Every finding on record at Holton Health Care Center

The facility identified a census of 34 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents. This placed the residents at risk for impaired mental and physical wellbeing.Findings included:- Review of the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) for Fiscal Year (FY) 2024 Quarter 4 and FY 2025 Quarter 2 revealed the facility triggered for excessively low weekend staffing. On 08/26/25 at 01:40 PM, Administrative Staff A stated the facility had low weekend staffing during that identified time from the PBJ report. Administrative Staff A stated the facility had struggled with staffing during that period. The facility was unable to provide a policy related to low weekend staffing.

The facility identified a census of 34 residents. The sample included 12 residents and two Certified Nurse Aides (CNA) reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure two of the two CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included:- A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA M, hired on 06/20/24, had no yearly performance evaluation upon request. CNA N, hired on 04/24/24, had no yearly performance evaluation upon request. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the director of nursing and she would be responsible for ensuring the yearly performance reviews had been completed annually for the direct care staff. The facility failed to provide a policy related to required yearly performance reviews.

The facility identified a census of 34 residents. The facility had one kitchen and a dining kitchenette. Based on interviews and record review, the facility failed to provide the services of a full-time certified dietary manager for the 34 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.Findings included:- On 08/24/25 at 07:25 AM, Dietary Staff BB stated he had been with the facility for a few months. He was not registered for the dietary program, but he had been looking at how to get into the dietary managers' classes. Dietary Staff BB stated the Registered Dietitian (RD) came to the facility monthly. On 08/24/25 at 10:25 AM, Administrative Staff A stated the facility did not have a certified dietary manager, and the dietary manager was not in the dietary managers' class at this time. She stated the RD came to the facility monthly. The facility did not provide a policy for the dietary manager's position.

The facility identified a census of 34 residents. The facility had one kitchen and a dining area kitchenette. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to dirty dishes and food storage. This deficient practice placed the residents at risk for food-borne illness.Findings included:- During the initial tour on 08/24/25 at 07:10 AM, observation revealed the following:The dietary manager was not wearing a hair net. The bowls and plates were not stored inverted. The steam table had dried food on the top, and dried food particles of tomatoes and a red substance had run down the front of the table. In the two-door stainless steel refrigerator, there was dried food on the outside of the refrigerator, and the handles were sticky and dirty. In the refrigerator, a plate with goulash and mixed vegetables was undated, an open Cool Whip container, an open sour cream container, and cucumbers were undated. A sliver bowl of cut-up lettuce was undated. On a single door white freezer, the handle had dark brown color on the handle, and on the outside of the freezer. The inside of the freezer had hamburger patties, French fries, and chicken strips open to air, all undated and no labels. On the floor, a sugar bin where two bags of sugar were open and undated; the bin had old, dried sugar and food particles at the bottom. On the lid of the bin was a dried brown substance. On the floor, the flour bin was a large bag of flour, the bin was undated, and a sticky, greasy substance was on the lid. In the dining area kitchenette, the ice machine had a dark brown substance along the spout where ice came out, and the drain had dark brown colored substance on the plastic grates. Under the kitchen cabinet was a two-gallon white bucket that was half full of a black substance. Around the white bucket were dead bugs. The brown refrigerator temperature log was dated 06/20/25. The top freezer of the refrigerator was full of frost, with ice cream and ice pops that were undated when opened. The refrigerator part had four ham sandwiches in a small steam table pan that were undated. Gallons of milk and juice that were unlabeled and undated. On 08/25/25 at 11:44 AM, the recheck of the kitchen in the double-door refrigerator revealed that salad dressings were unlabeled and undated. Dried eggs were on the steam table around the ham that was for lunch. On the plates and bowls were over 10-15 flies. On 08/24/25 at 07:25 AM, Dietary Staff BB stated all foods should be dated and labeled. He stated he did not know whether food in its original containers needed an open date. He stated he had been very short-staffed. Dietary Staff BB stated the steam table should be cleaned often and after each meal. He stated dishes should be inverted, or the covers should be on the plate and bowl hold containers. He stated he did not know sugar and flour should be dated; he stated the kitchen staff tried to clean the containers at least every six months. Dietary Staff BB stated he would get the food, and grime wiped off the front of the refrigerator and freezer. He stated the flies had been bad in the kitchen since the air conditioning system went out about five months ago. Dietary Staff BB stated he was unsure whose duty it was to clean the dining kitchenette. He stated he knew the refrigerator was the kitchen's duty, but did not know who should clean the bucket from under the sink. He stated the staff had gotten behind on taking temperatures in the dining area on the refrigerator, and the food on the top of the refrigerator, he thought, was the activity department's. Dietary Staff BB stated that the night snacks were the kitchen's duty. On 08/24/25 at 08:10 AM, Administrative Staff A stated the facility had been trying to get the dietary manager more staffing. She stated the facility had been talking to the dietary manager about keeping the kitchen clean. The facility's Sanitary Procedures policy, revised on 11/06/23, documented staff must wear a head covering with a hairnet.The facility's Dietary Equipment Operations policy dated 02/02/24 documented the dietary manager would record all cleaning and sanitation tasks for the dietary department. A cleaning schedule shall be posted with tasks designated to specific positions in the department. The policy stated all tasks shall be addressed as to the frequency of cleaning. The procedures to be used are listed in this Policies and Procedures Manual. General daily and weekly cleaning schedules may be used.

The facility identified a census of 34 residents. The facility identified six residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store Resident (R) 2 and R22's respiratory equipment in a sanitary manner. The facility additionally failed to supply the laundry room with a gown to sort dirty laundry and failed to transport laundry with the laundry being covered in a sanitary manner. The facility further failed to ensure it had trends and tracking for Legionella. These deficient practices placed the residents at risk for infectious diseases. Findings included:- On 08/24/25 at 07:17 AM, a walkthrough of the facility was completed. A canister with a nasal cannula sat inside R2's room; the nasal cannula was wrapped around the handle of the canister. The cannula was not stored in a sanitary manner. On 08/24/25 at 08:00 AM, a tour of the dirty laundry room revealed no gown to wear when sorting dirty laundry. Laundry Staff W stated she was unaware that the facility needed to wear a gown to sort dirty laundry. On 08/24/25 at 08:25 AM, Laundry Staff W pushed a clean laundry cart down the hall. The laundry cart had clothing and linens on top of the cart, uncovered and not stored in a sanitary manner. On 08/25/25 at 07:11 AM, R22 laid in her bed, and her nebulizer lay on the bedside table without a clean barrier or sanitary container. On 08/26/25 at 01:11 PM, upon request, the facility was unable to provide trend and tracking specific to the facility for the Legionella (Legionella is a bacterium which can cause pneumonia in vulnerable populations) monitoring. Administrative Staff A stated there had been a change in staffing, and she could not find any documentation for Legionella. She stated she did order a Legionella test kit. On 08/26/25 at 12:42 PM, Certified Medication Aide (CMA) R stated that any respiratory equipment not in use should be placed in a bag.On 08/26/25 at 12:55 PM, Licensed Nurse (LN) G stated that all respiratory equipment was washed and air-dried, then placed in a plastic bag, with the resident's name and date. On 08/26/25 at 01:25 PM, Administrative Nurse D stated all respiratory equipment should be cleaned and placed in a clear bag. She stated that clean laundry should always be transported covered and in a sanitary manner.The facility's Oxygen Administration Policy dated 05/18/24 directed to keep the delivery devices covered in a plastic bag when not in use.The facility's Handling Clean and Dirty Laundry policy dated documented it was the policy of the facility to handle, store, process, and transport clean and soiled linen in a safe and sanitary manner to prevent contamination of the linen, which can lead to infection. All used linen should be handled using standard precautions and treated as potentially contaminated. The facility's Legionella Surveillance policy dated 06/26/24 documented it was the policy of the facility to establish primary and secondary strategies for the prevention and control of Legionella infections.

The facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for the residents of the facility.Findings included:- Review of the Infection Control Log for tracking and trending infections from August 2024 through July 2025 lacked evidence of organism identifications, duration of antibiotic prescribed, and the infections treated. The facility was unable to provide evidence of tracking upon request. On 08/25/25 at 02:17 PM, Administrative Staff A stated the facility was unable to locate the binder for antibiotic surveillance. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the facility was unable to locate more than the month of surveillance that had been provided. The facility's Antibiotic Stewardship policy, revised on 06/29/23, documented that the purpose of the policy was to optimize antibiotic use in the nursing facility. The facility would reduce the unnecessary use of laboratory tests using a systematic approach.

The facility had a census of 34 residents. Two Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure two of the two CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included:- Review of the facility's in-service records revealed the following CNAs were employed with the facility for more than 12 months: CNA M, hired on 06/20/24, had not completed the required in-services in the past 12 months. CNA N, hired on 04/24/24, had not completed the required in-services in the past 12 months. On 08/26/25 at 01:25 PM, Administrative Nurse D stated that the director of nursing and she would be responsible for ensuring the yearly required in-services had been completed. The facility failed to provide a policy related to required yearly in-services.

The facility identified a census of 34 residents. The sample included 12 residents, with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 6 with the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial lung infections) and the Influenza vaccine as consented. The facility further failed to offer the PCV20, and Influenza vaccines for R24 and R14. This placed the residents at increased risk for complications related to pneumococcal (a type of bacterial infection).Findings included:- R6's Electronic Medical Record (EMR) revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. Review of Resident Consent for Immunization Form for R6 dated 01/23/25 provided by the facility revealed a signed consent to receive the pneumococcal vaccination and Influenza Immunization. The form indicated R6 was provided educational information related to the PCV20 vaccination and Influenza Immunization. R6's clinical record lacked evidence that R6 received the PCV20 vaccination and Influenza Immunization. Upon request, the facility was unable to provide evidence that the PCV20 and Influenza Immunization were administered to R6.Upon request, the facility was unable to provide evidence or documentation that R24 and R14 were offered the PCV20 and Influenza. On 08/25/25 at 01:13 PM, Administrative Staff A stated the facility was not able to find documentation for vaccines given or signed declinations. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the facility was unable to find documentation of vaccines. She stated there had been some staff changes, and she was unsure where the information was. The facility's Influenza and Pneumococcal Immunizations policy, revised on 05/14/24, documented that the purpose of the policy was to ensure all residents residing in the building were offered the influenza and pneumococcal immunization, to prevent infection and the spread of communicable diseases.

The facility identified a census of 34 residents. The sample included 12 residents, with seven residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician had clarified the indication for Resident (R) 14's psychotropic (alters mood or thought) medication. The facility failed to ensure that the physician had clarified R6's gradual dose reeducation (GDR) for R6's antipsychotic (a class of medications used to treat major mental conditions that caused a break from reality) medication, R2's as-needed (PRN) Lorazepam (antianxiety medication(a class of medications that calm and relax people)), and R9's PRN Ativan (antianxiety medication) had a 14-day stop date. The facility further failed to ensure that the physician ordered monitoring related to R24's antidepressant (a class of medications used to treat mood disorders). This deficient practice placed R14, R6, R2, R9, and R24 at risk for unnecessary medication use and physical complications. Findings included:- R14's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and heart failure. The “admission Minimum Data Set (MDS)” dated 09/25/24 documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R14 had received a diuretic (a medication to promote the formation and excretion of urine) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R14 had received diuretic medication and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. R14's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA)” dated 10/03/24 documented R14 had a self-care deficit and required staff assistance with most of his activities of daily living. R14's “Care Plan,” dated 10/07/24, documented nursing staff would administer medications as ordered by the physician. The plan of care documented nursing staff would monitor and document any side effects and effectiveness. R14‘s EMR under the “Orders” tab revealed the following physician orders: Mirtazapine (antidepressant) oral tablet 15 milligram (mg), give one tablet by mouth at bedtime for health maintenance, dated 07/08/25. On 08/24/25 at 09:03 AM, R14 laid on his bed with the head of his bed elevated as he watched TV. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated that she would clarify a physician order if there was a diagnosis that had an unusual indication for antidepressant medication. On 08/26/25 at 01:25 PM, Administrative Nurse D stated she expected the charge nurse to clarify the order, if there was an off-label indication for administration. The facility’s “Transcription of Orders/Following Physician Orders” policy, last revised 05/18/24, documented upon receiving a physician’s order via telephone, fax, written order, verbal order, transcribed order, or other, it would be documented in the residents’ electronic medical records in the orders section. Clarification of the Physician's Orders would be obtained if the order was either unclear or the nurse was uncomfortable with the implementation of the Physician's Orders. - R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), dysphagia (swallowing difficulty), Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The “Annual Minimum Data Set (MDS)” dated 08/09/24 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R6 had received antipsychotic medication and antidepressant medication (a class of medications used to treat mood disorders). The MDS lacked documentation a GDR had been attempted, or the physician had documented that a GDR was contraindicated for R6. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R6 had received antipsychotic medication, antidepressant medication, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) medication. The MDS lacked documentation a GDR had been attempted, or the physician had documented a GDR was contraindicated for R6. R6's Psychotropic Drug Use Care Area Assessment (CAA)” dated 08/19/25 documented she had potential complications with the psychotropic medication she received. R6's “Care Plan,” dated 05/08/24, documented the facility would consult with the pharmacist and physician to consider a dose reduction when clinically appropriate. R6‘s EMR under the “Orders” tab revealed the following physician orders: Seroquel (antipsychotic) oral tablet (quetiapine fumarate- antipsychotic), give 50mg by mouth one time a day related to unspecified mood affective disorder, dated 02/22/24. Quetiapine fumarate oral tablet (Seroquel) 100 milligram (mg), give one tablet by mouth at bedtime for schizoaffective disorder, dated 10/10/24. Review of the “Monthly Medication Review” (MMR) provided by the facility from April 2025 through July 2025 lacked the physician's response to the Consulting Pharmacist (CP) recommendation for a GDR on 04/08/25 and 06/10/25 for R6’s psychotropic medications. The facility was unable to provide a physician's response upon request. The facility was also unable to provide MMRs from August 2024 through March 2025 upon request. On 08/25/25 at 07:53 AM, R6 wheeled her wheelchair from her room to the dining room without difficulty. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated she did not address the MMRs. On 08/26/25 at 01:25 PM, Administrative Nurse D stated she expected the director of nursing to ensure the physician reviewed and addressed the CP recommendations and retain the MMRs once the physician had reviewed them. The facility’s “Gradual Dose Reduction of Psychotropic Drugs” policy, last revised 05/14/24, documented that residents who use psychotropic drugs received gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), hyperlipidemia (condition of elevated blood lipid levels), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acquired absence of left leg below the knee, schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual 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 R2 was dependent on staff for toileting, bathing, and dressing, and needed supervision or touching assistance from staff with eating. The MDS documented R2 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an antianxiety (a class of medications that calm and relax people) medication during the observation period. R2's The Psychotropic Use Care Area Assessment (CAA) dated 06/30/25 lacked analysis. R2’s “Care Plan” dated 09/24/24 documented R2 had an activities of daily living (ADL) self-care performance deficit with potential for decline related to dementia (a progressive mental disorder characterized by failing memory and confusion), impaired balance, limited mobility, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R2's EMR under Orders documented the following physician's order: Lorazepam (anxiety medication) oral tablet, give 1.0 milligrams (mg) by mouth every two hours as needed for anxiety, dated 07/14/25. R2’s Lorazepam order lacked a 14-day stop date. On 08/24/25 at 08:35 AM, R2 sat in the dining room in her Broda chair (specialized wheelchair with the ability to tilt and recline). On 08/25/25 at 08:50 AM, R2 sat in her Broda chair in the dining room. On 08/26/25 at 12:55 AM, Licensed Nurse (LN) I stated she did not know there needed to be a 14-day stop date on PRN medication. She stated the director of nursing put in the orders for residents. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the director of nursing was putting in the orders and checking the pharmacy reviews. She stated she knew there needed to be a 14-day stop date. Administrative Nurse D stated if the director of nursing did not follow through with the pharmacy reviews, it was ultimately her responsibility to ensure they were all done. The facility’s “Transcription of Orders/Following Physician Orders” policy, last revised 05/18/24, documented upon receiving a physician’s order via telephone, fax, written order, verbal order, transcribed order, or other, it would be documented in the residents’ electronic medical records in the orders section. Clarification of the physician's orders would be obtained if the order was either unclear or the nurse was uncomfortable with the implementation of the physician's orders. - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of insomnia (inability to sleep), sleep apnea (a disorder of sleep characterized by periods without respirations), hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hyperlipidemia (condition of elevated blood lipid levels), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and liver cell carcinoma (cancer). The “Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R9 needed supervision/touching with eating, partial/moderate assistance from staff for oral care, and was dependent on staff for toileting and bathing. The MDS did not document an antianxiety (a class of medications that calm and relax people) medication during the observation period. R9’s Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 03/16/25 lacked analysis. R9's “Care Plan” dated 07/08/25 directed staff to give medication as ordered by the physician, document, and monitor effectiveness and side effects. R9's EMR under Orders documented the following physician's order: Ativan (anxiety medication) oral tablet, give 0.5 milligrams (mg) by mouth as needed for anxiety, dated 07/29/25. R9’s PRN Ativan order lacked a 14-day stop date. On 08/25/25 at 08:34 AM, R9 sat in her wheelchair at the dining room table. R9 was eating from a red plate with raised edges. On 08/26/25 at 12:55 AM, Licensed Nurse (LN) I stated she did not know there needed to be a 14-day stop date on medication. She stated the director of nursing put in the orders for residents. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the director of nursing put in the orders and checked the pharmacy reviews. She stated she knew there needed to be a 14-day stop date. Administrative Nurse D stated that if the director of nursing did not follow through with the pharmacy reviews, it was ultimately her responsibility to ensure they were all done. The facility’s “Transcription of Orders/Following Physician Orders” policy, last revised 05/18/24, documented upon receiving a physician’s order via telephone, fax, written order, verbal order, transcribed order, or other, it would be documented in the residents’ electronic medical records in the orders section. Clarification of the physician's orders would be obtained if the order was either unclear or the nurse was uncomfortable with the implementation of the physician's orders. - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of bradycardia (low heart rate, less than 60 beats per minute), dementia (a progressive mental disorder characterized by failing memory and confusion), Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dysphagia (swallowing difficulty). The “Quarterly Minimum Data Set (MDS) dated [DATE] for R24 documented a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R24 needed supervision/touching with eating, and substantial to maximal assistance with bathing and toileting. The MDS did not indicate R24 received hospice care. The MDS documented R24 received an antianxiety (a class of medications that calm and relax people) and an antidepressant (a class of medications used to treat mood disorders) during the observation period. R24’s “Psychotropic Drug Use Care Area Assessment (CAA) dated 03/03/24 lacked analysis. R24's “Care Plan” dated 08/08/25 documented R24 had a terminal diagnosis of Parkinson’s disease. The plan of care documented R24 would be comfortable and feel supported in his prognosis. R24‘s EMR under the “Orders” tab revealed the following physician orders: Alprazolam (antianxiety medication) oral tablet 0.5 milligrams (mg) (Alprazolam), give 0.5 tablet by mouth one time a day for sundowners, dated 07/31/25. Venlafaxine (antidepressant medication) HCl ER oral capsule extended release 24 Hour 150 MG (Venlafaxine HCl) give 1 capsule by mouth one time a day for depression, start date-04/23/25 and discontinued date- 08/05/25. Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 75 MG (Venlafaxine HCl), give 1 tablet by mouth in the morning for depression, dated 08/06/25. A Review of R24’s “Treatment Administration Record” lacked documentation of monitoring of behaviors for anxiety and depression. On 08/25/25 at 08:26 AM, R24 was sitting in his wheelchair in the dining room. On 08/26/25 at 10:27 AM, R24 was sitting with a group of residents. On 08/26/25 at 12:55 AM, Licensed Nurse (LN) I stated she did not know there needed to be monitoring for antidepressant medications. She stated the director of nursing put in the orders for residents. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the director of nursing was putting in the orders and checking the pharmacy reviews. Administrative Nurse D stated that if the director of nursing did not follow through with the pharmacy reviews, it was ultimately her responsibility to ensure they were all done. The facility’s “Transcription of Orders/Following Physician Orders” policy, last revised 05/18/24, documented upon receiving a physician’s order via telephone, fax, written order, verbal order, transcribed order, or other, it would be documented in the residents’ electronic medical records in the orders section. Clarification of the physician's orders would be obtained if the order was either unclear or the nurse was uncomfortable with the implementation of the physician's orders.

