Every finding on record at Logan Manor Community Health Services

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in two kitchenettes and one pantry room.Findings included:- On 12/01/25 at 08:30 AM, the silver upright refrigerator located in Pod two kitchenette had the following:One large gallon zip-lock bag of potato salad, undated.One plastic bag of chicken patties, 16 count, undated.One plastic bag of chicken patties, six count, undated.One plastic bag of pancakes, three count, undated.On 12/01/25 at 08:40 AM, the silver upright refrigerator located in Pod three kitchenette, had the following:One large bowl, approximately 32 ounces (oz) of vegetable beef soup, undated.One covered plastic bowl, approximately 6 inches by 6 inches of cranberries, undated. One 32-oz plastic container of strawberry yogurt, undated.On 12/01/25 at 09:00 AM, observation of the pantry room two door silver upright refrigerated on the North Administration Hall upon entrance to the facility, had the following:Two plastic bags, approximately 16 oz of shredded American cheese, undated.One plastic bag of sliced Swiss cheese, approximately 160 slices, undated.Two plastic bags of chicken tenders, undated.One plastic bag of diced chicken, undated.On 12/01/25 at 09:05 AM, during the initial kitchenette tour in Pod one, Pod two, and Pod three, revealed the facility lacked and had failed to take daily temperature logs for the dishwashers since moving into the new facility in February 2025. On 12/01/25 at 9:10 AM, Administrative Staff A verified the above findings and stated staff should label and dated food items before placing them in the refrigerator or freezer. Administrative Staff A verified when the dishwashers were installed in the newly built facility and the manufacture representative informed them, they did not need to worry about the temperature of the dishwashers because the dish products they were using were a low temperature dishwasher detergent that would properly sanitize the dishes and silverware, so facility staff did not feel there was a need to document the water temperatures. The facility's Dietary Purchases, Receipt and Storage policy, dated 11/14/24, documented food and nonfood supplies would be purchased, received, and stored under sanitary, safe, and secure conditions as required to meet federal, state, and local laws. The Dining Service Manager would be responsible for receiving and storage of all food and supplies in a proper area. All products would be labeled with the date received in the facility, and all food would be rotated so that the first in would be the first out. All unlabeled, rusty, broken containers or cans with side dents or rim dents would be removed, marked unacceptable, and destroyed. The facility's Dietary Cleaning Procedure policy, dated 11/14/24, documented the facility would store, prepare, and serve food under sanitary conditions to ensure that proper sanitization and food handling practices to prevent the outbreak of foodborne illnesses are attained continuously. The policy documented the evening staff members would check the dates on containers of leftovers and dispose of food found to have been refrigerated for more than three days. The daily, weekly, and monthly cleaning schedule would be developed by the Certified Dietary Manager based on the needs of the residents and activities that occur in the kitchen and dining rooms.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to store and label biologicals adequately when staff failed to date one insulin (medications used to treat high blood glucose levels) pen when opened and failed to remove or dispose of one expired bottle of stock medications. Findings included:- On 12/01/25 at 10:56 AM, observation of Pod one medication room refrigerator revealed the following: R7's opened insulin glargine (long-acting insulin) pen without an open date or a discard date.On 12/01/25 at 11:05 AM, observation of Pod one medication cart revealed the following:One expired stock medication bottle:Thera High Potency Vitamin Dietary Supplement, 160 count bottle, expired June 2025, and the facility had dated the bottle on 10/26/25 when they placed the medication in the medication cart for use.On 12/01/25 at 11:10 AM, Licensed Nurse (LN) G verified the expiration date on the stock medication and the undated insulin pen. LN G verified staff were to date the insulin pens when opened and discard expired medications.On 12/03/25 at 8:15 AM, Administrative Staff A verified the medications should be discarded when the bottle has an expired date, and the insulin pens should be dated when opened and dated with an expiration date.The facility's Medication Administration policy, dated 08/29/24, stated all medications would be administered to every resident as ordered by the physician in a safe and sanitary manner. The policy documented prior to administering or removing floor stock, the dispensing pharmacist would review all medication orders or prescriptions unless a delay in administration would harm the resident in an urgent situation, including a sudden change in the resident's clinical status.The facility's Pharmacy Services policy, dated 09/28/24, stated drugs and biologicals used in the facility would be labeled in accordance with current accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. The policy stated the facility would provide pharmaceutical services, including procedures that assured the accurate acquisition, receiving, and administration of all drugs and biologicals to meet the needs of each resident.

The facility had a census of 32 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all residents who reside at the facility at risk for decreased quality of care.Findings included:- The Payroll Based Journal (PBJ- a required detail of staffing information submitted by nursing homes to the Centers of Medicare and Medicaid Services [CMS]) documented that the facility lacked RN eight-hour coverage for the following days: 04/06/25, 04/07/25, 04/13/25, 04/19/25, 04/20/25, 04/26/25, 04/27/25, 05/03/25, 05/04/25, 05/17/25, 05/18/25, 05/2425, 05/25/25, 05/31/25, 06/01/25, 06/07/25, 06/13/25, 06/15/25, 06/21/25, and 06/22/25.The Nursing Schedule, dated November 2025, documented that the facility lacked RN eight-hour coverage for the following days: 11/08/25, 11/09/25, 11/22/25, and 11/23/25. The Nursing Schedule, dated December 2025, ldocumented that the facility lacked RN eight-hour coverage for the following days: 12/01/25 and 12/02/25.On 12/02/25 at 09:45 AM, Administrative Staff A verified the above dates as days they did not have an RN in the building. Administrative Staff A stated that it was hard to find Registered Nurses since they are out in the country.The facility's Registered Nurse policy, dated 08/06/24, documented that the facility would employ services of a Registered Nurse for at least eight consecutive hours a day, seven days a week. The facility would designate a Registered Nurse to serve as the Director of Nursing on a full-time basis. The DON may serve as a charge nurse only when the facility has an average daily census of sixty or fewer residents.

The facility had a census of 32 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ). Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter (Q) 4 indicated no licensed nurse coverage on five dates.Review of the facility's licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty for 24 hours a day, seven days a week.On 12/02/25 at 09:45 AM, Administrative Staff A stated they have had problems with the PBJ in the past, but never were without a nurse in the building. Administrative Staff A stated that the dates that say there was not a nurse in the building were probably due to the use of agency nurse's and it was not documented.The facility's Mandatory Submission of Uniform Format Staffing Information (PBJ) policy, dated 09/08/25, documented the facility's complete submission of staffing based on payroll data in a uniform format as specified by regulatory requirements. The facility would electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by the Centers for Medicare and Medicaid Services.

The facility had a census of 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, facility medical director, and physician, the lack of a 14-day stop date or specified duration, for Resident (R) 32's as needed (PRN) antianxiety (class of medications that calm and relax people) medication. Findings included:- R32's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R32's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R32 had severely impaired cognition. The MDS recorded he required extensive assistance from staff with activities of daily living (ADL). The MDS documented R32 received an antianxiety medication during the observation period.R32's Care Plan dated 08/07/25 recorded R32 required one staff assistance with most activities of daily living (ADL) care. R32's care plan documented the resident had a mood problem related to depressive disorder and anxiety with physical and verbal aggression and resistance to cares. The care plan documented the resident received a mental health consult monthly and as needed, and staff would administer medications as ordered and document for side effects and effectiveness.R32's Physician's Order dated 03/25/25 directed the staff to administer Ativan (lorazepam- antianxiety medication) cream 1.0 milligram (mg)/per milliliter (ml), every six hours as needed for anxiety/aggression related to anxiety disorder. The order lacked a stop date.R32's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN lorazepam.The Consultant Pharmacist's monthly review for R32, completed on 11/13/25, lacked evidence the Consultant Pharmacist identified the PRN lorazepam with no stop dateOn 12/01/25 at 12:30 PM, R32 sat in a wheelchair in the Pod three hallway. Continued observation revealed the resident went to the partially opened equipment door, touched the door handle, then propelled down the hall to East exit door. Continued observation revealed the resident went to the East exit door and tried to grab at the door frame and was unable to open the door, then turned around and started propelling back down the hall to Pod three.On 12/01/25 at 12:40 PM, Certified Medication Aide (CMA) S verified the resident had received Ativan cream to her wrist approximately 20 minutes ago and stated R32 had been agitated and staff were not able to redirect her, so the nurse administered the Ativan cream to R32's wrist. CMA S verified the medication takes approximately one hour to kick in.On 12/03/25 at 08:15 AM, Administrative Staff A verified the resident received Ativan cream PRN, with a physician order date of 03/25/25. Administrative Staff A verified the facility failed to obtain the 14-day stop date or a reason for the continued use with the appropriate rationale. Administrative Staff A verified the Consultant Pharmacist had sent monthly reviews to the facility and lacked a recommendation for the 14-day stop date or a rationale for continued use of the medication. The Antipsychotic Medication Use policy dated 09/26/25 recorded antipsychotic medication would be prescribed when indicated by assessment and medical necessity and after other non-pharmacological interventions or alternatives had been considered or used, and at the lowest effective therapeutic dose for the shortest effective duration. The policy stated each resident who had an order for an antipsychotic medication would be assessed and periodically reassessed during their stay to determine the effectiveness of the medication.The facility's Pharmacy Services policy dated 09/28/24 documented the facility would provide pharmacy services in accordance with State and Federal regulations. The facility would employ or obtain services of a licensed pharmacist who would provide consultation on all aspects of the provision of pharmacy services in the facility, establish a system of records and receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, determine that drug records are in order and that an account of all controlled drugs are maintained and periodically reconciled. The facility would provide pharmaceutical services, including procedures that assured the accurate acquisition, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident.

