Every finding on record at Medicalodges Atchison

Based on observation, interview, and record review, the facility failed to store, prepare, and served food in a sanitary manner for the residents who reside in the facility and receive meals from the facility kitchen.Findings included:- On 04/06/26 at 09:50 AM, during the initial tour of the kitchen, the following dry goods lacked an open-on date:Two cocoa powder bags, one bag approximately half full and the second bag approximately two thirds full, were held closed with a clip.One buttermilk pancake mix bag approximately a quarter of the way full, held closed with a clip.One brownie mix bag approximately a quarter of the way full, held closed with a clip.One chocolate instant pudding mix bag approximately a third of the way full, held closed with a clip.One bag of [NAME] Krispy cereal approximately halfway full, held closed with a clip.One plastic Tupperware container without a lid had a handful of loose pretzels opened at the bottom of the container and an open sandwich bag of Pretzels dated 03/30.There were three large bins underneath the counter that had the toaster on it. These bins lacked identification that could be read. The lids on all three containers had multiple particles and crumbs on the lids and appeared dirty. One bin had a ladle hanging in it. The drawer below the toaster that held measuring cups and measuring spoons had crumbs visible along the left side of the drawer that ran the length of the drawer. The backsplash to the counter had particles of something on it and was gritty to touch. The windowsill that was above the backsplash, counter area contained spices and the windowsill had what appeared to be spices spilled all over the windowsill.On the rack that holds pans, there were two pans with a total of 27 pieces of cake between the two pans that were uncovered beside the toaster.There was black, gray residue on the floor underneath the clean dish counter. The area was moist and grimy.On 04/06/26 at 10:18 AM, Dietary BB stated that she was not trained to put an open date on anything that was opened. Dietary BB stated, but the opened bags do not sit for very long. She confirmed that the lids to the bins, that she reported were flour, sugar, and chicken batter, were not clean nor labeled. While looking at the bins, Dietary BB pulled the ladle out of the sugar. Dietary BB confirmed that there were crumbs along the left side of the measuring cups and measuring spoons drawer and that it should be cleaned and the crumbs should not be there. Dietary BB confirmed that the backsplash and windowsill were gritty and dirty, and they needed to be cleaned. When asked about the pieces of cake that were uncovered, Dietary BB stated that they should be covered. Dietary BB observed the floor beneath the clean dish counter and stated that it should not be grimy underneath the dish area.The facility's Sanitation of Dining and Food Service Areas policy, 2016 edition, documented the dining services staff would uphold sanitation of the dining areas according to a thorough, written schedule. The policy documented all staff would be trained on the frequency of cleaning, a cleaning schedule would be posted for all cleaning tasks, and staff would be held responsible for all cleaning tasks.The facility's Sanitizing Equipment and Food Contact Surfaces policy, 2016 edition, employees shall sanitize equipment and food contact surfaces utilizing proper sanitizing solution. The policy further documented employees would follow the sanitizing recommendations and procedures for each piece of equipment or food contact surface as discussed in the cleaning guideline.The facility failed to provide a policy for food storage, as requested on 04/08/26.

Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to change gloves or wash hands between cares for Resident (R)24. Staff also failed to place Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) signage on R3 and R6, who had Foley catheters (a tube inserted into the bladder to drain urine into a collection bag), and R20, who had a percutaneous endoscopic gastrostomy (PEG tube-a tube surgically placed through an artificial opening into the stomach). Staff also failed to wear appropriate EBP when providing wound care for R8. The facility also failed to document the times and dates the stagnant water areas were flushed to prevent the growth of Legionella disease (a serious type of lung infection caused by inhaling water droplets or mist contaminated with Legionella bacteria).Findings included:- 1. On 04/06/26 at 11:06 AM, observation revealed R20 had a peg tube, and his room door lacked EBP signage.On o4/06/26 at 11:20 AM, observation revealed R3 had a Foley catheter, and outside his room door lacked EBP signage.On 04/06/26 at 11:40 AM, observation revealed R6 had a Foley catheter, and outside his room door lacked EBP signage.On 04/07/2026 at 2:13 PM, Administrative Nurse D verified the above findings and stated she conducted an audit earlier today regarding EBP, and the EBP signs are now on the door. 2. On 04/07/26 at 08:50 AM, observation revealed R8 lying in bed on her back with eyes closed. Licensed Nurse (LN) G and LN H entered the room (without donning gowns) and asked R8 if they could change the wound dressing on her left buttocks. R8 replied yes. Both nurses applied gloves, and LNH assisted the resident in turning on her right side, while LN G removed the old dressing. Further observation revealed that LN H placed the calcium alginate into the wound bed, then topped it with an adhesive dressing.On 04/07/26 at 09:15 AM, when asked if R8 was on EBP, LN H replied she did not know; she would have to check R8's medical record. When asked what the EBP signage on the door frame meant, LN H replied that the resident was on EBP and stated she should have worn a gown when assisting with the wound dressing change.On 04/08/26 at 10:30 AM, Administrative Nurse D stated that if a resident is on EBP, she would expect staff to donn a gown and apply gloves when providing wound care.3. On 04/08/26 at 10:47 AM, Certified Nurse Aide (CNA) M and CNA N provided perineal (private area) to a resident. While transitioning from cleaning the resident up and removing the soiled brief to applying the clean brief, both CNAs doffed their gloves and applied a clean pair without sanitizing their hands. The CNAs completed the care for the resident, collected the trash, made sure that the call light was within reach, and then removed their gloves and washed their hands before leaving the resident's room. When asked about the transition from cleaning and removing the soiled brief to applying the clean brief, CNA M stated that they did not sanitize or wash their hands then because they did not want to leave the resident unattended in the bed. CNA N stated they had never really washed or sanitized their hands in between.On 04/08/26 01:55 PM, Administrative Nurse D stated they should have washed their hands.On 04/08/26 at 09:30 AM, a review of the white binder with the water management plan to prevent the growth of legionella and other water-borne pathogens revealed a lack of documentation regarding the date and times the stagnant areas in the facility were flushed.On 04/08/26 at 09:30 AM, Maintenance Supervisor (MS) U stated he was responsible for documentation regarding the water management plan. MS U verified he had not documented when he flushed the stagnant water areas in the facility and was unaware he should.Upon request, the facility failed to provide an EBP policy.Upon request, the facility failed to provide a Legionella policy.The facility's Infection Control Policy, revised 11/23, documented staff would be educated on hand hygiene and other infection control prevention practices upon hire and thereafter routinely.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for one resident, Resident (R) 7 for his dentures and glasses.Findings included:- The Electronic Medical Record (EMR) documented R7 had repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and need for assistance with personal care.R7's Significant Change Minimum Data Set (MDS) dated [DATE] documented R7 had severely impaired cognition. R7 was dependent on staff with oral cares, toileting, shower/bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene.R7's Delirium Care Area Assessment (CAA) dated 11/28/25, documented R7 was alert with very impaired cognition. Staff were to anticipate R7's needs throughout the day.R7's Communication CAA dated 11/28/25, documented he would miss communication or not understand what was being said to him. R7 has minimal hearing loss and chooses not to wear any hearing device.R7's Nutrition Care Plan initiated on 06/03/25, directed staff to please give verbal cues and reminders to assist him with eating.R7's Activities of Daily Living (ADL) Care Plan initiated on 06/03/25 directed staff that R7 needed assistance of one staff for dressing and personal cares. Staff were further directed that R7 needed assistance with grooming needs,R7's care plan lacked identification R7 had dentures or glasses. R7's care plan further lacked R7's preference related to his dentures and glasses and whether he wanted them on or off, or how he responded to using the dentures or glasses.The Social Service Progress Note dated 10/20/25 at 12:26 PM documented that R7's bottom dentures had been broken. Witnesses reported that R7 placed his dentures in his overall pocket, and when getting R7 ready for bed and taking his overalls off his dentures fell out and broke.The Registered Dietitian Note dated 02/18/26 at 01:58 PM documented R7 had poor intake concerns. R7 had dentures and reported difficulty chewing tougher meats.The Social Service Quarterly Note dated 02/27/26 at 12:21 PM, documented R7 did not always exhibit good eye contact during conversation.On 04/08/26 at 10:45 AM, R7 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the sitting area by the television. R7 did not have his glasses on or his dentures. R7 was restless and fidgeting.On 04/08/26 at 01:35 PM, Social Services X stated that R7's dentures and his glasses were in his room. She further stated that it depended on R7's mood as to whether or not he would allow staff to put the dentures in or the glasses on.On 04/08/26 at 02:02 PM, Administrative Nurse E stated R7's care plan should reflect that he had the dentures and glasses. She said that the care plan should documented that there were times that R7 did not want to wear them.On 04/08/26 at 1:55 PM, Administrative Nurse D stated that she expected R7's care plan to reflect that he had dentures and glasses and that there were times he did not want them.The facility utilizes Resident Assessment Instrument (RAI) dated October 2025 for developing care plans. The RAI documented that clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. The RAI documented helping the nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. The RAI further documented it also assisted staff with evaluating goal achievement and revising care plans accordingly.