The facility identified a census of 34 residents. The sample included 12 residents, with seven residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure that the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations for a gradual dose reduction (GDR) for Resident (R) 6's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and R14's psychotropic (alters mood or thought) medication indication. The facility also failed to ensure the CP identified and reported as needed diuretic (a medication to promote the formation and excretion of urine) medication lacked administration parameters. The facility further failed to ensure the CP identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for R19. The facility failed to follow the CP's recommendation for R24's recommendation for monitoring of antidepressant medication (a class of medications used to treat mood disorders) for continued use and a 14-day stop date for R2's Lorazepam (an antianxiety medication). These deficient practices placed these residents at risk for unnecessary medication use, adverse side effects, and physical complications. Findings included:- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), dysphagia (swallowing difficulty), Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The “Annual Minimum Data Set (MDS)” dated 08/09/24 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R6 had received antipsychotic medication and antidepressant medication (a class of medications used to treat mood disorders). The MDS lacked documentation a GDR had been attempted, or the physician had documented a GDR was contraindicated for R6. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R6 had received antipsychotic medication, antidepressant medication, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) medication. The MDS lacked documentation a GDR had been attempted, or the physician had documented a GDR was contraindicated for R6. R6's Psychotropic Drug Use Care Area Assessment (CAA)” dated 08/19/25 documented she had the potential for complications with the psychotropic medication she received. R6's “Care Plan,” dated 05/08/24, documented the facility would consult with the pharmacist and physician to consider a dose reduction when clinically appropriate. R6‘s EMR under the “Orders” tab revealed the following physician orders: Seroquel (antipsychotic) oral tablet (quetiapine fumarate- antipsychotic), give 50 mg by mouth one time a day related to unspecified mood affective disorder, dated 02/22/24. Quetiapine fumarate oral tablet (Seroquel) 100 milligram (mg), give one tablet by mouth at bedtime for schizoaffective disorder, dated 10/10/24. Review of the “Monthly Medication Review” (MMR) provided by the facility from April 2025 through July 2025 lacked a physician response to the CP recommendation for GDR on 04/08/25 and 06/10/25 for R6’s psychotropic medications. The facility was unable to provide a physician's response upon request. The facility was also unable to provide MMRs from August 2024 through March 2025 upon request. On 08/25/25 at 07:53 AM, R6 wheeled her wheelchair from her room to the dining room without difficulty. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated she did not address the MMRs. On 08/26/25 at 01:25 PM, Administrative Nurse D stated she expected the CP to identify and recommend a GDR when needed for psychotropic medications. Administrative Nurse D stated she expected the director of nursing to ensure the physician reviewed and addressed the CP recommendations and retained the MMRs once the physician had reviewed them. The facility’s “Gradual Dose Reduction of Psychotropic Drugs” policy, last revised 05/14/24, documented residents who use psychotropic drugs received gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. - R14's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and heart failure. The “admission Minimum Data Set (MDS)” dated 09/25/24 documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R14 had received a diuretic (a medication to promote the formation and excretion of urine) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R14 had received diuretic medication and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. R14's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA)” dated 10/03/24 documented he had a self-care deficit and required staff assistance with most of his activities of daily living. R14's “Care Plan,” dated 10/07/24, documented nursing staff would administer medications as ordered by the physician. The plan of care documented nursing staff would monitor and document any side effects and effectiveness. R14‘s EMR under the “Orders” tab revealed the following physician orders: Mirtazapine (antidepressant) oral tablet 15 milligram (mg), give one tablet by mouth at bedtime for health maintenance, dated 07/08/25. Torsemide (diuretic) oral tablet 10 mg, give half tablet (5 mg) by mouth twice a day as needed for edema or weight gain, dated 07/08/25. Torsemide oral tablet, give 5 mg by mouth two times a day, related to heart failure and atrial fibrillation, dated 07/08/25. The Torsemide orders lacked parameters for when to give the diuretic medication. Review of the “Monthly Medication Review” (MMR) provided by the facility from April 2025 through July 2025 lacked evidence of notification for a lack of administration parameters for as-needed diuretic medication. The CP had identified and requested a clarification for the indication for antidepressant medication. The facility was unable to provide MMRs from August 2024 through March 2025 upon request. On 08/24/25 at 09:03 AM, R14 laid on his bed with the head of his bed elevated as he watched TV. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated that there should be administration instructions on any order. LN I stated she would clarify any order that did not have administration parameters with the order. LN I stated she did not address the MMRs. LN I stated she had administered the as-needed diuretic at times per request of R14’s physician. On 08/26/25 at 01:25 PM, Administrative Nurse D stated she expected the CP to identify the lack of administration parameters for as-needed diuretic medication. Administrative Nurse D stated she expected the charge nurse to clarify the order if it lacked the administration instructions. Administrative Nurse D stated she expected the CP to identify any irregularities. Administrative Nurse D stated the director of nursing was responsible for ensuring the MMRs were reviewed by the physician and addressed on a regular basis. The facility’s “Medication Regimen Review” policy, last revised 06/26/24, documented the drug regimen of each resident was to be reviewed at least once a month by a licensed pharmacist and included a review of the resident's medical chart. Medication Regimen Review (MRR), or Drug Regimen Review, was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. - R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end-stage renal disease (ESRD- a terminal disease of the kidneys), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dependent on dialysis, and hypertension (HTN- elevated blood pressure). The “admission Minimum Data Set (MDS)” dated 02/02/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS lacked documentation R19 had received dialysis during the observation period. The MDS documented R19 had received antiplatelet (medication that helps prevent blood clots from occurring) and anticoagulant (a class of medications used to prevent the blood from clotting) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. The MDS lacked documentation that R19 had received dialysis during the observation period. The MDS documented R19 had received antiplatelet (medication that helps prevent blood clots from occurring) and anticoagulant (a class of medications used to prevent the blood from clotting) medication during the observation period. R19's Psychotropic Drug Use Care Area Assessment (CAA)” dated 02/17/25 documented will continue to monitor. R19's “Care Plan,” dated 02/15/25, documented nursing staff would educate R19 and her legal representative on the physician-ordered analgesics (medication to relieve pain) and/or anti-inflammatory (medication that relieves pain, redness, and swelling). R19‘s EMR under the “Orders” tab revealed the following physician orders: Voltaren gel (topical) to both thighs every six hours as needed for pain, dated 06/13/25. The order lacked dosing instructions. Review of the “Monthly Medication Review” (MMR) provided by the facility from April 2025 through July 2025 lacked evidence of notification for a lack of dosing instructions for the Voltaren gel. The facility was unable to provide MMRs from August 2024 through March 2025 upon request. On 08/25/25 at 01:53 PM, R19 laid on her bed. R19 had pulled the blanket over her head as she slept. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated that there should be administration instructions on any order. LN I stated she would clarify the Voltaren topical gel for R19. On 08/26/25 at 01:25 PM, Administrative Nurse D stated she expected the CP to identify the lack of dosing instructions for R19’s Voltaren topical gel. Administrative Nurse D stated she expected the charge nurse to clarify the order if it lacked administration instructions. The facility’s “Medication Regimen Review” policy, last revised 06/26/24, documented the drug regimen of each resident was to be reviewed at least once a month by a licensed pharmacist and included a review of the resident's medical chart. Medication Regimen Review (MRR), or Drug Regimen Review, was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of bradycardia (low heart rate, less than 60 beats per minute), dementia (a progressive mental disorder characterized by failing memory and confusion), Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dysphagia (swallowing difficulty). The “Quarterly Minimum Data Set (MDS) dated [DATE] for R24 documented a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R24 needed supervision or touching with eating, and substantial/maximal assistance with bathing and toileting. The MDS did not indicate R24 received hospice care. The MDS documented R24 received an antianxiety (a class of medications that calm and relax people) and an antidepressant (a class of medications used to treat mood disorders) during the observation period. R24’s “Psychotropic Drug Use Care Area Assessment (CAA) dated 03/03/24 lacked analysis. R24's “Care Plan” dated 08/08/25 documented R24 had a terminal diagnosis of Parkinson’s disease. The plan of care documented R24 would be comfortable and feel supported in his prognosis. The plan of care documented R24 had chosen a hospice provider. R24‘s EMR under the “Orders” tab revealed the following physician orders: Alprazolam (antianxiety medication) oral tablet 0.5 milligrams (mg) (Alprazolam), give 0.5 tablet by mouth one time a day for sundowners, dated 07/31/25. Venlafaxine (antidepressant medication) HCl ER Oral Capsule extended release 24 Hour 150 MG (Venlafaxine HCl) give 1 capsule by mouth one time a day for depression, start date- 04/23/2 and discontinue date- 08/05/25. Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 75 MG (Venlafaxine HCl), give 1 tablet by mouth in the morning for depression, dated 08/06/25. A review of R24’s “Monthly Medication Review” (MMR) from August 2024 through July 2025 revealed an MMR dated 06/10/25, directed staff to monitor the need for R24’s antidepressant medication. A review of R24’s “Treatment Administration Record” (TAR) lacked evidence or documentation of the monitoring of specific behaviors associated with each disorder daily. On 08/25/25 at 08:26 AM, R24 was sitting in his wheelchair in the dining room. On 08/26/25 at 10:27 AM, R24 was sitting with a group of residents. On 08/26/25 at 12:55 AM, Licensed Nurse (LN) I stated she did not know there needed to be monitoring for antidepressant medications. She stated the director of nursing put in the orders for residents. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the director of nursing was putting in the orders and checking the pharmacy reviews. Administrative Nurse D stated if the director of nursing did not follow through with the pharmacy reviews, it was ultimately her responsibility to ensure they were all done. The facility’s “Medication Regimen Review” policy, last revised 06/26/24, documented that the drug regimen of each resident was to be reviewed at least once a month by a licensed pharmacist and included a review of the resident's medical chart. Medication Regimen Review (MRR), or Drug Regimen Review, was a thorough evaluation of the medication regimen of a resident, to promote positive outcomes and minimize adverse consequences and potential risks associated with medication. - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), hyperlipidemia (condition of elevated blood lipid levels), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), acquired absence of left leg below the knee, schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual 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 R2 was dependent on staff for toileting, bathing, and dressing, and needed supervision or touching assistance from staff with eating. The MDS documented R2 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an antianxiety (a class of medications that calm and relax people) medication during the observation period. R2's The Psychotropic Drug Use Care Area Assessment (CAA) dated 06/30/25 lacked analysis. R2’s “Care Plan” dated 09/24/24 documented R2 had an activities of daily living (ADL) self-care performance deficit with potential for decline related to dementia (a progressive mental disorder characterized by failing memory and confusion), impaired balance, limited mobility, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R2's EMR under Orders documented the following physician's order: Lorazepam (anxiety medication) oral tablet, give 1.0 milligrams (mg) by mouth every two hours as needed for anxiety, dated 07/14/25. The facility lacked documentation or evidence the CP recommendations were acknowledged and/or acted upon for R2’s lorazepam order for anxiety. On 08/24/25 at 08:35 AM, R2 sat in her room, in her Broda chair (specialized wheelchair with the ability to tilt and recline). On 08/25/25 at 08:50 AM, R45 sat in her Broda chair watching TV and visited appropriately. On 08/26/25 at 12:55 AM, Licensed Nurse (LN) I stated she did not know there needed to be a 14-day stop date on medication. She stated the director of nursing was putting in the orders for residents. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the director of nursing was putting in the orders and checking the pharmacy reviews. She stated she knew there needed to be a 14-day stop date. Administrative Nurse D stated if the director of nursing did not follow through with the pharmacy reviews, it was ultimately her responsibility to ensure they were all done. The facility’s “Transcription of Orders/Following Physician Orders” policy, last revised 05/18/24, documented upon receiving a physician’s order via telephone, fax, written order, verbal order, transcribed order, or other, it would be documented in the residents’ electronic medical records in the orders section. Clarification of the physician's orders would be obtained if the order was either unclear or the nurse was uncomfortable with the implementation of the physician's orders.

The facility identified a census of 34 residents. The sample included 12 residents, two medication carts, one Licensed Nurse (LN) medication cart, and one medication room. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for the residents in the medication cart and the medication room that were labeled with opened on dates for the liquid vials and not expired oral medications. This deficient practice placed the residents at risk for an ineffective medication regimen.Findings included:- On [DATE] at 08:55 AM, during the review of the LN medication cart an Insulin Lispro ( fast-acting insulin that lowers blood sugar in people with diabetes) lacked a date for when it was opened, and an Insulin Glargine (long-acting insulin for type 1 and type 2 diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin)) vial was dated [DATE]. LN G verified that there was no open date for the Insulin Lispro vial and that the Insulin Glargine vial had expired. LN G stated both vials should be destroyed.On [DATE] at 10:05 AM, during the medication cart review, the following medications were found to be expired:Resident (R) 2's Midodrine (used to treat low blood pressure) 5 milligram (mg) tablets given as needed (PRN), 60 tablets expired on [DATE].R30's meclizine (treats or prevents motion sickness and vertigo) 12.5 mg tablets given PRN, on two expired cards: [DATE] and [DATE].R20's furosemide (a loop diuretic used to treat fluid retention and high blood pressure by increasing urine output) 20 mg tablets given PRN, 11 tablets, expired on [DATE].R23's Cyclobenzaprine (a muscle relaxant used to relieve muscle spasms) 10 mg tablets, 16 tablets given PRN, expired [DATE].On [DATE] at 10:09 AM, Certified Medication Aide (CMA) R confirmed the medications had expired and removed the cards from the medication cart.On [DATE] at 10:18 AM, during the medication room review, 19 over-the-counter medications were found to be expired in the supply shelves; CMA R confirmed the expired over-the-counter medications. In the refrigerator in the medication room, there were two opened Tuberculous (TB- a serious lung infection caused by bacteria) vials and one opened Insulin Lispro vial; all three vials lacked a date for when the vials were opened or when the vials would expire. CMA R verified the vials lacked any dates.On [DATE] at 01:27 PM, Administrative Nurse D stated that the medications that were expired should be removed from the medication cart and medication room, and all vials should be dated.The facility's Medication Storage Policy dated [DATE] documented the facility was to ensure all medications housed on the premises would be stored in the medication rooms according to the manufacturer's recommendations. The policy documented that the pharmacist would routinely inspect for discontinued, outdated, defective, or deteriorated medications.

The facility identified a census of 34 residents. The facility had one main kitchen and a dining kitchenette. Based on observation, record review, and interview, the facility failed to ensure that the facility had sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services. This deficient practice resulted in poor sanitary conditions in the kitchen and placed the residents at risk of potentially impaired nutrition.Findings included:- On 08/25/25 at 11:40 AM, Dietary Staff BB was the only dietary staff in the kitchen. Dietary Staff BB stated that he had two other staff members, but they both needed Mondays and Tuesdays off. Dietary Staff BB stated he did not have enough kitchen staff to keep the kitchen clean, cook food, and do dishes. He stated the facility had some applications, but the facility had not hired anyone yet.On 08/25/25 at 08:15 AM, Administrative Staff A stated she was aware there was not enough staff in the kitchen. She stated they did have applicants. Administrative Staff A stated that the dietary staffing was low, and she would try to get Dietary Staff BB some help in the kitchen.On 08/25/25 at 08:30 AM, approximately 10 residents sat at the dining room tables. R2 stated it was always after 08:30 AM before the breakfast trays were passed.On 08/25/25 at 08:32 AM, staff entered the dining room and began passing food trays out to residents in the dining room. The meal on the tray was scrambled eggs, bacon, and cereal.A review of the facility's posted meal service times listed the following times: Breakfast- 07:30 AM to 08:30 AM; Lunch- Noon to 01:00 PM; Dinner- 05:00 PM to 06:00 PM.The facility did not provide a policy for dietary staffing.

The facility identified a census of 34 residents. The sample included 12 residents. Based on observations and interviews, the facility failed to provide a clean, home-like environment for the residents who resided in the facility.Findings included:- On 08/24/25 at 07:18 AM, a walk-through of the facility revealed a wheelchair, a Hoyer (total body mechanical lift), and two commodes placed on the back of hall 100. On 08/24/25 at 07:30 AM, in Resident (R) 22's room, behind her bed, was an approximately six-inch square hole in the wall. On 08/24/25 through 08/26/25, flies were in the dining room, in the kitchen, and on the nurse's desk. On 08/26/25 at 02:30 PM, Licensed Nurse (LN) I stated that staff filled out a work order for repairs or notified the maintenance department. LN I stated the equipment was moved from the hallways when residents were out of their beds. LN I stated there were a lot of flies, she stated the flies come in when residents in wheelchairs go outside to smoke and hold the patio door open. She stated that most of the residents have fly swatters. On 08/26/25 at 04:02 PM, Administrative Nurse D stated maintenance made rounds on a regular basis to check for repairs. Administrative Nurse D stated she was unaware of the equipment in the hallways, and commodes should not be left in the hall. She stated maintenance should be taking care of the flies; she was unaware that the flies were a problem. The facility's Safe Homelike Environment policy dated 06/05/24 documented the purpose of the policy was in accordance with the residents' rights and the facility would provide a safe, clean, comfortable, and homelike environment, allowing the resident to use their personal belongings to the extent possible. This would ensure that the resident can receive care services safely and the physical layout of the facility maximized the resident's independence and does not pose a safety risk.

The facility identified a census of 34 residents. The sample included 12 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations for Resident (R) 2, R14, and R24. This deficient practice placed these residents at increased risk for COVID-19.Findings included:- Review of R2's clinical record revealed he was admitted on [DATE]. Review of R2's EMR under the Immunization tab lacked documentation of the COVID-19 vaccination offered or declined, and lacked documentation of a historical administration or physician-documented contraindication.Review of R14's clinical record revealed he was admitted on [DATE]. Review of R14's EMR under the Immunization tab lacked documentation of the COVID-19 vaccination offered or declined, and lacked documentation of a historical administration or physician-documented contraindication.Review of R24's clinical record revealed he was admitted on [DATE]. Review of R24's EMR under the Immunization tab lacked documentation of the COVID-19 vaccination offered or declined, and lacked documentation of a historical administration or physician-documented contraindication.Upon request for R2, R14, and R24's record of declination or administration of the COVID-19 vaccine, the facility was unable to provide a consent or declination for these residents. The facility was unable to provide a physician-documented contraindication. On 08/25/25 at 01:13 PM, Administrative Staff A stated the facility was not able to find documentation for vaccines given or signed declinations. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the facility was unable to find documentation of vaccines. She stated there had been some staff changes, and she was unsure where the information was. The facility was unable to provide a policy related to the administration of COVID-19 vaccination.

The facility had a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure effective pest control. This deficient practice placed the residents of the facility at risk for decreased health and wellness. Findings included: - On 08/24/25 at 08:05 AM, several flies were in the dining area, flying around the nutrition kitchenette. Two unidentified residents were swatting flies before getting their plate of breakfast. On 08/25/25 at 10:05 AM, more than ten flies were flying around the nurse's station. On 08/25/25 at 11:44 AM, in the kitchen, there were 10-15 flies on the plates and bowls. On 08/25/25 at 12:10 PM, Resident (R) 16 stated her partner at the table brings his fly swatter and kills flies. She stated there were always flies in the dining room. The facility's last pest control inspection reported that on 04/23/25, the provider sprayed for general pests. On 08/26/25 at 12:42 PM, Certified Medication Aide (CMA) R stated the facility did have more flies. CMA R stated the flies come in through the patio. CMA R stated it takes a long while for wheelchair residents to get outside to smoke. On 08/26/25 at 01:25 PM, License Nurse (LN) I stated there were a lot of flies, she stated she did not know if there was a pest control program for the flies. LN I stated the facility had several fly swatters. On 08/26/25 at 01:25 PM, Administrative Nurse D stated she was unaware of the fly problem. She stated that the maintenance personnel should be noting and taking care of the fly situation. The facility's Effective Pest Control Program policy dated 05/14/24 documented that it was the policy of the facility to maintain an effective pest control program that eradicated and contained household pests and rodents. The facility would maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services regularly.

