Every finding on record at Ignite Medical Resort Adams Parc

Based on record review and interview, the facility failed to:a. ensure a resident was not administered medications that were not prescribed to them; andb. ensure medication prescribed to a resident was administered as ordered for 1 (#18) of 3 sampled residents reviewed for medication administration. The general manager stated 47 residents were administered medication at the facility.Findings:A policy titled Administration of Medication,dated 10/2025, read in part, All medications are administered safely and appropriately to aid residents to and help in overcome illness, relieve and prevent symptoms and help in diagnosis.Procedure Check medication administration record prior to administering medication for the right medication, dose, route, patient and time.Identify resident by reading wrist band or checking the picture in the MAR.A medication administration record for Res #18, dated 02/01/26 through 02/28/26, showed on 02/22/26 the resident did not receive their prescribed medications scheduled for 8:00 p.m. The missed medications were:a. amlodipine besylate 5 mg for hypertension;b. Aricept 5 mg for dementia;c. atorvastatin calcium 20 mg for high cholesterol;d. citalopram hydrobromide 20 mg for depression;e. montelukast sodium 10 mg for allergies;f. doxycycline hyclate 100 mg for bullous pemphigoid (an autoimmune disorder causing itchy blisters on the skin);g. folic acid 1 mg for a supplement;h. lacosamide 50 mg for seizure prevention; [NAME]. methylphenidate 5m g for CNS stimulation (a medication that increases activity in the brain and spinal cord).A medication administration record for Res #23, dated 02/01/26 through 02/28/26, showed on 02/22/26 the resident was ordered to receive the following prescribed medications at 8:00 p.m.:a. lovastatin 40 mg for high cholesterol;b. apixaban 5 mg for deep vein thrombosis (a blood thinner medication);c. clindamycin HCL 300 mg for cellulitis (an antibiotic medication);d. hydralazine HCL 25 mg for hypertension; ande. metronidazole 500 mg for cellulitis (an antibiotic medication).A progress note for Res #18, dated 02/22/26 at 7:15 p.m., showed LPN #8 had administered Res #23's 8:00 p.m. medications to Res #18.An electronic medication administration record note for Res #18, dated 02/22/26 at 8:01 p.m., showed Res #18's prescribed 8:00 p.m. medications were withheld from the resident because they had erroneously received Res #23's 8:00 p.m. medications.A progress note for Res #18, dated 02/23/26 at 10:32 a.m., showed Res #18 had become unresponsive and was speaking in a nonsensical manner during morning medication administration. The note showed the resident was assessed by a nurse practitioner and sent to a local acute care hospital for evaluation.An acute care hospital discharge document, dated 02/23/26, showed the resident was evaluated for seizure activity and altered level of conciseness. The document showed Res #18 was discharged the same day they arrived at the hospital. On 06/08/26 at 2:15 p.m., RN #2 stated on 02/22/26, Res #18 had mistakenly been administered Res #23's evening medications. RN #2 stated because Res #18 had been given the wrong medication, they had to hold Res #18's own prescribed evening medications.

Based on record review and interview, the facility failed to ensure a resident did not elope from the facility for 1 (#21) of 4 sampled residents reviewed for accident hazards.The general manager stated three residents wandered in the facility.Findings:A Wander/Elopement Risk Evaluation for Res #21, dated 10/17/25, showed the resident had scored 5 on the evaluation. A score of five indicated the resident was not a risk for wandering or elopement. The evaluation showed a score of 6 would have indicated a resident would be at risk for wandering or elopement.A behavior narrative note, dated 10/18/25 at 7:04 p.m., showed Res #21 had eloped from the facility and walked to their apartment located approximately 600 feet to the west on an adjoining property. The note showed Res #21 knocked on the door of their apartment and their family told them to go back to the facility. The note showed facility staff located Res #21 next to their apartment and walked the resident back to the facility. The note showed Res #21 was missing from the facility for 15 minutes or less.An incident report, dated 10/19/25, showed Res #21 had eloped from the facilityA five-day assessment, dated 10/24/25, showed Res #21 had a BIMS score of 12 (a BIMS score of 12 indicated the resident's cognition was moderately impaired). The assessment showed Res #21 was admitted to the facility on [DATE].On 06/10/26 at 3:46 p.m., LPN #5 stated they had observed a person leaving the facility on 10/18/26 when they were coming to work but did not recognize the person. They stated when they went to shift report, they heard Res #21 had been missing and told the staff about the person they had seen leaving. LPN #5 stated they did not see any staff member following the resident when they left the building. LPN #5 stated they had written the wrong date of 10/19/26 as the incident date instead of the actual date of 10/18/26 when they completed the incident report. They stated they did not recall why they had faxed the incident report to OSDH on 10/20/25. LPN #5 stated they knew the incident report was supposed to have been faxed within 24 hours.On 06/10/26 at 4:17 p.m., the general manager stated they had been informed by LPN #5 the date Res #21 had eloped was 10/18/25 and not 10/19/25 as indicated on the incident report sent to the OSDH.

