (R) 1 to prevent falls and injuries. R1 required physical assistance from one staff member with staff stabilization via a gait belt (belt used to help transfer a person from one place to another). R1 also required the use of a walker (four-legged device used to provide stability while walking). These assistive devices as well as the staff assistance were not provided to R1 on two occasions which led to a fall on both occurrences. The second fall resulted in a major injury which required immediate medical intervention at an acute care hospital. Findings included: - R1's Electronic Medical Record (EMR), under the [DIAGNOSES REDACTED]. The Entry tracking Minimum Data Set (MDS) documented the resident admitted on [DATE] The Discharge Return Anticipated MDS assessment, dated 10/14/19, recorded the Brief Interview for Mental Status (BIMS) assessment was not completed. It documented R1 had no behaviors or rejection of cares. It recorded the resident used a walker and a wheelchair for mobility. The MDS documented R1 had two or more falls since admission with one fall resulting in an injury. The Care Plan dated 10/11/19 recorded R1 was at risk for falls related to pain and weakness. It directed staff to ensure R1 was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan lacked specifics regarding what kind of footwear. On 10/14/19 the care plan was updated to document the resident had an actual fall and directed staff that R1 required staff assistance with mobility, but lacked specifics regarding the amount of assistance. On 10/15/19, one day after R1 discharged , staff updated the care plan and recorded R1 had a self-care deficit. The care plan indicated that R1 required assistance of one staff member with a gait belt . The Occupational Therapy Treatment Encounter Note, dated 10/11/19, recorded Occupational Therapy (OT) evaluated R1 on that date. It documented R1 had decreased activity tolerance, decreased standing balance, and generalized weakness. It further revealed she was a high fall risk. R1 required contact guard assistance (CGA- hands on assistance) from staff and a walker for functional ambulation. The Physical Therapy Treatment Encounter Note, dated 10/11/19, recorded R1 required CGA, staff assistance, and walker for standing, pivoting, and toilet transfers. A Progress Note dated 10/12/2019 at 07:16 PM, recorded R1 was found on the floor in middle of room with her walker. She denied any injury or pain. Staff educated the resident on taking time to sit down prior to attempting to kick her shoes off. Nursing staff educated R1 about using her walker for balance and safety. R1 acknowledged the teaching and tolerated well. She requested preventative pain medication for stiffness she expected to have later in the night. Staff then assisted R1 into bed, changed the dressing to her right knee, and placed her call light within reach. A Progress Note dated 10/13/19 at 04:00 PM, documented at 03:30 PM on that date, Certified Medication Aid (CMA) R called Licensed Nurse (LN) G in to R1's room. LN G observed R1 sitting on her buttocks next to her bed. R1 stated that her walker was not in reach and she had wanted to grab something from under her bed. R1 rated her pain an eight out of 10 (zero to 10 scale with 10 being the worst), so staff administered a pain pill. Staff educated R1 to use her call button when she needed assistance getting up. Staff notified R1's Durable Power of Attorney (DPOA). The Incident Audit Report initiated by LN G on 10/13/19 documented the resident was attempting to get something off the floor. R1 did not want to wait and thought she could perform the task on her own. Staff educated her to use the call light to call for staff assistance. It further recorded R1's walker was out of reach at the time of the fall. CMA R left the walker out of R1's reach in order to discourage her from transferring independently because R1 had a fall the day prior. CMA R received education to keep assistive devices within reach. A Progress Note dated 10/14/2019 at 12:47 PM recorded Certified Nurse Assistant (CNA) M called LN H to the resident's bathroom. LN H observed R1 laying on her left side on the ground with a visible bone protruding from her left knee. R1's surgical site was open and blood was visible. R1 was not wearing a gait belt at the time. There were towels on the floor before the shower. LN H then called the ambulance and sent R1 to the acute care hospital. While waiting for the ambulance, staff covered R1 with blankets to keep her warm and clean towels were placed around her wound for the bleeding. Per CNA M's statement, CNA M and R1 were walking into the shower. When R1 stepped into the shower, she lost her balance and landed on her knee . The Incident Audit Report dated 10/14/19 created by LN H, recorded LN H went to R1's bathroom. R1 was lying on her left side on the ground. LN H assessed R1 and observed the surgical site to R1's right knee was open and bone was visible. The report documented R1 was alert to herself and her whereabouts It further documented R1 had a predisposing factor of gait instability. The report recorded predisposing situation factors of improper footwear. It further revealed that the gait belt and the walker were not being used during the transfer into the shower. The report documented CNA M attempted to transfer R1 into the shower holding her arm for support when the resident slipped and fell . R1 was taken to the hospital via ambulance. On an undated, signed Witness Statement CNA M documented she prepared R1's bathroom so R1 could get a shower before her doctor appointment. She reported R1 sat on the toilet, undressed, and walked toward the shower, CNA M documented R1 had been walking around the room by herself so CNA M did not place a gait belt on R1. CNA M documented that R1 placed her right hand on the right handrail, stepped to reach the rail in front of her, and slipped on the wet shower floor. CNA M documented R1's leg bent under her and R1 went down on her bad knee. CNA M further recorded that she went across the hall to get the nurse, after helping to lower R1 all the way to the floor. CNA M also summoned Therapy GG from the hall. Therapy GG sat with R1 while CNA M got blankets to cover R1 as CNA M knew she'd be in shock. The blood was running immediately. In a signed Witness Statement dated 10/14/19 Therapy GG documented she heard yells for help coming from the hallway. She found CNA M who told her we need help. Therapy GG documented that at approximately 09:00 AM she entered R1's room and observed R1 laying half in and half out of the shower, on the floor. R1 was naked and there was no gait belt observed on the resident. The resident's walker was over the toilet, not near the resident. R1's oxygen was not on. R1's knee incision was completely split open and bleeding. The hardware of the knee replacement was visible. LN H and LN I were assisting and LN H called 911. Therapy GG requested CNA M get a blanket to cover R1 as well as R1's supplemental oxygen and glasses. Therapy GG documented R1 began crying and was very upset with what happened. R1 asked for her cell phone in order to call her family. Therapy GG left the room when emergency services arrived. The notarized Witness Statement dated 10/16/19 recorded LN H went into the resident's room. Upon entering, she observed R1 lying on the bathroom floor, naked. There was blood on the ground. R1's knee was open and bone was visible. Staff activated Emergency 911 services and the resident was sent to the hospital. The statement recorded staff covered R1 with blankets to stay warm. Prior to the fall, the resident had drainage to her surgical site. The surgeon was aware and the resident had an appointment with the surgeon later that day. LN H documented R1 insisted on a shower to clean off the drainage before her appointment. A Corrective Action Notice for CNA M dated 10/16/19 recorded administrative staff suspended CNA M following an investigation of a patient fall. The investigation found that CNA M ambulated a patient in the bathroom without the use of a gait belt or walker. The notice recorded that CNA M received a report sheet (tool used to describe the cares required by the residents) that stated the patient required assistance of one staff with a walker. It further recorded CNA M failed to follow the policy of using a gait belt when ambulating or transferring patients' which was a violation of safety. On 10/25/19 CNA M was unavailable for interview. In an interview on 10/25/19 at 12:05 PM, CMA R stated her job was to give showers, pass medications, do laundry and anything else that came up. She stated staff get Abuse, Neglect, and Exploitation training yearly on the computer training site. She reported she knew that neglect was intentionally or unintentionally not taking care of a resident, whether on purpose or not. She stated