The facility identified a census of 39 residents. The sample included three residents reviewed for misappropriation of property. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 and R2 remained free from misappropriation of medications when during a random controlled substance audit it was discovered three of the nine entries from 03/01/25 to 03/26/25 for R1 and three out of six entries from 03/24/25 to 03/26/25 for R2 were signed out on the count sheet by Licensed Nurse (LN) G but were not documented on the Electronic Medication Administration Record (EMAR). Further investigation by the facility revealed LN G signed out medications as being destroyed using another nurse's initials and initials that were identified as not belonging to any member of the licensed facility staff. This deficient practice placed R1 and R2 at risk for missed medications and further misappropriation of medications. Findings included: - The facility's investigation, dated 04/03/25, documented on 03/26/25 Consultant GG conducted a monthly on-site visit that consisted of a medication documentation review and a controlled substance audit. The results of the audit were reviewed and indicated missing entries on two of the four residents that were selected through the random controlled substances audit. Upon further review, it was determined that three of the nine entries from 03/01/25 to 03/26/25 for R1 and three out of the six entries for R2 from 03/24/25 to 03/26/25 were signed out on the count sheet but were not documented on the EMAR. Administrative Nurse D analyzed these results and initiated an audit of R1's and R2's controlled medications. This audit consisted of a comparison of the controlled medication count sheet to each medication administration record for each resident with the scheduled and as-needed controlled medication orders. The results of this audit revealed the following for R1 and R2: On 03/10/25 hydrocodone-acetaminophen (a combination medication used to treat moderate to severe pain) 5 milligrams (mg)-325 mg was not signed out on the EMAR but was signed out on the controlled drug record. It was recorded as being given at 08:21 PM and then appeared that the number 19 was written over the 20 on the controlled drug record by LN G. On 03/11/25 it was indicated on the EMAR that the hydrocodone-acetaminophen 5 mg-325 mg was signed out by LN G at 01:38 AM and marked effective. When compared to the controlled medication record, this medication was signed out at 03:30 AM. On 03/15/25 LN H documented R1 was out of the facility. On 03/15/25 LN G pulled hydrocodone-acetaminophen 5 mg-325 mg and signed it out in the morning. This medication was an as-needed medication for pain. R1 was documented as not in the facility at that time, as R1 was admitted to the hospital on 03/14/25. Per investigation, on the controlled drug record, it was indicated that the medication pulled on 03/15/25 was destroyed by LN G. A second set of initials was indicated next to LN G's; however, those initials were unknown. The nurse on shift at the time was LN H who was unaware of this medication being destroyed and verified that the initials on the controlled drug record were not hers. On 03/15/25 LN G signed out the morning dose of tramadol (medication used to treat moderate to moderately severe pain) and the word destroyed was documented to the left of LN G's signature. A second set of initials was indicated on this same entry that was not legible and did not match any initials of licensed staff. LN H was on shift the same date LN G signed out the tramadol. When asked if the initials in question belonged to LN H, LN H stated that they were not her initials. On 03/24/25 R2 returned to the facility. A medication card for R2 that contained 15 oxycodone (medication used to relieve moderate to severe pain) 5 mg tablets was received at the facility and signed in by LN H. The oxycodone was ordered to be given every six hours as needed. On 03/24/25 LN G signed one oxycodone 5 mg out from the controlled drug record at 11:00 PM but did not chart on R2's EMAR. The investigation documented upon review of the controlled drug record, the number three, in the initial time indicated 11:00 PM, appeared to have been written over with the number one. On 03/25/25 LN G documented on the controlled drug record at 03:00 AM that one oxycodone 5 mg was pulled. LN G documented the administration time on the EMAR as 03:30 AM. Upon further review it was recorded that the entry had been created at 04:00 AM, time-stamped at 03:30 AM. On 03/25/25 at 07:52 PM LN G documented on the controlled drug record that an oxycodone HCL 5 mg was pulled. Next to LN G's initials, the word wasted was recorded with what appeared to be the initials for LN H. Upon review with LN H, she stated that the initials on this entry did not belong to her and that she did not waste this medication with LN G. An oxycodone was documented on the EMAR and progress note by LN G at 06:30 PM. This documentation was created on 03/25/25 at 10:22 PM. At 09:00 PM, LN G documented the medication was pulled, LN G did not document it on R2's EMAR and the medication was pulled three hours and 30 minutes after the previous dose was administered. The order was as needed every six hours. On 03/26/25 LN G documented that an oxycodone 5 mg was pulled, with no time documented on the controlled drug record, and the medication was not documented on R2's EMAR. The facility investigation further documented that once the audits were completed, Administrative Nurse D reached out to LN G to discuss the findings and was unable to make immediate contact. Administrative Nurse D then reached out to LN H as she was indicated as the second nurse involved in the disposal of medications with LN G. LN H stated that she had not destroyed any controlled medications with LN G and that she could not recall any other times she wasted narcotics with LN G. LN G reviewed the initials that were documented as the second nurse witnessing the disposal of narcotics and LN H stated that the initials documented were not hers because the handwriting was not hers. Administrative Nurse D then interviewed all other licensed nursing staff individually regarding the disposal of the controlled medications signed out by LN G. Upon completing interviews, there were no staff nurses that recalled ever wasting narcotics with LN G. During the interviews, Administrative Nurse D asked the nurses if LN H ever held the narcotic keys and counted with them at shift change and all nurses stated LN G was the night nurse on her rotation that would count and have possession of the narcotic keys. The investigation further documented Administrative Nurse D reached out to LN G via phone and asked LN G to come into the facility, but LN G was unable to come to the facility due to car trouble. Administrative Nurse D then discussed the findings of the audits with LN G. LN G explained to Administrative Nurse D that she could not recall wasting any medications. LN G stated she did not waste R1's narcotics and that she must have mistakenly documented they were wasted, but she did in fact administer the medications. Administrative Nurse D verified back to LN G what she stated and then Administrative Nurse D discussed with LN G that there was no way the medications were administered because R1 was out of the facility and admitted to the hospital on 03/14/25. The documentation for the medication being destroyed was on 03/15/25. LN G then stated they did not know what happened. The investigation documented Administrative Nurse D discussed the disposal of R2's oxycodone. There were doses pulled that were not administered and there were doses pulled that were administered within three hours of each other when the order stated the medication was to be administered every six hours as needed. LN G stated that she had to have wasted the medication if it was documented. Administrative Nurse D asked LN G if LN H was with her when wasting medications because LN H had stated she did not recall wasting medication with LN G. Administrative Nurse D questioned how LN H's initials were documented in LN G's handwriting and not LN H's. Per investigation, LN G stated LN H knew that LN G wasted medications that LN H had given LN G permission to sign LN H's name and credentials, and that LN G would just make LN H aware when she did it. The investigation documented Administrative Nurse D explained the policy required two nurses to be present when narcotic medications were wasted, and that it was against the law to document another nurse's initials and credentials. Administrative nurse D informed LN G that LN H denied giving permission for LN G to ever sign her name or initials on the controlled medication count sheet and did not have any knowledge of these medications being destroyed. Administrative Nurse D informed LN G that the same medication was pulled less than three hours later but it was never documented that the medication was given and that it would have been too early for that medication to have been given. The facility investigation further documented Administrative Nurse D and Administrative Staff A informed LN G that she was being released from duties and was no longer employed at the facility for falsifying documentation and for not following policy on the destruction of narcotics. The investigation documented local police, the State Agency, the Chief Nursing Officer, the Medical Director, the primary care provider, and the Regional [NAME] President were notified. The investigation documented the state board of nursing was notified and all missing medications were replaced with all expenses paid by the facility. A notarized Witness Statement dated 04/04/25 for LN H documented Administrative Nurse D questioned if LN H had witnessed the wasting of R2's oxycodone 5 mg on 03.25.25. The statement documented LN H did not provide witness and the initials on the narcotic count sheet were not LN H's and were not signed by her. The statement further documented LN H did not witness wasting hydrocodone 5 mg-325 mg on 03/15/25 for R1. R1 and R2 were not in the facility at the time of the investigation and no observations could be made. On 05/19/25 attempts to reach LN G via phone were unsuccessful. On 05/19/25 at 02:28 PM, LN H stated the issue with her signature was brought to her attention after there were noted inconsistencies with the handwriting style her initials were documented in the narcotic book. LN H stated LN G used random initials that did not belong to anyone at the facility and LN G attempted to use LN H's initials to sign. LN H stated when she signs in the narcotic book, she signs her last name and not just her initials. LN H stated she did not sign as a witness for any of the medications LN G documented as wasted and that she didn't know LN G had used her initials to sign with. LN H stated she never would have given permission for another nurse to sign using her name or initials and she stated she had to observe the medication being destroyed before she would have signed off. LN H further stated she did not know her name was being used until it was brought to her attention by other facility staff. On 05/19/25 at 02:54 PM, Administrative Nurse D stated Consultant GG comes to the facility monthly and if there are issues, they would do an audit. Administrative Nurse D stated the facility also has a consultant who comes quarterly to audit the pharmacist. Administrative Nurse D stated she has been reviewing the narcotic book to see if nurses are signing out PRN medications more often than others to see if there are any potential issues. Administrative Nurse D stated she reviews the narcotic book one to two times per week to track how often PRN medications are given out. Administrative Nurse D stated the facility was not able to say definitively that LN G took the medications; however, she stated while interviewing LN G there were too many red flags. Administrative Nurse D stated LN G stated there must have been some mistake when asked why she signed out medications while R1 was out of the facility and LN G stated she believed se must have thought the medications were for another resident. Administrative Nurse D stated they could not get LN G to come in to give an official statement as to what happened. On 05/19/25 at 02:59 PM Administrative Staff A stated the pharmacist conducted an audit and noted three out of nine entries were signed out on the count sheets but not documented in the residents' EMAR. Administrative Staff A stated this concerns reported in the audit prompted the facility to dig deeper and they noted LN G was the nurse to be tied to all three instances. Administrative Staff A stated the facility did further auditing to verify if anything else was signed out but not documented as administered. Administrative Staff A stated they were not notified that medications were missing, only that they were not being documented in both places and they noticed a trend with LN G and noted R1 was out of the facility when medication was signed out. Administrative Staff A stated she reported the issue to the State Agency as soon as she suspected there may be missing medications and reported it to local law enforcement shortly after. Administrative Staff A stated another concern was LN G signed out an AM dose of Tramadol for R1, who was out of the facility, and LN G was a night shift nurse. Administrative Staff A stated LN G made excuses as to why she could not come into the facility and give a statement and would only speak over the phone. Administrative Staff A stated LN G would say she was on her way to the facility but never showed up. Administrative Staff A stated they were trying to find out why she signed out medications for a resident who was out of the facility at the time. Administrative Staff A stated the facility replaced all suspected missing medications and the cost was charged to the facility. Administrative Staff A stated the facility leadership is doing audits and monitoring in the facility's daily clinical excellence meetings that are held each morning. Administrative Staff A stated they are monitoring for signatures and that everything is signed out accordingly. Routine audits will be done one to two times per month, the pharmacy consultant would continue with monitoring, and data would be tracked through QAPI to identify any trends, so the facility could get a head of any potential issues going forward. Administrative Staff A further stated in-depth education was provided to staff related to knowing who was in the building and who was not, proper documentation, and not signing for other staff. Administrative Staff A stated the facility also provided Elder Justice Act and ANE education for staff. The facility's Disposal of Medications, Syringes, and Needles: Disposal of Medications policy, copyrighted 2007, documented that controlled substances would be disposed of by the nursing care center in the presence of appropriately titled professionals. The policy further documented a single dose of a controlled substance would be destroyed by two licensed nurses employed by the nursing care center. The policy directed that if a controlled medication is unused, refused by the resident or not given for any reason, it could not be returned to the container and was to be disposed of and documented on the accountability record on the line representing that dose with the required signatures. The facility's Controlled Medication Reconciliation policy revised on 11/2024 documented that the controlled medication inventory sheet would be maintained for each medication cart or storage area with controlled medications. The facility's The 8 Rights of Medication Administration protocol, undated, directed that staff were to document the administration after giving the ordered medication. The protocol directed staff to chart the time, route, and any other specific information as necessary. The facility's Medication Administration: Controlled Substances policy, copyrighted 2007, documented that Controlled Medications were substances that had an accepted medical use (medications that fall under U.S. Drug Enforcement Agency (DEA) Schedule II-V), have the potential for abuse, ranging from low to high, and may also lead to physical and psychological dependence. The policy documented that these medications were subject to special handling, storage, disposal, and record-keeping at the nursing care center, in accordance with federal and state laws and regulations. The facility completed corrective actions, which were completed on 03/28/25 and included a controlled substance audit conducted, medications replaced, Licensed Nurse interviews conducted, Alleged Perpetrator Interviewed, suspended & terminated. Law enforcement was notified. Impromptu QAPI meeting conducted, ANE education conducted. Licensed nurse training was conducted regarding the following policies and procedures: controlled medication reconciliation, controlled medication inventory, controlled medication shift count sheet, the 8 rights of medication administration, controlled medication individual reconciliation, disposal of medications, controlled medication storage, documentation requirements, and controlled substances. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at an D scope and severity.

The facility identified a census of 37 residents. The facility had one main kitchen. Based on observations, record reviews, and interviews, the facility failed to properly label and store food and failed to follow standards for food and supply storage. This deficient practice placed the residents at risk for foodborne illness. Findings included: - On 06/25/24 at 07:13 AM, an initial tour of the kitchen revealed the following observations: The freezer contained a box of waffles that were open and were not sealed. The box did not have a resident's name or the date it was opened. An open bag of French fries was not dated with the date they were opened. On 06/25/24 at 07:21 AM the top of the dishwasher had a significant amount of calcium buildup. On 06/25/24 at 07:40 AM an inspection of the service hall was completed. The facility's ice machine's catch tray had calcium buildup and dirt around the opening of the door and water drain bin. On 06/26/24 at 07:10 AM bowls, soup cups, and dessert bowls were stored on open shelving in the kitchen and were not covered or stored inverted. On 06/27/24 at 09:49 AM, Dietary BB stated that all dishes were to be covered or stored inverted. She stated that cleaning the ice machine was a maintenance task and not a dietary task. Dietary BB stated that deliming the dishwasher was not on the cleaning list though upon review of the cleaning list, Dietary BB identified it was noted that deliming is on the cleaning list. The facility policy Food Storage (Dry, Refrigerated, and Frozen) dated 2016 stated that food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The facility policy Storing Utensils, Tableware, and Equipment dated 2016 stated that glass and cups should be stored inverted. The facility failed to properly label and store food, and failed to store clean dishes inverted and. This deficient practice had the risk of spreading foodborne illness to all affected residents.

The facility had a census of 37 residents. The sample included 12 residents with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous materials and equipment from nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 06/25/24 at 07:05 AM a walkthrough of the facility was completed. An inspection of an unsecured soiled utility room on 100 Hall revealed multiple cleaning aerosol deodorizers, a spray bottle of Virex II (used to kill viral germs), and a laundry presoak chemical on a counter in the room. The items contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. An inspection of an unsecured 400 Hall utility closet revealed a bottle of Virex II and multiple room deodorizer spray cans. The items contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. An inspection of an unlocked shower room the next day room revealed two unsecured aerosol room deodorizer cans on the shelf. The items contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 06/25/24 at 07:22 AM an inspection of the facility's service hallway revealed no locking mechanism on the door from the resident accessible hallway into the service hallway. An inspection of the service hallway revealed the rear kitchen door was propped open. The service hallway's laundry room door's key was left in the door lock. An inspection of the room revealed multiple cleaning chemicals and a laundry sink with a Hot Water warning sign above it. On 06/25/24 at 09:20 AM Resident (R)31, a severely cognitively impaired and independently mobile resident, sat in her wheelchair outside her room facing a Hoyer lift (total body mechanical lift) placed in an egress next to her room's entry. The lift contained a cloth bag with orange disinfectant (bleach) wipes. R31 stated she needed a wipe as she grabbed the cloth bag. R31 attempted to pull the wipe container out of the bag several times before she gave up and entered back into her room. On 06/27/24 at 10:10 AM the orange wipe container on the Hoyer lift next to R31's room's lid was open and two wipes dangled out from the container. On 06/27/24 at 10:12 AM Certified Nurse Aide (CNA) P stated staff was expected to keep all hazardous chemicals locked up and away from the residents. She stated the wipes should be kept within visual supervision and removed from the lift once the lifts were sanitized. She stated the resident did not go into the service hallway, but the doors should remain closed and locked. On 06/27/24 at 11:59 AM Administrative Nurse D stated the doors within the service hallway were to remain locked, but the residents didn't go back there. She stated staff should not be propping the doors open or leaving the keys in the locks. She stated the residents should not have access to potentially hazardous chemicals or utility areas within the building. The facility was unable to provide a policy related to safe chemical storage or accidents as requested on 06/27/24. The facility failed to ensure a safe environment free from hazardous materials and equipment for nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries.