The facility identified a census of 34 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to secure the facility's electrical panel, a razor, and cleaning chemicals in a safe, locked area, and out of reach of eight cognitively impaired, independently mobile residents. The facility also failed to assess R5 for smoking safety. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings included:- During the initial tour of the facility on 08/24/25 at 07:10 AM revealed an unsecured closet with open, unlocked electrical panels. Licensed Nurse (LN) G stated he was not sure if the closet should be locked and would let the director of nursing know. On 08/24/25 at 07:09 AM, the 100-hall shower room door was swung open. Inside the shower room, there was a cabinet that had a padlock hanging open on the lock, with the key in it. Inside the cabinet was shampoo, skin barrier wipes, a razor, and total bath skin and hair cleanser that read “Keep out of reach of children.” On the seat in the shower, there was a shampoo bottle left out that read “Keep out of reach of children.” On 08/25/25 at 07:58 AM, the closet with the electrical panel remained unsecured. Housekeeper Staff V stated he was not sure if the closet should be secured because there was no handle on the back of the door. Housekeeper Staff V stated he would report the unsecured door to the head of the maintenance department. On 08/25/25 at 08:24 AM, Maintenance Director U stated he was not sure the door should be secured. Maintenance Director U stated the door should be locked because the electrical panel’s keys did not lock the panels. On 08/26/25 at 12:57 PM, Licensed Nurse (LN) I stated that after the showers were completed, the supplies should be locked up. On 08/26/25 at 01:27 PM, Administrative Nurse D stated that the cabinet should be locked. On 08/26/25 at 01:40 PM, Administrative Staff A stated the closet with the electrical panels should be secured to prevent injuries. The facility’s “Accidents and Supervision Policy,” last revised 05/18/24, documented the resident environment would remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. - R5's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting right dominant side, hypertension (high blood pressure), aphasia (condition with disordered or absent language function), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The “Quarterly Minimum Data Set” (MDS) dated [DATE] documented that the facility was unable to conduct a Brief Interview of Mental Status (BIMS) score. R5’s MDS documented R5 was rarely or never understood. The MDS documented R5 needed supervision/touching assistance for eating and oral hygiene, and partial/moderate assistance from staff with toileting and bathing. R5's Falls Care Area Assessment (CAA) dated 03/17/25 documented no falls during the look-back period and would continue to monitor. R5’s “Care Plan” dated 06/06/25 documented R5 did own self-directed activities throughout the facility and in her room. R5’s plan of care documented that she would do activities of choice, and smoking was her favorite activity. R5’s plan of care lacked direction for staff to know how much assistance R5 needed with smoking materials. R5’s EMR under “Assessments” lacked a smoking assessment. Upon request, the facility was unable to provide a current smoking assessment. The facility did provide a smoking assessment for R5 dated 03/23. On 08/24/25 at 01:38 AM, R5 was at the nurse’s desk asking to go outside to smoke. On 08/25/25 at 10:36 AM, R5 was at the nurse’s desk asking staff to go outside to smoke. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated that all assessments pop up on the EMR when the assessment was due. She stated when the assessment came up, the nurse on duty or the director of nursing would ensure each assessment was done promptly. LN I stated that the facility did a smoking assessment on each resident who admitted to the facility. On 08/26/25 at 01:25 PM, Administrative Nurse D stated all nursing staff were responsible for ensuring the smoking assessment was done for each resident quarterly or as needed. She stated that normally the smoking assessment would pop up on the EMR, and that would be how the nurses would know the assessment was due. The facility’s “Accident and Supervision Policy” dated 05/18/24 documented the resident environment would remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. This includes identifying hazards and risks. Evaluating and analyzing hazards and risks, and implementing interventions to reduce hazards and risks.

The facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to complete the Care Area Assessment (CAA- analysis of findings) related to a Minimum Data Set (MDS), within the required time frame, for Resident (R) 4, R19, R2, and R9 to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. This deficient practice placed the residents at risk for unidentified care needs. Findings included:- Review of R4's Electronic Medical Record (EMR) under the MDS tab revealed an admission MDS dated 03/17/25. Review of the CAAs dated 03/26/25 identified the following care areas lacked analysis: Functional Abilities (Self-Care and Mobility), Nutritional Status, Falls, Urinary Incontinence and Indwelling Catheter, and Psychotropic Drug Use. Review of 19's EMR under the MDS tab revealed an admission MDS dated 02/02/25. Review of the CAAs dated 02/17/25 lacked analysis and had documented will continue to monitor (wctm) under the following care areas, Functional Abilities (Self-Care and Mobility), Urinary Incontinence and Indwelling Catheter , Dehydration/Fluid maintenance, Nutritional Status, Pressure Ulcer, Falls, and Psychotropic Drug Use. Review of R2's EMR under the MDS tab revealed a Significant Change MDS' dated 06/18/25. Review of the CAAs dated 06/26/25 lacked analysis and had documented wctm under the following care areas, Cognitive Loss/Dementia, Functional Abilities (Self-Care and Mobility), Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Mood State, Behavioral Symptoms, Activities, Falls, Nutritional Status, Pressure Ulcer, and Psychotropic Drug Use. Review R9's EMR under the MDS tab revealed an admission MDS dated 03/12/25. Review of the CAAs dated 03/26/25, the following care areas lacked analysis: Functional Abilities (Self-Care and Mobility), Nutritional Status, Urinary Incontinence and Indwelling Catheter, Communication, Delirium, Cognitive Loss/Dementia, and Pressure Ulcer. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the MDS was completed off-site by a regional staff member. Administrative Nurse D stated that all triggered CAAs should have a complete analysis with measurable goals to create the resident's person-centered care plan. Administrative Nurse D stated that wctm was not an analysis of the triggered care area. The facility's Care Assessment Summary and Individualized Care Plan policy, last revised 11/06/23, documented the MDS 3.0 with the Care Area Assessment Summaries as a much more user-friendly assessment tool that addressed the holistic person, including functional status, quality of life, and individual plan of care to address and meet the needs of the individual resident. Section V was to be completed by the entire interdisciplinary Team (formerly RAPs, now CAA's - Care Area Assessment). The most important aspect to remember in this section was that the MDS does not constitute a comprehensive assessment without the Care Area Assessment Summary being completed. The Care Area Assessment Summary drives the development of the individualized care plan. A Care Area Trigger (CAT) alerts the assessor that interventions must be in place to address the care concern in the plan of care for the individual resident. All Care Area Assessment Summary Triggers must be addressed in the individualized plan of care for the resident. This area provided guidance on how to focus on key issues that are identified during the comprehensive MDS assessment. This area directed the facility staff to evaluate triggered care areas.

The facility identified a census of 34 residents. The sample included 12 residents, with two residents sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22's call light was within her reach and further failed to ensure R6 was not pushed by staff without foot pedals. This deficient practice left R22 vulnerable for unmet care needs due to the inability to call for staff assistance and the possibility of falls and placed R6 at risk for preventable injury and avoidable accidents.Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and emphysema (long-term, progressive disease of the lungs characterized by shortness of breath). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented R22 needed supervision/touching assistance from staff for eating, partial/moderated assistance for oral care, and was dependent on staff for toileting, bathing, dressing, and personal cares.The Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 05/09/25 documented staff were to continue to provide and assist with activities of daily living (ADL). The CAA for R22 documented the facility would continue to monitor and update R22's plan of care as needed. R22's Care Plan dated 06/24/25 documented R22 was at risk for falls due to confusion, balance problems, poor safety awareness, and dementia. R22's plan of care documented staff were to ensure the call light was within her reach and encourage the resident to use it for assistance as needed. The plan of care for R22 directed staff to ensure prompt response to all requests. On 08/25/25 at 07:11 AM, R22's call light was clipped to the privacy curtain at the bottom of her bed. R22 was unable to reach the call light. On 08/25/25 at 08:35 AM, Administrative Staff A pushed R6 into the dining room without foot pedals.On 08/26/25 at 07:05 AM, R22's call light was clipped to the privacy curtain at the bottom of R22's bed. R22 was unable to reach the call light. On 08/26/25 at 12:42 PM, Certified Medication Aide (CMA) R stated the residents' call lights should always be placed within the residents' reach. She stated if a resident was being pushed by staff, the resident should have foot pedals on her wheelchair. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated the call light should never be clipped to the privacy curtain; the call light should always be placed where the resident could reach the call light. LN I stated when a resident was pushed by a staff member, the staff member should apply the foot pedals. On 08/26/25 at 01:25 PM, Administrative Nurse D stated the call lights should always be placed within the residents' reach. She stated that staff should apply the foot pedals when pushing a resident in a wheelchair. The facility did not provide an accommodation of needs policy.

The facility identified a census of 34 residents. The sample included 12 residents, with 12 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 33 for chronic pain, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), activities of daily living (ADL), vision, bowel and bladder, activities, falls, psychosocial, dehydration, risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). This deficient practice placed R33 at risk for impaired care due to uncommunicated care needs. Findings included:- R33's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic pain, muscle weakness, DM, respiratory failure, depression, and anxiety. The admission Minimum Data Set (MDS) dated 03/28/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R33 was dependent on staff assistance with bathing, transfers, toileting, and bed mobility. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R33 was dependent on staff assistance for bathing, transfers, bed mobility, and toileting. R33's Visual Function Care Area Assessment (CAA) dated 03/29/25 documented social services would follow up and schedule an eye appointment. R33's Functional Abilities (Self-Care and Mobility) CAA dated 03/29/25 documented staff would assist him with ADLs and update his plan of care. R33's Urinary Incontinence and Indwelling Catheter CAA dated 03/29/25 documented staff would assist him with peri-care and update his plan of care. R33's Psychosocial Well-Being CAA dated 03/29/25 documented will continue to monitor (wctm). R33's Activities CAA dated 03/29/25 documented that the activities department would follow up with him. R33's Falls CAA dated 03/29/25 documented wctm.R33's Dehydration/Fluid maintenance CAA dated 03/29/25 documented wctm. R33's Pressure Ulcer CAA dated 03/29/25 documented nursing would complete weekly skin assessment. R33's Psychotropic Drug Use CAA dated 03/29/25 documented no adverse effects noted during the look-back period. R33's Care Plan dated 04/24/25 documented he was at nutritional risk related to his diagnosis of obesity (excessive body fat). The plan of care dated 06/26/25 documented R33 had a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The plan of care lacked direction for medication administration, risk of dehydration, risk of falls, risk of development of pressure ulcers, psychosocial well-being, ADLs, activities, vision difficulties, and bowel and bladder function. On 08/25/25 at 8:20 AM, R33 laid on his back on the bed. R33's head of bed was slightly elevated. On 08/26/25 at 12:40 PM, Certified Medication Aide (CMA) R stated everyone had access to the residents' plan of care or their Kardex (nursing tool that gives a brief overview of the care needs of each resident). CMA R stated the person-centered plan of care, or the Kardex, should have the resident's individualized care needs listed. On 08/26/25 at 12:55 PM, Licensed Nurse (LN) I stated all staff had access to the residents' care plan or their Kardex. LN I stated that the residents' individualized care interventions could be found in the Kardex. LN I stated she had access to modify a resident's plan of care, but would let the director of nursing know what needed to be added or changed. On 08/26/25 at 01:25 PM, Administrative Nurse D stated all nursing staff had access to the resident's care plan and Kardex. Administrative Nurse D stated the director of nursing was responsible for ensuring the resident's person-centered care plan was developed, updated, and current with the resident's care needs. The facility's Comprehensive Care Plan policy, last revised 10/31/24 documented it was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

The facility identified a census of 34 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on the record review and interview, the facility failed to provide the cost for continued services information on the Advanced Beneficiary Notice (ABN Centers for Medicare and Medicaid Services (CMS) form 10055) for skilled services for Resident (R) 9. This placed the resident at risk for uninformed care decisions.Findings included:- Review of R9's ABN lacked documentation regarding the cost for continued skilled services ending on 7/24/25.On 08/26/25 at 01:27 PM, Administrative Nurse D stated that the beneficiary notice should have the cost on it to notify the residents.The facility's Advance Beneficiary Notices policy dated 11/05/24 documented the facility was to ensure timely notices regarding Medicare eligibility and coverage provided. The policy documented the facility would inform Medicare beneficiaries of his or her potential liability for payment.

The facility identified a census of 32 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to prevent an avoidable accident on 12/16/24 when Certified Nurse Aide (CNA) M propelled Resident (R) 1 in her wheelchair without utilizing foot pedals. R1 planted her feet, leaned forward, and then fell out of the wheelchair, hitting the floor. The facility sent R1 to the emergency room (ER) where they discovered via a computed tomography (CT scan- a test that used X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) that she had mildly displaced bilateral (both sides) nasal bone fractures as a result of the fall. This deficient practice also placed R1 at risk for pain. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not assessed. R1 had impairment on both sides of her lower extremities and was dependent on staff for wheelchair mobility. R1 had no falls since admission. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 13 which indicated intact cognition. R1 had impairment on both sides of her lower extremities and was dependent on staff for wheelchair mobility. R1 had no falls since her last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/11/24, documented R1 had a diagnosis of dementia, which could lead to her memory problems. The Falls CAA dated 6/16/24, documented R1 had a potential for falls related to impaired cognition and poor safety awareness. R1 required moderate to maximum assistance with mobility. R1's Care Plan dated 06/08/24, documented R1 had an increased risk for falls with injury related to confusion, balance problems, and poor safety awareness. The plan directed staff to provide a safe environment with even floors free from spills and/or clutter, adequate light, a working, and reachable call light, the bed in the lowest position at night, and personal items within reach. R1's Care Plan dated 06/08/24, documented R1 had an activities of daily living (ADL) self-care performance deficit related to confusion, dementia, impaired balance with mobility, and she required extensive to maximum assistance with most ADLs. The plan directed R1 required extensive assistance of two staff for transfers and moderate to maximum assistance of one staff for repositioning. CNA M's undated Witness Statement noted on 12/16/24 around 08:05 PM, she planned to lay R1 down for the night. CNA M pushed R1's wheelchair towards her room. CNA M stated that halfway to the resident's room, R1 leaned forward and fell , headfirst, to the floor. CNA M stated she called Licensed Nurse (LN) G for help. R1 had a nosebleed and a large bump on her forehead. CNA M stated R1's foot pedals were on the chair but were not in use at the time of the incident. The facility's Investigation dated 12/23/24, documented on 12/16/24 around 08:00 PM, CNA M pushed R1 down the hallway in the wheelchair. R1 fell forward from her wheelchair to the floor, hitting her face. CNA M immediately called for LN G who assessed R1 and noted an abrasion to R1's forehead and swelling around her face. R1 reported pain in her forehead. R1's vital signs were within normal limits. The facility notified Emergency Medical Services (EMS), R1'sphysician, R1's representative, Administrative Nurse D, and Administrative Staff A of the incident. Upon investigation, the root cause analysis of the fall concluded R1's wheelchair did not have foot pedals in place while CNA M pushed her. R1 sustained a possible hairline fracture to her nose per the ER report. R1's CT Maxillofacial (refers to the face, jaws, mouth, and neck region) scan dated 12/17/24 at 12:04 AM, documented minimally displaced bilateral nasal bone fractures. R1's Clinic Note from the Ear, Nose, and Throat (ENT) specialist on 12/26/24, documented R1 presented to the clinic after falling onto her face. R1's representative reported she was in her wheelchair and her feet got below the wheelchair while she was being pushed, causing her to fall forward. On exam, R1 had a palpable right nasal fracture but it was not displaced. On 12/30/24 at 12:06 PM, R1 sat in her wheelchair at the dining room table. Her feet rested on the wheelchair pedals in front of the wheelchair. On 12/30/24 at 01:04 PM, CNA N stated she kept residents safe during wheelchair propulsion by making sure their feet were on the foot pedals. She stated if staff pushed a resident's wheelchair, the resident's feet were put on pedals. She stated if a resident used their feet to self-propel then they did not use foot pedals. On 12/30/24 at 01:13 PM, Administrative Nurse D stated on 12/16/24, LN G reported to her that CNA M pushed R1 down the hall, R1 planted her feet, and then fell down face first. She stated if staff pushed a resident in a wheelchair, she expected them to use foot pedals. Administrative Nurse D stated R1 had foot pedals on her wheelchair but they were not utilized during the incident on 12/16/24. She stated the ER did not send any orders related to the nasal bone fractures but R1's representative made the ENT appointment. On 12/30/24 at 01:24 PM, Administrative Staff A stated her understanding of the incident was CNA M pushed R1 down the hall for bed and did not put the foot pedals on then R1 fell forward. She stated she expected staff to use foot pedals when propelling the residents in wheelchairs. On 12/30/24 at 06:13 PM, CNA M stated on 12/16/24, she got ready to take R1 to bed; normally R1's foot pedals were down. She stated she was pushing R1's wheelchair when R1 suddenly leaned forward and fell out. CNA M stated she did not realize R1's foot pedals were not in use. She stated the foot pedals were on R1's wheelchair but they were not around the front and used. CNA M stated she kept residents safe during wheelchair propulsion by making sure to check for foot pedals before pushing. The facility's Falls and Fall Risk, Managing policy, dated September 2024, directed staff to identify and implement relevant interventions to try to minimize serious consequences of falling. The facility's Assistive Devices and Equipment policy, dated December 2024, addressed the following factors to the extent possible to decrease the risk for avoidable accidents associated with devices and equipment: appropriateness for resident condition, personal fit, and device condition. The facility failed to prevent an avoidable accident for R1 when staff failed to utilize foot pedals during wheelchair propulsion. This deficient practice resulted in a fall with nasal bone fractures for R1 and also placed her at risk for pain. The facility put the following corrections into place before the onsite visit on 12/30/24: The facility updated R1's care plan to include foot pedal usage on 12/16/24. The facility started educating nursing staff on using foot pedals during staff wheelchair propulsion on 12/17/24 and continued until 12/20/24. CNA M received a corrective action on 12/18/24. Due to the facility having the corrective actions in place prior to the onsite visit, this deficient practice was cited at past noncompliance. The scope and severity remain a G.