The facility had a census of 32 residents. The sample included 12 residents, with nine reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure a safe environment to prevent falls for three sampled residents: Resident (R) 19, who fell out of her wheelchair; R26, who had an unwitnessed fall in his room; and R3, when staff failed to place her alarm on her wheelchair, and she fell.Findings included:- R3's Electronic Medical Record (EMR) documented the resident had diagnoses of rheumatoid arthritis (chronic inflammatory disease that affects joints and other organ systems), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), atrial fibrillation (rapid, irregular heartbeat), fracture of right femur (a break in the femur-thigh bone), and fractured right humerus (upper arm bone). R3's admission Minimum Data Set (MDS) dated [DATE] recorded R3 had a Brief Interview for Mental Status (BIMS) of five, indicating severely impaired cognition. The MDS recorded the resident used a cane or wheelchair for mobility and required substantial to maximal assistance with sit-to-stand, chair/bed to chair transfer, toilet transfer, with supervision or touching assistance to walk ten feet once standing. The MDS documented the resident had a bed and a chair alarm that was used daily. The MDS documented the resident had a fall in the last two to six months prior to admission and had a fall in the last month prior to admission. R3's Fall Care Area Assessment (CAA) dated 09/18/25 documented R3 had fallen at home and sustained a right femur fracture, right humerus fracture, and fracture of the superior rim of the left pubis (a pair of bones forming the two sides of the pelvis). The CAA documented R3 required staff assistance with dressing and grooming due to her immobilized arm, with physical therapy and occupational evaluations scheduled to guide her care plan and mobility goals. Currently, R3 uses a gait belt with a walker for pivot transfers or short distances. R3's Physical Restraint CAA dated 09/18/25 documented the resident does not have a physical restraint. R3's Fall Care Plan dated 09/21/25 documented R3 was a high fall risk, related to deconditioning, gait/balance problems, and multiple fractures. The care plan documented staff would ensure the resident's call light was within reach and encourage the resident to use it, and documented staff would ensure a prompt response to all requests for assistance. The plan of care documented staff would remind the resident to call for assistance, and staff would determine the root cause of the resident's past falls. The care plan documented staff would ensure a safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, personal items within reach, and alarms on bed and chair. R3's Activities of Daily Living (ADL) Care Plan dated 09/21/25 directed one staff to assist R3 with a quad cane and assist of one staff. The ADL care plan documented staff would encourage the resident to use the bell to call for assistance. R3' EMR lacked a Fall Risk Assessment. The Nurses Note dated 10/17/25 at 09:05 PM documented R3 was found on the floor in her room. Observation revealed R3's pull tab alarm was not attached according to Certified Nurse Aide (CNA) P, who stated she thought the resident had a pressure alarm in her chair. R3 stated she was on her way back from the bathroom when she fell, hit her elbow, and sustained a skin tear, approximately 0.5 centimeters (cm) by 0.5 cm, on her right elbow. The medication aide cleansed the area and applied a gauze wrap, while the resident complained of a dull, achy pain in her right shoulder. The nurse obtained vital signs, neuros were intact, pain medication was administered, and then the resident rested in her bed. The resident was re-educated about using the call light when she got up to use the restroom. The Fall Investigation Report dated 10/18/25 documented R3 was new to the facility, very independent, did not like to ask staff for help, and did not remember to ask for help. The investigation documented staff would ensure the alarm was in place and functioning, and staff would ensure R3 would be taken to the bathroom at normal intervals. The investigation documented R3's bed/chair alarm was off, and the environment had poor lighting when the fall occurred. On 12/02/25 at 11:35 AM, observation revealed R3 transferred herself from her wheelchair to a chair at the dining room chair which activated the TABS alarm the resident had on the wheelchair and it was attached to her right shoulder. Licensed Nurse (LN) G approached R3 and silenced the wheelchair alarm and attached the alarm to the device the resident had on the dining room chair. On 12/02/25 at 09:00 AM, LN G verified R3 would frequently get up and transfer from her wheelchair to the chair and from her wheelchair to her recliner in her room. LN G stated staff reminded the resident, but it continued to happen, and R3 has had a fall at the facility, but no significant injury that she was aware of. On 12/02/25 at 08:15 AM, Administrative Staff A stated the medical records documented the resident had a fall on 10/17/25 at 09:05 PM, and after investigation, it was determined R3 did not have the TABS alarm in place, and the aide thought the resident had a pressure pad alarm in her wheelchair. R3 sustained a fall with a skin tear to her right elbow. Administrative Staff A verified the staff are trained upon hire regarding falls and fall prevention, and they were to follow the resident's individualized care plan. The facility's Fall Prevention Program policy, dated 09/24/25, documented reach resident that resided in the facility would be provided services and care that ensured the residents' environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents. Every resident would be assessed for the causal risk factors for falling at the time of admission, upon return from a healthcare facility, and after every fall in the facility. On the day of admission, each resident would be assessed for falls by a licensed nurse. The initial care plan and communication tool would be used to identify activities or habits that place the resident at risk for falls. The resident would be instructed about safety measures and rationale, including to call for assistance before getting out o bed, raise slowly, keep necessary items within reach, and the proper use of canes, walkers, wheelchairs and crutches. The interdisciplinary team would develop a plan for services to improve of maintain the resident's standing and sitting balance and other interventions to reduce the elder's risk for falls. The plan would include specific, individualized information about the resident's routine and personal habits that may place the resident at risk for falls such as nighttime voiding or nighttime wandering. Every time the resident returns from a stay in another health care facility, a nurse would re-assess the resident to determine if the risk for falls increased/changed. The care plan would be reviewed and amended based on the re-assessment. - The Electronic Medical Record (EMR) for R19 documented diagnoses of hypertension (high blood pressure), transient ischemic attack (TIA- a temporary episode of inadequate blood supply to the brain), and chronic kidney disease (a long-term condition where your kidneys become damaged and can't filter waste and extra fluid from the blood). The Annal Minimum Data Set (MDS) dated [DATE] documented R19 had intact cognition. R19 was dependent upon staff for toileting hygiene, showers, and lower-body dressing. R19 required substantial staff assistance for oral hygiene, upper body dressing, personal hygiene, mobility, and transfers. R19 had upper functional impairment on both sides and had one fall with injury. R19's Quarterly MDS dated 09/10/25 documented R19 had severely impaired cognition. R19 required substantial staff assistance for showers, dressing, personal hygiene, mobility, transfers, and partial staff assistance for ambulation. R19 had upper functional impairment on both sides and had no falls. The Fall Risk Assessment dated 03/23/25, 06/18/25, and 09/08/25 documented R19 was a high risk for falls. R19's 09/04/25 Care Plan included the following interventions: 05/17/24 – Use a gait belt with all transfers. 09/15/24 - Ensure R19 had socks and shoes on with transfers and ambulation during the day. 11/30/24 – Use a wheelchair instead of ambulating when weak. 06/13/25 – Reeducate Licensed Nurse (LN) and Activity Director (AD) on how to load R19 into the facility van and to have foot pedals on her wheelchair. The Nurse's Note dated 06/13/25 at 03:57 PM (late entry) documented while leaving the museum, LN I and Activity Z loaded R19 into the wheelchair van, pulled her up the ramp, which had the resident tilt forward. R19 slowly slipped forward out of the chair and slid to the ramp on her bottom. R19 denied pain anywhere and stated, I'm alright! The note further documented that the two staff lifted her back into her wheelchair and proceeded to lock her into place in the van. After returning to the facility, the LN assessed the resident and discovered two small skin tears on her left elbow and placed steri-strips (adhesive wound closures) over each skin tear. The skin tears were covered with a non-adherent dressing and wrapped with Kerlix (stretchy gauze bandage) to hold it in place. The EMR lacked documentation an investigation was completed for the 06/13/25 fall. On 12/02/25 at 09:50 AM, Certified Nurse Aide (CNA) N placed a gait belt around R19's waist. CNA N and CNA O assisted R19 to stand in front of her walker, and R19 walked to the bathroom. On 12/02/25 at 08:45 AM, CNA M stated R19 was a two-person assistance for transfers and ambulation. R19 had a recent fall, which scared her, and it made her feel more secure if staff walked with her. On 12/02/25 at 01:30 PM, Activity Z stated R19 did not have foot pedals on her wheelchair, and that made it more difficult to push her in her wheelchair because she had a habit of straightening out her legs when she was pushed. Activity Z further stated that she decided to go up the ramp backward, and when she started to pull R19 up the ramp, R19 started to slide out. Activity Z put her hand on R19's chest to try to hold her in the wheelchair, but she still slid out. Activity Z stated that it happened so fast that LN I did not get to her in time to stop the fall. Activity Z stated that after the fall, she was reeducated on how to load residents into the facility van. On 12/03/25 at 09:30 AM, LN H stated R19 did not remember to use her call light and was a two-person assist with transfers. LN H further stated she has not had any recent falls. On 12/03/25 at 11:30 AM, Administrative Staff A verified that there was not a full investigation, including root cause analysis, on the fall, and R19 should have had foot pedals on her wheelchair. The facility's Fall Prevention Protocol, dated 09/24/25, documented that each elder residing at the facility would be provided services and care that ensured that the elder's environment remained as free from accident hazards as possible and each elder received adequate supervision and assistive devices to prevent accidents. Every elder would be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility, and after every fall in the facility. - The Electronic Medical Record (EMR) for R26 documented diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hypertension (high blood pressure), and falls. The Quarterly Minimum Data Set (MDS) dated [DATE] documented R26 had intact cognition. R26 required partial staff assistance for toileting hygiene, dressing, mobility, transfers, and ambulation. R26 had lower functional impairment on one side and had no falls. The Quarterly MDS dated 09/17/25 documented R26 had intact cognition. R26 required partial staff assistance for toileting hygiene, dressing, mobility, transfers, and ambulation. R26 had lower functional impairment on one side and had one fall with injury. The Fall Risk Assessments dated 01/06/25, 03/31/25, 06/24/25, and 09/16/25 documented R26 was a moderate risk for falls. R26's 09/11/25 Care Plan included the following interventions: 04/19/24 – Ensure R26 wore appropriate footwear when ambulated or while in a wheelchair. Ensure R26's call light is in reach and encourage him to use it. Encourage R26 to participate in activities that promote exercise, physical activity for strengthening, and improved mobility. 01/05/25 – Encourage R26 to sit down on the bath chair before taking his shoes off for bathing. 01/09/25 – Assist R26 to use the hall bathroom when he needs to use the bathroom, and his bathroom is in use. 01/19/25 – R26 to use a sit-to-stand mechanical lift (a medical device that helps individuals with partial mobility move safely from a seated to a standing position, or transfer between chairs, bed, and commodes) and wheelchair with no ambulation as his legs give out. This intervention was discontinued on 01/20/25. 01/20/25 – Ambulate R26 with the assistance of two staff and his wheelchair behind him in case of falls. R26's plan of care lacked an intervention after his fall on 01/27/25. The Nurse's Notes dated 01/27/25 documented R26 was lowered to the floor by staff while being assisted to the bathroom. Then R26 dropped himself to the floor on the way back to his bed. No injuries observed, and his vital signs were within normal range. The EMR lacked documentation an investigation was completed for the 01/27/25 fall. On 12/02/25 at 08:45 AM, Certified Nurse Aide (CNA) M placed a gait belt around R26's waist, R26 stood up in front of his walker, and walked with him down the hall. CNA M stated R26 had not had a fall in a long time, and staff were to use a gait belt when he was ambulated. CNA M further stated, he had falls in the past because he did not like to use his call light and would get up on his own. On 12/03/25 at 09:30 AM, Licensed Nurse (LN) H stated, she preferred to use the sit-to-stand lift with R26, but would expect there to be at least two staff with him for transfers and ambulation. On 12/03/05 at 08:55 AM, Administrative Staff A stated there should have been an investigation with root cause analysis for the fall, but was unable to find one. The facility's Fall Prevention Protocol, dated 09/24/25, documented that each elder residing at the facility would be provided services and care that ensured that the elder's environment remained as free from accident hazards as possible and each elder received adequate supervision and assistive devices to prevent accidents. Every elder would be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility, and after every fall in the facility.

The facility had a census of 32 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 8 with written information regarding the facility bed hold policy when he was transferred to the hospital and the facility failed to complete a Recapulation (a required component of a residents comprehensive discharge summary from the facility, the form is completed to provide a concise summary of the residents entire stay to ensure continuity of care when transitioning to another care setting, home, or other providers) after R37 was discharged from the facility. Findings included:- R8's Electronic Medical Record (EMR) revealed diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), gastroesophageal reflux (GERD- backflow of stomach contents to the esophagus), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R8's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R8 had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS recorded she required staff assistance with activities of daily living (ADL). The Fall Care Area Assessment (CAA) dated 01/24/25 recorded R8 required staff assistance with ADLs, mobility, and would ambulate without a device throughout the facility and in the room independently with a shuffling gait or with a gait belt and assist of staff as needed. The CAA documented the resident had moments of occasional confusion at times. R8's Care Plan dated 08/26/25 recorded R8 was able to feed himself with setup help and clean up assistance. The care plan documented staff would monitor R8 for targeted behavior symptoms, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others, and interventions effectiveness and document per facility protocol. On 06/21/25 at 04:37 AM the Nurse's Notes documented the resident woke up when kitchen staff arrived in the kitchenette and started making noises. R8 was shaking and pale, and an auxiliary (a body temperature reading taken from the armpit, normal range from 97.6 degrees Fahrenheit (F) to 99.4 degrees F) temperature was taken and was 100.4 degrees Fahrenheit (F). The nurses' notes indicated the resident was administered Tylenol (pain reliever and fever reducer medication), and staff placed lukewarm clothes on his face and neck during breathing treatment to help lower his temperature. On 06/21/25 at 05:21 AM the Nurse's Notes documented emergency medical personnel transferred the resident to the hospital for bilateral lower lung quadrant crackles and wheezing in the bilateral upper lung quadrant. The notes documented staff administered Tylenol and a breathing treatment at 04:31 AM, and the temperature rose to 100.4 degrees at 05:05 AM. The notes documented the resident's color was ash, and R8 was very anxious and had visible berating concerns. On 06/21/25 at 10:04 AM the Nurse's Notes documented the resident was admitted to the hospital for bilateral pneumonia (a lung infection that inflames the air sacks (alveoli), causing them to fill with fluid or pus, making it hard to breathe). On 06/22/25 at 12:00 PM the Nurse's Notes documented the resident returned to the facility. R8's clinical record lacked a bed-hold policy. On 12/03/25 at 08:15 AM, Administrative Staff A verified the facility lacked evidence a signed bed hold policy was provided or signed by the resident's representative when R8 was transferred and admitted to the hospital on [DATE]. The facility's Bed Hold policy, dated 10/04/25, documented before the facility transfers a resident to a hospital or therapeutic leave, the facility would provide written information to the resident and/or resident representative that specifies: the duration of the state bed-hold policy during which the resident is permitted to return and resume residency in the facility; the reserve bed payment policy in the state plan; the facility's policies regarding bed-hold period, which are consistent with the law permitting the resident to return. The facility would allow the resident whose hospitalization or therapeutic leave exceeds the bed-hold policy under the state plan to return to the facility to the resident's previous room if available or immediately upon the first availability of a semi-private room if the resident requires the services provided by the facility and is eligible for Medicare Skilled Nursing Facility (SNF) services or Medicaid nursing facility services or pays privately for the services. Prior to transferring a resident to a hospital or allowing a resident to go on therapeutic leave, the facility nursing staff would provide written information to the resident and/or representative and family that specified: The duration of the bed hold policy under the State law and regulation, during which the resident is permitted to return and resume residence in the facility. The facility's policies regarding bed-hold periods. Signature proof of receipt of bed-hold policy. If the resident is transferred on an emergency basis, facility staff would provide the bed-hold policy to the resident/representative at the first opportunity, either in person by the facility at the hospital or other healthcare facility, or by registered mail, return receipt requested. If the signature is not returned to the facility within three calendar days, facility staff would call the resident /representative for phone confirmation of receipt and a reminder to return the form to the facility at the first possible opportunity, and phone confirmation of the receipt would be documented in the resident's clinical record. - The Electronic Medical Record (EMR) documented R37 was admitted to the facility on [DATE] with diagnoses of fracture of an unspecified part of the neck of the left femur (broken thigh bone), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and hypertension (high blood pressure). The admission Five-Day Minimum Data Set (MDS) dated [DATE] documented R37 had severely impaired cognition. R37 required substantial staff assistance with toileting hygiene, dressing, transfers, and partial staff assistance with personal hygiene and ambulation. R37's 08/04/25 Care Plan documented the following interventions: 08/06/25 – R37 wished to return home with his wife. Encourage R37 to discuss feelings and concerns with impending discharge, and monitor for and address episodes of anxiety, fear, and distress. Evaluate and discuss with the resident, family, and caregivers the prognosis for independent or assisted living. Evaluate the resident's motivation to return to the community. Staff would make arrangements with the required community resources to support independence post-discharge with a home health service. Prepare and give the resident's daughter the contact numbers for all community referrals. The Nurse's Note dated 09/12/25 at 10:08 AM documented R37 was discharged to home with his daughter. R37's medication list was reviewed with his daughter; no medications were sent home, and they would be returned to the pharmacy. Review of R37's EMR lacked evidence of a completed discharge summary, which included a recapitulation of his stay. On 12/02/25 at 01:30 PM, Administrative Staff A stated the Director of Nursing would have completed the recapitulation but was unable to find one. The facility's Admission, Transfer and Discharge Policy, dated 09/24/25, stated the facility staff would document in the clinical record the reason for the discharge, treatments that were provided, diet, medication orders, and diagnoses. Staff would document a summary of the care and services that were provided, and the referrals given.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to complete an investigation, including root cause analysis for one resident who had falls, Resident (R) 19.Findings included:- The Electronic Medical Record (EMR) for R19 documented diagnoses of hypertension (high blood pressure), transient ischemic attack (TIA- a temporary episode of inadequate blood supply to the brain), and chronic kidney disease (a long-term condition where your kidneys become damaged and can't filter waste and extra fluid from the blood).The Annal Minimum Data Set (MDS) dated [DATE] documented R19 had intact cognition. R19 was dependent upon staff for toileting hygiene, showers, and lower-body dressing. R19 required substantial staff assistance for oral hygiene, upper body dressing, personal hygiene, mobility, and transfers. R19 had upper functional impairment on both sides and had one fall with injury.R19's Quarterly MDS dated 09/10/25 documented R19 had severely impaired cognition. R19 required substantial staff assistance for showers, dressing, personal hygiene, mobility, transfers, and partial staff assistance for ambulation. R19 had upper functional impairment on both sides and had no falls.The Fall Risk Assessment dated 03/23/25, 06/18/25, and 09/08/25 documented R19 was a high risk for falls.R19's 09/04/25 Care Plan included the following interventions:05/17/24 - Use a gait belt with all transfers.09/15/24 - Ensure R19 had socks and shoes on with transfers and ambulation during the day.11/30/24 - Use a wheelchair instead of ambulating when weak.06/13/25 - Reeducate Licensed Nurse (LN) and Activity Director (AD) on how to load R19 into the facility van and to have foot pedals on her wheelchair.The Nurse's Note dated 06/13/25 at 03:57 PM (late entry) documented while leaving the museum, LN I and Activity Z loaded R19 into the wheelchair van, pulled her up the ramp, which had the resident tilt forward. R19 slowly slipped forward out of the chair and slid to the ramp on her bottom. R19 denied pain anywhere and stated, I'm alright! The note further documented that the two staff lifted her back into her wheelchair and proceeded to lock her into place in the van. After returning to the facility, the LN assessed the resident and discovered two small skin tears on her left elbow and placed steri-strips (adhesive wound closures) over each skin tear. The skin tears were covered with a non-adherent dressing and wrapped with Kerlix (stretchy gauze bandage) to hold it in place.The EMR lacked documentation an investigation was completed for the 06/13/25 fall.On 12/02/25 at 09:50 AM, Certified Nurse Aide (CNA) N placed a gait belt around R19's waist. CNA N and CNA O assisted R19 to stand in front of her walker, and R19 walked to the bathroom.On 12/02/25 at 08:45 AM, CNA M stated R19 was a two-person assistance for transfers and ambulation. R19 had a recent fall, which scared her, and it made her feel more secure if staff walked with her.On 12/02/25 at 01:30 PM, Activity Z stated R19 did not have foot pedals on her wheelchair, and that made it more difficult to push her in her wheelchair because she had a habit of straightening out her legs when pushed. Activity Z further stated that she decided to go up the ramp backward, and when she started to pull R19 up the ramp, R19 started to slide out. Activity Z put her hand on R19's chest to try to hold her in the wheelchair, but she still slid out. Activity Z stated that it happened so fast that LN I did not get to her in time to stop the fall. Activity Z stated after the fall, she was reeducated on how to load residents into the facility van.On 12/03/25 at 09:30 AM, LN H stated R19 did not remember to use her call light and was a two-person assist with transfers. LN H further stated she has not had any recent falls.On 12/03/25 at 11:30 AM, Administrative Staff A verified that there was not a full investigation, including root cause analysis, on the fall, and R19 should have had foot pedals on her wheelchair.The facility's Abuse, Neglect, and Exploitation policy, dated 08/8/24, documented that the investigation was the process used to determine what happened. The designated facility personnel would begin the investigation immediately. A root cause investigation and analysis would be completed. The information gathered is given to the administration.