The facility identified a census of 37 residents. The facility identified four residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry and hand hygiene during care. These deficient practices placed the residents at risk for infectious diseases. Findings Included: -On 06/25/24 at 07:30 AM an inspection of the shower room next to the nurse's station revealed a pile of used towels placed directly on the floor of the shower room. On 06/26/24 at 07:17 AM Resident (R)1 lay on his bed. Certified Nurse's Aide (CNA) M put on an isolation gown, washed her hands, and donned her gloves. CNA M explained to R1 that she was going to do peri care get him dressed and put him in his chair for breakfast. CNA M had CNA O help tuck R1's brief and then rolled R1 to his left side. CNA M washed his buttocks with a wipe, and then was helped to roll to his back. CNA M washed R1's front peri area with the same gloves and a clean wipe. CNA M failed to doff her gloves and perform hand hygiene from the dirty area to the clean area. CNA M and CNA O changed their gloves, did hand hygiene, and put a clean brief on R1 by rolling him from right to left. On 06/26/24 at 08:49 AM an inspection of R2's room revealed dirty clothing on the floor next to his bed. On 06/26/24 at 07:28 AM CNA M stated she should have doffed her gloves and performed hand hygiene while doing peri care when going from a dirty area to a clean area. CNA M stated all nursing staff were educated on peri care and catheter care. She stated laundry should be taken directly to the soiled utility room and not placed on the floor. She stated that used towels should be placed in a soiled bin for washing. On 06/27/24 at 07:18 AM, Licensed Nurse (LN) G stated the facility's process was to doff gloves and to perform hand hygiene from dirty to clean when doing peri care or catheter care. She stated linen and clothing should never be placed on the floor. On 06/27/24 at 11:59 AM, Administrative Nurse D stated staff should have completed hand hygiene when going from a dirty area to a clean area, to avoid cross-contamination. She stated items should never be thrown on the floor due to the risk of contamination to other residents. She stated soiled items were expected to the taken to the soiled utility rooms. The facility's Infection Control and Surveillance policy revised 11/2023 indicated infection control and prevention training would be completed routinely. The policy indicated staff would be educated on the use of proper hand hygiene and practices to reduce the risks of preventable infections and illness. The policy indicates the facility will educate staff on the proper management of the resident's environment and infection control standards to manage equipment, environment, personal care, and treatments. The facility failed to follow sanitary infection control standards related to the handling of soiled laundry and hand hygiene during care. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation and interviews, the facility failed to provide a clean, home-like environment for Resident (R)11. This placed R11 at risk for impaired comfort and decreased psychosocial well-being. Findings included: - On 06/25/24 at 07:55 AM in R11's room, there were three flies on the top of the bed, on R11's sheet above his head. Further observation revealed there were three flies on R11's bedside table, two flies on his transfer pole, and a fly on R11's right upper arm. On 06/26/24 at 07:22 AM there were two flies on a cream-colored blanket in R11's room and two flies on the foot of the bed on a white sheet covering R11's right leg. On 06/27/24 at 07:14 AM five flies were observed on R11's bed on a white-colored sheet that covered the resident's abdomen. There were two flies on the bedside table and one fly on a cream-colored blanket in a chair in the resident's room. There were two flies flying in R11's room. On 06/27/24 at 07:30 PM Licensed Nurse (LN) G stated if there were issues with flies in a resident's room, she would get the resident a fly swatter, or she would just go into the resident's room and swat the flies. LN G stated the process to report rodents, pests, or broken equipment, was to let maintenance staff know with a work order. On 06/27/24 at 07:41 AM LN G stated she went into R11's room, killed the flies, and left R11 a fly swatter. LN G stated R11 said he was going to ask maintenance to make a hook for the fly swatter. On 06/27/24 at 08:01 AM Maintenance Staff U stated he was just informed about the flies in R11's room. Maintenance Staff U stated he would check on the room a couple of times daily and he would check windows and the air conditioner to find out how the flies were coming into the R11's room. Maintenance Staff U stated he would ensure R11 had a fly swatter. On 06/29/23 at 04:02 PM Administrative Nurse D stated staff would report to maintenance and fill out a work order for any rodents or pests that needed to be controlled. She stated the facility had a pest control program which comes monthly. The facility did not provide a home-like environment policy. The facility failed to provide a clean and homelike environment for R11. This placed R11 at risk for impaired comfort and decreased psychosocial well-being.

The facility identified a census of 37 residents. The sample included 12 residents with two reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 25's Care Plan to reflect her bed rail evaluation and current use. The facility additionally failed to revise R11's plan to reflect his weight monitoring. This deficient practice placed both residents at risk for uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (difficulty sleeping), hypertension (high blood pressure), and a history of repeated falls. R25's Admission Minimum Data Set (MDS) completed 05/07/24 noted a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS indicated she had no upper or lower extremity impairments. The MDS indicated she required partial to moderate assistance with bed mobility, toileting, bathing, dressing, and personal hygiene. The MDS indicated she had no falls since her admission. The MDS indicated she had no bed rails. R25's Functional Abilities Care Area Assessment (CAA) completed 05/10/2024 indicated she required staff assistance, prompting, and cueing for all her activities of daily living (ADLs). The CAA indicated she had weakness with poor endurance and participated in therapy strengthening services. R25's Care Plan initiated 03/23/23 indicated she required assistance from one staff for dressing, personal hygiene, toileting, bed mobility, and transfers. The plan indicated she utilized her wheelchair for mobility with minimal staff assistance. The plan indicated she had bilateral bed canes to assist with bed mobility and transfers. R25's EMR indicated a Clinical Health Review (dated 05/01/24) was completed upon her admission. The review indicated she attempted to get into and out of his bed unassisted, was able to turn herself from side to side, and currently used the bed rails for positioning. The review indicated she had a diagnosis that required increased safety measures. The review indicated side rails, grab bars, or transfer bars would not be used. On 06/27/24 at 09:04 AM an inspection of R25's room revealed she had non-skid strips in her restroom and a pressure-reducing mattress on her bed. R25's bed lacked bilateral bed canes. On 06/27/24 at 09:05 AM Certified Nurse's Aide (CNA) P stated R25 had bilateral bed canes on her bed to assist with transferring and rolling from side to side. Upon inspection of R25's bed, CNA P acknowledged R25 had no bed canes installed on her bed. She stated she was not sure why they were removed but remembered R25 having them. She stated all staff had access to the care plans. She stated she was not sure who was responsible for assessing the railings but stated the nurses evaluated the need for the railing. On 06/27/24 at 10:24 AM Licensed Nurse (LN) G stated maintenance installed the bed canes, but she was not sure if the railing was inspected or checked after they were installed. She stated the care plans should reflect the most recent safety assessments for the residents. On 06/27/24 at 11:59 AM Administrative Nurse D stated the facility sometimes used the bed canes on R25's bed for mobility. She stated they were removed recently. She stated the bed canes were used company-wide and she didn't think they needed to be assessed as bed railing. She stated maintenance installed the bed canes, but the facility was unable to provide documentation showing how often the canes were assessed, the potential risks related to the assistive canes, and consent for the bed canes. She stated the interdisciplinary team met weekly to review the care plan. She stated the plans would be updated by the MDS team. The facility's Electronic Care Plan policy dated December 2018 documented that the MDS coordinator was to initiate a review of the plan of care. Care plan review and revisions were to be completed with the wellness program. The interdisciplinary team (IDT) was to review, revise, and sign the person-centered plan of care related to their discipline. The MDS Coordinator was to complete the review of the care plan in the EMR. The facility failed to revise R25's care plan to reflect her bed rail evaluation. This deficient practice placed R25 at risk for uncommunicated care needs. 49634 - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of lymphedema (swelling caused by accumulation of lymph, cellulitis (skin infection caused by bacteria) of right limb, obesity (excessive body fat), need for assistance for personal care, muscle weakness, and urinary retention. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R11 was dependent on two staff members' assistance for activities of daily living (ADLs). The MDS documented R11 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) during the observation period. The ADL Functional Rehabilitation Potential Care Assessment Area (CAA) dated 08/09/23 documented R11 was admitted from the hospital after having worsening skin impairment from a yeast infection. The CAA documented R11 had morbid obesity and was unable to perform self-care due to impaired mobility. The CAA documented R11 was alert and oriented and could verbalize his needs. The CAA documented R11 requires extensive to dependent assistance of staff for completion of ADL. The CAA documented R11 had participated in occupation and physical therapies to improve his strength and endurance, basic self-care, and safe transfers. The CAA documented that the nursing staff was to perform wound care per the physician's orders until the area was healed. The facility would care plan continued assistance of R11's ADLs to ensure his needs were met. R11's Care Plan dated 08/04/23 documented R11 was at risk of losing or gaining weight due to his disease process of obesity. The plan of care dated 01/11/24 documented that staff would weigh R11 daily and report any changes to the charge nurse. R11's EMR under the Vitals tab revealed weights for 08/03/23, 09/12/23, 10/03/23,10/10/23, 10/19/23, 10/31/23, 11/10/23, 12/21/23, 01/04/24, 01/13/24, 02/02/24, 03/03/24, 04/09/24, 05/02/24, and 06/06/24. R11's EMR lacked orders or direction to staff when to obtain R11's weights. On 06/25/24 at 07:55 AM R11 lay in his bed on his back, R11 visited appropriately with the visitor. On 06/26/24 at 07:18 AM R11 lay in his bed talking on his cell phone. On 06/27/24 at 07:50 AM, Certified Nurses Aid (CNA) N stated the CNAs knew who needed to be weighed by looking at the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA N stated nursing had a notebook that indicated who needed to be weighed daily. On 06/27/24 at 07:54 AM, Licensed Nurse (LN) G stated the care plan should identify specific resident information. She stated all nursing staff have a part in the care plan. LN G stated all nurses were to ensure the care plan reflected accurate information for a specific resident. On 06/27/24 at 11:59 AM Administrative Nurse D stated the care plans were updated quarterly with anything that needs to be resolved or placed on the care plan. Administrative Nurse D stated all nursing staff can update or resolve a care plan. The facility's Electronic Care Plan policy dated December 2018 documented that the MDS coordinator was to initiate a review of the plan of care. Care plan review and revisions were to be completed with the wellness program. The interdisciplinary team (IDT) was to review, revise, and sign the person-centered plan of care related to their discipline. The MDS Coordinator was to complete the review of the care plan in the EMR. The facility failed to revise R11's Care Plan with his current care regarding weights. This deficient practice placed R11 at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 38 had a recapitulation of their stay including medication reconciliation. This placed R38 at risk for not receiving timely and appropriate care. Findings included: - The Electronic Medical Record (EMR) for R38 documented a diagnosis of rhabdomyolysis (breakdown of damaged skeletal tissue). The Admission Minimum Data Set (MDS) dated [DATE] documented R38 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The Functional Care Area Assessment (CAA) dated 02/26/24 for R38 documented he was skilled and was seen by therapy with the goal of returning home; improvement was anticipated as he worked with therapy. R38 required assistance with his activities of daily living (ADLs). R38's EMR recorded a Discharge Note dated 03/27/24 at 03:11 PM that documented R38 left the facility against medical advice (AMA) with family. R38's family was previously educated on leaving AMA and educated regarding the implications and risks. The facility's licensed master's social worker (LMSW) and nurse re-educated R38's family regarding leaving the facility AMA. R38's family asked questions and the LMSW answered their questions and the family voiced understanding. A Progress Note dated 03/28/24 at 09:21 AM recorded the LMSW made a report to Adult Protective Services with concerns for R38 due to cognition, safety awareness, and physical limitations. R38's clinical record lacked evidence the facility completed a recapitulation of R38's stay and lacked evidence of medication reconciliation. On 06/27/24 at 12:05 PM Administrative Nurse D stated that upon discharge the charge nurse was to send medications and set up services the resident would need to be successful in the home setting. Administrative Nurse D said when a resident left AMA, the charge nurse was to send enough medications to get the resident through a weekend if the pharmacy was closed. Administrative Nurse D said no services outside the facility could be set up when a resident leaves against medical advice but the charge nurse was expected to document a discharge with a recapitulation of the stay and include what medications were sent with the resident. The facility did not provide a policy and procedure for discharge. The facility failed to ensure R38's discharge summary had a recapitulation of the stay. This placed R38 at risk for not receiving timely and appropriate care.