The facility identified a census of 28 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 received care consistent with the standards of practice when staff failed to report abnormal x-ray findings and obtain physician involvement for treatment. On 06/04/24, R1 had a fall in the facility's van. On 06/06/24, R1 complained of right shoulder pain and staff obtained an order for an x-ray. The x-ray showed a medial subluxation (dislocation) of R1's right glenohumeral joint (ball and socket joint at the shoulder). Staff failed to notify R1's physician of the results. On 06/27/24, after continued complaints of right shoulder pain affecting R1's activities of daily living (ADLs), staff obtained an order for a referral to an orthopedic (specializing in bones) doctor. Staff called to schedule an appointment but did not follow up or ensure an appointment was made for R1 until 07/18/24 when staff received a call from the orthopedic physician's office for a scheduled appointment on 07/31/24 at 09:45 AM. At the 07/31/24 appointment, the orthopedic physician noted R1 had an anterior (near the front of the body) subluxation of the humeral head with a probable impaction fracture (fracture that occurs when the broken ends of the bone are jammed together by the force of the injury) of the humeral head on the right side and would require surgical repair. The facility's failure to report abnormal X-ray findings to the physician and the delay in physician involvement in R1's injury placed R1 in immediate jeopardy. Findings included: - R1 admitted to the facility on [DATE] and transferred to the hospital on 08/16/24. R1's EMR documented diagnoses of essential hypertension (high blood pressure) and other specified disorders of bone density and structure of the right shoulder. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had impairment on one side of her upper extremities and both sides of her lower extremities. R1 used a walker and a wheelchair. R1 required substantial/maximal assistance with showering, upper and lower body dressing, rolling left to right, sitting to lying, and lying to sitting on the side of the bed; partial/moderate assistance with toileting hygiene, sitting to standing, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers; and was independent with personal hygiene, oral hygiene, and eating. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 15, which indicated intact cognition. R1 had no impairment and used a walker and wheelchair. R1 required substantial/maximal assistance with showering, rolling left to right, and tub/shower transfers; partial/moderate assistance with upper and lower body dressing, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfers; supervision with toileting hygiene and toilet transfers, and was independent with eating, oral hygiene, and personal hygiene. The Functional Abilities Care Area Assessment (CAA) dated 04/24/24, documented R1 had a self-care deficit related to weakness and required assistance with ADLs. R1 had limitations with her right upper extremity and bilateral lower extremities. The Falls CAA dated 04/24/24, documented R1 had an increased risk for falls with injury due to impaired balance, limitations with range of motion, pain, and staff assistance with transfers. R1's Care Plan, initiated 05/13/24, documented R1 had a risk for falls with injury related to incontinence, impaired mobility with balance, and need for continuous oxygen. The care plan documented interventions, dated 05/28/24, that directed R1 needed a safe environment with even floors from spills and/or clutter and R1 used an electric wheelchair for independent mobility. R1's Care Plan, initiated 07/28/24, documented R1 had chronic pain in her shoulder and back related to arthritis and had a recent injury to her right shoulder from a fall. The care plan directed staff administered analgesia as per orders; staff evaluated the effectiveness of pain interventions; staff identified, recorded, and treated R1's existing conditions which increased pain; staff monitored/documented for probable cause of each pain episode and removed or limited the cause where possible; staff monitored/documented for side effects of pain medication and reported occurrences to the physician; staff monitored/recorded pain characteristics every shift and as needed (PRN); and staff notified the physician if interventions were unsuccessful or if current complaint was a significant change from R1's past experiences of pain. The Orders tab of R1's EMR documented an order with a start date of 04/10/24 for acetaminophen (pain medication) 650 milligrams (mg) every six hours as needed (PRN) for pain. R1's Medication Administration Record (MAR) for May 2024 revealed R1 received PRN acetaminophen for pain one time, on 05/31/24. R1's MAR for June 2024 revealed R1 did not receive any acetaminophen before 06/07/24. R1 received PRN acetaminophen for pain 14 times from 06/07/24 to 06/30/24. R1's MAR for July 2024 revealed R1 received PRN acetaminophen for pain 11 times. R1's MAR for 08/01/24 to 08/16/24 revealed R1 received PRN acetaminophen for pain 10 times. The facility's report on 08/15/24, documented on 06/04/24, Transportation Staff W transported R1 to a dental appointment, and during the ride, when the van took a turn, R1 heard a pop and the seatbelt came unbuckled. R1's electric wheelchair tipped sideways to the right. R1 stated the seat belt did not break but had come unlocked. R1 stated she stood up and held onto the seat and Transportation Staff W immediately pulled the van over to put R1's wheelchair back on all four wheels and helped R1 into her wheelchair. R1 had a skin tear on her right elbow which Transportation Staff W bandaged. Transportation Staff W and R1 continued to her appointment. On 06/06/24, R1 reported pain in her shoulder, which she stated was chronic. The provider ordered an x-ray, which showed a medial subluxation of the glenohumeral joint. R1's EMR revealed the following: A Skin/Wound Note on 06/04/24 at 02:28 PM documented R1 had a skin tear to her right elbow. R1 went to a dental appointment in the facility van and when the van made a turn, her wheelchair leaned, and her right elbow hit the van. A Health Status Note on 06/06/24 at 04:45 PM documented facility called Consultant GG regarding R1. R1 requested an x-ray of her right shoulder. Consultant GG ordered a portable two-view x-ray of R1's right shoulder. R1's medical record lacked evidence the facility notified R1's provider of the x-ray results on 06/06/24. R1's medical record lacked evidence the facility notified R1's provider of R1's continued right shoulder pain from 06/07/24 to 06/26/24. A Nurse Note on 06/27/24 at 01:38 PM documented R1 continued to complain of right shoulder pain affecting her ADL ability. The facility received an order for referral to orthopedics. The facility placed a call to orthopedics and waited for a return call for an appointment. R1's medical record lacked evidence the facility followed up with the orthopedic office to schedule an appointment for her referral from 06/28/24 to 07/17/24. A Nurse Note on 07/18/24 at 11:12 AM documented Administrative Nurse E and Social Services X made several calls over the past few weeks to orthopedics regarding setting up an appointment for a new referral due to continued right shoulder pain. The facility received a return call from orthopedics with an appointment scheduled for 07/31/24 at 09:45 AM. A Nurse Note on 08/05/24 at 02:30 PM documented R1 had an initial consult at orthopedics regarding her right shoulder pain. R1 informed the facility she needed surgery and needed clearance from a pulmonologist (a doctor who specializes in diagnosing and treating diseases of the lungs). The facility obtained an order for a referral to a pulmonologist, faxed the referral order to the pulmonologist, and awaited a reply to schedule the consult. R1's medical record lacked evidence the facility followed up with the pulmonologist's office to schedule an appointment for her referral from 08/06/24 to 08/14/24. A Nurse Note on 08/15/24 at 03:28 PM documented the facility notified the pulmonologist's office regarding the new referral and requested an appointment to assess clearance for shoulder surgery. The pulmonologist's office nurse informed the facility that late October was the earliest available. Social Services X notified another pulmonology clinic of the referral and requested an appointment. A Transfer to Hospital Summary on 08/16/24 at 05:12 AM documented R1 voiced complaints of lower abdominal pain, dizziness, and altered mental status. R1 requested to be sent to the hospital for evaluation and treatment. Upon request, the facility was unable to provide progress notes from R1's provider from 06/04/24 to the present. Upon request, the facility supplied a fax confirmation that revealed the facility faxed R1's referral to the orthopedic office on 07/02/24 at 02:19 PM. Upon request, the facility provided Progress Notes from R1's orthopedic consultation on 07/31/24. The Progress Notes documented R1 fell out of her wheelchair due to the seatbelt breaking onto her right shoulder against a lift gate and had pain ever since the incident. R1 could not raise her arm above waist level and when she tried to move it, her shoulder popped. R1 had not seen anyone about her shoulder since the injury. R1's x-ray of her right shoulder from 07/31/24 revealed an anterior subluxation of the humeral head with probable impaction fracture of the humeral head and possibly a fracture extending up superiorly into the humeral head as well. The Impression/Plan for R1 documented R1 had right shoulder pain after a fall two months ago with what appeared to be an impacted head fracture anteriorly subluxated and she might have had a rotator cuff (a capsule of fused tendons that supports the arm at the shoulder joint) tear. The orthopedic provider gave R1 the option of therapy injection medications which he did not believe would do much for her or a shoulder replacement. He recommended R1 think about her options and if she wanted surgery, she would need medical clearance. On 08/19/24 at 12:57 PM, Certified Nurse Aide (CNA) N stated R1 complained of right shoulder pain that had worsened over the last couple of months and slowed down her ability to perform ADLs. On 08/19/24 at 01:09 PM, Licensed Nurse (LN) G stated R1 complained of right shoulder pain after the van incident, and it affected her ADLs. He stated after the facility received X-ray results, the nurse notified the provider and documented the notification in a note. LN G stated if a resident had continued pain for more than a couple of days, he notified the provider and documented it in a note. He stated generally, the provider saw residents following incidents or new pain. He stated the facility should have followed up with R1's provider about her right shoulder pain prior to 06/27/24. LN G stated he thought Social Services X set up any referral appointments. He stated if he received a referral, he sent it to Social Services X. He stated there should be a follow-up system for setting up a referral appointment. On 08/19/24 at 01:23 PM, Social Services X stated Administrative Nurse E sent the referrals to the provider the referral was for. She stated sometimes the facility received a call back from the referred provider to schedule the appointment. Social Services X stated the facility called the referred provider within a couple of days to make the appointment and sometimes the referred provider stated they did not receive the referral or they would have to call back. Social Services X stated she did not put a note in every time she tried to call the referred provider to set up an appointment and she only handled the referrals when Administrative Nurse E was gone. She stated the facility faxed the referral as soon as they received it and followed up within a couple of days. She stated the facility faxed R1's orthopedic referral on 06/27/24 but when she called to follow up, they said they did not get it, so she refaxed it on 07/02/24. On 08/19/24 at 01:34 PM, Administrative Nurse E stated she did not know R1 had right shoulder pain until a week after the van incident and an x-ray had been completed. She stated R1 reported to her on 06/27/24 that her right shoulder pain affected her ADL ability and Administrative Nurse E received an order for a referral to orthopedics. She stated she called the orthopedic office that day and received a number to fax the referral order. Administrative Nurse E stated she called the orthopedic office at least three times between 06/27/24 and 07/18/24 and the office told her she would receive a call back. She stated she did not know why she did not document the follow-up attempts. She stated any nurse handled the referrals and the Director of Nursing (DON) at the time should have followed up with the referral. Administrative Nurse E stated the nurse on the floor should handle the referrals and keep calling until they get a reply. On 08/19/24 at 01:53 PM, Administrative Nurse D stated if a resident had new or increased pain, she expected nursing to assess the resident and notify the physician then document it in a note. She stated she expected the nurse to notify the physician of the X-ray results and document the notification. Administrative Nurse D stated the charge nurse sent referrals and she expected nursing to follow up in a couple of days to make the appointment and then document. The facility's Acute Condition Changes- Clinical Protocol policy, revised 07/05/24, documented that staff contacted the physician based on the urgency of the situation and the attending physician responded in a timely manner to the notification of problems or changes in condition or status. The policy directed staff to monitor and document the resident's progress and responses to treatment. The policy directed the physician to review the status of the condition change and document their evaluation at the next visit. On 08/19/24 at 02:07 PM Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed of the facility's failure to ensure R1 received care consistent with the standards of practice which placed R1 in immediate jeopardy. The facility completed the following corrective actions to remove the immediacy for R1: Licensed nurses were educated on physician recommendations and order follow-ups including appointments starting 08/19/24 and all licensed nurses were educated prior to their next shift. Licensed nurses were educated on post-incident follow-up starting on 08/19/24 and all licensed nurses were educated prior to their next shift. Licensed nurses were educated on pain management and observation starting on 08/19/24 and all licensed nurses were educated prior to their next shift. Licensed nurses were educated on physician notifications to include abnormal diagnostic testing starting 08/19/24 and all licensed nurses were educated prior to their next shift. All current staff were educated on abuse, neglect, and exploitation on 08/16/24. Staff notified R1's physician of abnormal x-ray findings and requested the physician to review pain medications to ensure pain control for R1 on 08/19/24. An ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting with the facility's medical director occurred on 08/19/24. The onsite surveyor verified the implementation of the above corrective actions and removal of the immediacy on 08/19/24. The scope and severity of the deficient practice remained at a G to reflect the actual injury to R1.

The facility identified a census of 28 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure staff provided safe activities of daily living (ADLs) care to Resident (R) 2, consistent with her level of need. This deficient practice resulted in a fracture across the right distal femur (fracture of the thigh bone near the knee) for R2. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) and cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS) dated [DATE], documented R2 had long-term and short-term memory problems. R2 was dependent on staff for all ADLs. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/25/24, documented R2 had a diagnosis of dementia that led to her memory impairment. R2's Care Plan, initiated 04/26/24, documented R2 had an ADL self-care performance deficit related to confusion, dementia, impaired balance, limited mobility, and poor trunk control. The plan documented an intervention, initiated 07/01/24 and created 07/26/24, that directed staff to know R2 required total dependence on staff for transferring. The intervention, revised on 08/12/24, directed staff to provide total assistance with a Hoyer (mechanical lift) lift and non-weight bearing for R2's transfers. Certified Nurse Aide (CNA) M's undated Witness Statement documented on 08/12/24 at 07:20 AM, she went into R2's room to get her up for breakfast. CNA M stated she noticed a bruise on R2's right knee and assumed it happened over the weekend. She stated she continued to dress R2 for the day and then transferred her into her wheelchair. CNA M stated she transferred R2 one-to-one with her right hand around R2's shoulders and her left hand under R2's knees. CNA O's undated Witness Statement documented she provided care to R2 over the weekend from 08/10/24 to 08/11/24. She stated she checked and changed R2 every two hours and R2 had no indications of bruising or swelling. CNA O stated on 08/12/24 at 05:30 AM, staff completed their last check and change and did not notice any bruising or swelling on R2. She stated staff left R2 in bed that morning because she did not want to get up. CNA P's undated Witness Statement documented she did not notice any marks on R2's body all weekend from 08/10/24 to 08/11/24. She stated on 08/12/24 at 05:30 AM, staff completed the last check and change on R2, and she had no bruising or marks of any kind. The facility's Investigation, dated 08/19/24, documented on 08/12/24 at 11:40 AM, staff assisted R2 up for lunch and noted a purple bruise to her right knee that measured 18 centimeters (cm) by 12 cm with swelling and pain with touching. The nurse reported the bruise, and the facility started an investigation. The facility notified the physician and hospice and obtained an order for an x-ray. X-ray results indicated a fracture across the right distal femur. After interviewing all staff who had contact with R2 over the previous three days, the facility established a timeline. Staff did not notice bruising on 08/12/24 at 05:30 AM but did notice bruising at 11:40 AM. The facility interviewed CNA M, who described the way she transferred R2 that morning and she indicated she transferred her alone and without a lift. The facility placed CNA M on the do not return list. R2's EMR revealed a Patient Report for x-ray results on 08/12/24 at 01:42 PM that documented R2 had a fracture across the right distal femur. R2's EMR revealed the following: An Order Note on 08/12/24 at 12:38 PM documented R2's right knee had a purple bruise that measured 18 cm by 12 cm with swelling and pain. The facility obtained an order from R2's provider for a two-view x-ray of her right knee due to swelling and bruising. A Nurse Note on 08/12/24 at 01:04 PM documented at 11:40 AM, staff assisted R2 up for lunch and noted purple bruising to her right knee that measured 18 cm by 12 cm with swelling and pain. The facility obtained an order for a right knee x-ray and notified her husband. A Nurse Note on 08/12/24 at 03:39 PM documented right knee x-ray results showed a fracture across R2's distal femur with diffuse soft tissue swelling. The facility notified R2's provider, hospice, and her husband. On 08/19/24 at 03:11 PM, R2 lay in bed with her eyes closed. Her right knee had an immobilizer in place. On 08/19/24 at 11:47 AM, Administrative Staff A stated she interviewed all staff who worked with R2 that weekend and they had not seen any bruising until the morning of 08/12/24. She stated from CNA M's witness statement, she seemed to cradle R2 to transfer her. On 08/19/24 at 12:57 PM, CNA N stated she knew how to care for a resident by looking at the care plan and from training on the floor. She stated R2 transferred with a Hoyer lift and it had been that way for a few months. On 08/19/24 at 01:09 PM, Licensed Nurse (LN) G stated staff knew how to care for residents by using the care plans and all direct nursing staff including the agency should have access to them. He stated the care plans directed staff to know how a resident transferred and if the care plan directed the use of a Hoyer lift, then the staff used a Hoyer lift. LN G stated if the care plan directed total dependence for transfers, that meant a Hoyer lift. He stated staff used a Hoyer lift with R2 for a while now and if a resident had a transfer status change, staff passed it on in the shift report. On 08/19/24 at 01:53 PM, Administrative Nurse D stated staff had access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) which included assistance needed for transfers, behaviors, and safety interventions. She stated if a care plan directed a resident was dependent on staff for transfers, she would ask more questions on what that meant because it needed more information. Administrative Nurse D stated CNA M stated she transferred R2 with one hand under her shoulders and one under her knees, cradling R2. On 08/20/24 at 12:15 PM, CNA M stated on 08/12/24, she went to get R2 up for the day and noticed she had a pink area on her knee, not purple. She stated the facility staff told her they do not use the Hoyer lift on her, and they pick her up by her arms. CNA M stated she went off of what staff told her and she did not have access to the care plan. On 08/20/24 at 01:32 PM, CNA O stated on 08/12/24, she completed their final check and change at 05:30 AM and did not see any bruising on R2. She stated R2 was not combative and did not want to get up yet, so they left her in bed. CNA O stated staff always transferred R2 using the Hoyer lift and two staff because one staff distracted R2 while the other hooked up the lift. She stated she informed all agency staff that R2 required two staff with the Hoyer lift. The facility's ADL, Supporting policy, revised in March 2018, directed staff to provide residents with care, treatment, and services to ensure that their ADLs did not diminish unless the circumstances of their clinical conditions demonstrated unavoidable diminishing ADLs. The policy directed the facility to provide appropriate care and services to residents who were unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with hygiene, mobility, elimination, dining, and communication. The facility failed to ensure R2 received safe and appropriate ADL assistance consistent with her level of need. This deficient practice resulted in a fracture across R2's right distal femur.