nursing staff knew how to care for the residents by the report sheet and they received verbal report as well. CMA R then pulled out a piece of paper and an observation was made of a paper report that contained detailed information regarding the resident's needs. She stated staff could also access the Kardex (electronic tool which tells staff specific care needs for the residents) in the Point Click Care (electronic medical record system) to see the care plan for each resident. She stated she is not sure how often staff updated the report sheets because she does not do it. CMA R reported that when somebody is CGA, that means she has to have her hands on them at all times. She further stated for CGA residents, she would almost always use a gait belt. She reported the facility had whiteboards that hang in the resident's rooms and they had pegs on them and that's where staff would place the gait belt. CMA R stated she could not think of a reason why staff would not use in a gait belt during a transfer or while ambulating a resident who required staff assistance and CG[NAME] CMA R reported that if a resident who needed staff assistance needed a shower, she would use every possible safety assurance including gait belts, walkers etc. CMA R reported staff could not keep R1 from getting out of her bed or chair. CMA R stated that Sunday, (MONTH) 13th R1 was sitting in her chair and her walker was placed against the window to her left. CMA R said she did not think R1 would have needed to stand to reach the walker, but she would have needed to lean over really far in order to reach it. CMA R said that LN G did provide her some education or correction to leave the walker in the resident's reach. She stated that R1 could walk, but she would become unsteady very fast. R1 was very unpredictable. When R1 fell on the 13th, she skinned her knee and staff placed a band-aid. In an interview with R1's DPOA/Family Member (FM) on 10/25/19 at 01:15 PM, FM stated she was aware of R1's falls. She said that on 10/13/19, had called her to tell her she had fallen. She said that R1 stated she was sitting in her recliner and she wanted to get back in bed. R1 told FM that the call light was out of reach and tied around the bedrail. R1 went on to inform FM that her walker was also out of reach and that was why she did not use it. The FM reported that R1 requested a shower prior to her follow up appointment with the orthopedic (bone and joint) surgeon on Monday. The FM stated that R1 reported to her that CNA M came into the room at approximately 09:00 AM to give her shower though R1 was due at her appointment in one hour. The FM stated R1 said she felt rushed. FM stated R1 had told her that staff did not use the gait belt and she thought the walker was in the bathroom, but could not remember. R1 told FM that after the fall, she laid on the floor, naked, for what seemed like a long time. The FM reported R1 told her that she felt very cold and exposed, and stated that staff did not cover her up right away. In an interview on 10/25/19 at 01:05, LN G stated the nursing staff knew how people transfer by the report sheet. The information stays on there every day. And the sheets are updated each shift. All the nursing staff were provided with a copy at the beginning of their shifts. LN G stated that while anybody could create the care plans, the admission nurse makes the initial basic care plan. She stated that how the resident transferred should be covered in the basic care plan. LN G stated the nurses do a fall assessment when a resident was admitted , If the resident triggered for high risk for falls, LN G thought it should probably be added to the care plan. She would expect staff to use a gait belt on CGA assistance people. LN G said that her expectation for showering would be for staff to use a gait belt, ensure non-slip socks are on the resident and assist the resident completely into the shower, to a seated position, before removing the gait belt and non-slip socks. LN G stated she remembered R1 and remembered the day that R1 fell (10/13/19). LN G stated R1 required one person staff assist, with a walker and gait belt. LN G stated she thought R1 mentioned that she did not have her call light next to her chair. It was over by her bed. LN G stated when she went to R1's room and said something about the walker, R1 said the walker was way over there and R1 could not reach it. At that point CMA R stated, yeah that's the point. LN G said CMA R thought she should place the walker out of the resident's reach as a safety precaution. LN G stated she educated CMA R that the walker should always be placed within reach. LN G said the resident did not have any injury that she knew about. LN G stated staff received abuse training yearly. LN G defined neglect as failing to give the patient the care and attention that they need and is required based off their situation. In an interview on 10/25/19 at 01:48 PM, Administrative Nurse D stated nursing staff knew how to care for the residents by the Kardex and by the report sheet. She stated CGA means assistance with holding onto a gait belt and staff were to maintain contact with the resident. She also explained that even residents who were stand by assist (SBA) would still need to have a gait belt. Administrative Nurse D stated the process for showering residents who required staff assistance included ambulating the resident completely into the shower as appropriate with a gait belt. Administrative Nurse D said that when R1 fell on the 13th, CMA R had been in R1's room, offered to help the resident, and educated R1 to call for assistance. R1 was later found on the floor by CMA R. R1stated that she lost her balance and fell . Administrative Nurse D said when she asked CMA R about the incident, CMA R said she pushed the walker out of reach of the resident because she did not want R1 to stand up on her own. CMA R reported the call light was attached to R1's chair, but was unsure if that was documented anywhere. Administrative Nurse D stated the CNAs stated there were times when the call light may have been in the bed because the resident was moving from location to location without taking her call light with her. Administrative Nurse D reported staff notified R1's family about the fall on the 13th. She said she knew there were no interventions put into place for that fall and that the care plan had not been updated. Administrative Nurse D stated that on the 14th, R1 had an appointment scheduled with the surgeon because her incision had been draining a lot. The resident requested a shower before the appointment. CNA M went to the resident's room to get her. Administrative Nurse D stated they believed R1 had taken herself into the bathroom, undressed herself, and then tried to get into the shower. She further stated R1's walker was in the bathroom, but the CNA did not use it and did not use a gait belt. The resident's knee buckled, she went down, and the incision opened. Administrative Nurse D stated she knew that CNA M received report and on that report sheet it did say the resident was CGA with a walker. Administrative Nurse D confirmed that CNA M said she saw R1 walk herself to the bathroom, so she thought it was okay for R1 to walk on her own. R1 was alert when she left the facility and requested her cell phone so she could call her family. Administrative Nurse D stated it was her understanding R1 admitted to the hospital and required sutures for the opened surgical incision. In an interview with Consultant Physician Extender HH on 10/28/19 at 01:20 PM, Consultant HH reported the fall had resulted in full exposure of the prosthesis (knee hardware) which required a surgical intervention. She stated that even prior to the fall, R1's post -operative course had been complicated, but since the fall R1 would now be non-weight bearing and needed to wear a full leg immobilizer to her right leg for several weeks. She further reported that due to the full exposure of the hardware in the environmental condition of a bathroom where the fall occurred, the resident required ongoing intravenous (IV-injected directly into the bloodstream via a vein) antibiotics and an extended stay in a rehabilitation facility. The facility policy titled Abuse Definitions, revised 9/17, documented the definition of neglect as failure of the location, it's employees, or service providers to provide goods and services that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility failed to prevent neglect of R1 when they failed to provide R1 her walker, staff assistance, and use of a gait belt. This deficient practice caused actual harm to R1 as she sustained an injury which required a surgical intervention at an acute care hospital. Due to the injury, R1 became non weight bearing, required a full leg immobilizer, IV antibiotics and prolonged rehabilitation.