Based on records review and interview, the facility failed to:a. report an incident of elopement to the OSDH within 24 hours for 1 (#21) of 4 sampled residents reviewed for accidents; andb. report an allegation of physical abuse to the OSDH and a local law enforcement agency within two hours of the allegation for 1 (#17) of 3 sampled residents reviewed for abuse. The general manager stated two allegations of abuse in the past 12 months and three residents that wandered in the facility.Findings:1. A policy titled Elopement Policy, dated 11/2018, read in part, Upon discovering an unaccountable absence of a resident by a staff member, the staff member will immediately contact a nurse. Record the time that the resident was discovered missing and when and where resident was last seen.The administrator will notify the State Agency to report an unusual occurrence and activation of the facility's Emergency Operations Plan.A behavior narrative note, dated 10/18/25 at 7:04 p.m., showed Res #21 had eloped from the facility and walked to their apartment located approximately 600 feet to the west on an adjoining property. The note showed Res #21 knocked on the door of their apartment and their family told them to go back to the facility. The note showed facility staff located Res #21 next to their apartment and walked the resident back to the facility. The note showed Res #21 was missing from the facility for 15 minutes or less.An incident report, dated 10/19/25, showed Res #21 had eloped from the facility. The incident report showed the elopement was reported to the OSDH on 10/20/25.On 06/10/26 at 3:46 p.m., LPN #5 stated they had observed a person leaving the facility on 10/18/26 when they were coming to work but did not recognize the person. They stated when they went to shift report, they heard Res #21 had been missing and told the staff about the person they had seen leaving. LPN #5 stated when they had completed the incident report for Res #21's elopement, they had written the wrong incident date of 10/19/26 instead of the actual date of 10/18/26. LPN #5 stated they did not recall why they had faxed the incident report to the OSDH on 10/20/25. They stated they knew the incident report was supposed to have been faxed within 24 hours.On 06/10/26 at 4:17 p.m., the general manager stated they had been informed by LPN #5 the date Res #21 had eloped was 10/18/25 and not 10/19/25 which had been indicated on the incident report sent to the OSDH. They stated the incident report should have been sent to the OSDH within 24 hours of the elopement.2. A policy titled Abuse Policy, dated 11/2025, read in part, If an allegation of abuse is made the facility employee who becomes made (sic) aware of the allegation is required to immediately report the allegation to the facility Administrator.The facility Administrator or designee shall report the initial notification to the Department of Health and Senior Services immediately (within 2 hours of being made aware).The Administrator or designee will also inform any responsible party of the allegation and that an investigation is being conducted. If reasonable suspicion of a crime has occurred, local law enforcement shall be notified immediately.A health status note, dated 06/02/26 at 7:45 p.m., showed Res #17 had reported to LPN #7 that LPN #6 had been rude and abused them on 06/01/26. An incident report, dated 06/03/26, showed Res #17 had reported to LPN #7 that LPN #6 had pushed them and yelled at them on 06/01/26. The incident report showed the local law enforcement agency was contacted about the allegation of abuse on 06/03/26. A fax sheet attached to the incident report showed the report was faxed to the OSDH on 06/03/26 at 11:05 a.m.On 06/10/26 at 10:05 a.m. the general manager stated their staff should have reported the allegation of abuse to the OSDH and local law enforcement within two hours of hearing of the allegation on 06/02/26.

Based on record review and interview, the facility failed to ensure restorative therapy was provided to a resident with limited ROM for one (#18) of one sampled resident reviewed for therapy services. The ADON reported 42 residents resided at the facility. Findings: A Restorative Nursing policy dated 12/2019, read in part, the facility believes that each resident will be provided with the opportunity to regain skills and abilities lost due to illness and disability. Therefore, each resident will be evaluated at move in, return from another health care facility, and after a significant change in condition for the potential benefit of participating in a restorative nursing program. Resident #18 had diagnoses which included difficulty walking and muscle weakness. A care plan focus, dated 10/11/21, documented the resident had an ADL self-care performance deficit. An associated care plan intervention, dated 01/03/25, documented the resident was to be in a restorative program for maintenance. A physician order, dated 01/10/25, documented Resident #18 was to continue restorative services two to three times a week to maintain strength, endurance and independence. On 01/22/25 at 10:44 a.m., PT #1 stated all residents were screened when admitted to the facility, transitioned from skilled to long term care, or when the need was identified for a current resident. They stated Resident #18 was to have been receiving restorative services since 01/10/25, but had not. On 01/23/25 at 9:44 a.m., PT #1 stated they had contacted RT #1 and they confirmed they had not performed any restorative services with Resident #18. PT #1 further stated there was a lapse in communication which had caused the omission of the services and training for RT #1 was required.

Based on record review and interview, the facility failed to notify a family member, identified as the resident's POA, of a change in the resident's medication regimen for one (#1) of six sampled resident reviewed for notification of change. A midnight census report, dated 01/16/24, documented 47 residents residing at the facility. Findings: A Family Notification Protocol, undated, read in part, .Please notify emergency contact/POA of the following and document all notifications in a clinical note .Medical Issues .Medication Change- i.e. New ATB order . The document did not refer to changes in medication regimen other than antibiotics. Resident #1 had diagnoses which included Alzheimer's disease and Body Mass Index 19.9 or less, adult. An Order Recap Report, dated 11/28/23 through 01/05/24, documented Resident #1 had been ordered Megestrol Acetate Suspension [an oral medication used to treat a loss of appetite] on 12/20/23. The report further documented that the medication was discontinued on 12/22/23. A medication administration record, dated December 2023, documented Resident # 1 received doses of Megestrol Acetate Suspension on 12/21/23 and 12/22/23. A review of Resident #1's medical record found no documentation that the resident's family or POA were notified of Megestrol having been added to the resident's medication regimen. On 01/16/24 at 11:43 a.m. the ADON stated there was no documentation in Resident #1's medical record to indicate the resident's family member had been notified of the addition of Megestrol to the resident's medication regimen. They stated the family member had never presented documentation they had been designated as the POA, but the medical record did indicate that person was the POA. The ADON was unable to provide a policy that stated a resident's representative or POA would be notified in the event of a medication change.