The facility identified a census of 28 residents. The sample included three residents. Based on record review and interviews, the facility failed to prevent accidents for Resident (R) 1 when on 06/04/24 during a van transport to an appointment, R1's seatbelt came unfastened. Her electric wheelchair tipped towards the right to the lift gate, and she hit her right arm/shoulder on the lift gate. R1 complained of right shoulder pain on 06/06/24 and the facility obtained an x-ray. This deficient practice resulted in a medial subluxation (dislocation) of R1's right glenohumeral joint (ball and socket joint at the shoulder). Findings included: - R1 admitted to the facility on [DATE] and transferred to the hospital on 08/16/24. R1's Electronic Medical Record (EMR) documented diagnoses of essential hypertension (high blood pressure) and other specified disorders of bone density and structure of the right shoulder. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 had impairment on one side of her upper extremities and both sides of her lower extremities. R1 used a walker and a wheelchair. R1 required substantial/maximal assistance with showering, upper and lower body dressing, rolling left to right, sitting to lying, and lying to sitting on the side of the bed; partial/moderate assistance with toileting hygiene, sitting to standing, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers; and was independent with personal hygiene, oral hygiene, and eating. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 15 which indicated intact cognition. R1 had no impairment and used a walker and wheelchair. R1 required substantial/maximal assistance with showering, rolling left to right, and tub/shower transfers; partial/moderate assistance with upper and lower body dressing, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfers; supervision with toileting hygiene and toilet transfers, and was independent with eating, oral hygiene, and personal hygiene. The Functional Abilities Care Area Assessment (CAA) dated 04/24/24, documented R1 had a self-care deficit related to weakness and required assistance with ADLs. R1 had limitations with her right upper extremity and bilateral lower extremities. The Falls CAA dated 04/24/24, documented R1 had an increased risk for falls with injury due to impaired balance, limitations with range of motion, pain, and staff assistance with transfers. R1's Care Plan, initiated 05/13/24, documented R1 had a risk for falls with injury related to incontinence, impaired mobility with balance, and need for continuous oxygen. The care plan documented interventions, dated 05/28/24, that directed R1 needed a safe environment with even floors from spills and/or clutter and R1 used an electric wheelchair for independent mobility. R1's Care Plan, initiated 07/28/24, documented R1 had chronic pain in her shoulder and back related to arthritis and had a recent injury to her right shoulder from a fall. The care plan directed staff administered analgesia as per orders; staff evaluated the effectiveness of pain interventions; staff identified, recorded, and treated R1's existing conditions which increased pain; staff monitored/documented for probable cause of each pain episode and removed or limited the cause where possible; staff monitored/documented for side effects of pain medication and reported occurrences to the physician; staff monitored/recorded pain characteristics every shift and as needed (PRN); and staff notified the physician if interventions were unsuccessful or if current complaint was a significant change from R1's past experiences of pain. Transportation Staff W's Witness Statement, dated 06/05/24, documented Transportation W anchored and buckled R1's chair in the van to transport her to an appointment. They turned at a stop sign and R1's chair tipped over, resulting in a skin tear. Transportation W checked on R1 and bandaged her skin tear. She had R1 stand up so she could get R1's wheelchair upright. The facility's report on 08/15/24, documented on 06/04/24, Transportation Staff W transported R1 to a dental appointment, and during the ride, when the van took a turn, R1 heard a pop, and the seatbelt came unbuckled. R1's electric wheelchair tipped sideways to the right. R1 stated the seat belt did not break but had come unlocked. R1 stated she stood up and held onto the seat and Transportation Staff W immediately pulled the van over to put R1's wheelchair back on all four wheels and helped R1 into her wheelchair. R1 had a skin tear on her right elbow which Transportation Staff W bandaged. Transportation Staff W and R1 continued to her appointment. On 06/06/24, R1 reported pain in her shoulder, which she stated was chronic. The provider ordered an x-ray, which showed a medial subluxation of the glenohumeral joint. R1's EMR revealed the following: A Skin/Wound Note on 06/04/24 at 02:28 PM documented R1 had a skin tear to her right elbow. R1 went to a dental appointment in the facility van and when the van made a turn, her wheelchair leaned, and her right elbow hit the van. A Health Status Note on 06/06/24 at 04:45 PM documented facility called Consultant GG regarding R1. R1 requested an x-ray of her right shoulder. Consultant GG ordered a portable two-view x-ray of R1's right shoulder. A Nurse Note on 06/27/24 at 01:38 PM documented R1 continued to complain of right shoulder pain affecting her ADL ability. The facility received an order for referral to orthopedics. The facility placed a call to orthopedics and waited for a return call for an appointment. A Nurse Note on 07/18/24 at 11:12 AM documented Administrative Nurse E and Social Services X made several calls over the past few weeks to orthopedics about setting up an appointment for a new referral due to continued right shoulder pain. The facility received a return call from orthopedics with an appointment scheduled for 07/31/24 at 09:45 AM. A Nurse Note on 08/05/24 at 02:30 PM documented R1 had an initial consult at orthopedics regarding her right shoulder pain. R1 informed the facility she needed surgery and needed clearance from a pulmonologist (a doctor who specializes in diagnosing and treating diseases of the lungs). The facility obtained an order for a referral to a pulmonologist, faxed the referral order to the pulmonologist, and awaited a reply to schedule the consult. A Nurse Note on 08/15/24 at 03:28 PM documented the facility notified the pulmonologist's office regarding the new referral and requested an appointment to assess clearance for shoulder surgery. The pulmonologist's office nurse informed the facility that late October was the earliest available. Social Services X notified another pulmonology clinic of the referral and requested an appointment. A Transfer to Hospital Summary on 08/16/24 at 05:12 AM documented R1 voiced complaints of lower abdominal pain, dizziness, and altered mental status. R1 requested to be sent to the hospital for evaluation and treatment. Upon request, the facility was unable to provide progress notes from R1's provider from 06/04/24 to the present. Upon request, the facility provided Progress Notes from R1's orthopedic consultation on 07/31/24. The Progress Notes documented R1 fell out of her wheelchair due to the seatbelt breaking onto her right shoulder against a lift gate and had pain ever since the incident. R1 could not raise her arm above waist level and when she tried to move it, her shoulder popped. R1 had not seen anyone about her shoulder since the injury. R1's x-ray of her right shoulder from 07/31/24 revealed an anterior subluxation of the humeral head with probable impaction fracture of the humeral head and possibly a fracture extending up superiorly into the humeral head as well. The Impression/Plan for R1 documented R1 had right shoulder pain after a fall two months ago with what appeared to be an impacted head fracture anteriorly subluxated and she might have had a rotator cuff (a capsule of fused tendons that supports the arm at the shoulder joint) tear. The orthopedic provider gave R1 the option of therapy injection medications which he did not believe would do much for her or a shoulder replacement. He recommended R1 think about her options and if she wanted surgery, she would need medical clearance. Upon request, the facility provided a Monthly Vehicle Inspection Report, dated 08/19/24, that documented safety belts/tether all worked but one sticks, and staff had to make sure it clicked into place. On 08/19/24 at 12:57 PM, Certified Nurse Aide (CNA) N stated R1 complained of right shoulder pain that had gotten worse over the last couple of months and slowed down her ADLs. On 08/19/24 at 01:09 PM, Licensed Nurse (LN) G stated R1 complained of right shoulder pain after the van incident, and it affected her ADLs. On 08/19/24 at 01:47 PM, Administrative Staff A stated on 06/04/24, staff notified her that R1 had an incident in the transportation van and received a skin tear. She stated R1 did not complain of right shoulder pain until 06/06/24. Administrative Staff A stated for wheelchair transportation, the driver strapped in the wheelchair and placed a seat belt on the resident. She stated per Transportation W and R1, Transportation W strapped in the wheelchair with the ratchet straps and R1 stated she heard a pop, and the seatbelt came unclamped. Administrative Staff A stated the facility had not been able to come to a conclusion on how the seat belt came unbuckled and how R1's wheelchair tipped over. On 08/20/24 at 12:11 PM, Transportation Staff W stated on 06/04/24, she got R1 into the transportation van and fastened her wheelchair down with four anchors and a lap band over R1. She stated they came to a stop and when she started to turn, R1's wheelchair tipped over towards the ramp on the right. Transportation Staff W stated she stopped and got R1's wheelchair situated back over and put some gauze on her skin tear. She stated none of the anchors had come undone, but the seat belt did. The facility's Transportation Policy, not dated, directed the policy to provide guidelines for transportation services at the facility and ensure the safety and well-being of the residents while promoting efficient use of resources. The policy did not address wheelchair use, seat belt safety, and/or accident prevention. The facility failed to prevent accidents for R1 when on 06/04/24 during a van transport to an appointment, R1's seatbelt came unfastened. Her electric wheelchair tipped towards the right to the lift gate, and she hit her right arm/shoulder on the lift gate. R1 complained of right shoulder pain on 06/06/24 and the facility obtained an x-ray. This deficient practice resulted in a medial subluxation of R1's right glenohumeral joint.

The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide trauma-informed care for Resident (R) 17 who had an extensive history of trauma. On [DATE], the facility performed a social services assessment on R17 which revealed an extensive history of traumatic relationships, experience with disaster, profound feelings of helplessness, history of serious accidents and/or injuries and a history of abuse and sexual harassment. Despite this information, the facility did not develop a plan of care which identified and addressed triggers in order to prevent recurring traumatization. On [DATE] R17 told Activity Staff Z about her history of traumatization, previous suicide attempts, and her feelings of wanting to shoot herself. R17 cried and stated she felt sad and suicidal. The facility's failure to identify and implement person-centered interventions to address the psychosocial well-being for R17, who had an extensive history of trauma, placed R17 in immediate jeopardy. The facility further failed to ensure trauma informed care was developed an implemented for R14 and R4. Findings included: - R17's Electronic Medical Record (EMR) recorded diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty), need for assistance with personal care, heart failure, pain, disease of the spinal cord, Parkinsonism (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS documented R17 had no behavioral symptoms and further documented R17 denied thoughts of being better off dead or hurting herself in some way. The Psychosocial Well-Being Care Area Assessment (CAA), dated [DATE], documented risk factors to include decreased socialization, worsening depression, and anxiety. R17's Care Plan, documented interventions dated [DATE] that noted R17 used antianxiety and antidepressant medications that had a black box warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R17's Care Plan directed staff to administer medications as ordered. R17's Care Plan dated [DATE] noted R17 had mood, behavior, and psychosocial problems. The plan noted R17 could be manipulative, and attention-seeking at times, and was known to fabricate stories. The plan directed staff to administer medications as ordered and allow R17 to voice concerns regarding life and physical and emotional challenges. The plan documented R17 received mental health counseling and directed staff to praise any indication of progress and improvements in behaviors. The Social Service Assessment, dated [DATE], documented R17's significant life events including her parents' home burned down. R17 had a traumatic birth experience and a history of unsettled relationships. The assessment documented R17 had a close family member sent to jail, had serious financial problems, a serious physical or mental illness. The assessment documented R17 had been emotionally abused, neglected, had an abortion or miscarriage at age 13, had seen violence between family members, been robbed, mugged, or physically attacked. The assessment further documented R17 had been abused and physically attacked and had touched or was made to touch someone else in a sexual way because she forced her in some way or threatened to harm her or someone else if did not before and after age 16. The resident reported the specific time of year which made it more difficult was Christmas, and the scent of pine trees, and Christmas cookies. R17 informed the assessor that talking with her granddaughter helped and the granddaughter could be contacted when anxious. R17 said listening to music was calming. R17's clinical record lacked evidence the assessment was used to develop interventions that addressed the identified areas of past trauma, potential triggers, and interventions to mitigate ongoing or recurring traumatization. A Progress Note dated [DATE] at 02:50 PM documented Administrative Staff A spoke with R17 after Activity Staff Z reported R17 was giving away her belongings and felt taken advantage of. The note documented R17 had been crying and reported being raped throughout her life and by a family member; R17 reported she had a baby at age 14 and was ready to snap. The note documented R17 further reported she did not feel secure in her head, and she reported trying to kill herself while she was in jail by hanging a sheet from a pipe. R17 said she was sad and if she had a pistol or a shotgun, she would shoot herself. The note documented R17 stated she woke up that morning feeling suicidal, sad and that she was not the same person she was a few days before. the note documented R17 told Administrative Staff A that R17 stated she would throw herself off the biggest building in Topeka. R17 told Administrative Staff A that R17's best friend had killed herself. The note documented R17 was difficult to follow, changed topics quickly, and avoided attempts to redirect back to current feelings and thoughts. A Progress Note, dated [DATE] at 08:11 PM documented Administrative Staff A and Administrative Nurse D met with R17 at 02:50 PM about R17's statements made earlier to Administrative Staff A. R17 was much calmer and was able to carry on an appropriate conversation. The note documented R17 reverted to things that happened in her past. The staff allowed R17 to revisit her thoughts and feelings and then redirected her to the present and how she felt at that time. Staff assured R17 the nurse practitioner would be in the facility that day and would visit R17. A Progress Note, dated [DATE] at 10:23 PM, documented Consultant Nurse Practitioner (NP) JJ arrived at the facility at approximately 06:00 PM and visited extensively with R17. Consultant NP JJ prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) to 1 mg every eight hours as needed for anxiety. A Progress Note, dated [DATE], documented R17 could change counseling providers and the intake was scheduled for Tuesday at 08:00 AM. R17's clinical record lacked the provider notes from Consultant NP JJ for the visit on [DATE]. R17's clinical record lacked evidence the facility did anything in response to R17's expressions of suicidal intent and/or ideation other than talking to her and setting up counseling sessions for the following week. The record lacked documentation of any safety or protective interventions initiated. The record lacked evidence of person-centered interventions to address the suicidal ideation or the history of traumatic experiences. The facility was unable to provide any evidence of the above upon request. A Progress Note, dated [DATE] at 02:08 PM documented R17 texted her texted her representative and said she was having min-strokes and would not make it through the day. The note documented that R17 felt her Parkinson's was progressing and R17 was seeing her dead mother at night and during the day for the last week and continued to talk to other staff about her paranoid ideations. A 'Progress Note, dated [DATE] at 11:12 AM documented R17 stated she felt as if her heart were going to explode. R17's vital signs were withing normal limits, and R17 said she believed the cause was stress. She stated she was stressed about her money situation and asked for her as needed antianxiety medication. A Progress Note, dated [DATE] at 07:02 PM documented R17 remained in isolation in her room. She was tearful and stated she was lonely. She complained of feeling fatigued but denied any other symptoms. She rested in bed and was up in a chair and listened to music. On [DATE] at 10:01 AM observation revealed R17 walked with assistance to the bathing room. R17 had a soft voice and movement consistent with Parkinsonism. On [DATE] at 01:33 PM, Certified Nurse Aide (CNA) M reported R17 was anxious and cried a lot. CNA M stated R17 was difficult to understand which made it difficult to figure out what was upsetting her. CNA M stated R17 had not been sleeping well. CNA M stated he tried to be a good listener and spend time with R17 which was helpful per CNA M. CNA M stated he did not know where to find information regarding specifics about R17's past or what triggers might upset her. On [DATE] at 12:11 PM, Certified Medication Aide (CMA) R reported R17 got anxious or agitated at times and when that happened, staff just gave R17 some space. CMA R reported the only thing she knew about R17's past was that R17 may have had a granddaughter who died . CMA R stated she had never heard R17 talk about self-harm. CMA R said she felt that knowing R17's history of trauma and specific triggers would help staff provide R17 care and help staff know what to do when R17 was upset. On [DATE] at 01:55 PM, Licensed Nurse (LN) G reported R17 presented with anxiety and behaviors. LN G reported R17 had been extremely anxious and requested as-needed antianxiety medication as soon as she could have it. LN G stated she did not know if R17's Care Plan included matters related to her R17's history of trauma or if it included any triggers and interventions for staff to know how to provide care to R17. LN G stated she had only worked in the facility for a few months and had not yet had time to read R17's Care Plan. On [DATE] at 04:40 PM, Administrative Nurse D stated she was not aware of R17's Social Service Assessment done in [DATE]. Administrative Nurse D reported R17 had shared her history of substance abuse and that she had to steal food and sell her body for drugs. Administrative Nurse D stated R17 attempted to manipulate situations for whatever she was seeking, like the use of as-needed medications. Administrative Nurse D verified information from the assessment would help staff provide care to R17. Administrative Nurse D stated that knowing R17's triggers now explained why R17 had increased her use of as-needed antianxiety medications to almost daily in [DATE]. On [DATE] at 12:16 PM, Administrative Staff A reported that as soon as she learned R17 had voiced thoughts of self-harm, Administrative Staff A and Administrative Nurse D went and talked to the resident and stayed with R17. Administrative Staff A stated she removed a pair of scissors from R17's room but nothing else. Administrative Staff D stated Consultant NP JJ came to the facility right away and spent a significant amount of time with R17. Administrative Staff A stated Consultant NP JJ told facility staff that she felt R17 was not going to harm herself and that R17 was just upset and made a mistake when she stated she was going to harm herself. Administrative Staff A verified the facility lacked documentation to support the conclusion that R17 would not harm herself. Upon request, the facility did not provide a policy related to trauma informed care. The facility's failure to identify and implement person-centered interventions to address the psychosocial well-being for R17, who had an extensive history of trauma, placed R17 in immediate jeopardy. The facility implemented the following actions to address the immediacy: R17 was interviewed on 01 /,d+[DATE] for current thoughts of harmful self and plan to execute. R17 denied any thoughts of self-harm or a plan to execute. R17 had a trauma-informed care assessment completed on [DATE] to identify experiences, triggers, stressors, and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. On [DATE] the facility scheduled the mental health counseling service provider to visit with R17. R17 was placed on 30-minute checks on [DATE] to be monitored by nursing staff for statements of self-harm or usual behaviors with immediate escalation to the licensed staff. Staff received education on [DATE] on monitoring for self-harm statements and usual behaviors with physician notification if indicated. Nursing initiated monitoring of R17 for mood and behavior changes, statements of self-harm, and usual behaviors each shift beginning [DATE] with physician notification of any changes. The resident would be placed on one on one if self-harm is identified. R17's Care Plan was revised to reflect traumatic experiences, triggers, de-escalation, and interventions on [DATE] based on the current assessment to minimize triggers and/or re-traumatization. On [DATE], an onsite inspection verified the removal of the immediacy for R17 on [DATE]. The deficient practice remained at a scope and severity of a G. -The Electronic Medical Record (EMR) documented R14 had diagnoses that included malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the bladder, foot drop of the right and left foot, other symptoms and signs involving the nervous system and other symptoms and signs involving cognitive functions and awareness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, and no delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by gross impairment in reality perception). R14 had verbal behavioral symptoms directed toward others and rejection of care for one to three days during the observation period. R14 was independent with most activities of daily living, had no pain, and received no high-risk medications. The Admission Care Area Assessment did not trigger cognitive loss, psychosocial well-being, communication, behavioral symptoms, psychotropic (alters mood or thought) drug use, or functional activities of daily living. R14's Care Plan, dated [DATE], documented that R14 was an elopement risk/wanderer, was disoriented to place, attempted to leave the facility unattended, and had impaired safety awareness. The plan documented R14 wandered aimlessly and significantly intruded on the privacy of others. The plan directed staff to distract R14 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. The care plan further documented R14 would pack up his belongings, give them to his spouse, and report the items as stolen. The plan directed staff to call R14's spouse when this happened. The plan lacked trauma-informed care interventions. R14's EMR lacked a Social Service Assessment (SAA) on admission and lacked evidence a trauma-informed care assessment was completed. The Progress Note dated [DATE] at 03:12 PM, documented R14 approached the nursing home administrator and talked about being upset because he was hard of hearing and had to speak loudly so others thought he was mean, and staff did not like him. R14 was allowed to vent frustrations and staff were available whenever he had concerns and would like to talk. The Progress Note dated [DATE] at 04:23 PM, documented R14 was very agitated and confused. R14's spouse was on the phone and R14's conversation and thought process was irrational. R14's spouse instructed staff to walk away and not argue with him. R14 approached a staff member who informed R14 that the staff would not argue with him. Staff told R14 that when he calmed down, the charge nurse would be glad to have a conversation with him. R14 was angry, however, and walked to the dining room for supper. The on-call physician ordered to monitor R14 for changes in mental status changes and if needed, send him to the emergency room to be evaluated. The Progress Note dated [DATE] at 02:10 PM followed up on emails received from Veteran Affairs regarding concerns with the resident's behaviors. R14 had not displayed behaviors that were unmanageable by staff. Referral to other facilities made for the possibility of transfer. The Progress Note dated [DATE] at 03:13 AM, documented R14 had agitation over medication that had already been administered. The staff attempted to re-orient R14 to the time and situation multiple times and contacted Administrative Nurse D for direction. R14 repeatedly approached the nurse station to ask about his medications. The Progress Note dated [DATE] at 10:40 PM, documented R14 was confused thinking he was commanding a warship, giving orders out to troops (staff). R14 had not had any aggravation or aggressive behavior thus far, just expected a response when he gave the orders. Staff tried to redirect, change the conversation, offer a book, drink, and snacks, and call his wife. R14 refused and he went back to commanding the ship, staff continued to have one-on-one staff nearby for observation due to several recent falls. The Progress Note dated [DATE] at 12:09 PM, documented R14 was confused, did not know his room, and was door-seeking. Staff offered R14 lunch which he refused and stated food killed him. Staff were unable to redirect. The Progress Note dated [DATE] at 12:41 AM, documented R14 wandered to rooms during the shift, and appeared verbally and physically aggressive, but was redirected and interventions became effective. The Progress Note dated [DATE] at 05:32 PM, documented R14 was found lying cross-legged in a female resident's bed. Staff attempted to get R14 out of the room without success. R14 stated he was going to stay there, and no one was going to tell him to leave. Staff offered chocolate milk and he agreed to come out. The Progress Note dated [DATE] at 04:25 PM, documented R14 had been wandering the facility, was found lying in empty rooms covered up several times that day, and in the employee breakroom. Staff attempted to redirect the resident from rooms marked as under construction and the resident told staff they were in the wrong business. The Progress Note date [DATE] at 03:10 AM documented R14 was observed with anxiety and wandering on the unit. R14 heard voices and refused to go back to his room. R14 was redirected when he wandered and calmed. R14 was able to take his medications at bedtime. On [DATE] at 09:44 AM observations revealed R14 sat at the commons area next to the dining room looking through a book. On [DATE] at 12:21 PM, ongoing observation revealed R14 left the dining room heading down the hall to an unoccupied room where he then laid in the bed and, covered himself up with a blanket. Shortly thereafter he exited that room and went to the hall in which his room was located. R14 went to the end of the hallway, stopped briefly to rest against the wall, opened the clean linen closet door, and then proceeded to the exit door. At the exit, he pushed the exit door until it sounded, then walked away to an empty room next to his room and proceeded to lay in the unmade bed which also had a chair placed on the foot of the mattress/bed. R14 then stretched his legs and pushed the chair to try to make room for his legs. Staff approached R14 and inquired about needing care in his room and he cooperated with the request and returned to his room with staff. On [DATE] at 08:32 AM observation revealed R14 had been in the dining room eating breakfast but was not in his room, activity room, or therapy room. Upon inquiring from staff, the staff reported R14 was probably in a bed down the other hall and staff reported this happened all the time. Upon looking surveyor found R14 in an unoccupied room (room [ROOM NUMBER]) lying in a bed covered with blankets. R14 then got out of bed and was asking the staff where the bank was located. Staff reminded the resident his spouse was coming to the facility for a care plan meeting and R14 inquired what happened at the meeting. Staff informed him the meeting was to talk about whether he liked staying in the facility, to which he replied, Well that's a stupid question. On [DATE] at 12:21 PM Administrative Nurse E stated R14 wandered, and the facility tried to get a consult for a diagnosis of dementia (progressive mental disorder characterized by failing memory, and confusion) dementia to be able to place the resident for possible placement in a dementia unit. On [DATE] at 12:51 PM, Certified Nurse Aide (CNA) P reported R14 wandered and constantly went into other residents' rooms and had to be redirected, which sometimes made the resident frustrated. CNA P stated staff had been directed to call his wife if he was looking for her or his wallet. CNA P stated to address the resident as Sir as he served in the military. On [DATE] at 01:31 PM, Licensed Nurse (LN) G stated R14 had behaviors that varied from day to day. LN G verified R14 wandered into other resident rooms and empty rooms. LN G stated staff tried to keep an eye on him for his safety. LN G also stated he was easily agitated, had a long history in the military and his family had reported increased confusion at night. LN G stated R14 had an increase in an antidepressant and the primary physician was to set an appointment for a psych consult and would call the facility when this was arranged. LN G reported R14 liked to sit by the dining room and look at books, she was not aware of a trauma-informed care assessment or care plan problem which addressed this. On [DATE] at 04:27 PM, Administrative Nurse D stated R14 lacked a dementia diagnosis upon admission. The resident's wife could no longer take care of him due to her medical needs. Administrative Nurse D was not aware if a trauma assessment had been completed but said she knew R14 had a military history. Upon request, the facility did not provide a trauma-informed care policy. The facility failed to ensure R14 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet behavioral health care needs. 27168 - The Electronic Medical Record (EMR) for R4 documented diagnoses of PTSD, Alzheimer's disease (a progressive mental disorder characterized by failing memory, confusion), and dementia (progressive mental disorder characterized by failing memory, confusion.) The Quarterly Minimum Data Set, dated dated [DATE], documented R4 had severely impaired cognition and required extensive assistance from two staff for activities of daily living (ADLs). The MDS further documented R4 had no physical behaviors and received antianxiety (class of medications that calm and relax people) medication. R4's EMR documented a Social Service Life Stressor Assessment completed for R4 on admission on [DATE]. The assessment documented the resident had witnessed violence, experienced inappropriate sexual experiences, and had been divorced. R4's Care Plan, dated [DATE], documented R4 had current and/or historical psychosocial events that affected his mood and behavior due to his time in the military. The plan directed staff to assist the resident from the room should there be a movie on the TV about the war. The care plan lacked any further interventions related to the Life Stressor Assessment triggers. The Physician's Order, dated [DATE], directed staff to administer lorazepam (antianxiety medication) oral concentrate 2 milligrams (mg) per milliliter (ml), administer 0.5 ml every two hours as needed for restlessness or anxiousness. A Nurse's Notes, dated [DATE] at 06:10 PM, documented R4 had no thoughts of self-harm. He was in a pleasant mood and felt safe. On [DATE] at 11:10 AM, Administrative Nurse D verified a care plan had not been developed to address R4's PTSD despite the trauma-informed care assessment completed on admission showed a history of trauma. Upon request, a policy for PTSD/Trauma Informed Care was not provided by the facility. The facility failed to ensure R4, who was diagnosed with PTSD, received trauma-informed care and services for his behavioral health needs This placed the resident at risk for unmet behavioral health care needs.