The facility had a census of 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with a rationale for Resident (R) 32's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. Findings included:- R32's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R32's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R32 had severely impaired cognition. The MDS recorded she required extensive assistance from staff with activities of daily living (ADL). The MDS documented R32 received an antianxiety medication during the observation period.R32's Care Plan dated 08/07/25 recorded R32 required one staff assistance with most ADL care. R32's care plan documented the resident had a mood problem related to depressive disorder and anxiety with physical and verbal aggression and resistance to cares. The care plan documented the resident received a mental health consult monthly and as needed, and staff would administer medications as ordered and document for side effects and effectiveness.R32's Physician's Order dated 03/25/25 directed the staff to administer Ativan (lorazepam- antianxiety) cream 1.0 milligram (mg)/per milliliter (ml), every six hours as needed for anxiety/aggression related to anxiety disorder. The order lacked a stop date.R32's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN Ativan (lorazepam).On 12/01/25 at 12:30 PM, R32 sat in a wheelchair in the Pod three hallway. Continued observation revealed the resident went to the partially opened equipment door, touched the door handle, then propelled down the hall to the East exit door. Continued observation revealed the resident went to the East exit door and tried to grab at the door frame and was unable to open the door, then turned around and started propelling back down the hall to Pod three.On 12/01/25 at 12:40 PM, Certified Medication Aide (CMA) S verified the resident had received Ativan cream to her wrist approximately 20 minutes ago and stated she had been agitated and staff were not able to be redirected her, so the nurse administered the Ativan cream to R38's wrist. CMA S verified the medication takes approximately one hour to kick in.On 12/03/25 at 08:15 AM, Administrative Staff A verified the resident received Ativan cream PRN, with a physician order date of 03/25/25. Administrative Staff A verified the facility failed to obtain the 14-days stop date or a reason for the continued use with the appropriate rationale.The Antipsychotic Medication Use policy, dated 09/26/25, recorded antipsychotic medication would be prescribed when indicated by assessment and medical necessity and after other non-pharmacological interventions or alternatives had been considered or used, and at the lowest effective therapeutic dose for the shortest effective duration. The policy stated each resident who had an order for an antipsychotic medication would be assessed and periodically reassessed during their stay to determine the effectiveness of the medication.

The facility had a census of 32. The sample included 12 residents. Based on record review, interview, and observation, the facility failed to provide care for Resident (R) 7 in a manner that protected and promoted their dignity. Findings included:- On 12/02/25 at 07:30 AM, observation revealed R7 sat in a chair at the dining room table. Licensed Nurse (LN) G obtained R7's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R7's left index finger. LN G then stated to the residents, Your blood sugar reading is 120. Continued observation revealed two residents were seated in the dining room awaiting breakfast to be served, while staff and other residents were in the hallways adjacent to the dining room.On 12/03/25 at 08:15 AM, Administrative Staff A stated staff should not check residents' blood sugar in a common area; staff should take the resident to their room or to a private area.The facility's Residents Dignity policy, dated 10/22/24, documented each resident had the right and would be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility without interference, coercion, discrimination, or reprisal. Residents' rights include but are not limited to privacy and confidentiality.

The facility identified a census of 35 residents, with three reviewed for elopement. Based on record review, observation, and interview, the facility failed to provide sufficient supervision for Resident (R) 1 to prevent R1 from exiting the building. This deficient practice placed R1 at risk for elopement, falls, and injury. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of nontraumatic brain dysfunction (brain damage that occurs form internal factors), dementia (progressive mental disorder characterized by failing memory, confusion), 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 psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception). The admission Minimum Data Set (MDS), dated 05/11/25, documented R1 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R1 required moderate staff assistance for bathing, upper body dressing, personal hygiene, transfer, bed mobility, and ambulation. The MDS documented R1 was dependent on staff for lower body dressing and donning/doffing footwear. The MDS documented R1 was independent with locomotion in his wheelchair. The MDS documented R1 had delusions. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/11/25, documented R1 was alert and oriented but had impaired decision-making skills and confusion. R1's Care Plan lacked any interventions for wandering/elopement prior to the incident. R1's care plan documented he required one staff assistance for most activities of daily living (ADLs) (05/12/25). The care plan directed staff R1 was a fall risk and required a chair and bed alarm to alert staff when R1 got up by himself (05/12/25). The care plan directed staff to call R1's wife when he hallucinated (05/12/25). The Health Status Note, dated 05/28/25, documented R1 sat in his wheelchair in the community room watching Maintenance Person U unwrap a new refrigerator. Maintenance Person U left the community room to go get a knife. When Maintenance Person U returned, he saw R1 outside in his wheelchair on the sidewalk by the generator. R1 left through the double door. As Maintenance Person U headed outside to bring R1 back in, he saw Licensed Nurse (LN) G, and they both went out to get R1 and assisted R1 back into the facility. R1 was asked where he was going, and he said, I was just looking around. A head-to-toe assessment was completed with no abnormal findings. R1's primary care physician and the responsible party were notified. A Wanderguard was applied to R1's wheelchair. The Notarized Witness Statement, dated 05/28/25, documented Maintenance Person U unpackaged some equipment which had just come in. The double doors to the community room were open. As Maintenance Person U worked on unpackaging the boxes, R1 came up behind and visited with Maintenance Person U as he worked. Maintenance Person U went back to his office to grab a knife to keep unpackaging boxes, and came right back. Maintenance Person U saw R1 was no longer by the equipment, and looked outside and saw R1 outside a set of unlocked doors in his wheelchair on the sidewalk. Maintenance Person U saw LN G in the main hallway and called for her to come help bring R1 back inside. LN G and Maintenance Person U brought R1 back into the facility. LN G's Notarized Witness Statement, dated 05/28/25, documented LN G was walking down the main hallway when Maintenance Person U caught her and asked if she could come with him as R1 got out. We arrived at the west exit doors just south of the double doors that lead to our facility. LN G stated she could see R1 in his wheelchair pedaling slowly along the sidewalk. R1 was looking all around and was calm. R1 was about sixty feet away from the building. R1 apparently exited the building through the west exit doors, which do not lock from the inside, only from the outside. LN G walked up behind R1 and asked R1 what he was doing and startling R1. LN G told R1 we needed to get him inside out of the rain. LN G pushed R1 to the west facility exit, and once inside R1 continued to pedal himself to his household. The Health Status Note, dated 05/31/25, documented R1 was found sitting outside in his wheelchair on the grass looking at the generator out the west door. R1's Wanderguard did not activate. R1 was assisted back into the building. A head-to-toe assessment was completed with no abnormalities noted. R1 stated he was trying to figure out what the generator was and was impressed with its size. R1's primary care physician and responsible party were notified. Certified Nurse's Aide (CNA) M's Notarized Witness Statement, dated 05/31/25, documented CNA M took out trash to the dumpster and saw R1 in his wheelchair on the grass between pod 3 and the building to the south. R1 stated he got out the southwest door of pod 3. The Facility Incident Report, dated 06/01/25, documented on 05/28/25, R1 was seen on camera exiting the building at 03:37:49 PM. R1 had sat in the hallway of the community room and watched Maintenance Person U open a new freezer and refrigerator. Maintenance Person U went to get a knife from his office. R1 then proceeded to exit the building. At 03:59:37 PM, Maintenance Person U and LN G exit the same door to get R1, and at 04:00:36 PM, LN G and R1 entered the west door of the facility. A head-to-toe assessment was done upon return to the facility, with no abnormalities noted. The outside temperature was 59 degrees, and it was sprinkling. Immediate intervention: a wanderguard was placed underneath R1's wheelchair. On 05/31/25 at 04:39 PM, CNA M went to take the trash out when she saw R1 sat in his wheelchair on the grass looking at the generator. Upon review of the camera footage, R1 kicked the west door open to exit the building at 04:23:31 PM. R1 and staff returned to the building at 04:46:05 PM. The outside temperature was 86 degrees and sunny. It was noted the wanderguard did not activate. A new wanderguard was placed an in working order. On 07/02/25 at 10:30 AM, observation revealed R1 self-propelled in his wheelchair around the household where he lived. A wanderguard was placed underneath R1's wheelchair. On 07/02/25 at 11:00 AM, observation revealed the door out of the community room led to a smooth, brand-new sidewalk with very nice grassy areas on each side. There were several air conditioning units in the grassy areas to the left side of the sidewalk, and then farther down was a very large generator (12 feet tall by 6 feet wide) for both the school and the facility. Out the west door was more sidewalk that led around the corner to the south (left) to the above area just described. In front of the west door was car parking on a gravel road with a baseball field that was fenced in behind the parking. To the north of the door (right) was more sidewalk leading to the north side of the building. The sidewalk had grassy areas on both sides and ran along the gravel parking area. On 07/02/25 at 11:30 AM, CNA M stated R1 waited until she was getting residents up for supper, and then he disappeared, and for whatever reason, she went to take the trash out the back (west) door and went around to the south side of the building and found R1. R1 had rolled his w/c into the grass and was watching the generator. On 07/02/25 at 12:30 PM, Administrative Nurse D stated R1 has been a farmer his whole life and just wanted to be outside. Administrative Nurse D stated R1 is a younger man who went in to have neck surgery, and the anesthesia messed with his head, and he has not been the same since. R1 is alert and oriented during the day, but as it gets closer to evening, his behavior worsens. After the initial exit, the new wanderguard was placed on R1, and they must not have programmed it wrong because initially it alarmed at the doors, but then when R1 went out the west door, it did not alarm. The video showed R1 kicking the door open and broke the door. Administrative Nurse D stated that all education on elopement and elopement drills on every shift had been completed. The facility's Elopement Policy, dated 08/23/24, documented the facility wished to ensure the safety of those residents who had been identified as being at risk for elopement. It is the policy of this facility to identify those residents at risk for elopement and take precautions to ensure their safety and well-being. Special secure living units are provided by the facility, and additional securing, including a Wanderguard door locking system, is provided.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the prevention of Legionella disease (a bacterium which can cause pneumonia in vulnerable populations) and failed to store Resident (R) 4's oxygen tubing in a manner to prevent infection. This placed the residents of the facility at risk for infections. Findings Included: - Upon request, the facility produced the information material for the water management process however was unable to provide evidence of implementation of the water management policy and procedure other than the log for hot water temperatures for resident rooms. On 01/04/23 at 09:04 AM, Administrative Staff A stated the maintenance staff person checked for waterborne infection potential. The facility's Water Management Policy, dated 01/05/24, stated the Director of Environmental Services was responsible for: Carrying out suitable and sufficient Legionella risk assessments. Description of building water systems. Identify areas where Legionella could grow and spread.Preparation of an action plan or written scheme for preventing or controlling the risk. Implementation, management, monitoring, and recording of precautions to include regular inspection, microbiological monitoring, temperature checks, and flushing where appropriate. Documentation of all monitoring. The scope of this policy includes hot and cold-water storage tanks, water heaters, pipes, valves and fittings, water filters, faucets, aerators, showerheads and hoses, humidifiers, ice machines, decorative fountains, and medical devices. The plan was to include: Building description of incoming cold water and distribution (including bathrooms, kitchen, all outside taps), hot water storage and distribution, fire control systems, and dead legs (unused water distribution point). On a monthly basis, the staff would monitor and log: The condition of cold-water storage or distribution, system water temperatures (cold and hot), water quality, and potential for exposure to droplets. The facility failed to thoroughly implement a water management program to test and manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia. - R4's Electronic Medical Record documented diagnoses of severe dementia (a progressive mental disorder characterized by failing memory, and confusion) and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS documented R4 required moderate to substantial staff assistance with all activities of daily living and received oxygen therapy. R4's COPD Care Plan, dated 11/30/23, directed staff to monitor breathing patterns and report abnormalities to the physician. The plan directed staff to provide oxygen therapy as ordered, initiated on 11/21/23. The Physician Order, dated 11/7/23, directed staff to provide oxygen via nasal cannula at 2-5 liters per minute (LPM) to maintain oxygen saturation at 92% or above. On 01/02/24 at 01:32 PM, observation revealed staff removed R4's nasal cannula, which was connected to the oxygen tank, and placed it in the wheelchair seat unbagged. Staff then placed the nasal cannula connected to the oxygen concentrator on the resident. On 01/03/24 at 07:50 AM, observation revealed R4 sat at the dining table and used a nasal cannula for oxygen from the concentrator. Staff draped the oxygen tank nasal cannula over the back of her wheelchair, unbagged. On 01/03/24 at 08:12 AM, observation revealed R4 sat at a dining table and her oxygen tubing and cannula connected to the oxygen tank had been draped over the back of her wheelchair in the hall. On 01/03/24 at 11:30 AM, observation revealed Certified Nurse Aide (CNA) M assisted R4 to a dining room chair, removed her oxygen cannula and placed it on the back of the wheelchair seat unbagged. CNA M wheeled R4's wheelchair to a commons area outside the dining room. On 01/04/24 at 11:00 AM, observation revealed R4 in a recliner in her room with her wheelchair in the hall and her oxygen cannula draped over the back of the wheelchair, unbagged. On 01/04/24 at 11:40 AM, Administrative Nurse E verified staff should place R4's oxygen nasal cannula in a bag when not in use. The facility's Oxygen Infection Control policy, dated 01/05/24, stated oxygen tubing would not be draped across furniture or equipment including but not limited to headboard or assistive devices. The policy directed staff to store all cannulas, nebulizer masks, and tubing in a labeled and dated bag. The facility failed to store R4's oxygen tubing in a sanitary manner, placing R4 at risk for infection.