Based on observation, record review, and interview the facility failed to ensure entrapment assessments were performed and consents for use of bed rails were obtained prior to the use of bed rails for two (#15 and #23) of two sampled residents reviewed for accidents. The General Manager reported 48 resident had bed rails attached to their beds. Findings: A Side Rails policy, review date of 05/23, read in part, .1. The resident will be assessed for the use of full side rails prior to being used/installed using the device evaluation in [product name withheld]. 2. The resident or responsible party will be informed of the risks and benefits with the use of full side rails and a consent will be obtained . 1. Resident #15 had diagnoses which included dementia and generalized muscle weakness. An annual assessment, dated 10/13/23, documented Resident #15's cognition was severly impaired and they were dependent of staff for activities of daily living. A review of Resident #15's medical records found no documentation of an entrapment assessment or consent for the use of bed rails. 2. Resident #23 had diagnoses which included generalized muscle weakness and difficulty walking. A significant change assessment, dated 09/07/23, documented Resident #23 was cognitively intact and required extensive assistance from staff for activities of daily living. A review of Resident #23's medical records found no documentation of a entrapment assessment or consent for the use of bed rails. A nurse note, dated 10/18/23 at 7:00 p.m., documented the Resident #23 was found with their knees on the floor and their head between the bed mattress and a side rail. No injuries were documented in the note. New interventions to prevent falls from the bed were noted to had been put in place at that time. On 10/23/23 at 3:02 p.m. Resident 15's room was observed for accident hazards. Bed rails were observed attached to the bed frame. On 10/24/23 at 10:35 a.m. Resident #23's bed was observed to have a bed rail attached to the bed frame. The resident stated they had slid from their bed onto the floor recently. They could not recall why they had fallen from the bed to the floor. They stated they sufferer no injuries as a result of the fall. They stated they lowered their bed and moved one side against a wall to prevent further falls. On 10/25/23 at 10:35 a.m., the Clinical [NAME] President reported bed rail assessments were not done at the facility because of the acute setting and that the rails are less than quarter rails. When informed of Resident #23's incident where their head was documented as having been found between the mattress and the bed rail the Clinical [NAME] President reported in that case an assessment should have been done. At 9:51 a.m., the Assistant Chief Nursing Officer reported to their knowledge bed rail assessments were not required. They stated there had been some assessments done but not consistently. They stated resident #23 did not have an entrapment assessment when they entered the facility or after the incident where their head was found between the bed rail and the bed mattress. At 10:16 a.m., the Clinical [NAME] President reported there was a bed rail assessment available in the electronic medical record product used at the facility but none had been completed for Resident #15 or Resident #23. On 10/26/23 at 9:03 a.m., the Assistant Chief Nursing Officer reported Resident #15 and Resident #23 had not been assessed for entrapment risk prior to their use. They further reported neither resident or their legal representative had been advised of the risks and benefits of the bed rails nor signed consents for their use which was required by their policy.

Based on record review and interview, the facility failed to monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on the steam table during meal service. The General Manager reported 48 residents resided in the facility. Findings: A facility policy titled Food, Revised 04/23, read in part, .The temperatures of food items served to elders will be tested and recorded before the delivery of food to the units/neighborhoods, at the time serving begins, at least once during serving if serving lasts longer than thirty (30) minutes, and at the conclusion of serving . The lunch temperature log, dated 10/23, did not document any food temperatures had been recorded between 10/18/23 and 10/24/23. The dinner temperature log, dated 10/23, did not document any food temperatures had been recorded between 10/18/23 and 10/24/23. On 10/24/23 at 12:00 p.m., Cook #2 was asked why no temperatures were documented between 10/18/23 and 10/24/23 they stated temperatures were not done. They also stated the chef on duty for the meal was responsible for ensuring staff documented temperatures on the temperature log.

Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#40) of one resident reviewed for discharge. The General Manager reported 48 residents resided in the facility. Findings: A facility policy titled discharges, revised 4/23, read in part, .Document in nursing notes time of transfer, where resident is going, condition of resident, method of transportation, disposition of all belongings and medications and that all parties are aware of the discharge . Resident #40 had diagnoses which included fracture of the third lumbar vertebra and hypertension. A 5-Day PPS assessment, dated 10/06/23, documented the resident was admitted on [DATE] and was discharged on [DATE]. On 10/25/23 at 1:30 p.m., Resident #40's electronic health record was reviewed, a discharge summary was not located. On 10/25/23 at 1:40 p.m., the Director of Hospitality reported they did not work on 10/06/23 and they were unsure if a discharge summary was completed. On 10/26/23 at 9:20 a.m., the Assistant Chief Nursing Officer was asked if a discharge summary or other documentation of Resident #40's discharge was completed, they stated not to my knowledge.