The facility identified a census of 37 residents. The sample included 12 residents with one resident observed for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record reviews, and interviews the facility failed to ensure the standard of care was provided for Resident (R)1, who had a history of urinary tract infection (UTI-an infection in any part of the urinary system). This deficient practice placed R1 at risk of catheter-related complications and further UTIs. Finding included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of, cerebral palsy (a progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), kidney failure ( a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and urine retention. R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R1 was dependent on two-member assistance for activities of daily living (ADLs). R1 had an indwelling catheter and was taking an antibiotic during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 12 which indicated moderately impaired cognition. The MDS documented R1 had a catheter during the observation period. R1's Care Plan dated 04/19/24 documented R1 had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) to dependent drainage related to chronic UTIs and urinary retention. The plan of care documented staff was to provide catheter care every shift and staff would wash R1's peri-area with soap and water and dry well. R1's EMR under the Orders tab revealed the following physician orders: Clindamycin Palmitate HCl Oral Solution Reconstituted (Clindamycin Palmitate Hydrochloride) (antibiotic), Give 400 mg via feeding tube four times a day for suprapubic infection for nine days dated 05/08/24. Suprapubic catheter, staff to apply split four-by-four gauze to the area and secure with tape, change daily and as needed (PRN), dated 05/13/24. Doxycycline Hyclate (antibiotic) oral tablet 100 mg, give 100 mg by mouth two times a day for suprapubic catheter drainage for seven days dated 05/28/24. Levofloxacin (antibiotic) oral tablet give 750 milligrams (mg), give one tablet by mouth one time a day for suprapubic catheter infection for seven days., dated 06/04/24. Change suprapubic catheter every month on the day shift, use 16 French with 10 milliliters (ml) of normal saline, dated 06/18/24. On 06/25/24 at 07:28 AM R1 lay in his bed. His bed was in a low position and his fall mat was in place on the side of his bed. R1 had a urinary catheter bag secured to his bed frame. On 06/26/24 at 07:17 AM R1 lay on his bed. Certified Nurse's Aide (CNA) M put on an isolation gown, washed her hands, and donned her gloves. CNA M explained to R1 that she was going to do peri-care and get him dressed and up for breakfast. CNA M had CNA O help tuck R1's brief and then rolled R1 to his left side. CNA M washed R1's buttocks with a wipe, and then R1 was helped to roll onto his back. CNA M washed R1's front peri area with the same gloves and a clean wipe. CNA M failed to doff her gloves and perform hand hygiene from the dirty area to the clean area. CNA M and CNA O changed their gloves, did hand hygiene, and put a clean brief on R1 by rolling him from right to left. On 06/26/24 at 07:28 AM CNA M stated she should have doffed her gloves and performed hand hygiene while doing peri care when going from a dirty area to a clean area. CNA M stated all nursing staff had been inserviced on peri care and catheter care. On 06/27/24 at 07:18 AM, Licensed Nurse (LN) G stated the facility's process was to doff gloves and to perform hand hygiene from dirty to clean when doing peri care or catheter care. On 06/27/24 at 11:59 AM, Administrative Nurse D stated staff should have completed hand hygiene when going from a dirty area to a clean area, to avoid cross-contamination. The facility did not provide a policy for peri care and or catheter care. The facility failed to ensure the standard of care was provided during peri care for R1. This deficient practice placed R1 at risk of catheter-related complications and further UTIs.

The facility identified a census of 37 residents. The sample included 12 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)7 had a documented safety assessment for the use of side rails, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R7 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) noted diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dysphagia (swallowing difficulty), repeated falls, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R7's Admission Minimum Data Set (MDS) completed 05/22/24 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated he had upper and lower extremity impairments. The MDS indicated he required maximal assistance from staff for bed mobility, transfers, bathing, dressing, and grooming. The MDS indicated he had one non-injury fall since his admission. The MDS indicated no bed rails or body restraints were in use. R7's Functional Abilities Care Area Assessment (CAA) completed 05/29/23 indicated he depended on staff for activities of daily living (ADLs). The CAA indicated he exhibited communication difficulties with disorganized thoughts and inattention. The CAA indicated had fractured his left humerus and ribs in a fall prior to his admission to the facility. R7's Care Plan initiated 05/16/24 indicated he required staff assistance with his ADLs related to his physical limitations. The plan indicated he required the assistance of two staff and a gait belt for all transfers. The plan noted he was at risk for falls and had a perimeter mattress placed on his bed. The plan instructed staff to ensure his bed was positioned against the wall to decrease his risk of falls. The plan lacked documentation related to his bed canes (railing attached to assist with transferring). R7's EMR indicated a Clinical Health Review (dated 05/16/24) was completed upon his admission. The review indicated he attempted to get into and out of his bed unassisted, was able to turn himself from side to side, and currently used the grab bars to promote increased independence, bed mobility, and positioning. R7's EMR and physical chart lacked documentation related to potential risks for the assistive device, assessment of the device's placement, and consent for use. On 06/26/24 at 02:02 PM, R7 slept in his bed. R7's bed was positioned next to his wall and a perimeter mattress was in place. R7's bed had bilateral bed canes mounted. R7's wheelchair sat next to his bed and his call light was within reach. On 06/27/24 at 10:10 AM Certified Nurse Aide (CNA) P stated staff would check each resident's bed each shift, but she was unsure who was responsible for assessing the bed canes for safety or checking for gaps in them. On 06/27/24 at 10:24 AM Licensed Nurse (LN) G stated maintenance installed the bed canes, but she was not sure if the railing was inspected or checked after they were installed. She stated she was not where the bed rail assessments were completed. On 06/27/24 at 11:59 AM Administrative Nurse D stated the bed canes were used company-wide wide and she didn't think they needed to be assessed as bed railing. She stated maintenance installed the bed canes, but the facility was unable to provide documentation showing how often the installed canes were assessed, the potential risks related to the assistive canes, and consent for the bed canes. The facility was unable to provide a policy related to the management or assessment of bed rails as requested on 06/27/24. The facility failed to ensure that R7 had a documented risk assessment for the use of side rails, a consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R7 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails.

The facility identified a census of 37 residents. The sample included 12 residents, three medication carts, and two medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in one of the three medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On 06/25/24 at 07:27 AM a medication cart in the common area between halls 300 and 400 was unlocked and unattended. Inspection of the medication cart revealed the cart contained eye drops, nasal spray, stock medications, and numerous cards of medication. Three residents in wheelchairs were sitting near the unlocked and unattended medication cart. On 06//25/24 at 07:37 AM Certified Medication Aide (CMA) R stated that the medication cart contained overflow medications. CMA R locked the medication cart and stated the cart should be locked at all times when unattended. On 06 /27/24 at 12:15 PM Administrative Nurse D stated that all medication carts were to be locked when unattended. The facility policy Medication Storage dated 2007 states that in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access. The facility failed to properly store medications. This placed the affected residents at risk for adverse consequences or ineffective treatment to the affected residents.

The facility identified a census of 33 residents. The sample included three residents reviewed for abuse. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1, R2, R3, and R4 remained free from abuse when Certified Nurse Aide (CNA) M recorded the residents with her phone and sent the videos to an individual outside the facility. This deficient practice placed the residents at risk for further abuse and a decline in psychosocial well-being. Findings included: - The facility's investigative report CP 4537, dated 12/08/23, documented on 11/29/23, Administrative Staff A received a phone call from a law enforcement officer (LEO) stating through routine audits of inmates' tablet correspondence, two videos were noted to contain what they believed were residents at the facility which they concluded based on knowledge of the sender's employment at the facility. The LEO stated he could not share the videos, but Administrative Staff A was welcomed to view them at the station. Administrative Staff A and Administrative Nurse D went to the station and watched a video dated 11/28/23 at 06:33 PM of R1. In the video, R1 was observed sitting in his wheelchair next to his bed, looking out his bedroom window with his bedroom door observed closed behind him. R1 was fully clothed and wearing glasses and R1 was pointing past the individual recording, to his bedroom window mentioning that he believed someone was outside. The individual recording the video began to speak to R1, sounded feminine, and sounded like CNA M, who was confirmed as the sender by the LEO. The video continued to pan back and forth from R1 and the window, while R1 continued to make statements about someone being outside. CNA M asked R1 what he saw outside of the window and R1 spoke in a soft tone, but his responses were not clear. The video lasted approximately 30 to 45 seconds. Administrative Staff A and Administrative Nurse D then watched a video, dated 11/18/23 at 08:45 PM of R2. In the video, R2 sat in her wheelchair in the back lobby of the facility. She was fully dressed and no other residents were in the vicinity. The individual recording was not captured on camera, but a feminine voice was heard which sounded like CNA M. CNA M asked R2 what she was doing as R2 rolled her wheelchair back and forth in slow motion. R2 looked at CNA M and smiled but did not reply. CNA M repeated her questions and R2 continued to smile then mumbled something inaudible. The video lasted approximately 20 to 30 seconds. The LEO explained that inmates had access to a communications application (app) on tablets issued by the station and it was available for inmates to communicate with approved family and friends to promote contactless visits. Communication on the app was monitored and maintained by law enforcement. The station was unable to remove the videos from the app platform, but they were able to hide the videos from the sender and receiver which prevented them from being viewed or shared by others. The videos were now only accessible by law enforcement. Upon Administrative Staff A and Administrative Nurse D's return to the facility, CNA M was removed from the unit she worked and met with them . Administrative Staff A informed CNA M there was an investigation for an allegation that she provided resident information to an outside source. CNA M could not recall a date or time where she compromised or shared resident information. CNA M was informed that she was suspended effective immediately while the investigation was conducted. On 11/30/23, Administrative Staff A and Administrative Nurse D had CNA M return to the facility where she was issued termination paperwork and was asked if any resident images or video clips were saved to her personal device. CNA M stated that she did not have any and that all of the video clips that she sent her boyfriend were captured within the app and not uploaded from her personal device. CNA M stated that the videos were no longer accessible within the app. She apologized and insisted that her actions were purely innocent, and she cared deeply for her residents. She stated that her boyfriend was interested in what she did for a living, so she sent him short video clips. On 12/06/23, the surveyor entered the facility to investigate the incident and contacted CNA M who mentioned she recorded and shared an interaction with R3 through the app. The surveyor notified Administrative Staff A and Administrative Nurse D of the new information and a message was left with the LEO asking for further analysis of CNA M's app account because she mentioned a third resident. Later that afternoon, the LEO returned Administrative Staff A's call, stating that he located three other videos sent by CNA M and that she and Administrative Nurse D could view them at the station. Administrative Staff A and Administrative Nurse D arrived at the station to view the other three videos. A video on 11/23/23 at 03:12 PM showed R2 slept in her recliner in her bedroom. As CNA M entered the room, she was heard asking R2 what she was doing. R2 startled awake and stared blankly at CNA M. CNA M repeated her question while R2 remained seated in the recliner with her eyes half open. She repeated her question for a third time to which R2 replied she was sleeping. The video lasted 15 to 20 seconds. A video on 11/23/23 at 03:13 PM showed R4 in her bedroom, seated in her wheelchair while sifting through paperwork. CNA M was heard asking R4 what she was doing. R4 was startled as she did not see CNA M enter her room. R4 laughingly stated if she had a gun, she could have shot CNA M. CNA M was heard giggling in the background at R4's remark. The video lasted between 15 to 20 seconds. The last video viewed was dated 11/24/23 at 03:02 PM and showed R3 sitting in her wheelchair in her room with her eyes closed, appeared to be asleep. As CNA M entered the room, she approached R3 and asked her what she was doing. R3 startled awake, and looked at CNA M. The video lasted between 15 and 20 seconds. The LEO stated he reviewed CNA M's entire account and did not locate any further videos. Upon Administrative Staff A and Administrative Nurse D's return to the facility, they completed corrective actions in response to the discovery of three additional videos. On 12/06/23, R1 was unavailable for observation, he was admitted to the hospital on 12/04/23. On 12/06/23 at 12:34 PM, R2 sat in her wheelchair at a table in the dining room and ate lunch independently. On 12/06/23 at 12:50 PM, R3 transferred herself from her wheelchair to her recliner and stated to surveyor she was going to put her blanket on and rest. On 12/06/23 at 11:49 AM, CNA M stated she did not know it was a violation to send photos, but she knew she could not send inappropriate pictures and did not understand the circumstances. She stated she sent a video of R1 telling her about something being outside the window and she told her boyfriend that R1 was really funny. CNA M stated she also sent a video of R3 because she startled awake and jumped out of her chair. She stated she also took a video of R2 coming up to her in the lobby in her wheelchair. CNA M stated it had been seven years since she took the CNA class, and she knew she could not take any inappropriate pictures. On 12/06/23 at 11:59 AM, Administrative Staff A stated CNA M said the videos were taken on the application she downloaded through the station, and she was specifically asked if there were any other videos and CNA M stated no. On 12/06/23 at 12:00 PM, Administrative Nurse D stated CNA M was asked if she had any other videos on her cell phone or the app and she stated that no, R1 and R2's videos were the only two she ever sent. On 12/06/23 at 01:25 PM, CNA N stated residents' privacy was protected by keeping their information private and by not talking about them around unauthorized people. She stated it was not okay to take videos or pictures and information was not shared with anyone outside the facility. On 12/06/23 at 01:30 PM, Certified Medication Aide (CMA) R stated residents' privacy was protected by keeping the computer screen closed when not in use, not sharing their information, and redirecting unauthorized people who ask for information. She stated it was not okay to take pictures and videos of residents. On 12/06/23 at 01:36 PM, Licensed Nurse (LN) G stated residents' privacy was protected by not talking about them to unauthorized people and keeping the computer screen hidden. He stated it was never okay to take pictures and videos of residents. On 12/06/23 at 02:26 PM, Administrative Nurse D stated staff were not supposed to have their cell phones out and they were educated not to take pictures and videos when they started the job. She stated she also reminded staff during morning huddles about cell phone and social media usage. On 12/06/23 at 02:29 PM, Administrative Staff A stated she had received a call from the LEO that he reviewed conversations on inmate tablets and observed two videos that they believed were residents of the facility. She stated the LEO knew the sender was an employee at the facility. Administrative Staff A stated she, and Administrative Nurse D, met with the LEO to view the videos Administrative Staff A stated the LEO could not delete the videos, but they could make them invisible and only law enforcement could access them. She stated her and Administrative Nurse D returned to the facility and called CNA M into her office. Administrative Staff A informed CNA M they were doing an investigation in regard to an allegation for resident information being disclosed to someone on the outside. CNA M seemed baffled and did not know what they were talking about. Administrative Staff A stated staff were not allowed to obtain a photo or a video of a resident and only Administrative Nurse D and herself obtained pictures or videos during activities of those who had signed authorizations to have their picture taken. She stated the pictures and videos were reviewed by corporate compliance before they were approved to be posted on the facility's social media. On 12/06/23 at 02:50 PM, Administrative Staff A stated she called CNA M to ask about R3's video. She stated CNA M did admit to sending the video and stated she already told them about it, which she did not. The facility's Abuse, Neglect, and Exploitation (ANE) policy, last revised October 2022, directed residents had the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The facility's Cell Phone, Personal Digital Assistant (PDA), and Recording Devices Use Policy, not dated, directed when required, employees were only authorized to transmit company information and protected health information (PHI) via authorized applications. The policy directed the use of recording devices was restricted as the facility was required to maintain confidentiality for patients and employees; and even incidental or causal use of recording devices was prohibited due to the potential violation of personal rights, PHI, or the disclosure of proprietary information. The policy directed only administrators and regional [NAME] Presidents were authorized to take pictures and videos and authorized consent was collected from patients and employees prior to the use or distribution of photography, video, or audio. The facility failed to ensure R1, R2, R3, and R4 remained free from abuse when CNA M recorded the residents with her phone and sent the videos to an individual outside the facility. This deficient practice placed the residents at risk for further abuse and a decline in psychosocial well-being.