The facility had a census of 32 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on following days. (Quarter 2: 02/24/24, 02/26/24, 03/18/24, 03/19/24 and 03/28/24) A review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 01/02/24 at 10:00 AM, observation revealed a registered nurse on duty in the facility. On 01/04/24 at 10:30 AM, Administrative Staff A verified the facility did not send in the correct data to CMS for payroll-based data. The facility's Registered Nurse policy dated 01/05/24 recorded the facility would employ the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility would designate an RN to serve as the Director of Nursing (DON) on a full-time basis. The DON may serve as a charge nurse only when the facility has an average daily of 60 or fewer residents. The facility would employ an RN at least 8 hours a day, 7 days a week, and the hours would be recorded and reported on a staffing sheet and would be reported on a Payroll Based Journal (PBJ) reporting system. Per the Facility Assessment, the facility may identify when the residents of the facility require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. The facility may choose a variety of hours of duty such as 8-hour or 12-hour shifts, but the facility would always ensure 8 consecutive hours of RN coverage every day, 7 days per week. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, for the 32 residents who resided in the facility. This placed the facility and residents at risk for inadequate nurse guidance and leadership. Findings included: - Review of the Registered Nursing Staffing Schedule for October, November, and December 2022, and January through December 2023, recorded the facility lacked a registered nurse on the following days: One day in October 2022 (10/29/22) Two days in November 2022 (11/05/22, and 11/19/22) One day in December 2022 (12/28/22) One day February 2023 (02/26/23) Six days March 2023 (03/01/23, 03/11/23, 03/12/23, 03/25/23, 03/26/23, 03/28/23) Six days April 2023 (04/08/23, 04/09/23, 04/15/23, 04/22/23, 04/23/23, 04/29/23) Seven days May 2023 (05/06/23, 05/07/23, 05/20/23, 05/21/23, 05/27/23, 05/28/23, 05/29/23) Seven days June 2023 (06/03/23, 06/04/23, 06/11/23, 06/17/23, 06/18/23, 06/24/23, 06/25/23) Six days July 2023 (07/01/23, 07/02/23, 07/04/23, 07/08/23, 07/15/23, 07/16/23) Three days August 2023 (08/06/23, 08/19/23, 08/20/23) Four days September 2023 (09/02/23, 09/03/23, 09/04/23, 09/16/23) Six days October 2023 (10/07/23, 10/08/23, 10/14/23, 10/15/23, 10/21/23, 10/22/23) Nine days November 2023 (11/04/23, 11/05/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/23/23, 11/25/23, 11/26/23) Eleven days December 2023 (12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/16/23, 12/17/23, 12/23/23. 12/24/23. 12/25/23, 12/30/23, 12/31/23) On 01/02/24 at 10:00 AM, observation revealed 32 residents resided in the facility. On 01/04/24 at 10:30 AM, Administrative Staff A verified the facility did not have a registered nurse in the building or working as a charge nurse for the required eight consecutive hours on the above-documented dates. The facility's Registered Nurse policy dated 01/05/24 recorded the facility would employ the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility would designate an RN to serve as the Director of Nursing (DON) on a full-time basis. The DON may serve as a charge nurse only when the facility has an average daily of 60 or fewer residents. The facility would employ an RN at least 8 hours a day, 7 days a week, and the hours would be recorded and reported on a staffing sheet and would be reported on a Payroll Based Journal (PBJ) reporting system. Per the Facility Assessment, the facility may identify when the residents of the facility require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. The facility may choose a variety of hours of duty such as 8-hour or 12-hour shifts, but the facility would always ensure 8 consecutive hours of RN coverage every day, 7 days per week. The facility failed to provide a registered charge nurse for the 32 residents who resided in the facility for at least eight consecutive hours a day, seven days a week, placing the facility and residents at risk for inadequate nurse guidance and leadership.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to dispose of expired medications appropriately. This deficient practice placed the residents at risk of receiving ineffective medication. Findings included: - On 01/02/24 at10:45 AM, observation in the facility's medication storage and preparation room revealed the following: One box of acetaminophen suppositories (pain reliever medication) with an expiration date of 09/2023. One bag of six acetaminophen suppositories with an expiration date of 04/2023. One box of 10 albuterol (medication which relaxes and opens the air passages to the lungs) 2.5 milligram (mg) inhaler solutions with an expiration date of 07/2023. On 01/02/24 at 10:45 AM, Licensed Nurse (LN) G verified the expired medications and stated staff should have disposed of them at the expiration date. The facility's Disposition of Unusable and Outdated Drugs policy, dated 01/05/24, stated all discontinued, outdated, or contaminated drugs would be returned to the provider pharmacy for proper disposal or destroyed onsite. Those drugs would be stored in an isolated area in the facility designated for the storage of unusable drugs. The policy stated all drug storage areas would be inspected for outdated drugs on a weekly basis by nursing and on a monthly basis by the contracted consulting pharmacist. The facility failed to dispose of expired medications appropriately, placing residents at risk of receiving ineffective medications.

The facility had a census of 32 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility's Consultant Pharmacist failed to notify the facility of the need to obtain an appropriate indication for the use of antipsychotic drugs (a class of medications used to treat major mental conditions which cause a break from reality) for Residents (R) 30 and R25. This deficient practice placed the residents at risk of receiving unnecessary antipsychotic drugs. Findings included: - R30's Electronic Medical Record documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental disorder characterized by apprehension, uncertainty and irrational fear), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and psychosis (any major mental disorder characterized by a gross impairment in reality perception). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R30 had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue), physical behaviors, and wandering. The MDS documented R30 was independent for eating, required maximum staff assistance for toileting, moderate assistance for mobility or transfers, and received antipsychotic medication. R30's Care Plan dated 11/30/23, documented the resident used psychotropic medications related to bipolar disorder, depressive disorder, and anxiety. The care plan directed staff to administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift (06/20/23). Consult with the pharmacist and physician to consider dosage reduction when clinically appropriate at least quarterly (06/20/23). Discuss with the physician and family the ongoing need for the use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy (06/20/23). Monitor/document/report any adverse reactions to medications (06/20/23). Monitor/record occurrence of target behavior symptoms wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, restlessness, and document per facility protocol (06/20/23). The Physician Order, dated 11/15/23, directed staff to administer risperidone (antipsychotic drug) 0.5 milligrams (mg), every day, for agitation related to psychosis. The Physician Order, dated 12/07/23, directed staff to administer risperidone 1 mg, for psychosis. The Medication Administration Record (MAR) included the target behavior for risperidone was combative behavior such as hitting and kicking. every day and night shift for behaviors, initiated 06/08/23. The Consultant Pharmacist Drug Regimen Reviews, dated 07/11/23, 08/08/23, 09/12/23, 10/10/23, 11/13/23, and 12/09/23, lacked the need for an approved indication for the use of risperidone. The Psychiatric Practitioner Note, dated 10/17/23, stated the resident's thought process was coherent, without delusions or hallucinations. Judgement and insight are poor. The Assessment/Plan for generalized anxiety disorder was to continue with the same medications and follow up in one month and listed diagnoses of recurrent major depressive disorder and dementia. The Psychiatric Practitioner Note, dated 11/14/23, stated the resident reported feeling anxious daily. She has been rude to staff and other patients and still talks about her husband coming back to get her. Her thought process is confused, without delusions or hallucinations. Will increase Risperidone to 0.5 mg in AM and 1 mg at bedtime since she is becoming aggressive with other residents. The Psychiatric Practitioner Note, dated 12/12/23, stated nursing reported the new timing of the Risperidone was not helping. The resident was feeling anxious daily, and rude to staff and others. Plan to increase buspirone (antianxiety drug). On 01/03/24 at 02:09 PM, observation revealed R30 sat quietly in a chair in the front lobby with her walker in front of her. Staff sat down by her, talked to her and R30 answered appropriately. On 01/08/24 at 01:30 PM, Administrative Nurse D verified the physician had not provided a rationale for the use of risperidone without an approved diagnosis and the consultant pharmacist had not requested an approved diagnosis during medication regimen reviews. The facility's Pharmacist Consultant policy dated 01/08/23 recorded the consultant pharmacist would review the resident's charts monthly incorporating federally mandated standards of care in addition to other applicable professional standards and document the review and findings in the resident's clinical record. Communicate potential or actual problems detected related to medication therapy orders to the responsible physician and Director of Nursing (DON). Review the resident Medication Administration Records (MAR) and physician orders monthly at the facility to ensure proper documentation of medication orders and administration of medications to the residents. Communicate to the responsible physician and the DON potential or actual problems detected and other findings related to medication therapy orders. Communicating recommendations for change in medication therapy and monitoring of medication therapy. Submit a written report of findings and recommendations resulting from the review of medication therapy as described above. Assist in the assessment and improvement of nursing staff medication administration through medication pass observance, as required by nursing and administration, and through medication record review. The facility's Consultant Pharmacist failed to notify the physician and the director of nursing of the need to obtain an appropriate indication for the use of antipsychotic drugs for R30, placing the resident at risk of receiving unnecessary antipsychotic drugs. 27168 - R25 's medical diagnoses include dementia (a progressive mental disorder characterized by failing memory, confusion with agitation including verbal and physical aggression, wandering, and hoarding), major depressive disorder (major mood disorder which causes persistent feelings of sadness,) and hypertension (HTN-elevated blood pressure.) R25's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R25 had impaired long and short-term memory and severe cognition impairment. The MDS recorded R25 was dependent and required one staff for most activities of daily living (ADLS.) The MDS recorded R25 received an antipsychotic medication. The Psychotropic Care Area Assessment (CAA), dated 05/24/23, recorded the resident was admitted to the facility on multiple psychotropic medications, was resistant to care, verbally and physically abusive at times with cares, restless and moved self around the facility in a wheelchair during the day and staff will obtain a behavioral health consult. R25's Care Plan, recorded R25 had a mood problem due to dementia and agitation, major depressive disorder, and anxiety disorder and staff would administer medication as the physician ordered. The resident would have behavioral health consults monthly and as needed. Staff will monitor the resident's mood to determine if the problems seem to be related to external causes, medications, or treatments. The Physician's Order, dated 05/15/23, directed the staff to administer Geodon (antipsychotic) 40 milligrams (mg), by mouth two times a day for a diagnosis of dementia with agitation. R25's monthly pharmacy reviews documented the following dates the pharmacist lacked identification of the inappropriate indication for the use of the Geodon: 06/05/23, 07/11/23, 09/08/23, 09/12/23, 10/10/23, 11/13/23, and 12/09/23. On 01/03/24 at 08:10 AM, observation revealed R25 seated in a wheelchair at the dining room table. Continued observation revealed Certified Medication Aide R crushed R25s medication, mixed in applesauce then opened the Geodon 40 mg capsule, sprinkled the medication in the applesauce, then administered the resident his morning medications. On 01/4/24 at 10:30 AM, Administrative Nurse D verified the resident received Geodon, an antipsychotic medication with a diagnosis of dementia with agitation which was an inappropriate diagnosis for the medication. Administrative Nurse D verified the pharmacist reviewed the resident's medications monthly and had failed to recommend an appropriate indication for the use of the Geodon. The facility's Pharmacist Consultant policy dated 01/08/2023 recorded the consultant pharmacist would review the resident's charts monthly incorporating federally mandated standards of care in addition to other applicable professional standards and document the review and findings in the resident's clinical record. Communicate potential or actual problems detected related to medication therapy orders to the responsible physician and Director of Nursing (DON). Review the resident Medication Administration Records (MAR) and physician orders monthly at the facility to ensure proper documentation of medication orders and administration of medications to the residents. Communicate to the responsible physician and the DON potential or actual problems detected and other findings related to medication therapy orders. Communicating recommendations for change in medication therapy and monitoring of medication therapy. Submit a written report of findings and recommendations resulting from the review of medication therapy as described above. Assist in the assessment and improvement of nursing staff medication administration through medication pass observance, as required by nursing and administration, and through medication record review. The facility failed to ensure the Consultant Pharmacist reported the inappropriate indication for the continued use of R25's antipsychotic medication. This placed the resident at risk for inappropriate use of an antipsychotic medication with side effects.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to revise the care plan to include interventions related to delusions when the physician prescribed an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medication new to the resident. This deficient practice placed Resident (R) 31 at risk for inadequate response to her mental health needs due to uncommunicated care needs. Findings included: - R31's Electronic Medical Record documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, delusional disorder mental health condition in which a person can't tell what's real from what's imagined), and psychotic disorder (mental disorder characterized by a disconnection from reality) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R31 required supervision for eating, transfer, mobility, and partial to moderate staff assistance for toileting, and dressing. The MDS documented R31 received antipsychotic medication. R31's Care Plan, dated 11/30/23, stated R31 was resistive to care at times related to Alzheimer's dementia and directed staff to administer medications as ordered, monitor for side effects and effectiveness, and cue, reorient, and supervise the resident as needed. The care plan lacked interventions for delusions. The Physician Order, dated 10/17/23, directed staff to administer risperidone (an antipsychotic drug), 0.5 milligrams (mg) daily for psychotic disorder with delusions. On 11/14/23 the physician increased the dose to 0.5 mg twice daily. On 12/12/23 the physician changed the time to bedtime only. On 12/29/23 the physician increased the risperidone order to 0.5 mg twice daily. R31's Medication Administration Record (MAR) documented the target behavior for risperidone was delusional disorder and aggression. The Psychiatric Practitioner Note, dated 11/14/23, documented that R31 was delusional, and staff stated she was aggressive with other residents and staff. The practitioner stated R31's thought process was without hallucinations. The Psychiatric Practitioner Note, dated 12/12/23, documented staff reported the resident was sleepier and fell this morning. The practitioner noted no anxiety, depression, or hallucinations, however R31 was having delusions and mood was anxious. On 01/03/24 at 02:06 PM, observation revealed Certified Medication Aide (CMA) R administered risperidone medication to R31 in her room. At 02:15 PM, R31 independently ambulated to the nursing station. She was confused and had a little trouble with her speech. On 01/08/24 at 01:30 PM, Administrative Nurse D verified R31's care plan lacked interventions for delusion/psychotic behaviors. The facility's Care Plan Revision policy, dated 01/05/24, stated the care plan would be revised whenever the physician or consulting practitioner adds, removes, or amends any medication in the resident's regimen. The care plan would be revised to include specific, individualized targeted behaviors of the resident and specific individualized instructions to staff with interventions to meet the needs of the resident. The facility failed to revise R31's care plan to include interventions related to delusions when the physician prescribed an antipsychotic medication new to the resident, placing her at risk for inadequate response to her mental health needs due to uncommunicated care needs.