Based on observation and record review, the facility failed to ensure medication error rate of less than 5% during medication administration for two (#153 and #35) of three sampled residents observed during medication pass. The facility had two errors out of 35 opportunities, resulting in a 5.71% medication error rate. The DON identified 50 residents received medications. Findings: 1. Resident #153 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #35 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/06/22 at 7:27 a.m., LPN #1 was observed to prepare medication for resident #153. She stated that the aspirin was not in the facility. At 7:43 a.m., LPN #1 was observed to prepare medication for resident #35. She was observed to administer [MEDICATION(S)] one tablet to the resident. The medication administration observation error rate was calculated to be 5.71%.

Based on interview and record review, the facility failed to ensure medications were available for three (#42, #35 and #153) of nine sampled residents who were reviewed for medication availability. The DON identified 50 residents who received medications in the facility. Findings: 1. Resident #42 had diagnoses which included [CONDITION(S)], [CONDITION(S)], mild pain, anxiety, hypertension, and depression. Physician's orders, dated April 2022, documented the resident was ordered the following medications: ~ [MEDICATION(S)] 20 mg by mouth at bedtime for [CONDITION(S)], ~ [MEDICATION(S)] 60 mg by mouth daily for depression, ~ Losartan 25 mg by mouth daily for hypertension, ~ [MEDICATION(S)] 2.5 mg by mouth at bedtime for anxiety, ~ Tylenol 650 mg three times a day for mild pain, and ~ [MEDICATION(S)] 300 mg by mouth four times a day for [CONDITION(S)]. Review of the MAR, dated April 2022, documented the resident was not administered [MEDICATION(S)] from 04/02/22 through 04/05/22, [MEDICATION(S)] on 04/02/22, Losartan on 04/04/22, [MEDICATION(S)] on 04/02/22, Tylenol on 04/02/22 at 8:00 a.m. and 2:00 p.m., and [MEDICATION(S)] from 04/02/22 at 8:00 p.m. through 04/04/22 at 8:00 p.m. Review of the clinical record documented the medications were not available in the facility. On 04/04/22 at 1:45 p.m., the resident's family stated the resident had missed some doses of their medication. On 04/06/22 at 9:12 a.m., LPN #2 was asked why all ordered medications were not available for resident #42. She reviewed the clinical record and stated she had noticed on 04/03/22 the resident only had one pill of [MEDICATION(S)] left and placed an order to the pharmacy at that time. On 04/06/22 at 9:20 a.m., the DON was asked how medications were monitored to ensure they were available. She stated medications were reordered three times a week. She was asked why resident #42 had not had the above listed medications available in April 2022. She stated she would need to check with the ADON and follow up with the pharmacy. On 04/06/22 at 9:57 a.m., ADON #2 reviewed the resident's MAR and stated they ordered medications on Monday, Wednesday, and Friday but did not see any documentation in the clinical record the medications had been reordered for the resident. 2. Resident #35 had a diagnosis of urinary tract infection. Resident #35 had a physician's order, dated 04/04/22, for [MEDICATION(S)] Tablet 875 mg to be administered twice a day for a [CONDITION(S)]. The MAR documented to start the medication on 04/05/22 at 8:00 a.m. The MAR progress notes, dated 04/05/22, documented the morning and evening doses of [MEDICATION(S)] were not available. On 04/06/22 at 10:10 a.m., Resident #35 was asked if she currently was being treated for a [CONDITION(S)]. She stated she was and started an antibiotic yesterday morning. She was asked if she had any symptoms of a [CONDITION(S)]. She stated she had confusion. At 10:16 a.m., LPN #1 was asked how she ensured new medications were available to be administer as ordered by the physician. She stated the pharmacy was called to make sure they received the medication. She stated the [MEDICATION(S)] had not been delivered. 3. Resident #153 had a diagnosis of [CONDITION(S)]. Resident #153 had a physician's order, dated 04/01/22, for aspirin 81 mg to be given one time a day for anticoagulant. The MAR documented to start the medication on 04/02/22 at 8:00 a.m. The MAR progress notes, dated 04/02/22, 04/03/22, 04/04/22, 04/05/22, and 04/06/22, documented the medication was not available. On 04/06/22 at 9:12 a.m., LPN #2 was asked what the facility protocol was if a resident did not have medication available. She stated they documented the medication was not available and ordered them from pharmacy. She stated they ordered medications on Monday, Wednesday, and Friday.