The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to implement immediate protective measures when Resident (R) 17 verbalized suicidal intent and/or ideations. The facility further failed to assess R17's underlying causes of distress and failed to implement person-centered interventions to address the distress and prevent recurring or ongoing distress. On [DATE] R17 told Activity Staff Z about her history of traumatization, previous suicide attempts, and her feelings of wanting to shoot herself or jump to her death. R17 cried and shared the reasons she felt this way with Activity Staff Z. Activity Staff Z told Administrative Staff A. At 02:45 PM Administrative Staff A and Administrative Nurse D spoke with R17 who confirmed the information. Staff then alerted R17's physician and removed some scissors from R17's room but did not remove all potentially harmful items or place R17 under enhanced monitoring despite her statements of suicidal intent. After visiting with her provider on [DATE] at 06:00 PM, R17 received new orders for psychotropic medications but no nonpharmacological interventions were identified or developed to address R17's source of distress or suicidal ideation. This failure placed R17 in immediate jeopardy. Findings included: - R17's Electronic Medical Record (EMR) recorded diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty), need for assistance with personal care, heart failure, pain, disease of the spinal cord, Parkinsonism (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS documented R17 had no behavioral symptoms and further documented R17 denied thoughts of being better off dead or hurting herself in some way. The Psychosocial Well-Being Care Area Assessment (CAA), dated [DATE], documented risk factors to include decreased socialization, worsening depression, and anxiety. R17's Care Plan, documented interventions dated [DATE] that noted R17 used antianxiety and antidepressant medications that had a black box warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R17's Care Plan directed staff to administer medications as ordered. R17's Care Plan' dated [DATE] noted R17 had mood, behavior, and psychosocial problems. The plan noted R17 could be manipulative, and attention-seeking at times and was known to fabricate stories. The plan directed staff to administer medications as ordered and allow R17 to voice concerns regarding life and physical and emotional challenges. The plan documented R17 received mental health counseling and directed staff to praise any indication of progress and improvements in behaviors. The Social Service Assessment, dated [DATE], documented R17's significant life events including her parents' home burned down. R17 had a traumatic birth experience and a history of unsettled relationships. The assessment documented R17 had a close family member sent to jail, had serious financial problems, a serious physical or mental illness. The assessment documented R17 had been emotionally abused, neglected, had an abortion or miscarriage at age 13, had seen violence between family members, been robbed, mugged, or physically attacked. The assessment further documented R17 had been abused and physically attacked and had touched or was made to touch someone else in a sexual way because she forced her in some way or threatened to harm her or someone else if did not before and after age 16. The resident reported the specific time of year which made it more difficult was Christmas, and the scent of pine trees, and Christmas cookies. R17 informed the assessor that talking with her granddaughter helped and the granddaughter could be contacted when anxious. R17 said listening to music was calming. A Progress Note dated [DATE] at 02:50 PM documented that Administrative Staff A spoke with R17 after Activity Staff Z reported R17 was giving away her belongings and felt taken advantage of. The note documented R17 had been crying and reported being raped throughout her life; R17 reported she had a baby at age 14 and was ready to snap. The note documented R17 further reported she did not feel secure in her head, and she reported trying to kill herself while she was in jail by hanging a sheet from a pipe. R17 said she was sad and if she had a pistol or a shotgun, she would shoot herself. The note documented R17 stated she woke up that morning feeling suicidal. A Progress Note, dated [DATE] at 08:11 PM documented Administrative Staff A and Administrative Nurse D met with R17 about her statements made earlier to Administrative Staff A. R17 was much calmer and was able to carry on an appropriate conversation. The note documented R17 reverted to things that happened in her past. The staff allowed R17 to revisit her thoughts and feelings and then redirected her to the present and how she felt at that time. Staff assured R17 that the nurse practitioner would be in the facility that day and would visit R17. A Progress Note, dated [DATE] at 10:23 PM, documented Consultant Nurse Practitioner (NP) JJ arrived at the facility at approximately 06:00 PM and visited extensively with R17. Consultant NP JJ prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) to 1 mg every eight hours as needed for anxiety. A Progress Note, dated [DATE], documented R17 could change counseling providers and the intake was scheduled for Tuesday at 08:00 AM. R17's clinical record lacked the provider notes from Consultant NP JJ for the visit on [DATE]. R17's clinical record lacked evidence the facility did anything in response to R17's expressions of suicidal intent and/or ideation other than talking to her and setting up counseling sessions for the following week. The record lacked documentation of any safety or protective interventions initiated. The record lacked evidence of person-centered interventions to address the suicidal ideation or the history of traumatic experiences. The facility was unable to provide any evidence of the above upon request. On [DATE] at 10:01 AM observation revealed R17 walked with assistance to the bathing room. R17 had a soft voice and movement consistent with Parkinsonism. On [DATE] at 01:33 PM, Certified Nurse Aide (CNA) M reported R17 was anxious and cried a lot. CNA M stated R17 was difficult to understand which made it difficult to figure out what was upsetting her. CNA M stated R17 had not been sleeping well. CNA M stated he tried to be a good listener and spend time with R17 which was helpful per CNA M. CNA M stated he did not know where to find information regarding specifics about R17's past or what triggers might upset her. On [DATE] at 12:11 PM Certified Medication Aide (CMA) R reported R17 got anxious or agitated at times and when that happened, staff just gave R17 some space. CMA R reported the only thing she knew about R17's past was that R17 may have had a granddaughter who died . CMA R stated she had never heard R17 talk about self-harm. CMA R said she felt that knowing R17's history of trauma and specific triggers would help staff provide R17 care and help staff know what to do when R17 was upset. On [DATE] at 01:55 PM, Licensed Nurse (LN) G reported R17 presented with anxiety and behaviors. LN G reported R17 had been extremely anxious and requested as-needed antianxiety medication as soon as she could have it. LN G stated she did not know if R17's Care Plan included matters related to her R17's history of trauma or if it included any triggers and interventions for staff to know how to provide care to R17. LN G stated she had only worked in the facility for a few months and had not yet had time to read R17's Care Plan. On [DATE] at 04:40 PM, Administrative Nurse D stated she was not aware of R17's Social Service Assessment done in [DATE]. Administrative Nurse D reported R17 had shared her history of substance abuse and that she had to steal food and sell her body for drugs. Administrative Nurse D stated R17 attempted to manipulate situations for whatever she was seeking, like the use of as-needed medications. Administrative Nurse D verified information from the assessment would help staff provide care to R17. Administrative Nurse D stated that knowing R17's triggers now explained why R17 had increased her use of as-needed antianxiety medications to almost daily in [DATE]. On [DATE] at 12:16 PM, Administrative Staff A reported that as soon as she learned that R17 had voiced thoughts of self-harm, Administrative Staff A and Administrative Nurse D went and talked to the resident and stayed with R17. Administrative Staff A stated she removed a pair of scissors from R17's room but nothing else. Administrative Staff D stated Consultant NP JJ came to the facility right away and spent a significant amount of time with R17. Administrative Staff A stated Consultant NP JJ told facility staff that she felt R17 was not going to harm herself and that R17 was just upset and made a mistake when she stated she was going to harm herself. Administrative Staff A verified the facility lacked documentation to support the conclusion that R17 would not harm herself. Upon request, the facility did not provide a policy related to responding to acute behavioral crises or suicidal ideation and/or attempts. The facility failed to implement immediate protective measures when R17 verbalized suicidal intent and/or ideations. The facility further failed to assess R17's underlying causes of distress and failed to implement person-centered interventions to address the distress and prevent recurring or ongoing distress. This failure placed R17 in immediate jeopardy. The facility implemented the following actions to address the immediacy: R17 was interviewed on 01 /,d+[DATE] for current thoughts of harmful self and plan to execute. R17 denied any thoughts of self-harm or a plan to execute. R17 had a trauma-informed care assessment completed on [DATE] to identify experiences, triggers, stressors, and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. On [DATE] the facility scheduled the mental health counseling service provider to visit with R17. R17 was placed on 30-minute checks on [DATE] to be monitored by nursing staff for statements of self-harm or usual behaviors with immediate escalation to the licensed staff. Staff received education on [DATE] on monitoring for self-harm statements and usual behaviors with physician notification if indicated. Nursing initiated monitoring of R17 for mood and behavior changes, statements of self-harm, and usual behaviors each shift beginning [DATE] with physician notification of any changes. The resident would be placed on one on one if self-harm is identified. R17's Care Plan was revised to reflect traumatic experiences, triggers, de-escalation, and interventions on [DATE] based on the current assessment to minimize triggers and/or re-traumatization. On [DATE], an onsite inspection verified the removal of the immediacy for R17 no [DATE]. The deficient practice remained at a scope and severity of a D.

The facility identified a census of 25 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff immediately reported allegations of abuse to the facility administrator. On 10/07/23 at approximately 04:45 PM Dietary Staff (DS) CC heard a loud verbal interaction between Administrative Nurse D and Resident (R)1 which DS CC perceived as verbal abuse. DS CC reported the alleged verbal abuse to DS BB on the evening of 10/08/23 and DS BB reported the event to Administrative Staff A on 10/09/23 at approximately 06:10 AM, almost two days later. Certified Nurse Aide (CNA) M also perceived the interaction as alleged abuse but did not report to the facility administrator because CNA M did not know who to report to, in Administrative Staff A's absence. On 10/08/23 at approximately 06:00 PM Activity Staff Z noted R3 was upset by an interaction which alleged verbal abuse or mistreatment by Administrative Nurse D to R3 earlier that day,10/08/23, though Activity Staff Z did not alert the facility administrator until 10/09/23 at approximately 10:10 AM, more than 16 hours later. The facility staff failed to identify potential abuse and report immediately to the facility administrator. This deficient practice placed R1 and R3 in immediate jeopardy. Findings included: - The facility reported incident on 10/09/23 documented incidents occurring on 10/07/23 and 10/08/23. The report alleged on 10/07/23 DS CC heard R1 yelling. DS CC looked up and saw Administrative Nurse D yelling at R1 to stop reading his book. Administrative Nurse D grabbed for R1's book and R1 yelled Don't touch my books. The incident report noted DS CC also heard Administrative Nurse D say that R1 did not know what he was talking about and told R1 that his spouse was not present. The report documented DS CC did not intervene at that time but the next day, on 10/08/23, DS CC told DS BB about the incident. The report noted that on 10/09/23 at 06:00 AM DS BB told Administrative Staff B of the alleged verbal abuse and Administrative Staff B instructed DS BB to inform Administrative Staff A of the allegation. The report further documented that on 10/08/23 at the noon meal, Administrative Nurse D raised her voice to R3. Administrative Nurse D was suspended, and an investigation was started. R1's Electronic Medical Record (EMR) documented a Nurse's Note dated 10/11/23 at 12:18 PM, late entry, which recorded that staff reported to Administrative Staff A an allegation of abuse perpetrated by a staff member. R3's EMR documented a Nurse's Note dated 10/09/23 at 03:22 PM which recorded staff talked with R3 about an incident from the weekend. R3 stated she was all right now. The note indicated R3 notified her family about the allegation and staff asked R3 if she wanted her physician to be notified about the incident and R3 stated No. Review of CNA M's notarized Witness Statement dated 10/16/23 documented on 10/08/23 Administrative Nurse D screamed at R1, because R1 was interrogating R2. Review of DS CC's undated, unnotarized Witness Statement, revealed DS CC worked on 10/07/23 at 04:45 PM. DS CC noted she heard R1 yelling and looked up to see what was going on. DS Cc noted Administrative Nurse D yelled at R1 about his spouse and his book and tried to grab R1's book. R1 told Administrative Nurse D to not touch his book and Administrative Nurse D told R1 he did not know what he was talking about, and his spouse was not present. DS CC recorded that R1, and Administrative Nurse D had several loud interactions, but she could not hear what it was all about. Review of DS BB's undated, unnotarized Witness Statement, revealed DS BB noted that DS CC told him on 10/08/23 that Administrative Nurse D yelled at R1, and that DS CC heard it all the way into the kitchen. Review of Administrative Staff B's undated, unnotarized Witness Statement, revealed that on 10/09/23 Administrative Staff B was informed by DS BB that DS CC heard Administrative Nurse D yelling at R1 on 10/07/23. Review of Administrative Nurse D's unnotarized Witness Statement, dated 10/09/23 documented R1 and R2 sat at a dining room table in a loud argument over who had served the most years in the service. Administrative Nurse D documented she approached the table and attempted to explain that the residents could sit anywhere. Administrative Nurse D reached out and touched R1's book. R1 stated Administrative Nurse D could not take his book. Review of another unnotarized Witness Statement, dated 10/09/23 by Administrative Nurse D documented that Administrative Nurse D heard R3 talking with an unknown visitor about the staff working that day. R3 told the unknown visitor there was only one CNA that came to work and R3 held up one finger repeating just one CNA to take care of all of the residents. At this point, Administrative Nurse D approached R3 and the unknown visitor and explained to both that there were enough staff to take care of the residents in the building. Administrative Nurse D stated there were six nursing staff in the building to assist with the 24 residents including licensed nurses and Administrative Nurse D acknowledged there was only one CNA. Review of Activity Staff Z's unnotarized Witness Statement, which lacked a date, documented on 10/08/23 at approximately 06:00 PM, R3 seemed upset. R3 explained to Activity Staff Z that Administrative Nurse D told both R3 and her visitor that there was enough coverage for the residents. R3 stated she was very embarrassed when Administrative Nurse D told her and her visitor that information. Activity Staff Z further documented on 10/09/23, the following day, at approximately 09:15 AM she went to R3's room and noted R3 was almost in tears and stated R3 was fearful that Administrative Nurse D might make living there uncomfortable with a retaliation. On 10/16/23 at 11:03 AM R1 sat on his bed reading a book. R1 appeared well groomed. R1 was hard of hearing, but when the speaker raised her voice R1 could hear what was being said. R1 could not recall anything that happened with a female staff member, but if it had happened it was taken care of now. R1 further stated he no longer saw that female staff member and that was ok by R1. On 10/16/23 at 01:20 PM R3 sat in her wheelchair. She appeared well groomed and was in good spirits. R3 stated that she was humiliated and did not like getting yelled at in the dining room by Administrative Nurse D. R3 further stated she wanted to know why Administrative Nurse D was eavesdropping on R3's conversation with her visitor. On 10/16/23 at 01:25 PM CNA M stated she was told to report concerns about abuse to Administrative Nurse D or Administrative Staff A. CNA M said since the concern was with Administrative Nurse D, she would have called Administrative Staff A, but Administrative Staff A was out of town. CNA M did not have Administrative Staff A's phone number and she did not know where to find it. CNA M further revealed she was taught to go up the ladder with any concerns but she did not have the contact numbers for Administrative Staff A or any above Administrative Staff A. On 10/16/23 at 03:40 PM Administrative Staff A stated she knew what happened was not good, but Administrative Nurse D claimed she did not yell at the residents. The facility's Abuse, Neglect, and Exploitation policy, lacking a date, documented the resident has a right to be free from verbal, sexual, physical, and mental abuse, and involuntary seclusion. It is the policy of Medicalodges, Inc., to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect and to take swift action to investigate and adjudicate alleged resident abuse and neglect. Mental abuse includes, but is not limited to, verbal or non-verbal conduct which causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment or threats of punishment or deprivation. The facility failed to identify, and report alleged abuse which delayed investigation, protective measures, and increased the potential of impaired psychosocial well-being due to potential prolonged abuse, or mistreatment for the affected residents. The facility implemented the following corrective actions on 10/09/23: All staff were educated on Abuse, Neglect, and Exploitation including identifying and reporting to Administrative Staff any allegations of abuse. Administrative Nurse D was suspended and upon completion of Abuse, Neglect, and Exploitation education prior to working. Due to the fact all corrective actions were completed prior to the onsite investigation, the deficient practice was deemed past non-compliance at a J scope and severity.