The facility had a census of 32 residents. The sample included 12 residents with one reviewed for hospitalization . Based on observation, interview, and record review the facility failed to notify the State of Kansas Long Term Care Ombudsman of facility-initiated discharges for Resident (R) 22, who was hospitalized twice in November 2023. This placed the resident at risk for decreased oversight and assistance with transfers and discharge. Findings included: - R22's Electronic Medical Record documented diagnoses of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), encephalopathy (a broad term for any brain disease that alters brain function or structure), and respiratory failure. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R22 was dependent on staff for most activities of daily living, had a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag), and received antibiotic medication. R22's census record documented he was discharged from 11/03/23 to 11/08/23 and again from 11/30/23 to 12/05/23. On 01/03/24 at 09:00 AM, observation revealed R22 sat in a wheelchair in the front lobby, with a catheter collection bag in a privacy bag under the wheelchair. On 01/03/24 at 03:00 PM, Administrative Staff A verified the facility had not notified the Ombudsman of the resident's discharges to the hospital twice in November 2023. The facility's Admission, Transfer and Discharge policy, dated 01/05/24, stated the staff would notify the State Ombudsman of any facility-initiated discharges. The facility failed to notify the State of Kansas Long Term Care Ombudsman of the discharge from the facility of R22, who was hospitalized twice in November 2023. This placed the resident at risk for decreased oversight and assistance with transfers and discharge.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure Resident (R)25, reviewed during the medication administration pass, remained free of medication errors This placed the resident at risk for adverse reactions from the medication and resulted in a facility medication error rate of 5.13 percent (%). Findings included: - R25's medical diagnoses include dementia (a progressive mental disorder characterized by failing memory, confusion with agitation including verbal and physical aggression, wandering, and hoarding), major depressive disorder (major mood disorder which causes persistent feelings of sadness,) and hypertension (HTN-elevated blood pressure.) The Physician order, dated 05/15/23 instructed staff to administer potassium chloride (potassium supplement) extended release (ER), 20 milliequivalents (mEq) 1 tablet a day for hypertension, and Pristiq (antidepressant) oral tablet, ER 50 milligrams (mg), 1 tablet a day for major depressive disorder. On 01/03/24 at 08:10 AM, observation revealed Certified Medication Aide (CMA) R crushed R25's pills, including the potassium chloride ER, and the desvenlafaxine (Pristiq) ER (extended release), and mixed the medication with applesauce. CMA R administered one spoonful of the medication and the resident ingested all the medications. On 01/03/24 at 09:10 AM, CMA R revealed R25 liked to take his medications with applesauce, and the staff crushed them, so he was able to take them more easily. On 01/03/24 at 10:30 AM, Administrative Nurse D verified the extended-release medication should not be crushed; it should be administered whole due to the extended release of the medication over time. Administrative Nurse D stated she would see if she could get the medications in another form except for pills. The facility's Medication Administration policy, dated 01/05/2024, recorded all medications would be administered to every resident as ordered by the physician in a safe and sanitary manner. Each resident's medication regimen would be free from unnecessary drugs, defined as: in excessive dose, including duplicate therapy; or for excessive duration; or without adequate, recommended monitoring; or without adequate indications for use; or in the presence of adverse consequences which indicate the dose should be reduced discontinued; or any combination of the above reasons. The facility would use the interdisciplinary process that includes the prescribing physician, consultant pharmacist, clinical nursing staff, therapy staff, and resident or the resident's decision-maker to monitor the resident's medication, including psychoactive and psychotropic medications. Psychotropic medications are prescribed when indicated by assessment and medically necessary. After other pharmacologic interventions or alternatives have been considered or used. At the lowest effective therapeutic dose and for the lowest effective duration. The interdisciplinary team monitors the use of each medication monthly through the Quality Assurance Performance Improvement (QAPI) Process. A diagnosis, condition, or indication for use exists for each medication ordered. The contracted consulting pharmacist would review the appropriateness of all medications to be administered at the facility monthly. Adhere to the manufacturer's recommendations for the route of administration unless the physician order specifically states an alternate and appropriate route of administration. The consulting pharmacist would review each resident's medication regimen monthly and would communicate with the physician, prescriber, and those involved in the resident's care the findings, conclusion, and recommendations that result from monitoring the medication regimen. Clinical staff would monitor each resident's response to medications by accounting for actual or potential adverse drug reactions, events, significant change, and medication errors through the appropriate specific policies and procedures. The facility failed to ensure staff did not crush the extended-release medication. This practice placed R25 at risk for adverse reactions from the medication and created a facility medication error rate greater than five percent.

The facility had a census of 32 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to obtain an appropriate indication, or the required physician documentation, for the use of antipsychotic drugs (a class of medications used to treat major mental conditions that cause a break from reality) for Residents (R) 30, R31, and R25. This deficient practice placed the residents at risk of receiving unnecessary antipsychotic drugs. Findings included: - R30's Electronic Medical Record documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental disorder characterized by apprehension, uncertainty and irrational fear), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and psychosis (any major mental disorder characterized by a gross impairment in reality perception). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R30 had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue), physical behaviors, and wandering. The MDS documented R30 was independent for eating, required maximum staff assistance for toileting, moderate assistance for mobility or transfers, and received antipsychotic medication. R30's Care Plan dated 11/30/23, documented the resident used psychotropic medications related to bipolar disorder, depressive disorder, and anxiety. The care plan directed staff to administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift (06/20/23). Consult with the pharmacist and physician to consider dosage reduction when clinically appropriate at least quarterly (06/20/23). Discuss with the physician and family the ongoing need for the use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy (06/20/23). Monitor/document/report any adverse reactions to medications (06/20/23). Monitor/record occurrence of target behavior symptoms wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, restlessness, and document per facility protocol (06/20/23). The Physician Order, dated 11/15/23, directed staff to administer risperidone (antipsychotic drug) 0.5 milligrams (mg), every day, for agitation related to psychosis. The Physician Order, dated 12/07/23, directed staff to administer risperidone 1 mg, for psychosis. R30's Medication Administration Record (MAR) included the target behavior for risperidone was combative behavior such as hitting and kicking. every day and night shift for behaviors, initiated 06/08/23. The Consultant Pharmacist Drug Regimen Review, dated 10/10/23, recommended a review of risperidone 1 mg at bedtime. The physician ordered no changes and wrote benefit outweighs risk without explaining why. The Psychiatric Practitioner Note, dated 10/17/23, stated the resident's thought process was coherent, without delusions or hallucinations. Judgement and insight are poor. The Assessment/Plan for generalized anxiety disorder was to continue with the same medications and follow up in one month and listed diagnoses of recurrent major depressive disorder and dementia. The Psychiatric Practitioner Note, dated 11/14/23, stated the resident reported feeling anxious daily. She has been rude to staff and other patients and still talks about her husband coming back to get her. Her thought process is confused, without delusions or hallucinations. Will increase Risperidone to 0.5 mg in AM and 1 mg at bedtime since she is becoming aggressive with other residents. The Psychiatric Practitioner Note, dated 12/12/23, stated nursing reported the new timing of the risperidone was not helping. The resident was feeling anxious daily, and rude to staff and others. Plan to increase buspirone (antianxiety drug). On 01/03/24 at 02:09 PM, observation revealed R30 sat quietly in a chair in the front lobby with her walker in front of her. Staff sat down by her, talked to her and R30 answered appropriately. On 01/08/24 at 01:30 PM, Administrative Nurse D stated R30 was admitted to the facility from a psychiatric hospital on 06/08/23 with orders for risperidone two mg at bedtime. Since then, risperidone has decreased, and the time of administration changed. She verified the physician had not provided a rationale for the use of risperidone without an approved diagnosis. The facility's Psychotropic Medication Use policy, dated 01/05/24, documented the regulation stated that residents who have not previously used antipsychotic drugs should not be given those drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The policy stated alternative non-pharmacological interventions for psychiatric disorders and problem behaviors related to dementia would be attempted prior to and during the administration of antipsychotic medications. The physician's order for a psychotropic drug would include a qualifying diagnosis for the drug and a list of specific behaviors for the staff to monitor. The psychiatric physician must certify that a psychotropic medication was necessary to treat a specific condition/behavior. For any resident receiving an antipsychotic medication a gradual dose reduction may be contraindicated if the physician had documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability. The facility failed to ensure an appropriate indication, or the required physician documentation was obtained for the use of antipsychotic drugs for R30. This placed the resident at risk of receiving unnecessary antipsychotic drugs. - R31's Electronic Medical Record documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, delusional disorder (mental health condition in which a person can't tell what's real from what's imagined), and psychotic disorder (mental disorder characterized by a disconnection from reality) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R31 required supervision for eating, transfer, mobility, and partial to moderate staff assistance for toileting, and dressing. The MDS documented that R31 received antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality). R31's Care Plan, dated 11/30/23, stated R31 was resistive to care at times related to Alzheimer's dementia and directed staff to administer medications as ordered, monitor for side effects and effectiveness, and cue, reorient, and supervise the resident as needed. The care plan lacked interventions for delusions. The Physician Order, dated 10/17/23, directed staff to administer risperidone (an antipsychotic drug), 0.5 milligrams (mg) daily for psychotic disorder with delusions. On 11/14/23 the physician increased the dose to 0.5 mg twice daily. On 12/12/23 the physician changed the time to bedtime only. On 12/29/23 the physician increased the risperidone order to 0.5 mg twice daily. R31's Medication Administration Record (MAR) documented the target behavior for risperidone was delusional disorder and aggression. The Consultant Pharmacist Review, dated 11/13/23, recommended a review of the risperidone diagnosis and a risk versus benefit rationale. On 11/15/23 the physician stated the diagnosis was a delusional disorder. On 12/07/23 the physician wrote benefit outweighs risk without further explanation and stated the diagnosis was psychosis/delusions. The Psychiatric Practitioner Note, dated 11/14/23, documented that R31 was delusional, and staff stated she was aggressive with other residents and staff. The practitioner stated R31's thought process was without hallucinations. The Psychiatric Practitioner Note, dated 12/12/23, documented staff reported the resident was sleepier and fell that morning. The practitioner noted no anxiety, depression, or hallucinations, however R31 was having delusions and mood was anxious. On 01/03/24 at 02:06 PM, observation revealed Certified Medication Aide (CMA) R administered risperidone medication to R31 in her room. At 02:15 PM, R31 independently ambulated to the nursing station. She was confused and had a little trouble with her speech. On 01/08/24 at 01:30 PM, Administrative Nurse D verified R31's care plan lacked interventions for delusion/psychotic behaviors and stated the care plan had interventions for when the resident was resistant to care. She stated the physician's response on 12/07/23 was the risk versus benefit statement. The facility's Psychotropic Medication Use policy, dated 01/05/24, documented regulation stated that residents who have not previously used antipsychotic drugs should not be given those drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The policy stated alternative non-pharmacological interventions for psychiatric disorders and problem behaviors related to dementia would be attempted prior to and during the administration of antipsychotic medications. The physician's order for a psychotropic drug would include a qualifying diagnosis for the drug and a list of specific behaviors for the staff to monitor. The psychiatric physician must certify that a psychotropic medication was necessary to treat a specific condition/behavior. For any resident receiving an antipsychotic medication a gradual dose reduction may be contraindicated if the physician had documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability. The facility failed to obtain an appropriate indication, or the required physician documentation, for the use of antipsychotic drugs for R31. This placed the resident at risk of receiving unnecessary antipsychotic drugs. 27168 - R25's Electronic Medical Record (EMR) recorded medical diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion with agitation including verbal and physical aggression, wandering, and hoarding), major depressive disorder (major mood disorder which causes persistent feelings of sadness,) and hypertension (HTN-elevated blood pressure.) R25's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R25 had impaired long and short-term memory and severe cognition impairment. The MDS recorded R25 was dependent and required one staff for most activities of daily living (ADLS.) The MDS recorded R25 received an antipsychotic medication. The Psychotropic Care Area Assessment (CAA), dated 05/24/23, recorded the resident was admitted to the facility on multiple psychotropic medications, was resistant to care, verbally and physically abusive at times with cares, restless and moved self around the facility in a wheelchair during the day and staff will obtain a behavioral health consult. R25's Care Plan, recorded that R25 had a mood problem due to dementia and agitation, major depressive disorder, and anxiety disorder and staff would administer medication as the physician ordered. The resident would have behavioral health consults monthly and as needed. Staff will monitor the resident's mood to determine if the problems seem to be related to external causes, medications, or treatments. The Physician's Order, dated 05/15/23, directed the staff to administer Geodon (antipsychotic) 40 milligrams (mg), by mouth two times a day for a diagnosis of dementia with agitation. R25's EMR lacked a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use. On 01/03/24 at 08:10 AM, observation revealed R25 seated in a wheelchair at the dining room table. Continued observation revealed Certified Medication Aide R crushed R25s medication, mixed in applesauce then opened the Geodon 40 mg capsule and sprinkled the medication in the applesauce, then administered the resident his morning medications. On 01/4/24 at 10:30 AM, Administrative Nurse D verified the resident received Geodon, an antipsychotic medication with a diagnosis of dementia with agitation and that was an inappropriate diagnosis for the medication. Administrative Nurse D verified the pharmacist reviewed the resident medications monthly and had failed to recommend an appropriate diagnosis for the use of the Geodon. Psychotropic Medication Use, dated 01/05/24 documented that Psycho-pharmacological medications are drugs that affect brain activities associated with mental processes and behavior. These drugs are also called psychoactive or psychotherapeutic medications, Psychotropic medications are divided into four broad categories: antipsychotic, anti-depressant, anti-anxiety, and hypnotic medications. CMS regulations state that each resident's drug regimen must be free from unnecessary drugs and define what is considered an unnecessary drug. An unnecessary drug is any drug used; in excessive dose, for excessive duration without adequate indication, without adequate monitoring or without adequate indication for its use; or in the presence of adverse consequences, which indicates the dosage should be reduced or discontinued. The resident's need for psychotropic medication would be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of the as-needed orders for psychotropic drugs and manage behaviors. The facility failed to ensure R25 did not receive antipsychotic medication without an appropriate diagnosis or required documentation for its use, placing R25 at risk for adverse side effects related to the use of Geodon.