Based on observation, interview, and record review, it was determined the facility failed to: ~ ensure a resident did not receive unnecessary antipsychotic medications without an indication for use for one (#1) of five sampled residents reviewed for [MEDICAL CONDITION] medication use. The resident census and condition report documented there were eleven residents in the building who were receiving antipsychotic medications. ~ ensure PRN orders for [MEDICAL CONDITION] drugs were limited to 14 days, unless renewed by the physician, for two (#17 and #21) of five sampled residents who were reviewed for [MEDICAL CONDITION] drug us. The resident census and condition report documented two residents received hypnotic medications, and ten residents received anxiolytic medications. The resident census and condition report documented there were 17 residents in the facility who were receiving psychoactive medications. Findings: 1. Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/08/19, documented the resident was moderately impaired cognitively, had no behaviors, and received an antipsychotic medication seven days out of the seven day look back period. A clinical note physician mental health visit, dated 10/03/19, documented the physician was in to see the resident. The note documented there was a new order for the resident to receive [MEDICATION NAME] 25 mg at bed time. A telephone order, dated 10/03/19, documented an order for [REDACTED].>An (MONTH) 2019 treatment sheet, documented only one behavior on 10/07/19. The treatment sheet documented the resident tried to hit the aide while they were trying to turn and reposition the resident. The treatment sheet documented the resident's behavior was getting more active since restarting [MEDICATION NAME]. There were no other behaviors documented for (MONTH) 2019. On 10/29/19 at 12:14 p.m., the resident was observed sitting at the dining table in a wheelchair with his legs elevated. The resident had no behaviors. At 1:07 p.m., the resident was observed in his room with a staff member. The staff member was waiting for help to use a Hoyer lift to transfer the resident to bed for incontinent care and then to his recliner in his room. The resident had no behaviors. At 2:09 p.m., the resident was observed in his recliner with his feet up watching television and had no behaviors. On 10/30/19 at 9:13 a.m., the resident was in the dining room being fed breakfast by staff. The resident had no behaviors. At 12:30 p.m., the resident was observed being fed lunch in the dining room and had no behaviors. On 10/31/19 at 9:05 a.m., CNA #1 was asked if the resident had any behaviors. She stated no he was just more talkative some days than others. She was asked if the resident ever became tearful or cried. She stated no. At 12:24 p.m., the DON was asked why the resident was receiving an antipsychotic. She stated it was family driven. She stated when the family face timed with him he cried and they thought he needed to be on [MEDICATION NAME] because he was on [MEDICATION NAME] in the hospital and they thought it had helped. The DON was asked if she had observed the resident being tearful. She stated she had not seen him be tearful. The DON was asked if the family had been educated about the drug. She stated yes. 2. Resident #17 was admitted with [DIAGNOSES REDACTED]. An EMAR physician's orders [REDACTED]. A comprehensive assessment, dated 10/10/19, documented the resident received four days of hypnotics during the seven day look back period. A care plan, dated 10/17/19, documented: Focus: Resident has a [DIAGNOSES REDACTED]. Goal: Resident will have restful sleep without difficulties over the next review. Interventions: Administer [MEDICATION NAME] as ordered. Monitor for s/e including anxiety, depression, unusual behaviors, [MEDICAL CONDITION], severe confusion, drowsiness or muscle weakness. Delay bedtime until resident is drowsy and ready to sleep. Engage in active daytime recreation/exercise program; minimize daytime sleeping events. Provide environment conducive to sleep, reduce/eliminate intake of caffeine. A pharmacy consultation report, dated 10/29/19, documented, (Resident #17) has a PRN order for a sedative/hypnotic, [MEDICATION NAME] 7.5 mg q hs prn [MEDICAL CONDITION] which has been in place for greater than 14 days without a stop date. Recommendation: Please consider discontinuing PRN [MEDICATION NAME]. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationals for the extended time period. On 10/29/19 at 11:22 a.m., the resident was observed in his room watching TV. On 10/30/19 at 1:00 p.m. the DON was asked how she ensured the PRN [MEDICAL CONDITION] medications were not used for more than 14 days without a new order. She stated that the RN rounding nurse would input the orders and catch the prn orders not having an end date. She stated she believed they needed to put stop dates on them so they did not miss them going over 14 days. On 10/31/19 at 11:00 a.m., the DON was asked about how the rounding nurse ensured the 14 day PRN [MEDICAL CONDITION] medications were not continued without review. She clarified that the rounding nurse only looked at the antipsychotic medications when ordered, not the [MEDICAL CONDITION] medications. The DON was asked what was in place to identify the 14 day PRN [MEDICAL CONDITION] medications when they are admitted . She stated there was nothing in place. 3. Resident #21 was admitted with [DIAGNOSES REDACTED]. An emar physician order, dated 10/04/19, documented [MEDICATION NAME] 1 mg tab prn three times a day. A comprehensive assessment, dated 10/11/19, documented the resident received seven days of an antianxiety medication out of the seven day look back period. A care plan, dated 10/21/19, documented: Focus: Resident is at risk for complications r/t [MEDICAL CONDITION]. Goal: Resident will have no complications from [MEDICAL CONDITION] through next review. Interventions: .Administer [MEDICATION NAME] as ordered. Administer [MEDICATION NAME] as ordered. Monitor for ASE that may include: dizziness, drowsiness, orthostatic [MEDICAL CONDITION], blurred vision, ECG changes, and [MEDICAL CONDITION] Monitor for new or worsening side effects of [MEDICAL CONDITION] that may include: increased fatigue, weakness, loss of appetite, muscle wasting .notify physician as indicated . On10/28/19 at 12:38 p.m., the resident was observed was eating lunch in his room. On10/29/19 at 1:08 p.m., the resident was observed lying in bed, lights off, and facing the wall. A pharmacy consultation report, dated 10/29/19, documented, (Resident #21) has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date: [MEDICATION NAME] 1 mg three times daily as needed for [MEDICAL CONDITION]. Recommendation: Please consider discontinuing [MEDICATION NAME]. If to be continued, please provide a duration of therapy .Rationale for recommendation: CMS requires that PRN orders for non-antipsychotic [MEDICAL CONDITION] drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. On 10/30/19 at 1:00 p.m., the DON was asked how she ensured the PRN [MEDICAL CONDITION] medications were not used for more than 14 days. She stated that the RN rounding nurse would input the orders and catch the prn orders not having an end date. She stated she believed they needed to put stop dates on them so they did not miss them going over 14 days. She clarified that the rounding nurse had only looked at the antipsychotic medications when ordered, not the [MEDICAL CONDITION] medications. The DON was asked what was in place to identify the 14 day PRN [MEDICAL CONDITION] medications when they are admitted . She stated there was nothing in place.