The facility identified a census of 36 residents. The sample included three residents. Based on record review and interviews, the facility failed to follow-up with Resident (R) 1's physician when he experienced a change in condition. This deficient practice had the risk for delayed treatment and unwarranted physical complications. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of hyperosmolality (increased concentration of dissolved particles in the blood) and hypernatremia (greater than normal concentration of sodium in the blood), dehydration, urinary tract infection (UTI), need for assistance with personal care, and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score was not completed due to R1 rarely or never understood. R1 required extensive assistance with two staff for bed mobility, dressing, and toileting; extensive assistance with one staff for locomotion, eating, and personal hygiene; and total dependence of two staff for transfers. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 03/23/23, documented R1 was alert with very impaired cognition that fluctuates throughout the day. The Dehydration/Fluid Maintenance CAA dated 03/30/23, documented R1 was readmitted from the hospital with weakness and severe impaired cognitive status. His cognition could have contributed to him forgetting to drink an adequate amount of fluids to keep hydrated. The Activities of Daily Living (ADL)/Communication/Skin care plan, initiated 10/03/21 and last revised 06/07/23, documented R1 required total staff assistance with ADLs related to his decline in health status. The Care Plan directed staff anticipated his needs as he had a decline in his health and was unable to verbalize his needs. The Notes tab of R1's EMR revealed the following: A Nurse's Note on 06/01/23 at 10:03 AM documented a fax to the provider that R1 had been more lethargic and required more assistance with ADLs. The fax asked the provider if staff could check a urinalysis (UA- examination of urine). A Nurse's Note on 06/04/23 at 01:48 PM documented R1 had a sudden onset of body tremors, his eyes were open, but he was not responding to any verbal or tactile reactions, and his body wa ridged. A phone order was received by the provider to send R1 to the Emergency Department (ED) for evaluation and treatment. R1's representative and Administrative Nurse D were notified. A Nurse's Note on 06/04/23 at 05:59 PM documented R1 was admitted to the hospital for hypernatremia, urinary retention (lack of ability to urinate and empty the bladder), and hypoglycemia (low blood sugar). R1's clinical record lacked evidence the facility followed up with R1's physician after he had a change in condition on 06/01/23. On 06/13/23 at 01:42 PM, Licensed Nurse (LN) G stated if a resident had a change in condition, such as lethargy or needing more assistance with ADLs, the physician was notified by phone or fax. He stated if it was via fax during the week and in the morning, he expected a reply by the afternoon. LN G stated he would want to know the physician response within 24 hours and if a fax was sent to the physician, then it was passed on in report for the next day to follow-up on. On 06/15/23 at 12:47 PM, Administrative Nurse D stated if a resident had a change in condition, the staff assessed the resident and called to doctor to see what orders they wanted. She stated if the doctor was notified via fax, then staff tried to get a response back that same day but if not then it should be followed up on the next day. Administrative Nurse D stated the facility should have followed up on the fax about the UA for R1. The facility did not have a policy on change in condition or physician notification of changes. The facility failed to follow-up with R1's physician when he experienced a change in condition on 06/01/23. This deficient practice had the risk for delayed treatment and unwarranted physical complications.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 34 residents who resided in the facility and received their food from the facility kitchen, when staff failed to use safe food handling in the dining room during the meal distribution to the residents seated at the dining room table. - On 09/12/22 at 11:43 AM, observation revealed Dietary Staff (DS) BB had her mask below her nose, covering her mouth. Continued observation revealed DS BB picked up Resident (R) 23's glass on the top of the cup with her bare hands filled the cup with apple juice from the beverage cart then delivered it to the resident, continuing to deliver by touching the top of the cup/lip service. DS BB picked up R19's glass on the top of the cup with her bare hands filled the cup with lemonade from the beverage cart then delivered it to the resident, continued to deliver by touching the top of the cup/lip service. Continued observation revealed DS BB did not use hand gel or wash her hands before she touched the beverage cart then readjusted her mask over her nose, picked up 134's glass on the top of the cup with her bare hands filled one cup with water and another cup with lemonade from the beverage cart then delivered it to the resident, continued to deliver by touching the top of the cup/lip service. DS BB picked up 17's glass on the top of the cup with her bare hands filled one cup with water and another cup with fruit punch from the beverage cart then delivered it to the resident, DS BB took a straw out of the paper cover and touched the lip surface on the straw and placed it in the glass and continued to deliver by touching the top of the cup/lip service. DS BB pushed the cart over to another table and continued with the same service of touching the top of the glasses and cups before delivery to the residents. On 09/13/22 at 12:07 PM, observation revealed DS BB pouring residents preferred beverage and touching the drinking surfaces of the glasses. On 09/13/22 at 12:20 PM, DS BB verified the touching of the cups lip surface was not sanitary. On 09/15/22 at 10:30 AM, Administrative Staff A verified staff should not touch the top of the cups and glasses before delivery to the residents and they had completed an in-service yesterday for all the dietary staff on 09/14/22 to review safe serving. Upon request the facility's lack providing a Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices policy. The facility failed to perform sanitary practices during the meal services, placing residents at risk for communicable illnesses.

The facility had a census of 34 residents. The sample included 12 residents with one resident reviewed for non-pressure related skin condition. Based on observation, record review, and interview, the facility failed to administer topical medication in an effective manner in accordance to standards of practice for Resident (R)27. This placed the resident risk for delayed healing. Findings included: -R27's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set, dated dated [DATE], documented R27 had severe cognitive impairment, required extensive to total care with the assistance of one to two staff, had functional range of motion impairment of one side to upper and lower extremities. R27 was always incontinent of urine and bowel, at risk of developing pressure ulcer/injury, had moisture associated skin damage (MASD-skin damage caused by prolonged exposure to various sources of moisture) and application of ointment/medications other than to her feet. The Pressure Ulcer Care Area Assessment (CAA), dated 08/17/22, documented R27 was at risk for additional skin breakdown and depended on staff to anticipate her needs and check and change every two to three hours with repositioning to keep R27 free from additional skin breakdown and to heal existing areas without signs or symptoms of infections. The Incontinence/Skin Care Plan, dated 08/29/22, documented R27 was at risk for skin breakdown, and to make sure skin folds stayed dry to prevent redness to the skin. The Skin Condition Note, dated 09/11/22, documented a new red rash under R27's right axillary (armpit), and to treat with [MEDICATION(S)] powder (powder which treats fungal or yeast infections of the skin) three times a day until healed. The Physician Order, dated 09/11/22, instructed staff to apply [MEDICATION(S)] Powder to right axillary three times a day for rash until healed. On 09/13/22 at 01:53 PM, observation revealed Licensed Nurse (LN) G applied [MEDICATION(S)] powder to R27's right axillary. LN G had Certified Nurse Aide (CNA) M assist with positioning the resident to expose the right axillary. LN G commented on the odor from R27's axillary. R27 had visible redness, irritation and notable residue of powder to the right axillary. Without cleansing the area, removing the old powder residue, or drying the area, LN G placed the [MEDICATION(S)] powder to the area. On 09/15/22 at 02:00 PM Administrative Nurse D stated the affected area would only need to be cleansed if indicated in the physician orders. The facility's Topical Medication Administration, undated policy, documented to administer topical in a safe, accurate, and effective manner. Examine resident's skin for exudate, drainage, or residue from previous treatment applications. Cleanse or irrigate the area per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to apply R27's medicated powder in an effective manner in accordance with the standards of care which placed the resident at risk for slowed or impaired healing to affected right axillary.

The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to identify and report to the Director of Nursing, facility medical director, and physician, an inappropriate diagnosis for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R)22. This placed the resident at risk for inappropriate use of an antipsychotic medication with side effects. Findings include: - R22's Physician Order Sheet (POS), dated 08/25/22, documented diagnoses of dementia (group of symptoms that affects memory, thinking and interferes with daily life) without behavioral disturbance, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure.) The Admission Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. The MDS documented R22 had physical behaviors towards staff and physical behaviors of hitting and rejection of cares. R22 required extensive assistance with activities of daily living (ADLS.) The MDS documented the resident received antipsychotic and antidepressant (medication used to treat mood disorders) medication six days of the look back period. The [CONDITION(S)] Care Area Assessment (CAA), dated 08/16/22, documented R22 was admitted from home with a diagnosis of Alzheimer's dementia and [CONDITION(S)] disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). The CAA directed the staff to proceed to the care plan to monitor for signs and symptoms of adverse reaction to [CONDITION(S)] (medications which alter mood or thought) medication during therapeutic use. R22 took [MEDICATION(S)] (antipsychotic) for dementia. The Cognitive/Dementia CAA, dated 08/16/22, documented R22 had a diagnosis of Alzheimer's disease and exhibited verbal and physical behaviors toward staff when the attempt to assist him with cares. Staff were to provide encouragement and praise for allowing prompts and cues and anticipate needs throughout the day. The Physician's Order, dated 08/03/22, directed the staff to administer R22 [MEDICATION(S)] 50 milligrams (mg), daily for a diagnosis of dementia with behavioral disturbance. The Consultant Pharmacist Review, dated 08/24/22, lacked note of any irregularities. On 09/12/22 at 09:35AM, observation revealed R2 sat at the living room, between the 300 and 400 halls, in a wheelchair. Certified Medication Aid (CMA) S administered [MEDICATION(S)] (anti acid medication) one packet, delayed release, 40 mg oral suspension, [MEDICATION(S)] sprinkles capsule (antianxiety medication) delayed release 125 mg, two tablets, [MEDICATION(S)] (diuretic medication) 20 mg, two tablets and liquid potassium chloride (potassium supplement) solution 15 milliliters (ml.) to the resident. On 09/15/22 at 10:15 AM, Administrative Nurse D verified the inappropriate diagnosis of dementia for the use of [MEDICATION(S)]. Administrative Nurse D verified the facility had contacted R22's primary care physician and he did not change the diagnosis for the medication stating it was for dementia with behavioral disturbance. Administrative Nurse D verified the pharmacist consultant made no recommendation in the 08/24/22 review. The facility's Behavior Management and [CONDITION(S)] Medications policy, dated 12/2017, documented to enhance the quality of life through behavioral interventions minimized [CONDITION(S)] drug use. Residents are to be assessed for appropriate diagnosis, utilization, adverse side effects, and targeted behaviors related to [CONDITION(S)] medication use. The facility is to review residents exhibiting new or prolonged behaviors weekly during Risk Committee Meetings. [CONDITION(S)] medications are not to be initiated without prior communication between physician, resident or responsible party and the facility interdisciplinary team. The consulting pharmacist is to complete a Medication Regimen Review monthly and provide information to the physician and facility regarding gradual dose reduction or continued use when indicated, appropriate diagnosis, and monitoring of target behaviors. The policy documented the [CONDITION(S)] medication uses and resident behaviors are to be reported to and reviewed by the facility Quality Assurance Process Improvement Committee monthly. The facility's Medication Regimen Review and Reporting policy , dated 09/2018. documented Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medications. The MRR includes review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. The MMR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative. The consulting pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consulting pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's order, progress notes, nurse's notes, the Resident Assessment Instrument(RAI) , Minimum Data Set(MDS), lavatory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the residents' care. He findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filled with other consulting pharmacist recommendation in the resident's chart. The facility failed to ensure the Consultant Pharmacist identified and made recommendations to the facility Director of Nursing (DON), medical director, and physician regarding the inappropriate diagnosis of antipsychotic medication, [MEDICATION(S)]. This placed the resident at risk for inappropriate use of an antipsychotic medication with side effects.