The facility identified a census of 14. The sample included four residents. Based on record review, observation, and interviews, the facility failed to transcribe and administer a physician's orders [REDACTED]. R1 subsequently developed a [MEDICAL CONDITION] ([MEDICAL CONDITION]- a blood clot, usually in the legs) in the left lower leg. Findings included: - R1's electronic medical record (EMR) under the [DIAGNOSES REDACTED]. The Progress Note dated 9/1/19 in R1's paper chart recorded a chief complaint of a left [MEDICAL CONDITION] and open reduction and internal fixation (ORIF-open reduction and internal fixation, a type of surgical procedure used to fix broken bones) of the left hip. The Entry Minimum Data Set (MDS) documented R1 admitted to the facility on [DATE]. The Admission MDS was in progress and not yet completed. The resident's baseline care plan created on 8/31/19 lacked interventions related to [MEDICAL CONDITION] prevention and/or treatment. The baseline care plan created on 8/31/19 recorded R1 had acute pain related to left [MEDICAL CONDITION] with ORIF. It directed staff the resident was able to alert staff when she was in pain and ask for medication. The hospital Discharge Instructions dated 8/30/19, received by the facility and located in R1's paper chart, recorded a physician's orders [REDACTED]. The paper orders were signed off on the bottom of the page by Consultant GG on 9/1/19. The pharmacy 'Shipping Manifest, dated 8/30/19 at 07:05 PM, documented a prescription for [MEDICATION NAME] 40 mg/0.4 milliliters (ml) syringes for R1 was filled and delivered to the facility on [DATE]. A Progress Note from Consultant Practitioner GG dated 9/1/19 recorded a medication list which included [MEDICATION NAME] 40 mg/0.4 ml every day for 10 days. A Progress Note from Consultant Practitioner GG dated 9/2/19 recorded a medication list which included [MEDICATION NAME] 40 mg/0.4 ml every day for 10 days. It further documented R1 had a trace of non-[MEDICAL CONDITION] in her ankles. A History and Physical by Consultant Physician HH recorded a medication list which included [MEDICATION NAME] 40 mg/0.4 ml every day for 10 days. It further documented R1 had no [MEDICAL CONDITION]. The Plan on the History and Physical recorded [MEDICATION NAME] for [MEDICAL CONDITION] therapy. Review of the Medication Administration Record [REDACTED]. A Summary of Skilled Services-Daily Skilled Note note dated 9/1/2019 at 12:24 PM recorded R1 was receiving skilled services related to left hip ORIF. The note recorded R1 had no [MEDICAL CONDITION] (swelling). A Summary of Skilled Services - Daily Skilled Note note dated 9/3/2019 at 09:48 AM recorded R1 had a surgical incision that was intact and covered with a dry dressing and no signs or symptoms of infection were noted. It further recorded R1 had no [MEDICAL CONDITION]. A Summary of Skilled Services - Daily Skilled Note note dated 9/4/2019 at 08:48 AM recorded R1 had +2 (scale used to grade [MEDICAL CONDITION], two would generally indicate a three to four millimeter indentation with a rebound time of 15 seconds or less) [MEDICAL CONDITION] to her left foot and ankle and pain in the left hip with weight bearing activity. It further recorded R1 had [MEDICAL CONDITION]-embolic deterrent (TED) stockings on. A Progress Note by Consultant Practitioner II dated 9/4/19 documented that medications were reviewed and instructed reader to Please see MAR. The History of Present Illness section on the Progress Note documented R1 was not currently receiving any anticoagulation ( blood-thinner) medications and that the hospital notes, no date mentioned, indicated the resident was not a candidate for anticoagulation due to falls. The note recorded R1 had a trace of [MEDICAL CONDITION] to the left lower extremity, and TED stockings in place. It further documented under the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. It ordered a venous doppler of the left lower extremity from knee to ankle for a [DIAGNOSES REDACTED]. The test was ordered for 9/5/19. A Summary of Skilled Services - Daily Skilled Note note dated 9/5/2019 at 09:13 AM documented R1 had a venous doppler, set up for that day, to left lower extremity (LLE) due to increased pain and [MEDICAL CONDITION] to the LLE. A Patient Report with a date of service of 9/5/19 documented the venous doppler (Left Duplex Scan, Veins, Extremity) was performed and the physician impression (results) recorded There is [MEDICAL CONDITION] seen in the left lower extremity. Follow-up recommended. A Progress Note by Consultant Practitioner JJ dated 9/5/19 recorded under the Medication section the MARS were reviewed at that time and also noted no current anticoagulation for [MEDICAL CONDITION] prevention was previously on the physician's orders [REDACTED]. Under the Diagnosis, Assessment and Plan section, a [DIAGNOSES REDACTED]. It further documented the resident had no complaints of pain, and [MEDICATION NAME] and [MEDICATION NAME] (oral anticoagulation medication which requires frequent blood tests to monitor for effectiveness) per protocol. It documented that administration and nurse were notified that R1 was not on anticoagulant as ordered at admission. A Physicians Orders sheet written and dated 9/5/19 by Consultant Practitioner JJ recorded an order for [REDACTED]. At that time, the order instructed staff to discontinue the [MEDICATION NAME]. It ordered the [MEDICATION NAME] and INRs would continue for three months for a [DIAGNOSES REDACTED]. The MAR/TAR for (MONTH) 2019 recorded an order dated 9/5/19 for [MEDICATION NAME] Solution 30 mg/0.3 ml. Inject 0.3 ml two times a day for [MEDICAL CONDITION]. The MAR/TAR documented the first administration at bedtime (HS-medical abbreviation used to denote bedtime) on 9/5/19. An observation on 9/10/19 at 02:00 PM revealed R1 lying in bed, on her right side. No [MEDICAL CONDITION] or redness were visible to the left lower extremity . R1 stated she was in the facility to get stronger to try to return to her new apartment. She stated she knows a test was done to check for a blood clot. She also reported staff are now giving her shots in the stomach every morning. She reported she knows she is now taking [MEDICATION NAME] and reported feeling uncomfortable with that because her husband had been on [MEDICATION NAME] and she knew it required a lot of tests and required the person to be very careful not to get any injuries due to the risk for bleeding. In an interview on 9/10/19 at 02:49 PM Licensed Nurse (LN) G stated that when the facility received a new admission, the receiving nurse was responsible for transcribing the discharge orders received from the hospital. She stated occasionally the facility had an admissions nurse that may do (transcribe) the orders but usually, it was the admitting nurse's responsibility to put in the orders. She stated the next nurse on duty was responsible for reviewing the orders for accuracy and that she believed a third nurse was supposed to audit the orders as well. She stated the hospital sent the discharge orders for R1 over to the facility approximately one hour before the resident arrived. LN G stated she faxed the orders to the pharmacy and began entering the orders into the EMR. She stated when R1 arrived, at around 04:45 PM, she was reviewing the discharge paperwork which was with the resident from the hospital and noted it contained a physician order [REDACTED]. LN G stated she instructed the oncoming nurse the orders needed reconciliation and some of the orders were not yet entered. In an interview on 9/10/19 at 03:17 PM with Administrative Staff A and Administrative Nurse D, Administrative Nurse D stated that when the facility gets an admission, the admission nurse received the hospital packet and inputs the medications into Point Click care (PCC- the EMR used in the facility). The admissions nurse was the nurse receiving the admission. She stated there was a checklist which instructs nursing staff to put in the orders, do assessments and completethe packet. Any admission after 05:00 PM, the night nurse should complete but the day nurse still puts in the orders. After the admission was complete, the oncoming nurse would review the orders. Administrative Nurse D stated she usually does care plan reviews and checks to see if a double check was done and a checklist filled out. She stated she discards the checklist after she reviews it and stated she did not have the checklist from R1's admission. She said she double checks to ensure the orders are in the system, the black box warnings were documented and the care plans were completed. She said she doesn't always check to see if the all medication orders were put in or do a medication reconciliation. She stated the MDS coordinator also does a review or reconciliation to review home medications. Administrative Nurse D stated the facility did not identify the medication error.,The nurse practitioner pointed the error out after the doppler study showed R1 had a [MEDICAL CONDITION]. Administrative Nurse D stated verbal education had been done with LN H and disciplinary action was pending for LN G and LN H. In a telephone interview on 9/11/19 at 02:35 PM LN H stated responsibility for entering orders belongs to the nurse on duty when the resident arrives, or admits. She said the facility has an admission checklist that the nurses were to initial as each task is completed. LN H reported if the tasks are not done at the end of the shift, the oncoming nurse should complete the tasks and initial the checklist. LN H stated she was aware of the medication error for R1 as it was brought to her attention a few days ago. She stated she received education to review the medications and reconcile the medication list. LN H stated that R1 had admitted late in the day shift. She reported the day nurse, LN G, had reported R1 had a [MEDICAL CONDITION] and three incisions. LN H stated LN G reported that staff faxed all physician medication orders to the pharmacy and should be coming out with the next delivery but could not remember if LN G had reported that there were still medications that had not been entered and transcribed into the EMR and onto the MAR/TAR. In a telephone interview on 9/12/19 at 09:44 AM, Consultant Practitioner JJ reported she was familiar with the situation with R1. Consultant Practitioner JJ confirmed she identified the medication error and reported it to the facility the day she identified it. She stated the resident's medications would have been reviewed on the initial visits and by the physician during the History and Physical. She stated the discharge orders sent from the hospital, which were reviewed by the physician and the other nurse practitioners clearly instructed the facility to administer [MEDICATION NAME]. She confirmed the [MEDICATION NAME] was prescribed on the discharge orders for [MEDICAL CONDITION] prevention, and that anticoagulation was considered routine care after the ORIF performed on R1. Consultant Practitioner JJ confirmed that in response to the [MEDICAL CONDITION] found on R1's LLE, she prescribed a concurrent therapy of [MEDICATION NAME] and [MEDICATION NAME]. She indicated she expected R1 to require on going anticoagulation with [MEDICATION NAME] for several months. The undated facility Admission/Readmission Checklist recorded that if there was no admit nurse, admissions arriving prior to 05:00 PM must be started by day shift with minimum completion of .order entry/confirmation. It further instructed staff to enter and note orders. It instructed a second nurse to print Medication Review from Reports and review all orders. The facility policy Physician/Practitioner Orders revised 11/2016 recorded under admission orders [REDACTED]. The facility failed to ensure R1 received her physician ordered [MEDICATION NAME], prescribed upon discharge from the hospital to the facility, for the purpose of [MEDICAL CONDITION] prevention. The medication error in which R1 did not receive the [MEDICATION NAME] for five days, was discovered by a consulting practitioner after R1 had developed a [MEDICAL CONDITION] in the surgical (left) leg .