Based on interview and record review, it was determined the facility failed to provide a written notice of transfer to one (#13) of one sampled resident reviewed for receipt of a written notice of transfer. The DON identified 11 residents who had been transferred to the hospital over the last two months. Findings: Resident #13 was transferred to the hospital on [DATE]. On 10/27/19, at 11:30 a.m., the DON was asked what documents were sent with a resident when transferred to the hospital. She stated a face sheet, and the resident's current MAR and TAR. She stated family members or the responsible party were notified by telephone of the transfer. The DON was asked if a written notice of transfer had been given to the resident, the responsible party, and to the Ombudsman. She stated no.

Based on interview and record review, it was determined the facility failed to provide a bed hold policy to one (#13) of one sampled resident reviewed for bed hold policy. The facility identified 11 residents that had been admitted to the hospital during the last two months. Resident #13 was transferred to the hospital on [DATE]. On 10/27/19, at 11:30 a.m., the DON was asked what documents were sent with a resident when transferring to the hospital. She stated a face sheet, and the resident's current MAR and TAR. She stated family members or the responsible party were notified by telephone of the transfer. The DON was asked if a bed hold policy had been sent with the resident. She stated no.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident received a beneficiary notification letter for one (#78) of three sampled residents whose records were reviewed for a beneficiary notification letter. The administrator identified 146 residents who should have received a beneficiary notification letter in the last six months. Findings: Resident #78 was admitted on [DATE] and discharged on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 03/14/19, documented the resident was severely impaired cognitively and required extensice assistance with most activities of daily living. On 10/31/19 at 9:15 a.m., the social services coordinator was asked when a resident should receive a Notice of Medicare Non-Coverage specifically regarding resident #78. She stated she thought if a resident went to another facility for long term care they did not need to give them the notice of Medicare non-coverage form. She stated she had not given the resident the form.

Based on observation, interview, and record review it was determined that the facility failed to apply compression hose per the resident's care plan for one (#3) of three sampled residents who had orders for compression hose. The director of nursing identified three residents in the facility who had orders for compression hose. Findings: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 04/19/18, documented the resident was cognitively intact and required extensive assistance with activities of daily living. A care plan, dated 04/27/18, documented ted hose to be applied to bilateral lower extremities as ordered related to the [DIAGNOSES REDACTED]. A monthly physician order [REDACTED]. On 06/06/18 at 9:20 a.m., resident #3 was asked if she was prescribed compression hose. She stated she was. An observation of the resident's legs found no compression hose on either leg. At 1:00 p.m., an observation of the resident found she continued to be without compression hose on either leg. At 1:05 p.m., RN #1 was asked if resident #3 had been prescribed to wear ted hose. She stated she did not know. She was made aware of the order and asked if the order was still active. She stated she did not know. At 1:10 p.m., RN #1 was asked to accompany this surveyor to observe the resident. She was asked if the resident was wearing ted hose. She stated the resident was not. At 1:43 p.m., RN #1 reported the ted hose order for the resident was still active and they had been placed on the resident at this time. She stated the resident had gone to physical therapy in the morning before the hose could be placed on her and they did not go back later to put them on. At 1:40 p.m., the director of nurses was asked who was responsible for ensuring ted hose were applied and removed each day. She stated the CNA's were supposed to put on and remove the hose then inform the nurse of those actions and the nurses were responsible for checking on the CNA's work.

Based on interview and record review, it was determined the facility failed to provide liability and appeals notices for 3 (#2 #3, and #149) of 3 sampled residents who had been discharged from skilled services before their Medicare coverage ended. The administrator identified 67 residents who had been discharged from skilled services before their Medicare coverage ended in the last 6 months. Findings: On 05/16/17 at 12:30 p.m., the administrator was asked for a copy of the liability and appeals notice for resident #2, #3, and #149. At 12:57 p.m., the administrator stated they had a liability and appeals notice form but they had not been issuing it because usually when a resident finished therapy they were ready to go home. She stated she understood they needed to know their rights and the facility would begin providing the liability and appeals notices.

Based on observation, interview, and record review, it was determined the facility failed to develop a comprehensive care plan to reflect the placement and maintenance of an indwelling urinary catheter for one (#46) of two sampled residents who had an indwelling urinary catheter. The census and condition report identified three residents who resided in the facility and had an indwelling urinary catheter. Findings: Resident # 46 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 03/21/17, documented the resident was cognitively intact, required extensive assistance with most ADLs, and was frequently incontinent of bowel and bladder. A clinical note, undated, documented the resident had an indwelling urinary catheter placed on 03/27/17 due to [MEDICAL CONDITION]. A care plan, dated 03/29/17, did not contain any documentation related to the resident's indwelling urinary catheter placement or the maintenance of the catheter. A clinical note, dated 04/27/17, documented the resident's catheter had been changed per protocol. On 05/09/17, at 11:30 a.m., resident #46 was observed sitting up a wheelchair in his room. A urinary catheter was observed with a dignity cover in place under the resident's wheelchair. A clinical note, dated 05/15/17, documented the urinary catheter had been discontinued due to increased pain and swelling to the penis. On 05/16/2017 at 11:45 A.M., the MDS/care plan LPN was asked how they ensured a resident's care plan accurately reflected the resident. She stated after the nurses received physician orders, a copy of the order was placed in a box for the care plan nurses to use for care plan development. She stated the orders were collected every morning and used to create or update the care plan. The nurse was asked about the care plan for resident #46 related to the indwelling urinary catheter. She stated the order would have been retrieved the morning following the placement of the catheter. The LPN stated she had not received a copy of the telephone order and therefore the care plan relating to the urinary catheter had not been done.