The facility had a census of 32 residents. The sample included 10 residents. Based on observation, interview, and record review the facility failed to implement appropriate infection control measures to prevent potential spread of COVID-19 (a mild to severe respiratory illness caused by a new strain of coronavirus) after 10 residents, Resident (R) 1, R2, R3, R4, R5, R6, R7, R8, R9, R10, displayed COVID-19 symptoms as directed by Centers for Medicare and Medicaid Services (CMS) and Center for Disease Control (CDC), placing the 32 residents in the facility in immediate jeopardy. Findings included: - The facility's undated Novel Coronavirus (2019-nCoV) (COVID-19) policy directed staff, if multiple residents present with suspected COVID-19, to initiate the emergency plan to cohort infected residents or isolate all infected residents in a separate area/unit of the facility, ensure no traveling between or through the designated infected area, no mingling of food service or laundry with the infected area, and consistent staff will be provided to the designated area for all shifts. The suspected COVID-19 resident room doors will be closed at all times and staff will follow full Personal Protection Equipment (PPE) precautions for airborne agents at all times including but not limited to: gown, gloves, eye protection, face covering, surgical mask, and at least a fit tested N95 mask when providing aerosol generating treatments. On 07/01/20 at 08:00 AM, upon entrance to the facility, Administrative Staff B reported 10 residents were currently in isolation on the South Hall and were tested Monday, 06/29/20 for suspected or potential COVID-19 infection. R1's Nurse's Note, dated 06/20/20 at 01:55 AM, documented the resident used the call light and complained of a tight chest and cough which kept her awake. Temperature 99.8 degrees Fahrenheit (F), oxygen 96% (normal 95-100%), and lungs clear. R1's Nurse's Note, dated 06/23/20 at 01:52 PM, documented staff notified the resident's physician who had no new orders. R1's Nurse's Note, dated 06/28/20 at 02:35 PM, documented the resident complained of body aches, loose stools, fatigue, decreased appetite and upset stomach. Staff placed the resident on contact precaution, and notified the resident's physician and family. R2's Nurse's Note, dated 06/28/20 at 02:19 PM, documented the resident complained of a sore throat, cough, fatigue, and upset stomach. The nurse documented the resident had low grade temperatures and placed R2 on contact isolation. Review of R3's Vital Sign Records from 06/28/20-06/29/20 documented the following temperatures: 06/28/20 103.8 F 06/23/20 100.1 F 06/29/20 100.0 F R3's Nurse's Note, dated 06/28/20 at 08:46 AM, documented nursing staff sent a fax to the resident's physician regarding fevers over the last two days with complaints of back pain, amber colored urine, fatigue, and general malaise. Review of R4's Vital Sign Records from 06/26/20-06/29/20 documented the following temperatures: 06/26/20 100.7 F 06/27/20 101.1 F 06/29/20 100.6 F The June 2020 Monthly Infection Control Log documented R4 began showing an elevated temperature, pain, and loose stools on 06/26/20. Review of R5's Vital Signs Records from 06/20/20-06/30/20 documented the following temperatures: 06/20/20 100.4 F 06/29/20 102.0 F 06/20/20 101.7 F The June 2020 Monthly Infection Control Log documented R5 began showing an elevated temperature, sore throat, and loose stools on 06/28/20. Review of R6's Vital Signs Records from 06/25/20-06/28/20 documented the following temperatures: 06/25/20 100.9 F 06/26/20 101.2 F 07/27/20 100.8 F, 100.3 F 06/28/20 101 F The June 2020 Monthly Infection Control Log documented R6 began showing a fever, fatigue, and decreased appetite on 06/25/20. The June 2020 Monthly Infection Control Log documented R7 began showing a low grade fever on 06/20/20, and cough and sore throat on 06/28/20. The June 2020 Monthly Infection Control Log documented R8 began showing an elevated temperature on 06/20/20, and sore throat and fatigue on 06/25/20. The June 2020 Monthly Infection Control Log documented R9 began showing signs of [MEDICAL CONDITION] on 06/29/20. Review of R10's Vital Signs Records for 06/29/20 documented the following temperatures: 06/29 101.1 F, 101.2 F The June 2020 Monthly Infection Control Log documented R10 began showing a low grade fever, sore throat, and fatigue on 06/28/20. On 07/01/20 at 09:00 AM, observation of the COVID-19 unit revealed 11 rooms with unsealed plastic sheeting from floor to ceiling partway down the hall with a gap in the middle. The resident room doors in the isolated area were all open. Further observation revealed one isolation room located outside the plastic sheeting. On 07/01/20 at 09:00 AM, observation revealed Certified Medication Aide (CMA) R wore a cloth face mask, selected medications from the medication cart outside the COVID-19 unit, and entered the COVID-19 unit to administer medication. Observation revealed CMA R stopped outside the resident's room, removed her cloth mask, laid it on the isolation cart in the COVID-19 area, applied PPE from the cart and entered the resident's room. After administering medication, CMA R removed isolation PPE, left the isolation room, and applied the cloth face mask she had left on the isolation cart. CMA R then walked out of the COVID-19 area, through the plastic sheeting, to the medication cart and applied hand sanitizer prior to opening the medication cart. On 07/01/20 at 09:00 AM, observation revealed Housekeeping Staff (HS) U worked in the COVID-19 unit and then came through the plastic sheeting with a face mask in place, set her handheld cleaning bucket on the floor, and went to the clean linen cart. HS U removed and held clean linen supplies under her arm, picked up the cleaning supplies off the floor, and re-entered the COVID-19 unit. Continued observation revealed HS U set the linens on the isolation cart outside a resident room, gowned, gloved and entered the resident room. On 07/01/20 at 11:12 AM, observation revealed Administrative Nurse D and Certified Nurse Aide (CNA) M placed tape at the bottom of the plastic separation sheet on South Hall, COVID-19 unit then applied isolation gowns, gloves, goggles, cloth face masks, and wiped down surfaces of isolation carts in the hall. CMA R exited an isolation room wearing a cloth mask and Administrative Nurse D educated CMA R what PPE to use and when. Before exiting the COVID-19 unit, CMA R put on an isolation gown, kept on the same cloth mask, applied hand sanitizer, and went to North Hall. On 07/01/20 at 01:00 PM, observation revealed the plastic sheeting taped shut and three staff inside the unit wore N95 face masks, eye protection, and gowns. On 07/01/20 at 05:20 PM, observation revealed a screening station at the far end of the COVID-19 unit beside the exit door and staff with gowns, gloves, and goggles or face mask in place. The fire doors at the front of the South Hall were closed. At 05:25 PM, staff dedicated one medication cart for the COVID-19 unit. On 07/01/20 at 05:30 PM, observation revealed facility staff waiting outside the building, standing six feet apart, waiting to be tested by the county health department, and received COVID-19 education at that time. On 07/01/20 at 08:35 AM, Administrative Staff A stated a few residents had COVID-19 symptoms on Friday, 06/26/20, more on Sunday, 06/28/20, and 10 residents and two staff displayed COVID-19 symptoms on Monday, 06/29/20. On 06/29/20, staff notified the local health department and requested COVID-19 testing for the 10 residents. Administrative Staff A verified staff should have placed residents with symptoms in isolation immediately on 06/26/20, when one resident had a temperature of 100.7. On 07/01/20 at 09:00 AM, CMA R stated the residents in the COVID-19 unit had been tested for COVID-19, but the results had not come back yet, so the residents were not actually in isolation until the COVID-19 tests came back positive. On 07/01/20 at 11:05 AM, Administrative Nurse D verified earlier that morning the facility received positive COVID-19 test results for four of five residents tested . Administrative Nurse D stated on Friday, 06/26/20, two residents complained of sore throat, sinus pressure, body aches, and one resident had an upset stomach, so staff reported the symptoms to the residents' physicians. Administrative Nurse D verified staff should have placed those residents in respiratory isolation on 06/26/20. On 07/01/20 at 11:36 AM, Administrative Staff A stated the facility's policy for suspected COVID-19 symptoms directed staff to isolate and implement contact precautions, which staff did on Sunday, 06/28/20 after contacting the county health department. Administrative Staff A stated staff contacted the facility's medical director and were informed loose stools were a possible symptom of COVID-19. Administrative Staff A stated staff followed county health department directives on 06/28/2020, and placed all febrile residents in contact isolation. Administrative Staff A verified staff did not place the plastic sheeting barrier until Monday, 06/29/20. Administrative Staff A stated the county health department arrived 06/29/2020 at 02:00 PM and performed COVID-19 testing on the 10 isolated residents. On 07/01/20 at 12:05 PM, Licensed Nurse (LN) G stated the protocol for suspected COVID-19 was to isolate the resident, wear gowns and whatever masks we have available. LN G stated on Friday, 06/26/20 she worked the night shift and had some concerns regarding resident temperatures higher than normal range, but did not suspect COVID-19. LN G stated, it was so hot that night and the resident's temperatures were not that high anyway. LN G stated one resident complained of a cough and sore throat, but she is one of those residents who always cries wolf anyway. On 07/01/20 at 05:36 PM, Administrative Staff A stated she notified all appropriate health agencies including Kansas Department for Health and Environment (KDHE), CDC, CMS, and the local health department of the positive COVID-19 cases. Administrative Staff A stated the facility would immediately enact COVID-19 isolation policies with any other residents with signs or symptoms related to COVID-19. A symptomatic resident would be relocated to the COVID-19 unit via the closest exit and the outside COVID-19 unit door. Administrative Staff A stated dedicated staff would be used for the COVID-19 unit and would not be allowed to come into the rest of the facility. Administrative Staff A stated staff education began during the COVID-19 testing outside today. On 07/01/20 at 0:6:00 PM, Housekeeping Staff V stated staff placed signs indicating no visitors- isolation at the entrance to the COVID-19 unit, exit door locked, and staff dedicated to that area were let in and screened at the screening station by that exit. On 07/02/20 at 09:25 AM, Physician GG stated she expected the facility to immediately implement all COVID-19 infection prevention practices on Monday, 06/29/20 when staff requested COVID-19 testing on 10 residents of the facility. The facility failed to immediately implement COVID-19 protocols for 10 residents suspected of having COVID-19, tested [DATE], and not placed in airborne precautions until 07/01/20. This deficient practice placed all 32 residents of the facility in immediate jeopardy to contract a serious infection. The facility presented an acceptable plan for removal of the immediate jeopardy on 07/01/20 at 07:35 PM, which included staff education for proper PPE, handwashing, and isolation protocol. Respiratory/droplet precaution signs were placed on resident doors and on entrance to the COVID-19 unit, with precautions taken for all residents on the isolation unit. Any resident displaying signs or symptoms of COVID-19 was placed in isolation immediately via the outside door. A dedicated medication cart, medical equipment, laundry barrel, and staff were provided for the COVID-19 isolation unit. Nursing staff were trained on proper cleaning techniques so they could clean the isolation unit if housekeeping unable to. All staff to enter and leave the COVID-19 unit by the south door (outside exit). The deficient practice remained at a scope and severity of F.