The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for one of the five sampled residents, Resident (R) 22's, antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication [MEDICATION(S)]. This placed R22 at increased risk for side effects related to medications and unnecessary medication use. Findings include: - R22's Physician Order Sheet (POS), dated 08/25/22, documented diagnoses of dementia (group of symptoms that affects memory, thinking and interferes with daily life) without behavioral disturbance, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure.) The Admission Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. The MDS documented R22 had physical behaviors towards staff and physical behaviors of hitting and rejection of cares. R22 required extensive assistance with activities of daily living (ADLS.) The MDS documented the resident received antipsychotic and antidepressant (medication used to treat mood disorders) medication six days of the look back period. The [CONDITION(S)] Care Area Assessment (CAA), dated 08/16/22, documented R22 was admitted from home with a diagnosis of Alzheimer's dementia and [CONDITION(S)] disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). The CAA directed the staff to proceed to the care plan to monitor for signs and symptoms of adverse reaction to [CONDITION(S)] (medications which alter mood or thought) medication during therapeutic use. The resident took [MEDICATION(S)] (antipsychotic) for dementia. The Cognitive/Dementia CAA, dated 08/16/22, documented R22 had a diagnosis of Alzheimer's disease and exhibited verbal and physical behaviors toward staff when the attempt to assist him with cares. Staff were to provide encouragement and praise for allowing prompts and cues and anticipate needs throughout the day. The Physician's Order, dated 08/03/22, directed the staff to administer R22 [MEDICATION(S)] 50 milligrams (mg), daily for a diagnosis of dementia with behavioral disturbance. On 09/12/22 at 09:35AM, observation revealed R22 sat at the living room, between the 300 and 400 halls, in a wheelchair. Certified Medication Aid (CMA) S administered [MEDICATION(S)] (anti acid medication) one packet, delayed release, 40 mg oral suspension, [MEDICATION(S)] sprinkles capsule (antianxiety medication) delayed release 125 mg, two tablets, [MEDICATION(S)] (diuretic medication) 20 mg, two tablets and liquid potassium chloride (potassium supplement) solution 15 milliliters (ml.) to the resident. On 09/15/22 at 10:15 AM, Administrative Nurse D verified the inappropriate diagnosis of dementia for the use of [MEDICATION(S)]. Administrative Nurse D verified the facility had contacted R22's primary care physician and he did not change the diagnosis for the medication stating it was for dementia with behavioral disturbance. Administrative Nurse D verified the pharmacist consultant made no recommendation in the 08/24/22 review. The facility's Behavior Management and [CONDITION(S)] Medications policy, dated 12/2017, documented to enhance the quality of life through behavioral interventions minimized [CONDITION(S)] drug use. Residents are to be assessed for appropriate diagnosis, utilization, adverse side effects, and targeted behaviors related to [CONDITION(S)] medication use. The facility is to review residents exhibiting new or prolonged behaviors weekly during Risk Committee Meetings. [CONDITION(S)] medications are not to be initiated without prior communication between physician, resident or responsible party and the facility interdisciplinary team. The consulting pharmacist is to complete a Medication Regimen Review monthly and provide information to the physician and facility regarding gradual dose reduction or continued use when indicated, appropriate diagnosis, and monitoring of target behaviors. The policy documented the [CONDITION(S)] medication uses and resident behaviors are to be reported to and reviewed by the facility Quality Assurance Process Improvement Committee monthly. The facility's Medication Regimen Review and Reporting policy, dated 09/2018. documented Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medications. The MRR includes review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. The MMR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative. The consulting pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consulting pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's order, progress notes, nurse's notes, the Resident Assessment Instrument(RAI) , Minimum Data Set(MDS), lavatory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the residents' care. He findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filled with other consulting pharmacist recommendation in the resident's chart. The facility failed to ensure R22 did not receive antipsychotic medication without an appropriate diagnosis or clinical justification for its use, placing R22 at risk for adverse side effects related to the use of [MEDICATION(S)].

The facility had a census of 31 residents. The sample included 12 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to implement timely interventions for Resident (R) 12, identified as at risk for pressure ulcer development, to prevent the development of an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed due to the wound bed being obscured by slough, non-viable or dead tissue with yellow, tan, gray, green or brown appearance) to the right heel for one of two sampled residents. Findings included: - R12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Admission Minimum Data Set (MDS), dated [DATE], documented the resident's brief interview for mental status (BIMS) score was 10, which indicated moderately impaired cognition. The resident needed extensive assistance of one staff for bed mobility, transfers, locomotion on unit, dressing, toilet use, and personal hygiene. She required supervision and set up help for eating. The resident was at risk for pressure ulcer development with no unhealed pressure ulcers at the time of the assessment. She had a pressure relieving device for her chair and bed. She was on a repositioning program, received nutrition interventions to manage skin problems, and used ointments/medications other than to her feet. The Activity of Daily Living Care Area Assessment (CAA), dated 02/12/21, documented R12 admitted from home where she lived by herself. She had significant weakness and required assistance for personal cares. The Pressure Ulcer/Injury CAA, dated 02/12/21, documented R12 had significant weakness and required extensive staff assistance for all transfers and re-positioning. She admitted with open areas to her left buttocks and her coccyx. The Activities of Daily Living Care Plan, dated 02/03/21 directed staff that R12 needed extensive assistance of one staff with transfers and toileting, and required total assistance for peri-cares. The Skin/Incontinence Care Plan, dated 02/03/21, documented the resident had a pressure reducing mattress to her bed and a pressure reducing cushion to her wheelchair. The care plan directed staff to reposition the resident to relieve pressure to her buttocks every 2-3 hours. On 04/16/21, staff initiated a low loss air mattress, the resident had an open area to her right heel, and bilateral heel boots were to be worn at all times. The Admission Skin Assessment, dated 02/02/21, documented R12 admitted to the facility with two open area to her left inner buttock and one open area to her coccyx. The resident had 1+ [CONDITION(S)] (swelling) in her bilateral lower extremities. The documentation lacked an assessment of R12's heels. The Braden Scale Assessment (assessment for predicting pressure ulcer risk), dated 02/02/21, recorded a score of 18 which indicated a mild risk for developing pressure ulcers. The Skin Condition Note, dated 03/01/21, documented R12's right heel was boggy (soft), red, with 2+ [CONDITION(S)] in the right foot, and 1+ [CONDITION(S)] in the left foot. The intervention recorded on this note instructed staff to float the resident's heels when in bed and apply skin barrier (skin protectant) to the right heel twice a day. Notification was sent to the doctor and the wound care nurse. From 03/01/21 through 04/15/21 the Skin Condition Notes lacked documentation of the status of the resident's right heel. Staff completed weekly skin checks every Wednesday. The Skin Condition Note, dated 04/15/21 (46 days later), documented a new break down on the resident's right heel. The note identified the surrounding area of the wound as boggy (soft and mushy to touch). Measurements of the wound were 0.6 centimeters (cm) x 0.6 cm x 0.1 cm. Treatment was to clean with wound cleanser, apply hydrogel to wound bed, cover with 4 X 4 dressing, and paint skin around the wound with wound wipe. Staff should float the resident's heels at bedtime. Notification was sent to the doctor and the wound care nurse. The note lacked a description of the appearance of the wound. The Skin Condition Note, dated 04/20/21, documented the existing right heel wound measured 0.9 cm x 0.6 cm x 0.1 cm. Interventions included bilateral heel protectors and to float the heels when lying in bed. The note also indicated the resident was a total assist for all activities of daily living at that time. Notification was sent to the doctor and the wound care nurse. The note lacked a description of the appearance of the wound. On 04/20/21 at 02:38 PM, observation revealed Licensed Nurse (LN) G entered the resident's room to perform a dressing change to the right heel. LN G washed his hands, applied gloves, and removed the old dressing with no drainage noted. The wound bed had 75% granulation (new connective tissue) tissue and 25% slough. LN G cleansed the wound with wound cleanser and a 4 x 4 gauze. The wound measured 0.9 cm x 0.6 cm x 0.1 cm. LN G applied Hydrogel (a type of dressing used to remove slough and promote wound healing) to the wound bed and then applied a bordered dressing over the wound. On 04/21/21 at 01:00 PM, observation revealed R12 seated in her wheelchair with a pressure relieving cushion in place and heel protectors in place. On 04/21/21 at 01:30 PM, observation revealed two staff assisted the resident in bed and positioned her on her right side. Staff floated her heels off of the bed with pillows. On 04/21/21 at 09:16 AM, Certified Nurse Aide (CNA) M stated staff repositioned the resident every two hours. The resident declined since her admission and now she required two-person assistance for positioning and transfers. CNA M stated staff started using the heel protectors a couple of weeks ago . On 04/21/21 at 02:44 PM, LN G stated the resident had a new pressure ulcer to her right heel that was found last week. He stated the resident used to have a pressure ulcer to her left buttock and coccyx that was present on admission, but it had since healed. Nursing staff assessed the resident's skin weekly. Staff used skin prep (protective solution for skin) to her heel twice a day and floated her heels on a pillow. On 04/21/21 at 03:41 PM, Consultant GG stated the resident declined since admission and her skin was very frail. On 04/22/21 at 04:17 PM, CNA N stated staff repositioned the resident every two hours, but she personally repositioned the resident every hour because her skin is so frail. CNA N stated staff have been placing the heel protectors to her feet for about two weeks now. On 04/26/21 at 11:43 AM, Administrative Nurse D stated the wound care nurse should be the one to perform all of the wound assessments. R12 had [CONDITION(S)] (swollen) skin and staff changed the ace wraps to her legs 4-5 times a day because of weeping. There was a lack of communication between the wound care nurse and the charge nurse. Administrative Nurse D verified the nurse that found the boggy heel on 03/01/21 should have reported that information to the wound nurse. The facility's Wound Prevention and Management policy, dated December 2017, stated all residents will be assessed in the first 4 hours of admission and with significant change using the Braden scale to determine the risk for breakdown. If risk is identified, interventions will be implemented and documented in the care plan. The facility failed to implement timely interventions to prevent the development of an unstageable pressure ulcer to R12's right heel after staff discovered the heel was boggy.

The facility identified a census of 42 residents, 33 of which were noted to be independently mobile. Based on observation, record review, and interview the facility failed to provide an environment that was free from accident hazards. The facility failed to have a system in place to monitor hot water temperatures in common areas accessible to residents. This placed the residents in immediate jeopardy Findings included: - During the initial tour on 12/12/13 at 9:45 A.M. it was noted the sink in the dining room, which was accessible to all residents at any time had inappropriately high temperatures of water. On 12/12/13 at 10:26 A.M. the temperature registered at 153.5 degrees Fahrenheit. A second thermometer was used at 10:29 A.M. and revealed a result of 159.4 degrees Fahrenheit. Maintenance staff X used his/her thermometer to check the temperature of the dining room sink on 12/12/13 at 10:31 A.M. which revealed a temperature of 158.7 degrees Fahrenheit. Interview with maintenance staff X on 12/12/13 at 10:32 A.M. revealed he/she was responsible for monitoring water temperatures for the facility. He/she stated the dining room sink was not included in the monitoring of water temperatures. Interview on 12/19/13 at 9:48 A.M. with administrative staff A revealed he/she expected all sinks accessible to residents to be part of the spot checks of water temperatures performed by the maintenance department, including the dining room sink. The undated policy regarding testing water temperatures provided by the facility revealed all designated sinks were to be checked weekly, resident rooms on a rotating basis with a minimum of 1 room per week off each water heater. The facility failed to provide an environment that was free from accident hazards over which the facility had control regarding hot water temperatures in residential common areas. The immediate jeopardy was abated on 12/18/13 at 7:30 A.M. when the facility inserviced all staff on identification of water temperature variances, the maintenance department installed a temperature reducing valve on the dining room sink so the water would not exceed 120 degress Fahrenheit, and the facility implemented the policy to check the dining room sink temperature weekly. The environmental director and safety committee would be responsible for ongoing compliance. This deficient practice of failure to monitor water temperatures remains at a scope and severity level of E.