The facility reported a census of 17 residents and the sample included 11 residents. Based on observation, record review, and staff interviewed, the facility failed to provide adequate supervision for 1 of 1 residents sampled for elopment resident #233 to prevent the cognitively impaired resident from leaving the facility unattended. The resident exited the facility and went into the facility parking lot adjacent to a large hospital parking lot , with snow and ice present in 21 degree weather when facility staff let the resident leave the facility thru the front door. This failure placed this resident in immediate jeopardy. Findings included: Resident # 233 [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) was not completed on 01/04/2015 at 1:13 P.M. The care plan dated 12/28/2015 documented the resident had limited physical mobility, bladder incontinence and activities of daily living (ADLs) related to weakness and confusion. The resident will be free of falls through the review date. The resident was noted to have had significant changes in cognition, safety awareness, decision-making capacity and progressive neurological impairments. The change in neurological status was related to the viral disease. The resident and family were educated related to neurological status, staff were to monitor the resident's orientation to reality every shift and monitor and document/report to health care provider signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness, and slurred speech. The nursing staff were to check the resident every hour and review as indicated for significant changes in cognition, safety awareness and decision-making capacity. Admission assessment 12/28/2015 Elopment assessment was not done until after the residnet eloped on 12/30/2015 The nursing notes documented the following : On 12/28/2015 at 9:08 P.M.admitted ,[DATE] P.M. from a local hospital for viral [DIAGNOSES REDACTED], weakness, and confusion. An Neurological exam indicated he/she was oriented to him/herself only. Confusion was noted. Unable to assess resident as he/she did not want to get out of bed. On 12/29/2015 at 12:28 P.M. documented in the nursing notes he/she had safety and cognitive deficits. No discharge plans at this time. On 12/29/2015 at 13:08 The resident was oriented x 2-3 and confusion was observed . On 12/29/2015 at 10:14 P.M. He/she was alert to self oriented to place (city), and disoriented to time and situation. Hourly safety checks were conducted due to non-compliance with call light On 12/30/2015 at 08:08 A.M. resident was found in the parking lot at 0640 A.M. and returned to the facility. Vital signs T 97.0,P 75,R 18,BP 159/80,O2 SAT 98%. Normal vital signs would be T 98.9, P 60-70, R 18 , 120/80 O2 SAT 100 %. On 12/30/2015 at 12:37 P.M. An Elopement Assessment was completed by staff two days afteradmission to the facility and after he/she eloped that morning. The assessment stated He/she was at risk for elopement due to viral [DIAGNOSES REDACTED], confusion, and history of elopement. On 12/30/2015 at 3:59 P.M. staff completed MDS Brief Interview for mental status (BIMS) was completed and a scored a 10 which indicated he/she was moderately cognitively impaired. On 12/30/2015 at 16:04 A.M. documented he/she was alert to self only , required continuous staff monitoring and was an elopement risk. On 12/31/2015 at 15:01A.M. Resident was alert to self and place at times. He/she was disoriented to time and situation. The resident was at risk for Elopment due to leaving the facility. Staff were to check on the residnet frequently. On 01/02/2016 at 12:34 P.M. He/she was alert and oriented to person and place at times. Frequent checks on the resident are required. The resident utilized a cane and walker at times. The staff needs to remind him/her to utilize walker/cane and call light due to forgetfulness. On observation on 12/30/2015 at approximately at 06:44 surveyor QQ sat his/her car in the facility parking lot, facing the building prior entering the facility. A direct care staff LL walk towards the door of the building. At this time, resident # 233 left the building as direct care staff LL entered. The resident was then in the parking lot, which had ice and snow on the ground and it was 21-degrees. The resident was wearing an unzipped coat, the first three buttons on his/her shirt were not buttoned, no hat or gloves and he/she looked disheveled. The resident was looking around the parking lot and he/she walked over to surveyor QQ's car and tried to get in on the passenger side. Surveyor QQ got out of the car and walked to the other side and asked the resident his/her name. The resident could not tell surveyor QQ at this time. The resident said he/she thought his/her family member went out the side door and they were going to breakfast in another town. Direct care staff QQ1 then walked the resident back into the building and asked direct care staff NN, if he/she knew this person. Direct care staff NN stated he/she did not know the resident. Direct care staff OO stated he/she knew this resident and escorted the resident back to his/her room. An observation 12/30/2015 at 7:00 A.M. revealed the resident sat in the dining talking with another resident the resident told his table mate that his/her family member was going to take him/her to breakfast in another town. On 12/30/2015 at 7:10 A.M. request of surveyor QQ asked that licensed nursing staff J assess the resident before eating his/her breakfast. The resident was not assessed for 1 hour and 24-minutes. The residnet's Vital signs T 97.0,P 75,R 18,BP 159/80,O2 SAT 98%. Normal vital signs would be T 98.9, P 60-70, R 18 , 120/80 O2 SAT 100 %. On 12/30/2015 at 3:06 P.M. surveyor QQ and surveyor RR reviewed the video with administrative staff A. At 6:44 A.M. the resident approached the front door of the facility. Direct care staff MM unarmed the front door by punching in a code to the door at 6:44 A.M. to let in a staff member and the resident left as another staff left the building 6:44 A.M. Direct care staff MM returned at 6:45 A.M. and checked the door. Surveyor QQ came into the facility with the resident 6:48 A.M. The resident was out of building for 4-minutes. On 12/30/2015 at 12:18 P.M. The resident was seated in the dining room with a direct care staff member eating lunch. He/she was talking with the other resident at his table. An interview on 12/30/2015 at 7:21 A.M. with direct staff OO stated I last saw him when he/she was walking to the dining room he/she said staff were to check on the residnet hourly because the residnet would not ask for help. Staff moved the resident to another room to be across from the nurses station. Direct care staff OO stated he/she was not sure what was in the care plan, but if he/she was at risk for Elopment the nurse would have told us. He/she had to walk out of the building behind someone. He/she had an infection that swelled his/her brain. He/she was dressed, with his/her coat on and two buttons on his/her shirt were undone, he/she was not wearing a hat or gloves at the time of the Elopment. An interview with direct care staff NN on 12/30/2015 at 7:21 A.M. stated we see so many people go in and out, I would not have questioned him/her. I did not see him/her go out the front door. The alarms did not go off because someone let the resident out. He/She passed me in the hall and I did not think twice of it. I did not see him/her again until surveyor QQ brought him/her into the facility. Direct care staff NN did not know the resident. An interview on 12/30/2015 at 8:42 A.M. direct care staff MM stated one of the new trainee was at the door knocking because the doors do not open until 7 AM. As soon as I turned around and started walking away he/she passed me. He/she was walking down the front hallway by the nurses office and he/she was going to clock in and we passed. His/her thought process was he/she needed to go clock in. I didn't see the resident after that. I haven't worked for a week, so I didn't know the gentleman. When we get report we go see the new resident, but I didn't know he was a resident. If I had know he/she was resident I would asked him/her where he/she was going. A lot of residents get confused and we redirect the resident. During an interview on 12/30/2015 at 7:05 A.M. licensed staff L stated this resident was not compliant due to being cognitively impaired from viral encephalitis. On 12/30/2015 at 9:06 A.M. direct care staff J stated he/she was PRN (as needed) and did not know the resident. If the alarm sounds and staff we check the door. If you do not see anyone, they have to use the code to stop the noise. Direct care staff J stated he/she was in the middle of something when the alarm went off, it was when the morning staff was coming in and he/she did not think much of it. Direct care staff J stated he/she saw the resident come into the facility about 6:45 A.M. He/she then assessed the resident, he/she went to the dining room. Two direct care staff MM and NN told me about the