The facility had a census of 33 residents. The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview the facility failed to investigate allegations of abuse made by 2 of the 3 sampled residents and report the incidents to the state agency. Resident #1 and #2 stated the same nurse aide failed to provide assistance to use the toilet resulting in an incontinent episode for Resident #1 and a demeaning experience for Resident #2. The staff member continued working throughout the facility for approximately 4 weeks after the allegations were made known to administrative staff. This deficient practice placed all residents in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 4/7/15, indicated the resident had moderate cognitive impairment, no behaviors, required extensive assistance of 1 staff for (ADLs) Activities of Daily Living, and supervision at meals. The MDS indicated the resident's balance unsteady, but the resident could re-stabilize him/herself without assistance, and he/she had range of motion impairment on 1 side of the upper extremities. The 1/14/15 urinary incontinence (CAA ) care area assessment stated the resident had frequent urinary incontinence and required assistance to walk to the bathroom and for toileting needs. The 3/31/15 care plan stated the resident had bladder incontinence and required staff assistance to toilet. On 4/13/15 at 4:36 PM, observation revealed Nurse Aide D provided stand by assistance to transfer for Resident #1 and walked him/her to the bathroom. The aide applied a gait belt and assisted the resident to stand, then walk forward. The resident had a slow gait and balanced him/herself with staff assistance. On 4/13/15 at 2:21 PM, the resident stated he/she asked to use the bathroom a while back and turned on his/her light. Nurse Aide C entered the room, shut the light off then left the room. The resident stated he/she wanted to use the bathroom at the time, but Nurse Aide C did not help him/her. The resident stated this made him/her mad at the time because he/she soiled him/herself which caused him/her to be embarrassed. Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 2/17/15, indicated the resident cognitively intact, with no behaviors, and required extensive assistance of 1 staff for transfer and toileting. The MDS indicated the resident required supervision of 1 staff for hygiene and walking, was occasionally incontinent of urine, and had shortness of breath. The urinary incontinence CAA, dated 11/24/15, stated the resident had rare instances of urinary incontinence due to obesity and poor bladder control. The 2/24/15 care plan for Resident #2 stated the resident had limited ability to manage his/her own ADL cares, needed to wait for a nurse aide prior to standing, and used a cane/walker to assist with walking to and from the bathroom. The resident requested assistance of 1-2 staff for transfers to ensure his/her safety, had a urinary incontinence problem On 4/13/15 at 3:54 PM, observation revealed Nurse Aide E assisted the resident to transfer with stand-by assistance, from the bed to a standing position. The aide assisted the resident to swing his/her legs from the top of the bed to the floor as the resident used a trapeze to pivot his/her upper body to a sitting position. The resident stood without difficulty using a wheeled walker. He/she walked into the bathroom with stand-by assistance from Nurse Aide E with a steady gait. On 4/14/15 at 9:56 AM, Resident #2 stated Nurse Aide C told him/her that he/she had better not wet the bed, quit being lazy, and get up and go to the bathroom. The resident stated the nurse aide's actions hurt his/her feelings and stated he/she was upset for a long time about the incident. On 4/13/15, a review of the grievance log revealed entries on missing items: teeth, clothing, watches, etc., but lacked entries related to allegations of abuse/neglect. On 4/13/15 at 3:05 PM, Administrative Nurse B stated Nurse Aide C stated to him/her that 4 nurse aides planned to call the hotline number to report him/her for abuse/neglect and to give statements. Administrative Nurse B stated he/she obtained the staff names from Nurse Aide C and worked on an investigation for 2 weeks. Administrative Nurse B verified Nurse Aide C continued to work during the investigation. Administrative Nurse B stated the result of the investigation revealed the incident was not abuse/neglect and Nurse Aide C continued to work at the facility. On 4/14/15, a review of the facility investigation revealed the facility failed to obtain witness statements from the staff interviewed by Administrative Nurse B and failed to complete a thorough investigation of the allegations. On 4/14/15 at 5:15 PM, Administrative Nurse B verified the grievance log listed resident's reporting missing personal items, but lacked resident complaints related to other areas: mistreatment and/or inappropriate care. He/she stated during the staff interviews, the facility did not obtain signed witness statements regarding the incidents with Resident #1 and Resident #2. On 4/14/15 at 5:26 PM, Administrative Staff A verified Nurse Aide C continued working as a nurse aide during the investigation and acknowledged staff verbalized an allegation of abuse/neglect which the facility did not report to the state reporting agency. He/she verified the facility did not obtain signed witness statements as a part of the investigation. On 4/15/15 at 1:30 PM, Social Service Staff J stated Resident #1 reported he/she had been neglected two times by Nurse Aide C . Social Service Staff J verified he/she had notified Administrative Staff A and Administrative Nurse B of the allegation of neglect. The facility's undated Reporting Resident Abuse policy included: Protection - to protect our residents from any of the above abuses (verbal, physical, and mental), the following policies will be followed: *Ensure that all allegations of abuse, neglect, or exploitation are investigated and reported immediately to the administrator of the facility and to the KS Dept. of Health and Environment. *If an employee is suspected of abuse, suspension will occur until the investigation is completed. Investigation: *An investigation will be done immediately by the charge nurse, DON, and Administrator. *The Administrator or DON will notify the Kansas Department of Health and Environment. *All investigations of abuse should be done with care and good judgment, and to have reasonable cause to believe there has been abuse. The facility did not follow their policy regarding abuse. The facility failed to report failed to report the incidents to the state agency as required, failed to investigate Resident #1 and Resident #2 ' s allegations of abuse, and protect all residents during the investigation. The failure placed all residents in immediate jeopardy. The facility abated the immediate jeopardy, on 4/20/15, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines, suspended Nurse Aide C, educated residents without significant cognitive impairment on abuse/neglect and how to report, and designated social services to routinely interview residents to determine if there are any potential abuse or neglect issues. The deficient practice remains at a scope and severity of an F.