The facility had a census of 42 residents. The sample included 18 residents. Based upon observation, record review and interview the facility failed to provide adequate services and treatment to prevent and promote the healing of pressure ulcers for 2 (#17, #5) of 3 sampled residents. Findings included: -Resident #17 ' s physician's orders [REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 dated 11/23/13 identified the resident scored 8 (moderately impaired cognition) on the Brief Interview for Mental Status, did not have behaviors, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, toilet use, and personal hygiene, limited staff assistance with eating, and did not walk in the room/corridor. The MDS coded the resident was frequently incontinent of urine, weighed 114 pounds and had not experienced a weight loss. The MDS identified the resident was at risk for the development of pressure ulcer and had (1) unstageable pressure ulcer not present upon admission/entry or reentry, that measured 0.9 centimeter (cm) by 0.8 cm by 0.0 cm. The MDS recorded the resident had a pressure relieving device on his/her bed, chair and was on a turning/repositioning program. The resident ' s Activities of Daily Living Care Area Assessment (CAA) dated 6/16/13 documented the resident was dependent upon staff for his/her daily needs, had impaired decision making skills, and required staff assistance with transfers. The resident ' s Nutritional Status CAA dated 6/16/13 documented the resident required set up and cueing during meals, and received nutritional supplements with meals due to weight loss. The resident ' s Pressure Ulcer CAA dated 6/16/13 documented the resident had an unstageable pressure ulcer and received nutritional supplements and ProStat (a liquid protein supplement) to promote healing. The resident ' s care plan with a print date of 6/19/13 included the resident had a Stage 4 pressure ulcer on his/her right ankle and was at risk for additional skin breakdown due to periods of incontinence, impaired decision making skills and decreased mobility. The care plan included staff offloaded the resident ' s heels and ankles as the resident allowed, and the resident preferred to lay on his/her right side. The resident received nutritional supplements three times a day with meals and staff also offered the nutritional supplements between meals. Staff offered the resident 30 cubic centimeters (cc ' s) of ProStat twice a day to promote wound healing. The care plan included an entry dated 10/4/13 that included staff offered the resident fortified foods at meals. The resident ' s weight log revealed the following weights: 3/1/13: 132 pounds (#) 5/1/13: 124# (decrease of 8# or 6.06 percent (%) of the resident ' s body weight in 2 months) 6/1/13: 119# (decrease of 13# or 9.84 percent (%) of the resident ' s body weight in 3 months) A laboratory report dated 10/2/13 recorded the resident ' s serum [MEDICATION NAME] level at 2.0 grams/deciliter (gm/dL), normal reference range 3.4-5.0 gm/dL. The resident ' s laboratory report dated 10/28/13 recorded the resident ' s [MEDICATION NAME] level at 12 milligrams/deciliter (mg/dL), normal reference range 20-40 mg/dL. A registered dietician (RD) note dated 5/20/13 documented the resident had developed an unstageable pressure ulcer on his/her right ankle, and the RD recommended re-starting the resident on Pro-Stat 30 cc twice a day to promote wound healing. The resident consumed the house shakes and to continue the house shakes twice a day. A RD note dated 11/1/13 documented the resident had a Stage 4 pressure ulcer o his/her right ankle, the resident ' s current weight was down 11 pounds in less than 30 days, and the resident ' s [MEDICATION NAME] and total protein level were low. The resident had received ProStat 30 ccs twice a day, and recommended changing from the current ProStat to ProStat AWC (Advance Wound Care) 30 cc ' s three times a day. The resident had received house shakes three times a day between meals and recommended the resident received fortified foods at meals. A physician's order [REDACTED]. A physician's order [REDACTED]. The facility ' s Wound Management Log dated 5/2/13 documented on 4/26/13 staff observed the resident had an unstageable wound on his/her right heel from shearing caused by the resident ' s shoe that measured 0.3 centimeter (cm) by 0.3 cm X undetermined depth (UTD). The log also documented the resident had an unstageable pressure ulcer on his/her right lateral ankle that measured 0.3 cm by 0.2 cm by UTD. The unstageable wound on the resident ' s heel healed between 5/9/13 and 5/16/13. The facility ' s Wound Management Log dated 6/6/13 documented the unstageable pressure ulcer on the resident ' s right lateral ankle measured 0.8 cm by 0.5 cm by UTD The facility ' s Wound Management Log dated 7/2/13 documented the unstageable pressure ulcer on the resident ' s right lateral ankle measured 1.0 cm by 0.9 cm by UTD. The facility ' s Wound Management Log dated 8/1/13 documented the unstageable pressure ulcer on the resident ' s right lateral ankle was debrided on 8/1/13 and now measured 1.3 by 1.1 by 0.1 cm. The facility ' s Wound Management Log dated 9/6/13 documented the resident had a Stage 4 pressure ulcer on his/her right lateral ankle that measured 1.5 cm by 1.5 cm by 0.2 cm. The resident ' s right lateral foot had multiple blanching [DIAGNOSES REDACTED] spots. The wound was larger and progressed to a stage four wound. The facility ' s Wound Management Log dated 10/3/13 documented the Stage 4 pressure ulcer on the lateral aspect of the resident ' s right ankle measured 1.4 cm by 1.4 cm with minimal depth The facility ' s Wound Management log dated 11/26/13 documented the Stage 4 pressure ulcer on the lateral aspect of the resident ' s ankle measured 1.3 cm by 1.3 cm by UTD. The log further documented on 11/24/13 the resident acquired a suspected deep tissue injury pressure ulcer on the distal lateral aspect of his/her right ankle that measured 1 cm by 1.3 cm by UTD. The facility ' s Wound Management Log dated 12/12/13 documented the Stage 4 pressure ulcer on the proximal lateral aspect of the resident ' s right ankle measured 0.6 cm by 1.2 cm by UTD. The pressure ulcer on the distal lateral aspect of the resident ' s right ankle was a Stage 3 that measured 1.2 cm by 1.3 cm with minimal depth. Review of the resident ' s November and December 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the resident ' s November 2013 MAR indicated [REDACTED]. Review of the resident ' s October, November and December 2013 MAR indicated [REDACTED]. On 12/17/13 the resident sat in his/her wheelchair in the main lobby of the facility at 11:24 A.M., 11:31 A.M., 11:45 A.M, and 11:55 A.M. At 11:55 A.M. staff pushed the resident from the main lobby of the facility to a dining room table. At 12:05 P.M., 12:09 P.M., 12:19 A.M., 12:33 P.M. 12:45 P.M., 12:59 P.M., 1:05 A.M. and 1:09 P.M. the resident continued to sit in the wheelchair at the dining room table. Observation at 12:33 P.M. did not reveal the resident received the nutritional supplement with the lunch meal. The resident finished the lunch meal at 12:59 P.M. and observation did not reveal the resident had received the supplement during the lunch meal. At 1:24 P.M., 1:37 P.M and 1:49 P.M. the resident sat in his/her wheelchair in the area adjacent to the main lobby of the facility (the resident sat in the wheelchair for a duration of 2 hours 2 minutes). On 12/17/13 at 3:00 P.M. the resident sat in a recliner in the main lobby area of facility, Observation revealed the foot rest of recliner elevated, staff did not offload the resident ' feet and the resident ' s white gripper socks in direct contact with the foot rest of recliner. Observation also revealed the sides of the resident ' s feet in direct contact with each other. On 12/17/13 at 3:10 P.M., 3:25 PM., 3:41 P.M., 4:00 P.M., 4:15 P.M. and 4:27 P.M., the resident sat in the recliner in the main lobby area of the facility. The resident had on white gripper socks. Observation revealed the bottom of the resident ' s left foot in direct contact with the top of the resident ' s right foot. On 12/18/13 at 8:01 A.M. observation revealed the resident laid in bed on his/her left side,on a low air loss mattress, and the resident ' s feet offloaded on pillows. The resident remained in bed on his/her left side at 8:15 A.M., 8:30 A.M., 8:45 A.M., 9:00 A.M., 9:15 A.M., 9:30 A.M., 9:45 A.M., 9:58 A.M., 10:15 A.M., 10:30 A.M. and 10:40 A.M. (duration of 2 hours and 39 minutes). On 12/18/13 at 10:40 A.M. licensed nurse J entered the resident ' s room to perform the resident ' s pressure ulcer treatment. Observation revealed the resident had 2 pressure ulcers on the outer aspect of his/her right ankle. The Stage 4 pressure ulcer (acquired 11/24/13) contained approximately 50% slough (non-viable tissue) and measured approximately 1.0 cm by 1.0 cm. The Stage 3 pressure ulcer (acquired 4/26/13) measured approximately .5 cm by .5 cm and the wound bed contained approximately 5% slough. Licensed nurse J stated the pressure ulcers were facility acquired; staff turned the resident from left side to back every 2 hours. Licensed nurse J stated the resident received nutritional supplements at meals and if the resident was restless staff offered the resident, Boost, the nutritional supplement the hospice provider provided. Licensed nurse J stated the facility had not consistently documented the resident ' s consumption of the nutritional supplements and the facility was in the process of developing new documentation guidelines for nutritional supplements. After licensed nurse J completed the treatment, he/she placed a pillow between the resident ' s right and left leg (the resident ' s right leg was on top of the pillow), did not offload the resident ' s left foot; therefore the resident ' s left foot was in direct contact with the mattress cover. Licensed nurse J placed a sock and a heel protector on the resident ' s right foot. On 12/19/13 at 9:40 A.M. the resident laid in bed on his/her right side. Observation revealed the resident ' s feet not offloaded, no heel protectors or socks on and the resident ' s feet in direct contact with the mattress cover. On 12/19/13 at approximately 10:10 A.M. physician Y entered the resident ' s room. Observation revealed the resident in bed, the resident ' s feet were not offloaded and no heel protectors on. Physician Y stated staff should reposition the resident on his/her back or left side every 2 hours. Physician Y stated staff should offload the resident ' s feet and the resident should wear heel protectors. On 12/18/13 at 12:02 P.M. direct care staff V stated staff repositioned the resident every 2 to 3 hours, and the resident wore heel protectors and gripper socks bilaterally when he/she was in bed. Direct care staff V stated the resident received nutritional supplement with meals and the facility communicated the resident ' s needs and care via the resident ' s profile sheet. On 12/19/13 at 7:28 A.M. dietary staff DD stated the resident should receive nutritional shakes at each meal. On 12/19/13 at 9:52 A.M. licensed nurse J stated staff offloaded the resident ' s feet with pillows during the day and at night the resident wore heel protectors. Licensed nurse J stated the resident received ProStat three times a day and the resident would consume the ProStat if staff mixed it with juice or nutritional supplement. On 12/19/13 at 10:29 A.M. physician Y stated if the resident ' s [MEDICATION NAME] and/or protein levels were not within normal range, ProStat and nutritional supplements would promote wound healing. On 12/19/13 at 11:44 A.M administrative nursing staff D stated the pressure ulcers on the resident ' s right ankle were facility acquired. Administrative nursing staff D stated staff should reposition the resident at least every 1 ? hours to 2 hours, and staff offloaded the resident ' s bony prominences with pillows. Administrative nursing staff D stated staff should administer and document the ProStat and nutritional supplements were administered as physician ordered. The facility Pressure Ulcer policy and procedure revised 1/13/12 included early intervention and prevention included individualized repositioning, for residents who were non-complaint or simply chose not to reposition, nursing staff at least weekly educated the resident of the risks of not repositioning in a timely manner, and documented in the nurse ' s notes and care plan. Proper positioning included use of pillows, and heel floats. Vitamins and mineral supplements would be given to residents as recommended by the physician. The facility failed to reposition the resident at least every 2 hours, failed to offload the resident ' s feet and failed to consistently offer the ProStat and nutritional supplements as physician ordered. The clinical record lacked evidence the facility acquired pressure ulcers were unavoidable. - The December 2013 physician's orders [REDACTED]. It documented the resident received Prostat (a liquid protein supplement). The Quarterly Minimum Data Set 3.0 dated 9/28/13 documented a Brief Interview for Mental Status (BIMS) score of 14 (13 to 15 indicated intact cognition). The Care Area Assessment (CAA) dated 2/1/13 for cognition noted the resident was in need of staff assistance for cognitive difficulties. He/she had MS and was in need of staff to perform daily tasks. Staff continued to offer the resident choices in clothing, activities and food selection. The care plan dated 10/10/13 for cognition noted staff allowed the resident access to a clock or watch to enable him/her to know what time of day it was and staff introduced themselves to the resident. Staff broke activities into manageable tasks, gave the resident one instruction at a time, and provided rest between each task. Staff explained each activity/care procedure before it was started, and provided cueing and prompting. The care plan dated 10/10/13 for skin breakdown noted staff reminded the resident of the importance of changing positions and assisted him/her every two to three hours. Staff assisted the resident to lay down to relieve pressure between meals. The resident used a cushion in the wheelchair and an air mattress on the bed. Cushioned heel protectors were worn at all times. It failed to document new interventions due to the development of a new pressure ulcer. The Braden assessment dated [DATE] noted a score of 15 (15-18 indicated mild risk). The Braden assessment dated [DATE] noted score of 16. The dietary progress note dated 11/1/13 revealed the resident had trauma to his/her right great toe and right second toe, and had a moisture acquired area between the buttock folds. It noted the resident was already on Prostat, on a regular diet, and staff assisted with eating. Meal intakes were adequate. No nutritional interventions were warranted for his/her skin needs. The current diet and Prostat were meeting his/her needs. Review of laboratory results dated [DATE] revealed a protein level of 7.3 grams per deciliter, and an [MEDICATION NAME] level of 0.7 grams per deciliter with normal reference range of 3.4-5.0 grams per deciliter. A physician's orders [REDACTED]. It documented to limit the time the resident spent in the wheelchair to mealtimes. The wound assessment dated [DATE] noted a new pressure ulcer to the right buttock which measured 2 centimeters (cm) by 5 cm. It was acquired on 12/9/13, and was unstagable. It documented staff were to continue the zinc, and the resident needed to be out of the wheelchair except for meals and placed on his/her side every 2 hours. The clinical record lacked evidence the dietician reassessed the resident after the development of the pressure ulcer. Observation on 12/17/13 at 7:30 A.M., 7:45 A.M., 8:00 A.M., and 8:15 the resident rested in bed. Observation on 12/17/13 at 8:45 A.M., 9:00 A.M., 9:30 A.M., 9:45 A.M., 10:00 A.M., 10:15 A.M., 10:30 A.M., 10:45 A.M., 11:00 A.M., 11:15 A.M., 11:30 A.M., 11:45 A.M., 12:00 P.M., 12:15 P.M., 12:30 P.M., 12:45 P.M., 1:00 P.M., and 1:15 P.M. (a duration of 4 1/2 hours) the resident sat in a geri chair (a specialized recliner that provided seating for people who had difficulty supporting themselves in a seated position). No additional cushion was noted in the geri chair. Observation on 12/17/13 at 9:30 A.M. the resident was served ? cup oatmeal, 6 ounces (oz) of water, 6 oz of juice, 6 oz of milk, and 12 oz of hot cocoa. The resident was fed by staff and ate all the oatmeal and drank all the juice and hot cocoa. Observation on 12/17/13 at 12:30 P.M. the resident was served 6 oz of water, 6 oz of juice, a baked chicken wing, 4 oz of rice, 4 oz of veggies and yogurt. The resident was fed by staff. He/she ate the chicken, 3/4 the rice, 1/2 the veggies, drank all of the juice. Observation on 12/17/13 at 1:20 P.M. staff transferred the resident to bed. The resident laid on a low air loss mattress. The skin on the resident's buttocks was red and blanched. Observation on 12/17/13 at 1:30 P.M., 1:45 P.M., 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 3:00 P.M., 3:15 P.M., 3:45 P.M. and 4:00 P.M. the resident laid in bed on his/her back with a pillow positioned under the resident's right hip. Observation on 12/17/13 at 8:20 A.M. wound care was performed. Licensed nursing staff I cleansed the wound with a wound cleanser and patted it dry with gauze. He/she applied zinc ointment to the wound and left it open to air. The wound was approximately 4 cm in diameter with beefy red tissue. Yellow slough (moist dead tissue) covered less than half of the wound. There was grapefruit sized scar over the sacrum. Interview on 12/18/13 at 11:20 A.M. direct care staff O stated the resident was repositioned 4 or 5 times each shift. Interview on 12/18/13 at 3:00 P.M. direct care staff P stated the resident was repositioned every 2 hours. Interview on 12/17/13 at 4:50 P.M. licensed nursing staff I stated the resident's pressure ulcer was a Stage 2 (a partial loss of skin that presented as a shallow open ulcer). He/she said staff were to reposition the resident every 2 to 3 hours. Interview on 12/18/13 at 4:15 P.M. administrative nursing staff D expected staff to reposition a resident with a pressure ulcer every 1 to 2 hours, keep resident off the area, monitor weights and protein levels, and keep the wound clean and dry. He/she notified the dietician of residents with a new pressure ulcer. Nurses did skin assessments periodically and notified him/her of their findings. Interview on 12/19/13 at 10:30 A.M. physician Y stated he/she expected staff to reposition residents with a pressure ulcer every 2 hours and keep the resident off the area. The facility policy "Wound Care/Pressure Ulcer" revised 1/13/12 noted "individualized repositioning will be done for the resident by the staff. The Registered Dietician will assess all residents for nutritional risk factors on admission, with significant change, and with the development of a pressure ulcer". The facility failed to prevent the development of an avoidable pressure ulcer and failed to timely reposition this resident after the development of the pressure ulcer.