resident and .i assessed the resident's vital signs: Blood Press 159/80; Pulse 75; O2 Sat 98%; and Temperature-97.0 and Respirations 18. I asked him/her why didn't tell us where he/she was going and he/she stated he/she needed to leave. The CNA (Certified Nursing Assistant) did not give me report and left me a written report. Direct care staff J stated he/she was going to check the orders since he/she didn't know the resident. He/she also relied on the direct care staff for assistance. Direct care staff stated he/she didn't know when he/she left his room, the CMA ( certified medical assistant) got the resident up and dressed. Direct care staff confirmed he/she never saw the resident until he/she was brought to me for assessment. Direct care staff J stated he/she did not peek in on the residnet as , the CMA was to report any information he/she needed to know. An interview on 01/04/2016 at 2:11 P.M., administrative nursing staff D stated there have been no reports of him/her wandering. During an interview on 12/30/15 at 8:46 A.M. with administrative staff A was asked if the front door entry is monitored from the time day staff leave and the alarm automatically is programmed to alarm at 9:00 P.M. and remains in place until 7:00 A.M. 12/30/2015 9:21:26 AM,the Administration staff stated the doors automatically alarm at 9 PM and unalarmed at 7 am. Said the doors are not monitored between 5 PM and 9 PM, but hourly rounds are completed by staff. Confirmed a resident could leave the building in between the one hour rounds without staff being aware. Stated the facility determined times to set the alarms and times could be changed. An interview with physician KK on 12/30/2015 at 11:05 A.M. stated the resident could have walked into traffic in front of the building and estimated the average speed was 30-mph. It would have taken 15-30-minutes for hypothermia to set in due to low temperatures. Physician KK stated the residnet could have fallen on the ice and hit his head. He/she also stated the facility should be able to identify all residents, and the facility should have some type of educational process to educate staff. The Elopement Policy dated September 2012 documented the center will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring and managing residents at risk for elopement. These include identifying environmental hazards and resident risks; evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. Staff assessed all residents at for risk of Elopment through the pre-admission and/or admission process and as needed. Each center will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. The facility failed to provide adequate supervision to prevent Elopment for this cognitively impaired and independently mobile resident who exited the facility un attended when a staff member exited the facility via coded doors and staff did not know he/she was a resident. The investigation documented the resident was not appropriately dressed for the weather. According to http://www.wunderground.com/weather-forecast/US/KS/Olathe.html, the temperature for December 30, 2015 at 6:53 A.M. was 19-degrees Fahrenheit (F). The wind chill temperature was 14.9-degrees F. Surveyor QQ observed the parking lot had snow and ice from the precipitation the previous day. The immediate jeopardy was abated on 12/30/2015 when the facility submitted the following corrective action plan: 1) the main entrance door was changed and will now be locked at all times rather than being unlocked from 0700-2059. A staff member will be required to assist anyone needing to exit the building. 2) All current residents will have theElopement Risk Checklist completed by a nurse by 12/30/2015 and all new admissions on or after 12/30/2015 will have the Elopement Risk Checklist completed upon admission to identify if they are at risk for Elopment. 3) All staff wil be re-educated on the process of how to identify who is a resident and which residents are at risk for elopement prior to assisting anyone exiting the building by 12/30/2015 or prior to returning to work. In-service for staff is attached. 4) Staff would create A Resident Photo Book and put it in the front office for staff reference by 12/30/2015. Any resident that is at risk for elopement would have a red circle next to their photo. Staff will use the resident photo book prior to assisting persons from leaving the building to ensure they are not a resident who is at risk for elopement. Social Services will be responsible for ensuring that upon admission new resident photos are put in the Resident Photo Book. This deficiency remained at the scope and severity of a D. - During an observation on 12/28/15 at 9:26 A.M. in neighborhood 1, the occupational therapy (OT) kitchen area, under double-sink one of two cabinet doors was unlocked and contained the following hazardous chemicals: 1 (32 ounce (oz).) Heavy-Duty Acid Kling Bathroom Cleaner (do not drink and wear protective clothing; causes severe skin burns); 2 (14 oz.) bottles of Weiman Glass Cook Top cleaner (keep out of reach of children), 1 (32 oz.) Ecolab Oasis 137 Orange Force (do not drink and wear protective clothing) , 1 ( 32 oz.) Deep Blue Glass Cleaner (keep out of reach of children), 1 (32 oz.) Becton AF315 Disinfectant (keep out of reach of children), 2 ( 32 oz.) BETCO Sanibet (keep out of reach of children),1 (14 oz.) 409 All-Purpose Cleaner (keep out of reach of children). There were 4 of 17 residents that were cognitively impaired and independently mobile. During an observation on 12/28/15 at 9:36 A.M.in neighborhood 1 common bathroom the door was open and in dresser drawers (top right and 3rd on left) was the following: 1 (6.17 oz.) Great Value Hawaiian air freshener refill (harmful to children; harmful or fatal if swallowed; eye irritant; highly flammable), (harmful to children and harmful if swallowed; eye irritant). During an observation on 12/29/15 at 7:04 A.M. in neighborhood 1 in the common bathroom, the door was open and hazardous chemicals remained. During an observation on 12/29/15 at 10:02 A.M. in neighborhood 1 in the OT kitchen under the double-sink both cabinet doors were locked and the common bathroom door was closed but unlocked and the air freshener refill remained in the bathroom door. During an observation on 12/29/15 at 10:16 A.M. in neighborhood 1 common bathroom housekeeping supervisor DD removed the hazardous chemical (Great Value air freshener refill from the dresser drawers. During an interview on 12/28/15 at 9:28 A.M. with rehab staff AA said that staff should lock both cabinets under the double-sink in the OT kitchen if they contained hazardous chemicals. He/she was informed that the residents were in the OT kitchen unassisted. During an interview on 12/28/15 at 9:36 A.M. with direct care staff O was informed there were hazardous chemicals located in the drawers of neighborhood 1 common bathroom. He/she said that there should be no hazardous chemicals in the common bathroom. He/she said the common bathroom in this neighborhood was usually used by staff and visitors. During an interview on 12/29/15 at 8:02 A.M. with rehab staff AA said that there were hazardous chemicals in the unlocked cabinets on 12/28/15 that staff removed. During an interview on 12/29/15 at 10:02 A.M. with licensed staff H said the unlocked cabinets in the OT kitchen or the dresser drawer in the common bathroom in neighborhood 1 should not contain any hazardous chemicals. This surveyor informed him/her that hazardous chemicals remained in the dresser drawers of neighborhood 1 common bathroom. During an interview on 12/29/15 at 10:15 A.M. with maintenance supervisor X said housekeeping supervisor DD was responsible for hazardous chemical security and storage. During an interview on 12/29/15 at 10:18 A.M. with housekeeping supervisor DD said he/she expected the facility staff should secure all hazardous chemicals. He/she was made aware that hazardous chemicals remained in neighborhood 1 in the unlocked common bathroom. During an interview on 12/29/15 at 2:25 P.M. with administrative staff D said hazardous chemicals should be in secured cabinets and closets. During an interview on 1/4/16 at 11:02 A.M. with housekeeping supervisor DD said all hazardous chemicals were secured and stored in the storage closet which was locked at all times and accessible by staff only. During an interview on 1/4/16 at 10:09 A.M. with administrative staff A said according to facility policy all hazardous chemicals were always secured in locked cabinets or closets according to facility policy. Review of the facility Safety with Chemicals policy dated 2/2013 and Infection Control Laundry policy dated 4/1999 regarding hazardous chemicals documented specific storage guidelines such as secure storage at all times. The facility failed to secure hazardous chemicals described as harmful to children and harmful or fatal if swallowed which allowed access by 4 cognitively impaired independently mobile residents for 1 of 4 days in 1 of 2 neighborhoods.