Based on interview and record review, it was determined the facility failed to ensure: ~ residents received education regarding the influenza and/or pneumococcal vaccine ~ residents were provided a consent/declination form to sign for five (#41, #62, #69, #138, and #150) of five sampled residents who were in the facility between October 1, 2016 through March 31, 2017. The administrator identified 187 residents had been admitted between October 1, 2016 through March 31, 2017. Findings: 1. Resident #41 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 02/23/17, documented the resident was cognitively intact, required limited to extensive assistance with ADLs, had an indwelling urinary catheter, had received the influenza vaccine outside of the facility, and the resident's pneumococcal vaccine was up to date. The clinical record did not contain any documentation the resident had signed a declination regarding his refusal of the influenza and pneumococcal vaccines. The record did not contain any dates as to when the vaccines had previously been administered. 2. Resident #62 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 02/11/17, documented the resident was cognitively intact, required extensive assistance with ADLs, was occasionally incontinent of urine and always continent of bowel, had received the influenza vaccine outside of the facility, and the resident's pneumococcal vaccine was up to date. The clinical record did not contain any documentation the resident had signed a declination regarding her refusal of the influenza and pneumococcal vaccines. The record did not contain any dates as to when the vaccines had previously been administered. 3. Resident #69 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/28/17, documented the resident was cognitively intact, required limited to extensive assistance with ADLs, had an indwelling urinary catheter, was frequently incontinent of bowel, documented the reason the influenza vaccine had not been received as resident not in this facility during this years influenza vaccination season, and the resident's pneumococcal vaccine was up to date. The clinical record did not contain any documentation the resident had been educated and offered the influenza vaccine. The record did not contain documentation of a signed declination regarding her refusal of the influenza and pneumococcal vaccines. The record did not contain any dates as to when the vaccines had previously been administered. 4. Resident #138 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 02/19/17, documented the resident was cognitively intact, required supervision to extensive assistance with ADLs, was continent of bowel and bladder, had received the influenza vaccine outside of the facility, and the resident's pneumococcal vaccine was up to date. The clinical record did not contain any documentation the resident had signed a declination regarding her refusal of the influenza and pneumococcal vaccines. The record did not contain any dates as to when the vaccines had previously been administered. 5. Resident #150 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 03/13/17, documented the resident was severely impaired cognitively, required limited to extensive assistance with ADLs, was frequently incontinent of bladder, was occasionally incontinent of bowel, had received the influenza vaccine outside of the facility, and the resident's pneumococcal vaccine was up to date. The clinical record did not contain any documentation the resident or resident's representative had signed a declination regarding his refusal of the influenza and pneumococcal vaccines. The record did not contain any dates as to when the vaccines had previously been administered. 05/16/17 2:48 p.m., the DON was asked about their flu and pneumonia vaccine policy. The DON stated the facility asks the resident when they are admitted if they would like/need a flu or pneumonia vaccine. If the resident refuses we document the resident refused on the TAR. We go over the education with the resident and/or their representative but we do not document it anywhere.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's wheelchair was properly secured prior to the vehicle being put in motion for one (#40) of one sampled resident who was transported on a facility vehicle. The Administrator identified 135 residents who had been transported in the facility vehicle during the past three months. Findings: A facility transportation procedure, undated, documented, .Turn and position where wheelchair wheel is touching back seat .Lock wheel chair brakes .Squat down and attach strap #1 to wheel chair bracing .Strap #2 to wheel chair front wheel assembly .Apply locking device to seatbelt . Resident #40 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A nurse's note, dated 4/12/17 at 4:57 p.m., documented, .Guest returned from Dr appt. Guest obtained skin tear to L shin area upon return to facility. Guest states she is in pain, Tylenol offered. Bruising noted clear down to ankle area. Skin tear approximated and dressing along with TAO applied to site. Notified wound care nurse to eval tomorrow when she returns. Guest denied any further needs at this x. Will continue to monitor .(staff name deleted) . An admission assessment, dated 04/13/17, documented the resident was severely impaired cognitively and required extensive assistance with most ADLs. An incident report, dated 04/13/17, documented, .(resident name deleted) .date of incident 4/12/17 .time of incident 4:40 p.m .department Transportation .Job title Driver .Describe exactly what happened .Forgot to strap chair down, Pt on O2 and got out of routine of strapping in first because I had to get O2 tank back on for pt. Wheelchair rolled forward and scrapped left anterior tibia skin tear. LPN #2 notified upon arrival . A care plan, dated 04/24/17, documented the resident was at risk for falls due to weakness and decreased mobility. On 05/09/17 at 2:01 p.m., resident #40 was observed lying in bed awake with her daughter in the room. The daughter reported to this surveyor the resident's leg suffered a skin tear when the facility van operator failed to secure the resident's wheelchair prior to putting the van into motion. On 05/15/17 at 2:40 p.m., the TD was asked to recount the incident involving resident #40 which resulted in an injury. The TD stated the resident was injured when the resident's improperly secured wheelchair rolled forward after the facility van was put into motion. The TD stated he had strapped one side of the wheelchair but had been distracted and had not secured the second strap to the wheelchair. The TD was asked if he had received any retraining in the task of securing wheelchairs in the facility van since the incident. The TD stated he had not. At 2:56 p.m., LPN #2 was asked if resident #40 had been injured during a transport on the facility van on 04/12/17. LPN #2 stated the resident suffered a skin tear to her left leg. At 3:07 p.m., the administrator was asked if she was the TD's direct supervisor. She stated she was. She was asked if the TD had received any retraining on the task of securing a wheelchair prior to transporting after the resident's incident. She stated she was unsure if he had been retrained.