The facility identified a census of 27 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to provide adequate supervision to prevent accidents when R1, who required staff assistance with eating and drinking, spilled hot coffee on himself on the morning of 10/09/22. The facility further failed to assess and identify risks and implement interventions aimed to prevent an avoidable accident related to hot liquids. The deficient practice resulted in a second-degree (type of burn affecting both the epidermis and the second layer of skin, which may cause swelling and red, white or splotchy skin; blisters may develop, and pain can be severe) burn to R1's abdomen. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of [CONDITION(S)] (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and dysphagia (swallowing difficulty) following cerebral infarction (localized necrosis (localized tissue death that occurred in a group of cells in response to disease or injury) of brain tissue caused by impaired blood flow). The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six which indicated moderately impaired cognition. R1's required extensive assistance of one staff member for eating, locomotion on and off the unit. R1's required extensive assistance of two staff for toileting, dressing, and personal hygiene. R1 was dependent on two staff for transfers. The Dental Care Area Assessment (CAA) dated 04/15/22 documented R1 required assistance with eating. R1's Quarterly MDS assessment dated [DATE] documented a BIMS score of five which indicated severely impaired cognition. R1's required supervision with set up help for eating. The ADL Care Plan revised on 03/10/22 documented R1 was able to feed himself, but staff were to assist him with cutting up meat and buttering bread, and if assistance was needed eating, staff were to assist. The Nutritional Care Plan created on 03/25/22 directed staff to raise R1's head of bed to 90 degrees while eating to prevent aspiration and 45 degrees while not eating. On 05/13/22 the care plan documented R1 had a no concentrated sweets diet, mechanical soft texture, and regular consistency with fortified food diet. The Restorative Nursing Care Plan revised on 08/11/22 directed restorative staff that R1 preferred to eat in his room and staff were to stay with him. The Speech Therapy: Treatment Encounter Note(s) dated 02/25/22, electronically signed on 03/01/22, documented R1 needed assistance with, and during, all oral intakes. Verbal educations, as well as a written list of strategies were shared with R1's care team as well as with R1. The note further documented all parties verbalized understanding. The Clinical Health Review: Nutrition assessment dated [DATE], signed as completed on 07/19/22, documented R1 required extensive assistance with dining. The Clinical Health Review: Nutrition assessment dated [DATE], signed as completed on 08/17/22, documented R1 required extensive assistance with dining, a plate guard, and a two handled cup. R1 needed to be fed and R1 spilled food or fluids when eating or drinking. The assessment further documented R1 had loss of liquids or solids from mouth when eating or drinking. The Clinical Health Review: Nutrition assessment dated [DATE], signed as completed on 10/01/22, documented R1 required extensive assist when dining, a plate guard, built-up utensils, and a two handled cup. R1 spilled food or fluids when eating or drinking. The assessment further documented R1 had coughing or choking while eating or drinking. Review of R1's clinical record lacked evidence the facility performed an assessment to determine R1's safety with hot liquids. The Skin Condition Note dated 10/09/22 at 09:00 AM documented R1 appeared to have [CONDITION(S)] to his abdomen on the left lower quadrant. R1 had one intact blister noted to be approximately 1.5 centimeter (cm) by 3 cm and one area that appeared to have a blister popped approximately 3 cm by 1.5 cm and a reddened area 6.5 cm by 6 cm. The Skin/Wound Condition assessment dated [DATE] documented three different [CONDITION(S)] located on the left iliac crest (the curved area at the top of the ilium bone, the largest of three bones that make up the pelvis) first area measured 1.5 inches (in) length by 3 in width, second area measured 3 in length by 1.5 in width, and third area measured 6.5 in length by 6 in width. Review of the Eating Task on 10/09/22 documented R1 had supervision and set up help only. This was initialed by Certified Nurse Aide (CNA) O. The Facility Reported Incident Investigation documented on 10/09/22 R1 had what appeared to be [CONDITION(S)] on his abdomen, left of midline, with a blister 1.5 cm by cm, open area 3 cm by 1.5 cm, reddened peri wound area 6.5cm by 6.0 cm. The investigation documented the [CONDITION(S)] were likely caused by a coffee spill due to R1 had coffee on his clothing. R1's EMR under the Orders tab revealed an order dated 10/09/22 to leave the Opsite (transparent, adhesive film dressing) in place for 7 to 10 days and change as needed every shift related to burn and corrosion of trunk. This order was discontinued on 10/13/22. R1's EMR revealed an order dated 10/14/22, which directed staff to clean abdominal wound with wound cleanser, and apply triple antibiotic ointment then place a bordered gauze over the wound daily. Review of the Witness Statement from CNA M, documented CNA M was gathering residents and taking them to the dining room for breakfast. CNA M noticed R1 had markings on his stomach so CNA M showed Licensed Nurse (LN) G immediately at 09:45 AM. Review of the Witness Statement from LN G documented CNA M brought R1 to LN G and asked if LN G had seen the areas on R1's left abdomen. LN G documented the areas appeared to be a burn. On 10/17/22 at 11:03 AM R1 laid in bed on his back, blanket pulled up to his chest, and his head was at a 45-degree angle on the bed. There were two cups with liquids in R1's room on the over the bed side table at the head of his bed. One cup appeared to be a large plastic mug with one handle, a lid and a straw with clear liquid. The second cup had two handles, a lid on the top, and brown liquid inside of the cup. R1 stated that he had recently burned himself with coffee, but it no longer hurt. R1 could not recall if he was fully awake, but he stated the coffee that spilled was enough to wake him up. R1 revealed he sometimes ate and drank in his room. On 10/17/22 at 02:30 PM Administrative Nurse D stated he received a call the morning of 10/09/22 regarding the incident. He stated upon arrival, staff had already dealt with situation so Administrative Nurse D was not sure whether the incident occurred in R1's room or in the dining room. Administrative Nurse D believed it was in the main dining room and that R1 had received assistance eating and drinking. On 10/17/22 at 02:40 PM LN H stated she asked R1 what happened, and he told LN H that he spilled his coffee, but he was unsure when it happened. LN H revealed that R1 had spilled his coffee in the past, but it had not resulted in a burn or any negative outcome. LN H further revealed that R1 required help with his meals. LN H stated she did not but would have him out in the dining area where he could be seen. LN H stated she worked on 10/09/22 and remembered R1 was in his room for breakfast. On 10/17/22 at 02:44 PM LN I stated R1 could not remember when or what day the coffee spill occurred, R1 only remembered it was the last time he drank coffee. LN I further stated that she only gave R1 coffee in the cup with handles and a lid. On 10/17/22 at 03:30 PM CNA N stated residents were supposed to be assessed for hot liquids and that was a task completed by speech therapy. CNA N stated she knew R1 was supposed to use special cups with lids, but the special cups had not arrived yet. CNA N further stated the two handled cups the facility currently had did not have the right lids to prevent spills. CNA N said the lids could not be ordered, so the facility had to order different two handled cups with the right lids. On 10/17/22 at 04:00 PM Administrative Nurse D stated CNA O and CNA Ps' log ins were used by all agency CNA staff for charting. He further stated there was no way to tell who had logged in and documented with those identifiers. Administrative Nurse D further stated he did not know who would have charted R1 was only supervised at meals because R1 needed help from staff for eating/drinking. Administrative Nurse D stated that R1 was to have staff assist him when he was eating and that there should not be coffee or drinks left in R1's room without staff present to help him. Administrative Nurse D revealed that he should investigate the situation more. The Precautions for Handling Hot Beverages guideline 2016 edition directed additional precautions may be implemented based on the needs of each resident and may include: assessing and identifying residents served who are at high risk for burning themselves with hot beverages; ensuring staff monitors the identified high risk resident during meal times and/or when hot beverages are served; and utilizing specialized spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning. The facility failed to provide adequate supervision to prevent accidents when R1, who required staff assistance with eating and drinking, spilled hot coffee on himself on the morning of 10/09/22. The facility further failed to assess and identify risks and implement interventions aimed to prevent avoidable accident related to hot liquids. The deficient practice resulted in a second- degree burn to R1's abdomen.

The facility identified a census of 31 residents. The sample included three residents reviewed for medication administration. Based on record review, observations, and interviews, the facility failed to prevent a significant medication error when Licensed Nurse (LN) G incorrectly administered insulin (hormone that lowers the level of glucose in the blood) to Resident (R) 1, a newly admitted resident who did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She then entered R1's room, obtained her blood sugar (BS), then administered R2's insulin to R1 in error. As a result, R1 developed [CONDITION(S)] (low blood sugar) despite multiple administrations of oral glucose. R1 required a glucose injection, emergent transport to the emergency room (ER), and admission to the hospital for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN G failed to implement the standard of practice regarding medication administration when she failed to verify the right medication was given to the right resident. This placed R1 in Immediate Jeopardy. Findings included: - R1 admitted to facility on 05/18/22 and discharged to hospital on 05/19/22. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 05/19/22, directed R1 required staff assistance with activities of daily living (ADLs) related to physical limitations. The Orders tab of R1's EMR revealed an order with a start date of 05/18/22 for glucose blood testing two times a day for DM. The Orders tab of R1 lacked orders for insulin. The facility's Investigation dated 05/26/22 documented on 05/19/22 at 05:06 PM, LN G obtained R1's blood sugar and it was 214 milligrams per deciliter (mg/dL). LN G accessed the Medication Administration Record (MAR) for R2, who was also a new admission and also had DM and administered 20 units of R2's Insulin [MEDICATION(S)] Pro Mix 70/30 to R1. LN G immediately realized her mistake and explained to the family what had happened. She reported the incident to the hospice nurse who contacted Consultant G who ordered blood sugar checks every 30 minutes and to administer glucose gel and report if blood sugar was less than 120 mg/dl. At 05:40 PM, R1's BS was 194 mg/dL and she had received half a tube of glucose gel. At 06:15 PM, R1's BS was 101 mg/dL and she received the second half of the tube of glucose gel along with another tube of glucose gel. At 06:35 PM, the hospice nurse returned call with order to send R1 to the ER. At 06:45 PM, emergency medical services (EMS) arrived andR1's BS was 86 mg/dl. At 09:58 PM, the ER called the facility to state R1's BS had been stable, and they planned to discharge her back to facility. R1 arrived back to facility at 10:35 PM. At 10:50 PM, R1's BS was 61 mg/dL, LN G rechecked with another glucometer (device used to measure blood sugar) and BS was 56 mg/dL. LN G called EMS and hospice nurse, received order for [MEDICATION(S)] (medication used to treat low blood sugar) 1 milligram, injected in R1's left arm. At 11:05 PM, R1 departed the facility with EMS and was admitted to the hospital. In a Witness Statement on 05/20/22, LN G stated on 05/19/22 at 05:06 PM, she checked R1's blood sugar, it was 214 mg/dL, and she administered Insulin [MEDICATION(S)] Pro Mix 70/30. At 05:18 PM, LN G realized insulin had been administered to the wrong resident and contacted the hospice nurse to report incident. The hospice nurse contacted Consultant G and received orders to administer Insta Glucose (glucose gel) as many as available and check blood sugars every 30 minutes; notify hospice if blood sugar 120 mg/dL or lower. At 05:40 PM, BS was 194 mg/dL and staff administered half a tube of Insta Glucose. At 06:15 PM, R1's BS was 101 mg/dL and staff gave the remaining amount of Insta Glucose and administered a second tube of Insta Glucose in full. LN G called the hospice nurse at 06:35 PM and reported the resident's BS; hospice nurse returned call with an order from Consultant G to send R1 to ER. EMS arrived at 06:45 PM. R1's BS was 86 mg/dL. R1 was transferred to EMS in stable condition at 06:51 PM. On 06/08/22 at 11:36 AM, LN G stated on 05/19/22 she pulled up the MAR for R2 for blood sugar and insulin, then went into the wrong room. She stated R1 did not get insulin, but did get her blood sugar checked. LN G administered R2's insulin to R1 and immediately realized it was the wrong patient and called hospice. The hospice nurse called Consultant G who gave orders to give glucose gel then check BS every 30 minutes, if below 120 mg/dL call hospice back as they would send R1 to the hospital. LN G stated the first blood sugar check was okay, second check was maybe 118 or 112 mg/dL. R1 had received two tubes of glucose gel. LN G stated R1 never had a change in mental status, her baseline was alert with intermittent confusion. R1 was sent to the hospital. At 08:30 PM, she called the ER to check on R1. The ER reported R1's BS was good for them, and they planned to send her back if the BS was still good at 09:30 PM. R1 returned to facility at 10:35 PM, in the middle of shift report. LN G reported to the night nurse that R1 was to have blood sugar checks every two hours as ordered by the ER. She stated she checked R1's BS when she returned to the facility; BS was 61 mg/dL and R1 was diaphoretic (sweating heavily) and warm. She rechecked with another glucometer; BS was lower on that meter. LN G immediately called EMS to come back and take R1 to the ER. She stated R1 was admitted for low blood sugar and low blood pressure. On 06/08/22 at 12:17 PM, Administrative Staff A stated on 05/19/22 she was working in the facility and LN G notified her that she had taken R1's blood sugar and mistakenly gave R1, R2's insulin. She stated LN G immediately realized it and informed family and administrator then notified hospice and monitored R1. On 06/08/22 at 01:00 PM, Administrative Nurse D stated she was first notified of the incident on 05/19/22 shortly after it occurred and knew every step that had been taken. She stated LN G immediately reported she had given R1, R2's insulin. Administrative Nurse D stated she expected her staff to follow the eight rights of medication administration and LN G did not follow the eight rights of medication administration at that time. The facility's Medication Administration General Guidelines dated September 2018, directed prior to administration, staff reviewed and confirmed medication orders for each individual on the MAR and compared the medication and dosage schedule on the resident's MAR with the medication label. The policy directed staff verified medication was correct three times before administering the medication when medication package was pulled from med cart, when dose was prepared, and before dose was administered. Residents were identified before medication was administered using at least two resident identifiers which may include checking identification band, checking photograph attached to medical record, and verifying resident identification with other nursing care personnel. The facility's The Eight Rights of Medication Administration not dated, directed the eight rights were right person, medication, dose, time, route, documentation, reason, and response. The facility failed to prevent a significant medication error when facility staff incorrectly administered R2's insulin to R1, a newly administered resident who did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 required a glucose injection, emergent transport to the ER, and admission to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN G failed to implement the standard of practice regarding medication administration when she failed to verify the right medication was given to the right resident. This placed R1 in Immediate Jeopardy. The facility completed the following corrections by 05/20/22: All applicable staff were trained on the eight rights of medication administration. LN G received immediate correction, in service and administrative action. Interdisciplinary team (IDT) reviewed incident and implemented temporary name plates for all new residents upon admission. IDT implemented system where all new admission will be photographed immediately for placement in the EMR for identify verification purposes. The deficient practice was cited as past non-compliance.