The facility identified a census of 16 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to monitor meal intake and nutritional supplements for 2 (#22, #45) residents with reported weight loss of the 4 residents reviewed for nutrition. Findings included: - The admission Minimum Data Set 3.0 ((MDS) dated [DATE] for resident #22 revealed a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. The resident required extensive assistance with bed mobility, transfer, toilet use, and bathing and supervision with eating. He/she had limited range of motion (ROM) in an upper extremity on one side and both lower extremities. The resident was not steady and was only able to stabilize with human assistance when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers. The resident had no weight loss or gain noted, no swallowing disorder, and received a therapeutic diet. The 6/3/13 Care Area Assessment (CAA) for cognitive loss/dementia revealed the resident had short term memory deficits and was only oriented to person and place, but was easily reoriented. The 6/3/13 CAA for nutrition revealed the resident was diabetic (when the body can not use glucose, there is not enough insulin made or the body can not respond to the insulin) and received oral medication for blood sugar control, staff monitored blood sugars four times each day, and the resident's weight was stable. The initial care plan dated 5/20/13 revealed the resident received a carbohydrate controlled diet with thin liquids, a supplement of Glucerna (a dietary supplement) twice daily, and on 6/4/13 received 2 scoops of protein powder each day. The nurse's Medication Administration Record (MAR) revealed the resident weighed 158.8 pounds at admission on 5/20/13 and weighed 143.8 pounds on 6/24/13, a loss of 15 pounds in 36 days. The MAR for June 2013 revealed on 6/19/13 the physician ordered Glucerna by mouth twice per day. Documentation lacked percentages of the amount of Glucerna the resident consumed. The MAR also revealed the resident received [MEDICATION NAME], a diuretic medication. The nurse's note (NN) dated 5/20/13 at 8:00 P.M. revealed the resident had 3 plus (+) [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) in his/her right arm. The NN dated 6/19/13 at 7:45 P.M. revealed the resident had no [MEDICAL CONDITION] in his/her right arm. The diet order notification dated 6/4/13 revealed staff provided 2 scoops of protein powder daily for increased healing. The clinical record lacked evidence the resident received protein powder as ordered, as of 6/24/13 at 1:39 P.M. Review of dietary documentation of meal percentage intake lacked documentation on 5/20/13, 5/21/13, 5/22/13, 5/23/13, 5/24/13, 5/25/13, 5/26/13, 5/27/13, 5/28/13, 5/29/13, 5/30/13, 5/31/13, 6/1/13, 6/2/13, 6/5/13, 6/6/13, 6/7/13, 6/13/13, 6/14/13, 6/15/13, 6/18/13, 6/19/13. Observation on 6/24/13 at 12:14 P.M. revealed the resident received 3 ounces (oz) of chicken salad on 2 slices of bread and ate 50 percent (%), a 4 oz bowl of corn and ate 90%, 4 oz of roasted potatoes and ate 100%, 2 oz of strawberries on top of a slice of angel food cake and ate 90%, and a glass of 160 milliliters (ml) of water and drank 100%. The resident fed him/herself independently. On 6/19/13 at 12:05 P.M. with licensed nursing staff J revealed the facility did not list the order for 2 scoops of protein powder on the resident's MAR but was administered by dietary. Staff documented on the MAR the resident received Glucerna twice daily but lacked documentation of percentage intake. Interview on 6/24/13 at 3:25 P.M. with direct care staff Q revealed the certified medication aids (CMAs) administered the nutritional supplements to the residents and documented it on the MAR. In the past the dietary staff administered some supplements but no longer did. Staff Q was unable to provide documentation that protein powder administration was included on the MAR and failed to show documentation of percentage intake of the Glucerna supplement. Staff Q reported the CMAs notified the nurse if the resident refused any supplements. Interview on 6/25/13 at 9:13 A.M. with consultant staff GG revealed he/she was aware of issues with documentation of nutritional supplement intake. Most information regarding supplemental intake of residents reported to consultant staff GG from the facility staff, was by verbal report and not written documentation. Interview on 6/25/13 at 12:20 P.M. with administrative nursing staff D revealed he/she was aware the facility had an issue regarding documentation of supplement and meal intakes. Staff D was unable to show evidence that staff documented protein powder intake and reported that staff did not document the percentage of supplement intake. The policy provided by the facility regarding meal intake monitoring with a revision date of 8/12 revealed staff recorded meal intake (food and fluids) daily after each meal for all residents, or as indicated per individualized care plan. The policy provided by the facility regarding medical nutritional supplements with a revision date of 7/12 revealed staff provided "medical nutritional supplements between meals to residents with decreased appetite, weight loss, or special medical conditions when needed." "Intake of medical nutritional supplements is documented and evaluated for acceptance. Adjustments are made to optimize intake." The facility failed to monitor staff's administration of protein powder, failed to monitor percentage of Glucerna consumed, and failed to consistently monitor meal intake for this resident with documented weight loss. - Resident #45's admission Minimum Data Set 3.0 Assessment ((MDS) dated [DATE], documented the resident's Brief Interview for Mental Status score of 5, which indicated the resident had severely impaired cognition. The resident required limited assistance with bed mobility, transfers, and dressing. The MDS documented the resident's weight at 129 pounds (lbs), without an altered diet and without eating concerns. The Nutrition Care Area Assessment (CAA) for the 4/22/13 assessment did not trigger. The interim 4-16-13 care plan documented the resident had a poor appetite and decreased intake and interventions included a regular diet, and Ensure (a protein supplement), three times daily between meals due to the resident's decreased intake. The resident lacked a comprehensive care plan to address the resident's nutritional status. The 4/2013 Medication Administration Record (MAR) directed staff to notify the physician if the resident had a 3 pound (lb) weight gain. The 4-16-13 physician orders [REDACTED]. The resident admitted to the facility on [DATE] and on 4-17-13 he/she weighed 128.4 lbs. Staff weighed the resident daily from 4-17-13 through 5-15-13 on which he/she weighed 112.8 lbs. On 4-29-13 review of the physician's orders [REDACTED]. On 4-30-13 at 3:00 P.M. the nurse's note (NN) documented the resident was more alert and able to consume a can of Ensure On 4-30-13 the dietician documented the resident's current weight of 119.6 lbs and staff monitored the resident's weight due to his/her [MEDICAL CONDITION]. The resident currently received Ensure three times daily between meals for increased protein for healing, had complaints of nausea and his/her appetite decreased. The dietician recommended staff monitor the resident's eating behavior and intake. Review of the record lacked evidence the facility provided Ensure three times daily to the resident. Review of the meal intake monitoring record revealed staff monitored the resident's meal intake on the following dates: On 4-28-13 at the evening meal, the resident ate 50 percent (%) of his/her meal. On 5-1-13 at the evening meal, the resident ate 50% of his/her meal. On 5-2-13 at breakfast, the resident ate 75%, lunch 100%, and evening meal ate 75% of his/her meal. On 5-3-13 at breakfast, the resident ate 100% and ate 50% of the evening meal. On 5-6-13 at breakfast, the resident ate 100% and at noon ate 100% of his/her meal. On 5-7-13 at the evening meal, the resident ate 100% of his/her meal. On 5-8-13 at the breakfast meal, the resident ate 100% of his/her meal. On 5-9-13 at the breakfast meal, and the evening meal the resident at 100%. The record lacked consistent monitoring of the resident's meal intakes, administration of ensure, and monitoring of the resident's behavior during meal times. On 6-25-13 at 9:13 A.M. consultant dietician GG stated dietary monitored residents' meal intakes when they ate in the dining room but did not monitor room trays. He/she also stated staff lacked follow up when the resident received supplements between meals. On 6-25-13 at 9:42 A.M. administrative licensed staff D acknowledged the record lacked consistent documentation of the resident's meal intake and stated that dietary monitored residents' intakes if they ate in the dining room, but did not monitor intakes if resident's had room trays. He/she stated that nursing did not monitor intakes of room trays either. Administrative licensed staff D stated when staff received an order for [REDACTED]. He/she acknowledged the record lacked documentation the resident received Ensure. The 8/12 facility provided Meal Intake Policy and Procedure documented staff documented meal intakes after each meal for all residents, or as indicated by the resident's individualized care plan. The 7/12 facility provided Medical Nutritional Supplements Policy and Procedure documented staff recorded the intake of medically nutritional supplements on the MAR or the nourishment/supplement intake record. The facility failed to monitor the resident's meal intakes consistently as recommended by the dietician and failed to monitor the resident's consumption of ensure three times daily as ordered by the physician.