The facility had a census of 33 residents. The sample included 3 residents. Based on observation, interview, and record review the facility failed to ensure all residents remained free from potential verbal abuse and neglect after 2 of 3 sampled residents, voiced allegations of abuse . (#1 and #2) This practice palced these residents in immediate jeopardy as the facility did not protect these residents from further abuse. Findings included: - The 3/3/15 Physician order [REDACTED].#1 had [DIAGNOSES REDACTED]., essential hypertension (elevated blood pressure) and muscle weakness. The quarterly (MDS) Minimum Data Set assessment, dated 4/7/15, indicated the resident had moderate cognitive impairment, no behaviors, required extensive assistance of 1 staff for (ADLs) Activities of Daily Living, and supervision at meals. The MDS indicated the resident's balance unsteady, but the resident could restabilize him/herself without assistance, and he/she had range of motion impairment on 1 side of the upper extremities. The 1/14/15 ADL (CAA) Care Area Assessment stated the resident required assistance with transfers and walking, had poor balance, difficulty moving him/herself around the room, and used a wheelchair on admission. The 1/14/15 urinary incontinence CAA stated the resident had frequent urinary incontinence and required assistance to walk to the bathroom and for toileting needs. The 3/31/15 care plan stated the resident would improve his/her current ability to perform ADLs. The resident required the assistance of 1 staff for transfers and the majority of transfers only required stand by assistance. The bladder incontinence problem revealed the resident dribbled urine, required staff assistance to toilet, use of incontinence products upon the resident's request, and staff ensured an unobstructed path to the bathroom. On 4/13/15 at 4:36 PM, observation revealed Nurse Aide D provided stand by assistance to transfer and walk the resident to the bathroom. The aide applied a gait belt and assisted the resident to stand, then walk forward. The resident had a slow gait and balanced him/herself with staff assistance. On 4/13/15 at 2:21 PM, the resident stated he/she asked to use the bathroom a while back and turned on his/her light. The aide entered the room, shut the light off, then left the room. The resident stated he/she wanted to use the bathroom at the time, but the aide did not help him/her. The resident stated this made him/her mad at the time because he/she soiled him/ herself which caused him/her to be embarrassed. The resident added the aide comes to the door and glares at him/her as if he/she was a "criminal", and that was not alright with him/her. The resident acknowledged he/she did not state to the aide what he/she needed because he/she felt like a criminal and didn't feel like he/she could say anything. On 4/13/15 at 3:05 PM, Administrative Nurse B stated Nurse Aide C stated to him/her that 4 nurse aides planned to call the hotline number to report him/her for abuse/neglect and to give statements. Administrative Nurse B stated he/she obtained the staff names from Nurse Aide C and worked on an investigation for 2 weeks. Administrative Nurse B stated Nurse Aide C continued to work during the investigation. Nurse B stated the result of the investigation revealed the incident was not abuse/neglect and Nurse Aide C continued to work at the facility. On 4/13/15 at 8:09 PM, Nurse Aide E stated the resident transfer required assistance of 1 staff and the resident had a stumbling type gait. The aide stated the resident confused at times, but knows what he/she is talking about, and at times he/she attempted to go to the bathroom on his/her own. Nurse Aide E stated the resident verbalized a complaint that a nurse aide on the night shift did not help him/her and he/she had an incontinence accident. Nurse Aide E stated the incident happened last month and the resident did not like the nurse aide because he/she said the nurse aide was rude and did not want to help him/her. On 4/13/15 at 8:27 PM, Nurse I stated a nurse aide reported Resident #1 voiced staff had not answered his/her call light timely. Nurse I stated he/she reviewed the call light log and found no lengthy call light response time frames. Nurse I stated he/she worked near the nursing desk and call light control panel most of the night. Nurse I stated the resident's call light did not sound or light up. Nurse I stated he/she interviewed the resident and the resident denied that staff did not assist him/her. On 4/13/15, a review of the grievance log revealed entries on missing items: teeth, clothing, watches, etc., but lacked entries related to allegations of abuse/neglect. On 4/14/15, a review of the facility investigation revealed, on 3/16/15, Nurse Aide C reported to the administrator that the other aides were going to report him/her to the hotline. On 4/14/15, a review of the facility investigation revealed the facility failed to obtain witness statements from the staff interviewed by Administrative Nurse B and failed to complete a thorough investigation of the allegations. On 4/14/15 at 1:02 PM, Nurse Aide F stated Resident #1 reported to him/her that Nurse Aide C responded to the resident's sounding alarm and the resident verbalized he/she had asked for help to the bathroom but Nurse Aide C refused to take him/her. The resident reported to Nurse Aide F that Nurse Aide C stated the day shift coming on would have to help him/her, or he/she could lie in the bed and wet him/herself. Nurse Aide F stated the resident cried from being so upset. Nurse Aide F reported the Administrative Staff A and Nurse B directed him/her to notify the administrative staff when a resident requested a grievance form and not to hand the form out directly to the resident or resident representative. On 4/14/15 at 1:25 PM, Nurse Aide G stated Resident #1 asked Nurse Aide C to use the bathroom. Nurse Aide G heard Nurse Aide C state to the resident he/she had to wait because the aide had recently taken him/her to the bathroom. Nurse Aide G observed Nurse Aide C place the resident's walker outside in the hallway. Nurse Aide G informed Resident #1 he/she would help him/her to the bathroom. Nurse Aide G stated on another date, he/she observed the resident's walker in the hallway, at the beginning his/her shift. The resident verbalized to the aide he/she was upset because he/she had soiled him/herself because Nurse Aide C refused to assist him/her to the bathroom. On 4/14/15 at 2:10 PM, Nurse Aide C stated the resident rang his/her light, requested to use the bathroom and stated he/she informed the resident it would be a minute before he/she could help him/her. Nurse Aide C stated he/she informed Nurse Aide K the resident needed to use the bathroom and asked the other aide to assist the resident. Nurse Aide C stated Nurse Aide K must have forgotten to help the resident. On 4/14/15 at 2:30 PM, Nurse Aide K stated he/she did not assist the resident to the bathroom prior to the resident incontinent episode and stated no one had told him/her the resident needed to use the bathroom. On 4/14/15 at 5:15 PM, Nurse B verified the grievance log listed resident's missing personal items, but lacked resident complaints related to other areas: mistreatment and/or inappropriate care. Nurse B verified staff grievances reported to a supervisor or administrative staff related to resident care were not listed on the grievance logs. On 4/14/15 at 5:26 PM, Administrative Staff A verified Nurse Aide C continued working as a nurse aide during the investigation and acknowledged staff verbalized an allegation of abuse/neglect which the facility did not report to the state reporting agency. On 4/15/15 at 12:36 PM, Nurse I stated Nurse Aide F reported to him/her an incident that involved Resident #1, but the resident denied it when Nurse I interviewed him/her. Nurse I reported the incident and the information staff discussed, concerning the aide, to Administrative Nurse B. On 4/15/15 at 1:05 PM, Nurse Aide H stated he/she observed the resident crying in his/her room. The resident reported he/she rang the call light, but the nurse aide with the long pulled back hair had shut off the light and stated to the resident he/she had already gone to the bathroom. The resident stated he/she wet his/her pants because the nurse aide did not help him/her. The resident stated he/she didn't know why the night nurse aide hated him/her so much. Nurse Aide H returned the walker to the resident as another aide helped him/her to the bathroom. The aide stated he/she reported the incident to the charge nurse at 6:30 AM the same day. On 4/15/15 at 1:30 PM, Social Service Staff J stated the resident reported he/she had been neglected two times. Social Service Staff J notified Administrative Staff A and Administrative Nurse B of the allegation of neglect. The facility's undated Reporting Resident Abuse policy included: Protection - to protect our residents from any of the above abuses (verbal, physical, and mental), the following policies will be followed: *Ensure that all allegations of abuse, neglect, or exploitation are investigated and reported immediately to the administrator of the facility and to the KS Dept. of Health and Environment. *If an employee is suspected of abuse, suspension will occur until the investigation is completed. Investigation: *An investigation will be done immediately by the charge nurse, DON, and Administrator. *The Administrator or DON will notify the Kansas Department of Health and Environment. *All investigations of abuse should be done with care and good judgement, and to have reasonable cause to believe there has been abuse. The facility failed to ensure Resident #1 remained free from verbal abuse and neglect. The facility abated the immediate jeopardy on 4/20/15 at 4:01 PM, when the facility:*Terminated Nurse Aide C. *Revised the abuse/neglect policy including how to report, and protection of residents during investigations, then completed in-service training to all staff on 4/20/15. *Educated residents without significant cognitive impairment on abuse/neglect and how to report, *Residents will be routinely interviewed by the social service department to determine if abuse and neglect is occurring and the administrator and director of nursing will review the forms. The deficient practice remains at a scope and severity of a D. - The 1/14/15 Physician order [REDACTED].#2 had [DIAGNOSES REDACTED]. emotional reaction characterized by apprehension, uncertainty and irrational fear), [MEDICAL CONDITION] ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), chronic pain (pain persisting for a long period of time), and hyperkinetic [MEDICAL CONDITION] (an abnormal amount of uncontrolled muscular action, spasms). The quarterly (MDS) Minimum Data Set assessment, dated 2/17/15, indicated the resident cognitively intact, with no behaviors, and required extensive assistance of 1 staff for transfer, bed mobility, dressing, and toileting. The MDS indicated the resident required supervision of 1 staff for hygiene and walking, was occasionally incontinent of urine, and had shortness of breath. The (ADLs) Activities of Daily Living (CAA) Care Area Assessment, dated 11/24/15, revealed the resident's ability to perform ADLs improved since admission. The resident increased his/her daily walking distance, dressing ability, now used a motorized scooter, and participated in a daily restorative program. The urinary incontinence CAA, dated 11/24/14, stated the resident had rare instances of urinary incontinence due to obesity and poor bladder control. The CAA stated the resident declined the use of incontinence products other than a pad, and denied the need for a scheduled toileting program. The 2/24/15 care plan stated the resident had limited ability to manage his/her own ADL cares due to obesity. Staff directed the resident to wait for a nurse aide prior to standing, and use a cane/walker to assist with walking to and from the bathroom. The resident requested assistance of 1-2 staff for transfers to ensure his/her safety. The urinary incontinence problem stated the resident had a history of [REDACTED]. The care plan instructed staff to provide personal hygiene care after incontinent episodes, ensure the resident wears an incontinent pad daily, and has an unobstructed path to the bathroom. On 4/13/15 at 3:54 PM, observation revealed Nurse Aide E assisted the resident to transfer with stand-by assistance, from the bed to a standing position. The aide assisted the resident to swing his/her legs from the top of the bed to the floor as the resident used a trapeze to pivot his/her upper body to a sitting position. The resident stood without difficulty using a wheeled walker. He/she walked into the bathroom with stand-by assistance from Nurse Aide E. The resident's gait and balance were steady. On 4/13/15 at 3:05 PM, Administrative Nurse B stated Nurse Aide C stated to him/her that 4 nurse aides planned to call the hotline number to report him/her for abuse/neglect and to give statements. Administrative Nurse B stated he/she obtained the staff names from Nurse Aide C and worked on an investigation for 2 weeks. Administrative Nurse B stated Nurse Aide C continued to work during the investigation. Nurse B stated the result of the investigation revealed the incident was not abuse/neglect and Nurse Aide C continued to work at the facility. On 4/13/15, a review of the grievance log revealed entries on missing items: teeth, clothing, watches, etc., but lacked entries related to allegations of abuse/neglect. On 4/14/15, a review of the facility investigation revealed, on 3/16/15, Nurse Aide C reported to the administrator that the other aides were going to report him/her to the hotline. On 4/14/15, a review of the facility investigation revealed the facility failed to obtain witness statements from the staff interviewed and failed to complete a thorough investigation of the allegations. On 4/14/15 at 9:56 AM, Resident #2 stated Nurse Aide C told him/her that he/she had better not wet the bed, quit being lazy, and get up and go to the bathroom. The resident stated the nurse aide's actions hurt his/her feelings and stated he/she was upset for a long time about the incident. On 4/14/15 at 1:02 PM, Nurse Aide F stated Resident #2 reported to him/her that Nurse Aide C accused the resident of intentional incontinence and Nurse Aide C told the resident he/she needed to make it to the bathroom. The resident also reported Nurse Aide C used a mean tone of voice that offended him/her. On 4/14/15 at 1:25 PM, Nurse Aide G stated he/she was at the nurse's station when Nurse Aide C approached the desk and reported to Nurse I the resident had urinated in the bed and all over the floor. Nurse Aide G stated Nurse Aide C reported the resident verbalized it was an accident. Nurse Aide C informed Nurse I he/she told the resident, he/she wet the bed on purpose, and it was not an accident. Nurse Aide C told Nurse I, he/she informed the resident he/she would have to sit on the toilet until staff cleaned up the urine. On 4/14/15 at 5:15 PM, Administrative Nurse B verified the grievance log listed resident's reporting missing personal items, but lacked resident complaints related to other areas: mistreatment and/or inappropriate care. Nurse B verified staff grievances reported to a supervisor or administrative staff related to resident care were not listed on the grievance logs. On 4/14/15 at 5:26 PM, Administrative Staff A verified Nurse Aide C continued working as a nurse aide during the investigation and acknowledged staff verbalized an allegation of abuse/neglect which the facility did not report to the state reporting agency. On 4/15/15 at 11:55 AM, Nurse L stated the resident verbalized he/she was incontinent of urine several times during a shift. The resident informed the nurse he/she was mad at someone. Nurse I stated the resident did not provide the staff member's name. On 4/15/14 at 12:36 PM, Nurse Aide I denied knowledge of an incident involving this resident. The facility's undated Reporting Resident Abuse policy included: Protection - to protect our residents from any of the above abuses (verbal, physical, and mental), the following policies will be followed: *Ensure that all allegations of abuse, neglect, or exploitation are investigated and reported immediately to the administrator of the facility and to the KS Dept. of Health and Environment. *If an employee is suspected of abuse, suspension will occur until the investigation is completed. Investigation: *An investigation will be done immediately by the charge nurse, DON, and Administrator. *The Administrator or DON will notify the Kansas Department of Health and Environment. *All investigations of abuse should be done with care and good judgement, and have reasonable cause to believe there has been abuse. The facility failed to ensure Resident #2 remained free from verbal abuse and neglect. The facility failed to report the allegation of abuse/neglect to the state agency as required, failed to thoroughly investigate the allegation of abuse/neglect as reported by the staff members, and failed to protect the residents during the investigation. The facility abated the immediate jeopardy on 4/20/15 at 4:01 PM, when the facility:*Terminated Nurse Aide C. *Revised the abuse/neglect policy including how to report, and protection of residents during investigations, then completed in-service training to all staff on 4/20/15. *Educated residents without significant cognitive impairment on abuse/neglect and how to report, *Residents will be routinely interviewed by the social service department to determine if abuse and neglect is occurring and the administrator and director of nursing will review the forms. The deficient practice remains at a scope and severity of a D.

The facility reported a census of 32 residents with 5 sampled for review. Based on observation, interview and record review, the facility failed to follow physician's order [REDACTED]. (1 and 2) Facility failure to follow physician's order [REDACTED].#1 in immediate jeopardy. The resident subsequently developed a blood infection as a result of the urinary tract infection, was hospitalized , and died . The facility also failed to adequately assess and treat resident #2 ' s symptoms of urinary tract infection, and failed to notify the physician of the resident ' s symptoms. Findings included: - A [DATE] admission MDS (minimum data set) 3.0 assessment showed resident #1 had cognitive impairment, required extensive to total staff assistance for all activities of daily living and had an indwelling catheter. An undated care plan included an intervention for staff to observe the resident ' s urine for any signs or symptoms of infection including a change in color, foul odor, visible blood, blood clots, complaints of pain, sediment or mucus in the urine. A [DATE] fax to the physician noted a small to moderate amount of cloudy white/yellow drainage around the catheter insertion site. The nurse noted no odor and informed the physician that the catheter was changed the evening prior with no drainage noted at that time. The physician ordered a urinalysis with a culture and sensitivity. The record lacked any results from the ordered urinalysis. On [DATE] at 12:48 pm, administrative nursing staff B reported the facility did not have the results of the urinalysis ordered on [DATE]. She stated she had contacted the hospital and lab services and they have no record of the specimen being sent. She stated that at the time of the incident, the facility did not have a system in place to ensure that ordered lab tests were completed in a timely manner. Review of the clinical record revealed no evidence of thorough, ongoing nursing assessments of resident #1 ' s physical condition, bladder function status in the 12 day time period after staff first noted white/yellow discharge from the catheter insertion site. Nurses Notes dated [DATE] at 8:30 a.m. included an entry related to the presence of blood coming from around resident #1 ' s catheter insertion site. According to that note, the nurse cleaned the area and noted no pain or swelling. Nurses Notes dated [DATE] at 10:30 a.m. included an entry related to the presence of blood in the the resident ' s urine, describing the urine as, " dark but clear. " The nurse subsequently notified the physician and received orders to irrigate the catheter and monitor the resident. Four hours after receiving that physician order, at 2:30 p.m., nursing staff irrigated the catheter. Additional Nurses Notes written at 5:30 p.m. describe resident #1 with increased agitation and shivering. Vital signs taken at that time revealed an elevated temperature of 100.6 degrees F (Fahrenheit). Normal body temperature is 98.6 degrees F. The nurse then called the physician and received orders to send the resident to the emergency room . In the 50 minute time period between when the nurse obtained the order to send to the emergency room and the time the ambulance arrived to transport the resident at 6:30 p.m., the resident ' s medical condition continued to deteriorate. The resident developed vomiting and more blood present in the urine. Nurses Notes dated [DATE] at 7:30 p.m. included an entry by a licensed nurse noting she spoke with the emergency room physician who reported resident #1 had a [DIAGNOSES REDACTED]. During a telephone interview on [DATE] at 2:23 p.m., the resident ' s attending physician stated resident #1 ' s blood cultures and urine cultures obtained at the hospital grew out the same bacteria, indicating the resident had a urinary tract infection that progressed to a blood infection/sepsis. According to the physician, the resident had lethargy at the time of arrival in the emergency room , and was not expected to survive. The resident expired on [DATE] from complications related to the blood infection. In summary, the facility failed to follow physician's order [REDACTED]. This facility failure placed resident #1 in immediate jeopardy. The resident subsequently developed a blood infection as a result of the urinary tract infection, was hospitalized , and died . The facility abated the immediate jeopardy on [DATE] following implementation of a system to ensure all ordered lab tests were completed timely and following nurse education related to follow-up assessments. The deficient practice remained at a G level. - A [DATE] quarterly MDS (minimum data set) 3.0 identified resident #2 with cognitive impairment, the need for extensive assistance with all activities of daily living, and use of an indwelling bladder catheter. Nurses Notes dated [DATE] included a notation resident #1 had, "bright red blood dripping " from the catheter insertion site. According to the notes, the resident had, "blood clot trying to come out ....around the catheter." The clinical record did not include any evidence of additional nursing assessments of the resident's urinary/catheter status. Additional nurses notes dated [DATE] included an entry describing resident #2 as tearful (crying) with complaints of back pain to the entire lower back. The clinical record did not include any evidence of additional nursing assessments of the resident's back pain and/or urinary status. Nurses Notes dated [DATE] included an entry describing a lack of urine output from resident #2's catheter for a 7 hour time period between the hours of 2 p.m. and 9 p.m. According to the Nurses Notes, the nurse irrigated the catheter and obtained a small amount of blood tinged urine. After that irrigation, the catheter then drained amber colored urine. The clinical record did not include any evidence of additional nursing assessments of the resident's bladder function status. During an observation on [DATE] at 2:05 pm, Direct Care Staff E and F assisted resident #2 with catheter care. The catheter contained opaque yellow urine with large amounts of sediment in the bag and collected along the tubing. Normal urine appears clear/transparent. The nurse aides could not confirm or deny if this was usual for this resident. During an interview on [DATE] at 2 pm, administrative nurse B confirmed resident #2's clinical records lacked evidence of ongoing, thorough nursing assessments of the resident's catheter, back pain, and bladder status. Additionally, Nurse B confirmed the clinical record lacked evidence of physician notification of the resident's urinary status. In summary, resident #2 showed symptoms of a possible urinary tract infection on [DATE], [DATE] and [DATE]. The facility failed to notify the physician of the symptoms and failed to provide any further assessments of the resident ' s urinary status.