Citation Text for Tag 0315, Regulation FF07 The facility identified a census of 58 residents. The sample was 16 residents. Based on observation, record review and staff interview, the facility failed to assess one resident (#67) after the removal of the catheter, and three of three (#26, 15 and #12) residents for urinary incontinence. Findings included: - The November 2010 physician's orders [REDACTED]. This was a closed record review for this resident. The 11-29-10 Admission Minimum Data Set (MDS), with an admission date of [DATE] from an acute care hospital noted the resident had clear speech, understood/understands; the Brief Interview for Mental Status (BIMS) score of 5 indicated severe impairment; had total dependence on 2 staff for bed mobility, transfers, dressing and toileting; total dependence on one staff for locomotion on/off the unit and personal hygiene; required supervision/set-up for eating; had frequent incontinence of urine; had no pain; received antipsychotic and antibiotic medications; received Occupational and Physical Therapies; and the resident expected to be discharged to another facility/institution. The 12-3-10 Care Area Assessment (CAA) for Cognition: noted a BIMS score of 13 indicating intact cognition. The 12-3-10 CAA for Activity of Daily Living (ADL) noted the resident required total staff assistance with toileting. The 11-25-10 Bowel and Bladder Assessment noted the resident had bladder incontinence, wet clothes, impaired mobility, stress incontinence and was on scheduled toileting. A Temporary Care Plan for this resident dated 11-23-10 included the interventions sit to stand transfer and used a wheelchair with self propulsion. The clinical record lacked evidence of development of individualized care plans for this resident. The 11-22-10 physician's admitting orders revealed the resident transferred from an acute care hospital with a Foley catheter. The Nurses Notes on 11-23-10 revealed the resident's Foley catheter had cloudy urine on admittance. The Nurses Notes on 11-24-10 revealed the licensed nursing staff clarified orders, noting removal of the Foley catheter in one week. On 11-24-10 at 4:54 A.M. the Foley catheter drained cloudy dark amber to red urine. The resident denied dysuria (pain on urination). Staff sent a fax to the physician. The 11-24-10 at 2:26 P.M. record revealed the Foley was in place and the physician ordered staff to remove the Foley catheter later that day. The 11-24-10, 11:13 P.M. record revealed the staff removed the Foley catheter today. The Nurses Notes on 11-25-10 at 7:30 P.M. revealed the resident had incontinence at times. The Nurses Notes on 11-26-10 revealed the resident had incontinence of bladder. The Nurses Notes on 11-28-10 at 3:39 A.M. revealed the resident had urine incontinence; he/she requested to use a urinal and voided 50 cc (cubic centimeters) of dark amber urine. The resident denied dysuria. The Nurses Notes on 11-29-10 at 3:43 A.M. revealed the resident had incontinence of bowel and bladder, had agitation, increased confusion and attempted to exit his/her bed. Staff assisted the resident to the bathroom for incontinent stool. At 10:54 A.M. The resident was alert and lethargic, had 2+ lower extremity [MEDICAL CONDITION], had incontinence of bowel and bladder, his/her abdomen was soft and non-tender, and the resident did not assist with peri-care. On 11-29-10 at 6:55 P.M. the record revealed staff contacted the physician regarding an increase in weight since admission and bilateral lower extremity [MEDICAL CONDITION] of 2-3+ for this resident. The resident continued to receive Occupational and Physical Therapy. At 9:43 P.M. the [MEDICAL CONDITION] was 3+ to the lower extremities, and the resident had bleeding from his/her rectum after sitting on the toilet. Licensed nursing staff faxed the physician and received orders for the medications [MEDICATION NAME] 40 milligrams and Potassium Chloride twice daily for 5 days. The Nurses Notes on 11-30-11 at 2:38 A.M.revealed the resident was alert and confused, had no rectal bleeding, had 3+ [MEDICAL CONDITION], and a soft non-tender abdomen. By 8:52 P.M. the [MEDICAL CONDITION] decreased to 2+ and the resident had incontinence of bladder. The Nurses Notes on 12-2-10 at 11:00 A.M. revealed the Physician's Assistant came to assess the resident for the 23 pound weight gain in the previous 9 days. The record noted the resident voided 4 times the previous day. Per direct care staff, there was no increase in urination despite the [MEDICATION NAME]. The resident went to the acute care hospital. Staff noted a report from the physician that emergency room staff extracted 2 liters from the resident's bladder, the resident had kidney failure and a urinary tract infection and the hospital admitted him/her. The 12-2-10 Physician's Progress Notes revealed the resident had a 13-17 pound weight gain since admission 10 days prior and nursing requested the physician to see the resident. The resident was not eating well, had some decreased level of consciousness, and had bilateral lower extremity [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The physician sent the resident to the hospital. The facility Intake and Output (I&O) record for this resident noted on 11-24-10 the resident had a 50 cc output. The clinical record lacked evidence of further I&O records for this resident prior to or after the removal of the Foley catheter and re-admittance to the hospital on 12-2-10. The hospital emergency room reported admission of the resident on 12-2-10 at 12:05 P.M. and revealed the family reported the resident as more lethargic; the resident gained 14 pounds in one week; the resident's abdomen was very distended with a hard, round painful area to the left of the umbilicus; his/her temperature was 91.7 degrees Fahenheit with a blood pressure of 91/54; and the resident reported pain of 10+ on a scale of 1-10; had admission [DIAGNOSES REDACTED]. The resident was alert, calm and cooperative with weak motor responses. emergency room staff placed a Foley catheter with an immediate return of 850 cc of dark brown urine and still draining at 12:05 P.M. By 12:45 P.M., a total of 2100 cc drained from the Foley. The resident reported he/she felt a little better. Once staff removed the urine, the abdomen was soft and only slightly tender to touch with a round hard area. The resident's temperature was 92.5 F rectally at 1:05 P.M. The physician ordered an abdominal series and admitted the resident to the hospital. The hospital records of 12-2-10 revealed the resident had admitting [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE] with an order for [REDACTED]. The facility Re-entry MDS dated [DATE] revealed the resident had no speech, never understood and had severely impaired cognitive skills for daily decision making; had total dependence on staff for all Activity of Daily Living tasks; had a life expectancy of less than 6 months, and was on Hospice care. The Social Service Progress record noted on 11-29-10 the facility admitted the resident from the hospital with a Do Not Resuscitate (DNR) status, and there were no plans to discharge the resident. The resident passed away 12-25-10 at 12:45 A.M. On 3-10-11 at 8:10 A.M., licensed nursing staff B reported, if a resident had a Foley catheter, the staff watched the I & O records to see if the resident voided sufficiently, and if not they would contact the physician. The facility did not keep good records for this resident per staff B. As far as being able to determine if a resident voided sufficiently after removing a Foley catheter, the staff could see if the incontinent briefs were heavy as the facility did not have a bladder scanner and did not use a voiding hat to measure this resident's urine. If the incontinent briefs were heavy, that meant the resident voided a lot. Licensed nursing staff B stated that none of the staff informed him/her that this resident had problems. Nursing should have been monitoring the situation. Staff should have weighed the incontinent product of the resident. Physician Consultant B reported on 3-10-11 at 11:34 A.M., "the physicians make a visit every 60 days to see the residents and would not be aware of a problem with a resident unless the nursing staff notified them and then would come and see the resident." The undated facility protocol for Foley Catheter Care and Removal revealed: Recoding and Reporting -record amount of urine in drainage bag every 8 hours; indicate voided amounts after catheter removal. Empty drainage bag and record amounts at least every 8 hours. Initiate I & O records. The facility failed to assess this resident's urine output after the removal of the foley catheter resulting in the resident being admitted to the hospital and the removal of 2100 cc of urine. - The February 2011 physician's orders [REDACTED]. The 12-4-2010 quarterly Minimum Data Set (MDS) noted the resident sometimes understood; had no speech; had short and long term memory impairment with severely impaired cognitive skills for daily decision making skills; required the total assistance of 2 staff for bed mobility, transfers, toileting and dressing; total dependence on one staff for personal hygiene, eating and locomotion; and was incontinent of urine. The 3-2-11 Care Area Assessment (CAA) for Cognition noted the resident was totally dependent on staff for all Activity of Daily Living (ADL), had short and long term memory loss, and was difficult to tell if he/she was declining due to [MEDICAL CONDITION]. The 3-2-11 Care Area Assessment (CAA) for Urinary Incontinence noted the resident was incontinent of urine, had a previous [MEDICAL CONDITIONS]; the resident was unable to tell verbally of his/her incontinence due to [MEDICAL CONDITION]; and staff attempted to keep him/her clean and dry, provide peri-care, and look for skin breakdown. The 1-7-11 Quarterly Assessment for Bladder noted the resident wore briefs day and night; was on maintenance check and change program; and was continent of bowels and incontinent of bladder. The 1-5-11 Care Plan for Self Care Deficit noted the right [MEDICAL CONDITION], staff to monitor the resident's skin for redness or trauma during bathing and ADLs and report to the charge nurse; the resident was totally dependent on staff for dressing and personal hygiene. The 1-5-11 Care Plan for Urinary Elimination/Incontinence noted a scheduled check and change program, staff to check for wetness every 2 hours, change and provide peri-care if the product wetness indicator was seventyfive percent (75%) or more blue, and apply a moisture barrier with each change. During an observation 3-9-11 at 11:37 A.M., direct care staff D and E washed their hands and gloved. After ascertaining that the resident was incontinent of urine, direct care staff E provided peri-care to the front of the perineal area after removing the incontinent product. Both direct care staff then assisted in rolling the resident to his/her side and pulled up the depends on the rear side. The direct care staff failed to provide incontinent care to the resident's buttock area after removing a heavy incontinent product that he/she sat in. During an interview on 3-9-11 at 11:45 A.M., direct care staff E said he/she usually cleaned the buttocks as part of the peri-care but did not this time. The facility Policy on Pericare, undated noted as follows: - Expose area you are cleansing, dispose of brief - Remove any stool, change gloves (wash hands/use alcohol gel if able) - WIpe from front to back with one stroke, use new wipe with each stroke. - Cleanse lower abdomen, inner thighs, vulva and inner labia, dry as indicated. - Assist the resident to turn to side - Cleanse buttocks, anal area, dry as indicated. The facility staff failed to provide complete peri-care for this dependent resident. - The February 2011 physician's orders [REDACTED]. The 1-22-11 Annual Minimum Data Set (MDS) noted the resident usually understood; had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired; required total assistance of 2 staff for bed mobility, transfers, and toilet use; required total assistance of one staff for personal hygiene, eating, dressing and locomotion on/off the unit; had unsteady balance and impairment of functional limitation of range of motion on one side for both upper and lower extremities; and had frequently incontinence of urine and occasional incontinence of bowel. The 1-28-11 Care Area Assessment (CAA) for Cognition note a decreased ability to make self understood. The 1-28-11 Care Area Assessment (CAA) for Incontinence noted a past history of [MEDICAL CONDITIONS], took diuretics, antipsychotics, antidepressants which could cause incontinence; and had progressive [MEDICAL CONDITION] and cognitive decline which limited his/her mental ability to remember when he/she needed to go to the bathroom; the resident wore briefs. The 1-21-11 Quarterly Bladder Assessment noted the resident wore briefs day and night; was on scheduled toileting; and was continent of bowel and incontinent of bladder. The 11-5-10 Care Plan for Incontinence of bladder instructed staff to provide cuing and assistance with scheduled toileting, upon arising, within 1 hour before and after meals and at bedtime; staff were to toilet every 2-3 hours during the night at the resident's request; staff provided tab briefs to manage incontinence, and provided incontinent care after each episode; encouraged fluids; do not leave on the toilet unattended; and provide peri care after each toileting or incontinent episode. The 11-5-10 Care Plan for a history of recurring history of recurring Urinary Tract Infection [MEDICAL CONDITION] noted antibiotics per physician's orders [REDACTED]. During an observation on 3-9-11 at 9:24 A.M., direct care staff F and G brought this resident to the common bath for toileting. Both staff washed hands and gloved, stood the resident and removed his/her wet incontinent product and placed the resident on the toilet. When the resident finished voiding, direct care staff B came to assist in providing peri-care. While direct care staff F and G held the resident in a standing position. Direct care staff B wiped the residents back side between the gluteal folds, from the bottom up with single swipes. The staff did not cleanse the frontal area or the buttocks. During an observation on 3-9-11 at 12:00 P.M., direct care staff F and G brought the resident to the common bath for toileting. Staff assisted the resident to a standing position and removed his/her heavy wet incontinent product. Direct care staff D arrived to assist with peri-cares. Direct care staff F wiped between the resident's thighs and peri area as he/she sat on the toilet, then staff F and G assisted the resident to a standing position and direct care staff D used wippettes to wipe in the gluteal fold from the bottom up, but failed to wipe the the buttock area or anterior perineal area. During an interview on 3-10-11 at 6:55 A.M., direct care staff F stated, "the staff in the back should reach under between the resident's legs and going front to back, cleanse the labia and then they should cleanse the entire buttocks, especially when the resident was incontinent. Direct care staff F said he/she was not aware that the direct care staff cleaning from behind did not provide the cares as he/she just stated". During an interview on 3-10-11 at 10:22 A.M., direct care staff H said, "the peri-area should be cleaned from front to back and the entire buttock area should be cleaned". Licensed nursing staff B on 3-10-11 at 4:00 P.M. said, "the staff should clean the labia and the entire buttocks with peri cares". The facility Policy on Pericare, undated noted as follows: - Expose area you are cleansing, dispose of brief - Remove any stool, change gloves (wash hands/use alcohol gel if able) - WIpe from front to back with one stroke, use new wipe with each stroke. - Cleanse lower abdomen, inner thighs, vulva and inner labia, dry as indicated. - Assist the resident to turn to side - Cleanse buttocks, anal area, dry as indicated. The facility staff failed to provide peri-care after this dependent resident's incontinence. The Physician order [REDACTED]. The resident's significant change Minimum Data Set 3.0 (MDS 3.0) with an assessment reference date of 1/29/11 identified the resident had a score of 12 on the Brief Interview for Mental Status (a score of 12 indicated the resident had mild cognitive impairment for daily decision making skills. The assessment identified the resident totally dependent upon staff for bed mobility, extensive staff assistance for transferring, walking in the room, locomotion on and off the unit, dressing and toilet use. The assessment also identified the resident did not walk in the corridor. The assessment also identified the resident frequently incontinent of urine and not on a scheduled toileting program. The resident's care area assessment (CAA) summary dated 1/31/11 documented the resident was incontinent of urine, wore briefs for dignity since incontinent of urine and that direct care staff would make effort to keep the resident clean and dry. The summary also documented the resident more incontinent of urine and wore a brief at all times for dignity. The summary documented the resident had frequent UTI's and took a daily antibiotic for the UTI's as well Cranberry capsules twice a day. This summary documented the resident's skin intact but that the resident was incontinent of urine more often than he/she used to be. The resident's current care plan documented the resident's wore briefs for dignity while out of bed, asked for toileting if needed as other routine activities of daily living were provided. The care plan also addressed that staff would complete a 3 day bowel and bladder program upon admission and yearly. The care plan also documented that the resident received [MEDICATION NAME] (diuretic). The resident's monthly summary dated 1/11/11 documented the resident incontinent of urine, wore briefs all day and at night. The summary also documented the resident on a scheduled toileting program, on a maintenance check and change, and the resident's most likely experienced mixed incontinence (urge and stress). A nurse's note dated 1/28/11 and timed 12:45 P.M. documented the resident as alert and oriented times 3, pleasant and cooperative, incontinent of bowel and bladder but had some control. A nurse's note dated 1/25/11 and timed 2:47 P.M. documented the resident incontinent of bladder at times. A nurse's note dated 12/18/10 timed 10:32 P.M. documented the resident came out of his/her room for supper via electric wheelchair, the resident transferred self and took self to the bathroom with the use of a walker with no staff assistance. The note also documented the resident was incontinent of bladder and did not require staff assistance with perineal care. On 3/9/11 at 7:45 A.M. direct care staff E & F entered the resident's room to get the resident up for breakfast. This observation revealed the resident was totally dependent upon staff for bed mobility and transferring. The staff transferred the resident from the bed to the wheelchair and from the wheelchair to the toilet. The observation also revealed the resident had an incontinent brief on and direct staff reported the resident was incontinent of urine. On 3/9/11 at 3:45 P.M. direct care staff G and H transferred the resident from the recliner to the wheelchair. Direct care staff H asked the resident if he/she needed to go to the toilet and the resident responded no. The staff did not check to see if the resident was incontinent of urine. During an interview with direct staff H at that time the staff reported the resident told staff when he/she needed to use the bathroom, therefore staff did not automatically toilet the resident or check the resident for incontinence. During interview with direct care staff E on 3/10/11 at 7:45 A.M. the staff reported the resident was not incontinent of urine when he/she got the resident up that morning. The staff also stated the resident voided after staff placed the resident on the toilet. The staff also reported that in the last month or so the resident was more dependent upon staff for transferring and bed mobility and that prior to that the resident could get out of bed without staff assistance. During interview with direct care staff F on 3/10/11 at 9:30 A.M. the staff reported the resident was usually incontinent when staff placed the resident on the toilet. During interview with licensed staff C on 3/10/11 at 9:45 A.M. the staff reported the resident was usually incontinent of urine and not on a scheduled toileting program. The staff also reported that the care plan interventions regarding when staff should take the resident to the bathroom was discontinued because the resident was not on a scheduled toileting program. During interview with Administrative Staff B on 3/10/11 at 11:15 A.M. the staff stated the was resident frequently incontinent of urine and should be on a check and change program. The staff also stated that staff should check the resident for incontinence upon awakening, before meals and after meals. The facility failed to develop a care plan to address when staff should toilet this resident with a history of urinary tract infections and frequently incontinent of urine but with some continent voiding. The facility also failed to communicate the toileting expectations for this resident to all direct care staff.

The facility had a census of 58. The sample included 16 residents of which 3 were sampled for acceptable parameters of nutritional status. Based upon observation, record review and staff interview the facility failed to ensure that 1 (#9) of the 3 sampled residents maintained acceptable parameters of nutritional status. Findings Included: -Review of resident # 9's Physician order [REDACTED]. Review of the resident 's quarterly Minimum Data Set 3.0 with an assessment reference date of 12/18/10 identified the resident had short and long term memory problems and had moderately impaired cognitive skills for daily decision making skills. The assessment also identified the resident did not exhibit any behaviors and required limited assistance from staff for bed mobility, transferring, walking in the room and personal hygiene. The assessment also identified the resident required extensive assistance from staff for dressing. The assessment also identified the resident required supervision with set up help only with eating. The assessment also identified the resident had not experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The assessment also identified the resident received a mechanical altered diet and weighed 144 pounds. The resident's Minimum Data Set 3.0 with an assessment reference date of 9/27/10 identified the resident required limited assistance with set up help only for eating, received a mechanical altered diet and weighed 144 pounds. The assessment also identified the resident had not experienced a weight loss of 5% or more in the last month or a 10% weight loss or more in the last 6 months. The resident's current care plan addressed the resident had a potential for alteration in nutrition. The care plan also documented the resident would consume 75% of meals, staff would monitor and record meal intake and would weigh the resident weekly. The care plan also addressed the Registered Dietician would evaluate the resident's nutritional status annually and as needed. The care plan also documented staff would offer the resident healthy shakes 3 times a day. The care plan did not address that the resident had experienced a significant weight loss. During interview with licensed staff C on 3/10/11 at 10:15 A.M. the staff confirmed the resident's care plan had not been revised and/or updated to reflect the resident's weight loss. Review of a dietary progress note signed and dated by a Registered Dietician on 3/8/11 documented the resident's current weight as 133 pounds (the resident's weight log documented the resident weighed 129 pounds on 2/28/11), the resident weight decreased 4.3% in 1 month, 8 percent in 3 months, and 13.1% in 6 months (a significant weight loss in 6 months). The dietician also recorded the resident received a pureed diet with 4 ounces of Ensure Plus Shake twice a day (BID), average intake at meals 39% and recommended 2 ounces of 2 cal (a nutritional supplement) three times a day to stabilize the resident's weight. Review of the dietary progress notes revealed the dietician assessed the resident's nutritional status on 9/1/10 and did not reassess the resident's nutritional status until 3/8/11. On 9/1/10 the dietician recorded the resident's weight as 153 pounds. Review of the resident's weight log recorded the resident's weights as: 10/4/10: 150 pounds 11/8/10 148 pounds 11/8/10: 148 pounds 11/30/10: 144 pounds 12/6/10: 142 pounds 12/20/10: 138 pounds 1/17/11: 135 pounds 2/7/11: 133 pounds 2/15/11: 131 pounds 2/28/11: 129 pounds The resident experienced a 21 pound weight loss from October 4, 2010 to February 28/2011 or 14% of his/her body weight in 4 months. This represented a significant weight loss. The resident Physician order [REDACTED].M. and 3:00 P.M. and .5 milligrams of [MEDICATION NAME] for [MEDICAL CONDITION] every night. This review also revealed the resient had received the 4 ounces of Ensure Plus Shakes since 8/30/10. Review of a physician's progress note dated 7/14/10 documented the resident had increased confusion, decreased alertness, very sleepy and the family requested the resident received a sleeping pill routinely at 8 P.M. to see if it would help with the sedation. Review of the resident's 11/1/10 POS revealed that on 10/27/10 the resident received a physician's orders [REDACTED]. A progress noted dated 11/10/10 documented the resident somnolent, arousal and the [MEDICATION NAME] increased to 200 mg. During interview with consultant pharmacist B on 3/9/10 at approximately 2:30 P.M. the consultant reported that when an individual takes both [MEDICATION NAME] and [MEDICATION NAME] the person's appetite is affected. Review of the resident's nurse's notes revealed the resident often times stayed in bed until the afternoon. For example, a nurse's note dated 10/25/10 timed 12:58 P.M. documented the resident took his/her A.M. medications to help with alertness, remained in bed until 11:15 A.M. and then walked with staff to the dining room. A nurse's note dated 10/21/10 and timed 2:08 PM documented the resident awake on and off this shift, took morning medications, woke up and got up this shift around 2:00 P.M. A nurse's note dated 10/19/10 documented the resident took his/his medications this A.M. but remained in bed until noon. A nurse's note dated 10/16/10 timed 4:04 A.M. documented the resident noted awake at 3:00 A.M. and out to main dining room for cookies and milk. Review of the resident fluid and diet intake for 3/1/11 through 3/9/11 recorded the resident consumed 56% of the breakfast meals, 55% of the lunch meals and 58% of the dinner meals from 3/1/11 to 3/4/11. This review also revealed staff did not record the resident's intake for the breakfast meal on 3/5/11 and recorded the resident did not consume any of the breakfast meal on 3/6, 3/7, 3/8 and 3/9/11. The resident's meal intake for the lunch meal on 3/5/11 was not recorded. Staff did not documented the resident's fluid and intake sheet for the dinner meals for 3/5/11 through 3/8/11. Review of the resident's laboratory report dated 11/4/10 recorded the resident's [MEDICATION NAME] as 5.0 milligrams/deciliter (mg/dl) (normal reference range 20.0-40.0 mg/dl), protein 7.2 grams/deciliter (normal reference range 6.0-8.5 grams/deciliter), [MEDICATION NAME] 3.3 grams/deciliter (normal reference range 3.5-5.0 grams/deciliter). Observation on 3/8/11 at 1:15 P.M. revealed licensed staff A assisting the resident with the lunch meal, the resident had finished eating and the resident consumed 100 percent of the lunch meal. Observation on 3/9/11 at 7:05 A.M. and 7:55 A.M. revealed the resident in bed on his/her back. At 8:15 A.M. observation revealed the resident in bed and when spoken to the resident opened his/her eyes (the resident was non-verbal). At 9:00 A.M. the resident remained in bed and the resident's eyes open. Observation throughout this time revealed the resident did not receive the breakfast meal. At 9:45 A.M. the resident remained in bed, eyes open and the resident had not received the breakfast meal. During interview with an alert and oriented resident at 9:45 A.M. the resident stated the resident had not had breakfast and also stated the resident often did not eat breakfast or lunch. During interview with dietary staff A on 3/9/11 at 9:45 A.M. the staff stated that nursing staff informed him/her the resident was sleeping and informed him/her to hold the resident's tray and that when the resident awakened dietary staff A would heat up the resident's breakfast tray. During interview with direct staff A on 3/9/11 at 10:34 A.M. the staff reported the resident did not get up this A.M. for the breakfast meal and that he/she always got the resident up by lunch time. Observation on 3/9/11 at 11:00 A.M. revealed the resident in bed on his/her back, and the resident's eyes were open. Observation at 11:30 A.M. revealed the resident in bed on his/her back and the resident's eyes open. Observation on 3/9/11 at 12:33 P.M. revealed the resident in bed on his/her back and the resident had not received the lunch meal. During interview with an alert and oriented resident at this time the resident reported that the resident often stayed in bed until 3 or 4 o'clock in the afternoon. The resident also reported that staff does not always attempt to get the resident up for the breakfast and lunch meal. During interview with administrative staff B on 3/09/11 at 1:10 PM the staff reported that he/she was aware that the resident in bed during the breakfast and lunch meal. The staff reported staff offered the resident the health shake at 10:00 A.M. and the resident consumed 100%. The staff also reported the resident stayed up all night and slept all day. The clinical record lacked evidence that the facility offered the resident the breakfast meal when they offered the resident the shake at 10:00 A.M. Observation on 3/9/11 at 4:50 P.M. revealed the resident remained in bed. Observation on 3/10/11 at 8:25 A.M. revealed the resident in bed sitting up, rubbing his/her eyes. At 8:45 A.M. observation revealed the resident in bed sitting up. At 9:00 A.M. observation revealed staff in the resident's room assisting the resident with dressing. After the staff finished assisting the resident with dressing the resident ambulated to the dining room with the walker. At 9:15 A.M. observation revealed licensed nurse A assisted the resident with the breakfast meal. At 9:30 P.M. observation revealed the resident had finished eating and had consumed 75% of the breakfast meal. The clinical record lacked evidence that the facility had assessed for the causal factor of the resident's weight loss. The clinical record also lacked evidence that the facility attempted interventions to minimize the resident's weight until 3/9/11 when the dietician ordered the 2 cal. The facility failed to record the resident's meal intake as care planned, failed to update the resident's care plan to address the resident's significant weight loss, failed to assess for the causal factor of the resident's weight loss and failed to timely implement interventions to prevent further weight loss. This failure led to this resident experiencing a significant weight loss.