The facility identified a census of 32 residents. The sample included 5 residents of which 3 were reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to provide timely and effective interventions for the prevention of weight loss for two residents. (#251, #189) Findings included: - The 8-1-2013 Admission Minimum Data Set (MDS) 3.0 for resident #251 documented the Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The resident required supervision and setup with eating. The resident did not have a swallowing disorder and weighed 131 pounds. The resident had no weight loss of 5 percent (%) or more in the last month or loss of 10% or more in the last 6 months. The 7-26-13 care plan for potential/alteration nutrition and/or hydration related to new environment documented a low sodium diet, limited processed foods, and thin liquids. The nutrition assessment dated [DATE] documented the resident's current diet order as regular. The resident fed himself/herself. The resident made his/her food requests known. The resident's admission weight was 130.8 pounds and his/her current weight was 119.4 pounds. Nursing reported the left leg and foot had [MEDICAL CONDITION]. The dietician recommend protein powder 2 scoops per day for healing needs. The telephone order dated 8-13-13 recommend protein powder 2 scoops per day for healing needs. The telephone order dated 8/21/13 revealed an order for [REDACTED]. The care plan revised 8/21/13 listed the interventions for protein powder 2 scoops per day and weekly weights on Friday. The treatment administration record documented weekly weights at bedtime to monitor health status, if 3 pound weight gain in 1 week please notify the doctor: 7/26/13: 130.8 pounds 8/2/13: No documentation 8/10/13: 119.4 pounds 8-16-13: No documentation 8-21-13: 116.8 pounds Consisting of a 14 pound or 10.7 percent weight loss in approximately 4 weeks. Observation on 8-22-13 at 1:54 P.M., direct care staff O weighed the resident standing on the scale. The resident weighed 116.8 pounds. The Meal Intake Record dated August 2013 revealed the staff did not document the meal intake 32 times out of the 66 opportunities The 7-26-2013 Initial Interdisciplinary Data Collection Tool revealed the resident had [MEDICAL CONDITION] to the left leg and foot but did not identify the extent of the [MEDICAL CONDITION]. On various daily skilled nursing notes from 7/26/13 to 8/22/13 revealed left lower extremity [MEDICAL CONDITION] but not specific as to the extent. July and August 2013 medication administration records revealed the resident did not receive a diuretic (medication to relieve [MEDICAL CONDITION]). An undated handwritten note in the record documented the resident was on a regular diet and his/her family brought in his/her own food. Staff had to heat up the meals. On 8-22-13 at 7:21 A.M., nursing staff I stated the resident had his/her own refrigerator and would often eat his/her own food but would sometimes eat the facility's food. On 8/22/13 at 11:12 A.M. nursing staff I stated the protein powder was recorded in the meal intake book. He/she further stated the protein powder started yesterday and was not recorded in the meal intake book but was signed for in the medication administration record. Nursing staff I stated dietary staff were responsible for monitoring the meal intake, administering the supplements, and monitoring the intake of them. Interview on 8-22-13 at 12:36 P.M., the resident stated the food was all right. It was good but was not what he/she was accustomed to. The resident did not like over processed foods or foods out of a can. Staff have not tried to accommodate his/her dining needs. The resident felt some foods were over cooked. Dietary staff and nursing staff had not spoke to him/her about his/her likes and dislikes of foods. Dietary staff have a set menu. The resident stated they had lost weight. This morning he/she had cereal, juice and fruit. For his/her lunch he/she had green beans and potatoes. Interview on 8-22-13 at 3:30 P.M., dietary consultant staff JJ stated on August 13 th, at the standard visit the resident did not have weight loss. I talked to nursing they said [MEDICAL CONDITION] impacted his/her weight loss. The resident had lost 10 pounds or more and that was not all fluid loss. I worked with the dietary manager who knows how the resident's ate. The resident was very challenging because he/she had very bad hearing. The dietary manager tried to get his/her preferences and I recommended to add protein powder due to the fracture because the resident was eating ok. Staff were going to work on his/her preferences other than adding something else. When I come in I get a list of residents to be seen. I did not get a list of weights. The dietary manager did not have the weights so I had to get them from nursing. Interview on 8-22-2013 at 4:00 P.M., dietary staff DD stated I take inventory of the resident's likes to see if there was something the resident liked. The resident's family brought food. Staff usually add protein powder to his/her hot chocolate or mix it in juice, or whatever the resident liked. The facility provided procedure meal intake monitoring revised on August 2012 revealed meal intake (food and fluids) was recorded daily after each meal for all residents, or as indicated per individualized care plan. Documentation of meal intakes was on the meal intake record. If using paper documentation forms, the director of dietary services or designee was responsible for placing the current month's meal intake records in a notebook kept in the dinning area. The director of dietary services would monitor meal intake records routinely, residents determined to be at nutrition or hydration risk was added to the Nutrition Risk List, and was followed monthly by the Nutrition Risk Committee and received monthly follow-up and assessment by the registered dietician. Dietary staff DD on 8/22/13 at 7:45 A.M. stated the facility did not have a nutrition risk committee. The facility provided weight and height procedure revised September 2010 revealed residents at nutritional risk were weighed weekly. The registered dietitian or director of dietary services would monitor weights monthly for changes. The licensed nurse should notify the director of dietary services within 24 hours regarding any significant weight change. Significant weight change was defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days. The licensed nurse should immediately notify they physician regarding any significant weight change. The facility's provided weight monitoring procedure revised February 2005 revealed based on a resident's comprehensive assessment, the center would ensure that a resident maintained acceptable parameters of nutritional status such as body weight, unless his/her clinical condition demonstrated this was not possible. The facility failed to provide interventions for weight loss for this resident with a severe weight loss. - The 7-9-2013 Admission Minimum Data Set (MDS) 3.0 for resident #189 documented the Brief Interview for Mental Status score of 15 which indicated intact cognition. The resident required supervision and setup help with eating and the resident did not have a swallowing disorder. The resident weighed 196 pounds. There was no weight loss of 5 percent (%) or more in the last month or loss of 10% or more in the last 6 months. The resident was on a therapeutic diet. The 8-5-2013 Care Area Assessment for Nutritional Status documented the resident had nutritional problem or potential for a nutritional problem related to therapeutic diet evidenced by dietary restrictions of no added salt diet. Interventions documented staff to monitor and record intake at each meal and staff to monitor the resident's weight weekly. The 7-2-13 care plan for potential/altered nutrition and/or hydration related to new environment, documented the resident was on a regular no added salt diet with thin liquids. The resident liked cookies, hashbrowns, bananas and disliked potatoes. The clinical record lacked evidence of a comprehensive care plan for weight loss. The nutrition assessment dated [DATE] documented a current weight of 195.6 pounds. The resident's weight was monitored due to [MEDICAL CONDITION]. The resident was on a regular no added salt diet. The resident fed herself/himself in the main dining room. The resident's intake was varied and the resident complained of nausea and poor appetite. The [DIAGNOSES REDACTED]. The resident's admission weight was 195.6 pounds and the resident had a blister on the left calf. The lab dated 7-12-13 documented a low [MEDICATION NAME] of 2.2 grams/deciliter (g/dl) with the normal range of 3.5-5.5 g/dl and a low total protein of 5.0 g/dl with the normal