Based on interview and record review, it was determined the facility failed to promptly notify the physician of laboratory results for 2 (#1 and #4) of 3 sampled residents whose laboratory results were reviewed. This had the potential to affect the 36 residents who resided in the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident's admission assessment, dated 02/29/16, documented the resident was moderately cognitively impaired, required extensive assistance with toilet use and personal hygiene, was frequently incontinent of urine, and had a urinary tract infection in the previous 30 days before the assessment. A daily skilled nursing note, dated 03/29/16 at 6:03 p.m., documented the resident's urine was cloudy and had an odor. A urinalysis (UA) with reflex micro laboratory report, dated that it was printed on 04/07/16, documented the resident's urine had been collected and received on 03/29/16. The laboratory report documented the final report had been reported on 03/30/16. The resident's urinalysis final report documented, the resident had amber colored urine; turbid in appearance; had 2 plus leukocyte esterase; positive for [MEDICATION NAME]; and had protein, blood, and 3 plus bacteria in the urine; and was above the normal levels of white and red blood cells and crystals. The resident's clinical notes report, had an entry, dated 04/07/16 at 4:34 p.m., which documented the resident's UA results had been reviewed with the resident's physician. The note documented the physician had ordered the resident [MEDICATION NAME] and [MEDICATION NAME]. The resident's clinical notes report, had an entry, dated 04/08/16 at 9:07 a.m., documented the resident had been given a dose of [MEDICATION NAME] for a urinary tract infection [MEDICAL CONDITION]. Another note at 4:40 p.m., documented the resident had started the [MEDICATION NAME] for UTI. On 04/26/16 at 2:43 p.m., licensed practical nurse (LPN) #1 was shown the resident's UA report that a UA was obtained on 03/29/16 and the final report was 03/30/16. The LPN was asked when the resident's physician had been made aware of the resident's UA results. She reviewed the resident's electronic clinical record. She stated she did not see the date the physician was notified. She stated he was notified on 04/07/16 when the physician had visited the facility. The LPN was asked based on that information was there a delay in notifying the physician of the UA results. She stated, I do believe so. On 04/26/16 at 3:04 p.m., the director of nursing was asked what was the facility's process for notifying the physician of residents UA and culture results. She stated when the results were delivered the physician was notified by phone, unless the physician was coming to the facility that day, then the results were put in their box to review. The DON stated the facility had been having a problem getting their laboratory results returned in a timely manner and the facility had been working on the problem. The DON was asked based on the above information was there a delay in notifying the physician. She stated yes. 2. Resident #4 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident's admission assessment, dated 04/04/16, documented the resident was cognitively intact, required extensive assistance with toilet use, limited assistance with personal hygiene, and was occasionally incontinent of urine. The resident's care plan, dated 04/15/16, documented the interventions the facility would take to prevent and care for a UTI. A clinical notes report, had an entry, dated 04/13/16 at 5:14 a.m., which documented the resident complained of foul smelling urine and increased frequency. The note documented that a UA was obtained and taken to the lab. A clinical notes report, had an entry, dated 04/14/16 at 5:05 a.m., which documented the preliminary report had been received and showed a culture was in process. The note documented the report was placed in the resident's physician's box for further review. The resdient's clinical record contained the resident's urine culture final report which was documented as verified on 04/15/16 at 3:12 p.m. The report documented the resident's urine had greater than 100,000 colony-forming units/milliliter (cfu/ml) of Proteus mirabilis. The report contained a hand written notation of noted by an LPN on 04/18/16. A clinical notes report, had an entry, dated 04/18/16 at 1:41 p.m., which documented, the results from the UA culture were received from the lab. The note documented the report was given to the director of nursing (DON) to review with the nurse practioner. An order was obtained to start the resident on Bactrim DS for a UTI. On 04/26/16 aty 1:52 p.m., LPN #2 was asked when the resident's physician had been made aware of the UA and culture results as stated above. She reviewed the resident's electronic record and stated she could not see who or when the physician had been notified except there was an order for [REDACTED]. She was asked including on nights and weekends. She stated, yes unless the physician was coming to the facility later that day. On 04/26/16 at 3:09 p.m., the above situation was discussed with the DON. The DON was asked if there was a delay in notifying the physician of the resident's UA and culture result. She stated yes.