range of 6-8 g/dl. The dietician recommended protein powder 2 scoops per day, Ensure 1 can at bedtime (HS), and staff to offer calorie dense food choices at meals. The physician's telephone orders dated 7-16-13 recommended protein powder 2 scoops per day and Ensure ( high calorie supplement) 1 can at hour of sleep (HS) and offer protein/calorie dense foods at meals (fried eggs, cottage cheese, pudding) due to low [MEDICATION NAME] and low total protein stores. The 7/2013 and 8/2013 treatment administration record documented weekly weights at bedtime to monitor health status if there was a 3 pound weight gain in one week please notify the doctor. Weights documented: 7/19/13 - 174.6 pounds 7/26/13 - Resident refused 7/28/13 - 163.2 pounds 8/2/13 - No documentation 8/5/13 - 161.6 pounds 8/9/13 - No documentation 8/12/13 - 159.8 pounds 8/16/13 - No documentation Consisting of a 35.8 pound weight loss from the admission weight on 7/2/13 to 8/16/13 or 18.3 percent in 6 weeks. This is considered a significant weight loss. On 8-22-13 at 4:00 P.M. the menu card for the resident documented a low fat diet for two weeks and then can resume a regular diet. The Ensure, the order for dense calorie foods, and the protein powder was not documented on menu card. Dietary staff DD on 8/22/13 at 4:00 P.M. identified the low fat diet was for the first two weeks in the facility (should have ended on 7/17/13) The signed and dated 7/2/13 Interdisciplinary Data Collection Tool documented the patient had [MEDICAL CONDITION] to left knee, left thigh and ankle (no documentation of the extent of the [MEDICAL CONDITION]). The resident lost weight and had a decreased appetite. The resident liked to eat cookies, hot chocolate and banana between meals. The resident liked hashbrowns but was not crazy about potatoes. The documentation displayed the information obtained came from the family member and not the alert and oriented resident. Various daily skilled nursing notes from 7/2/13 to 8/22/13 revealed there was [MEDICAL CONDITION] present but was not specific as to where and the extent. The July and August 2013 Medication Administration Record [REDACTED]. Meal intake documentation from August 1st to August 21, 2013 revealed the staff did not document the meal intake for 30 meals out of the possible 66 meals. Observation on 8-22-13 at 7:27 A.M., the resident sat in a wheel chair at the dining room table. The staff served the resident plain oatmeal, a small bowl of fruit, coffee, small cup of orange juice and a small glass of milk. The resident ate 100 percent (%) of the meal. On 8/22/13 at 12:05 P.M., the staff served the resident water and orange juice. At 12:21 P.M. the staff served a taco salad and a slice of banana cream pie. At 12:39 P.M. the resident consumed 100% of his/her meal and consumed 100% of the orange juice and 50% of the water. On 8-22-13 at 12:55 P.M., Administrative nursing staff D weighed the resident with the brace and in the wheel chair. The weight was 214.8 pounds. At 1:49 P.M. direct care staff O weighed the resident's wheel chair with brace and revealed a weight of 51.4 pounds. The resident weighed 163.4 pounds. Interview on 8-22-13 at 7:45 A.M., Dietary staff DD stated the three hot cereals provided were cream of wheat, oatmeal and flavored oatmeal. The flavored oatmeal had the protein powder in it. The staff allowed the residents to choose which oatmeal they wanted and they may not choose the flavored oatmeal. On 8/22/13 at 11:00 A.M. dietary staff DD stated the meal percentages either did not get documented or they were documented elsewhere. Sometimes when the residents received room trays there was a lack of communication on the consumption percentages. On 8/22/13 at 4:00 P.M. dietary staff DD stated when he/she did the initial dining assessment, he/she asked the resident if they wanted to talk to the registered dietician. If they were on a therapeutic diet, he/she would refer them to the registered dietician. The dietician ordered the protein powder and it could be given with meals. Staff should record it on the meal intake record as a supplement. If a supplement was ordered between meals like at HS, the nursing staff come to the kitchen to collect the snack. Dietary staff DD stated he/she did not know what they picked up. There were several things here, peanut butter, milk, juice, and mighty shakes. He/she stated he/she did not send snacks out to the floor. Dense calorie foods included broccoli, sturdy vegetables, and grain products. He/she did not have a list of dense calorie foods but for lunch today he/she identified the Prince William vegetables as a dense calorie food. Interview on 8-22-13 at 7:45 A.M., nursing staff H stated staff followed the dietary recommendations for protein powder and staff would record the order on the Medication Administration Record [REDACTED]. Dietary staff also got the memo from the registered dietician and between the three of them the registered nurse, certified nursing assistant/certified medication aide, and dietary staff, they made sure the resident received the protein powder everyday. On 8-22-13 at 11:04 P.M., nursing staff I stated the resident did not receive the protein powder or ensure supplement at this time. Staff did not provide the discontinued physician's orders [REDACTED]. Interview on 8-22-13 at 2:23 P.M., the resident stated the food was fairly good. The staff did not talk to him/her about his/her food likes and dislikes. The staff gave me a menu of choices and I choose what I want for meals. I know I have lost weight. Interview on 8-22-13 at 3:30 P.M., dietary consultant staff JJ stated I have not seen the resident recently. At the time I saw the resident, he/she came into the facility with fractures. On 7-16-13 I reviewed the resident and he/she had nausea and poor appetite. The resident had a blister and two fractures. The resident's [MEDICATION NAME] was low at 2.2 g/dl and total protein was low at 5.0 g/dl. The consultant stated the Ensure was still ordered for the resident. The resident's meal intake was varied due to nausea and vomiting. I asked the dietary manager to offer the resident protein foods such as yogurt. I have not reviewed the resident at this time. He/she was very concerned but I was not notified to see him/her again. The resident had recent [MEDICAL CONDITION] for small cell [MEDICAL CONDITION]. The consultant staff recommended protein and calorie dense foods (yogurt, milk, eggs, cottage cheese, pudding). Protein powder was put into hot cereal at breakfast or added to food-pudding, applesauce, or mashed potatoes. It did not go into drinks. Dietary staff administered the protein powder not nursing staff. The consultant stated he/she came every Tuesday and was dependent of the dietary manager, nursing, and speech therapy for referrals. The interventions for protein powder and supplements were recorded on the resident's dietary card. The facility provided procedure meal intake monitoring revised on August 2012 revealed meal intake (food and fluids) was recorded daily after each meal for all residents, or as indicated per individualized care plan. Documentation of meal intakes was on the meal intake record. If using paper documentation forms, the director of dietary services or designee was responsible for placing the current month's meal intake records in a notebook kept in the dinning area. The director of dietary services would monitor meal intake records routinely, residents determined to be at nutrition or hydration risk was added to the Nutrition Risk List, and was followed monthly by the Nutrition Risk Committee and received monthly follow-up and assessment by the registered dietician. Dietary staff DD on 8/22/13 at 7:45 A.M. stated the facility did not have a nutrition risk committee. The facility provided procedure weight and height revised September 2010 revealed residents at nutritional risk were weighed weekly. The registered dietitian or director of dietary services would monitor weights monthly for changes. The licensed nurse should notify the director of dietary services within 24 hours regarding any significant weight change. Significant weight change was defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days. The licensed nurse should immediately notify the physician regarding any significant weight change. The facility's provided weight monitoring procedure revised February 2005 revealed based on a resident's comprehensive assessment, the center would ensure that a resident maintained acceptable parameters of nutritional status such as body weight, unless his/her clinical condition demonstrated this was not possible. The facility failed to provide interventions as planned for this resident with a significant weight loss.