The facility identified a census 54 residents. The sample included 3 residents. Based on observation, interview, and record review the facility failed to provide services for 1 resident of the sample (#3) for urinary catheter. Findings included: - [DIAGNOSES REDACTED]. disabilities. The Minimum Data Set (MDS) 3.0 an annual assessment dated [DATE] listed the Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. The resident was totally dependent on 2 staff and required physical assistance with all activities of daily living (ADLS). The MDS listed the resident had an indwelling catheter. The Care Area Assessment (CAA) dated 2/9/13 for urinary incontinence listed the foley catheter to dependent drainage (DD) due to [MEDICAL CONDITION].The resident required total staff assistance when in bed. The resident was alert and oriented and was able to verbalize his/her needs. The resident had frequent kidney stones and was followed by a urologist. The resident was at risk for signs and symptoms of infections, and at risk for impaired skin integrity. The care plan reviewed 2/20/13 for incontinence/at risk for altered skin integrity listed the resident had a foley catheter to DD due to [MEDICAL CONDITION]. Interventions included: monitor for signs and symptoms of infection, history of kidney stones, monitor for bladder distention, pain upon urination, decreased urine output, etcetera and report to the charge nurse. Offer fluids during routine cares, meals, and hydration passes, check to see if the resident would like to have coffee. Upon personal cares, please monitor for signs and symptoms of infection, discolored urine, increased sediment, pain, elevated temperature and notify the charge nurse. Upon personal cares monitor for signs and symptoms of nonverbal pain such as crying, tearfulness, withdrawn, frowning, and guarding. Check him/her every 2-3 hours and as needed. Upon personal cares observe for any changes in amount of urine, frequency, concentration, or odor. Provide catheter care every shift, and report output to the charge nurse every shift. Review of the nurse's notes (NN) dated 2/26/13 at 3:21 P.M. listed the resident requested a catheter change. Staff replaced the catheter with a16 French and a 30 milliliter (ml) balloon inflation as physician ordered. The resident tolerated the procedure well with immediate return of amber urine. Staff encouraged the resident to increase fluid intake. Staff to continue to monitor. NN on 2/27/13 documented at 2:30 A.M. the resident complained of the catheter hurting. The nurse looked at the catheter, noted no leaking or bleeding and resident had yellow drainage around the tip of his/her genitals.The nurse gave the resident Tylenol at approximately 6:20 P.M. The resident still complained of pain and discomfort at 1:00 A.M. Staff gave the resident more Tylenol at approximately 1:30 A.M. adjusted the brief and checked the catheter, no blood or leakage present. The resident stated the catheter felt better at this time. NN on 2/27/13 at 6:21 A.M. documented staff found the resident with bright red blood in his/her brief,and had vomited on self. The resident complained of severe pain to the genitals. Staff removed the catheter. Only 3 to 4 inches of the catheter remained in the resident. The resident began to bleed profusely from the genital area, staff applied pressure for approximately 30 minutes with no results. Bleeding continued, and the resident began to complain of feeling cold and shaking. The staff was unable to obtain vital signs due to resident's shaking. The resident's temperature was 99.5 degrees Fahrenheit. Staff received physicians orders to send the resident to the emergency room for evaluation and treatment of [REDACTED]. The history and physical from the second hospital dated 2/27/13 listed the resident transferred from the emergency department of the local hospital after having hematuria(blood in the urine) overnight. His/her foley catheter was swung out accidentally and presented with hematuria, subsequently at the nursing home where he/she lived they could not put in a foley, and took him/her to the local emergency room where the resident was found to have a temperature of 104 degrees Fahrenheit and with hematuria. They were not able to put a catheter in so he/she was transferred to this hospital. After consultation with urology physician, hospital staff placed a catheter. The fever subsided and the resident was not complaining of pain, had no cough, or shortness of breath, no nausea or vomiting,and no abdominal pain.He/she had [MEDICATION NAME] (antibiotic) at the local hospital but there was not any mention of cultures taken at the local hospital. Assessment and Plan: [MEDICAL CONDITION] (blood infection) with a temperature of 104 degrees Fahrenheit. [MEDICAL CONDITION](rapid heart rate) and pending blood work. Urinary tract infection possible with chronic indwelling catheter with [MEDICAL CONDITION] bladder due to [MEDICAL CONDITION], will obtain urinalysis and urine culture and continue certriaxone (antibiotic).Urethral bleeding hematuria (blood in the urine) likely,after traumatic removal of foley catheter. Observation of the resident on 3/18/13 at 8:45 A.M. revealed the resident was in his/her electric wheelchair self propelling around the facility. The catheter bag was to dependent drainage, and the tubing was apparent from the residents clothing and was covered as was the drainage bag. Interview on 3/19/13 at 2:54 P.M. with licensed staff C stated he/she was in the facility at 5:45 A.M. the day of the incident getting report when a certified nursing assistant (C.N.A.) came up and stated the resident had 450 cubic centimeters (cc's) of straight blood in his/her catheter bag. He/she had completed the routine monthly catheter change the day before, and the catheter functioned properly. He/she went to the resident's room which smelled of vomit and removed the brief. It was soiled with bright red blood, as well as the tubing and the catheter bag. He/she did not recall if the leg strap was in place, but stated he/she placed a new one when he/she performed the catheter change the day before. The nurse going off of the shift stated to licensed nurse C that the resident complained of pain at the site all night and he/she gave the resident Tylenol 2 times(a pain medication) He/she did not look at the catheter, but did rearrange the tubing. Licensed staff C stated the site looked like the catheter had been pulled out 3 to 4 inches of the catheter remained in place in the genital site. Licensed staff C deflated the balloon and removed the catheter. The resident's genitalia bled profusely. This nurse requested help from the other licensed day staff to bring down the treatment cart for supplies to control bleeding. Staff applied pressure for 30 to 45 minutes while waiting for the on call doctor's return call, and emergency medical staff (EMS) to arrive. Staff used 4 packages of 4 x 4s (measured gauze) to attempt to control bleeding. He/she stated the resident said he/she was sorry, he/she did not mean to. The resident told the staff about it, and no one would help me. Staff stated the resident vomitted when he/she got worked up or excited. Interview on 3/19/13 at approximately 4:30 P.M. with administrative nursing staff B, stated the facility did not have a policy for catheter assessment or care. They refer to the Perry and Potter Skills and Procedure Book. Further interview revealed the facility did not conclude how the bleeding occurred. Administrative nursing staff B stated he/she referred to the hospital report that the catheter was traumatically dislodged. On 3/19/13 at approximately 4:30 P.M. administrative staff A stated the facility did not assess or provide appropriate care for this resident with a foley catheter. The facility failed to thoroughly and timely assess and provide timely interventions for this resident who had a traumatically dislodged foley catheter and required hospitalization for increased temperature and hematuria.

The facility identified a census of 43 residents. The sample included 14 residents of which 1 was reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to prevent the development of 2 avoidable pressure ulcers for 1 resident. (#16) Findings included: - Resident #16's Physician order [REDACTED]. The annual minimum data set (MDS) 3.0 dated 3/5/11 recorded the resident with severe cognitive impairment. The MDS further recorded the resident required extensive to total assistance for all activities of daily living (ADLs), including transfers and positioning. The MDS further recorded the resident had 1 stage 2 pressure ulcer, and noted worsening of the stage 2 ulcer from the previous assessment. The MDS further recorded the resident was always incontinent of bladder and bowel. The ADL Care Area Assessment (CAA) dated 3/17/11 recorded the resident required assistance for all ADLs. The pressure ulcer CAA dated 3/17/11 lacked causal factors for the development of the resident's pressure ulcers and lacked interventions that were implemented to prevent future pressure ulcers. The incontinence/skin care care plan dated 3/21/11 directed staff to: ? assist resident with repositioning every 2 hours and as needed, ensure body is in alignment while in bed and up in tilt recliner, and use pillows as needed to help position ? assist resident with moving knees due to contractions and left sided weakness, and left wrist drop, and use a tilt reclining chair for positioning ? assist resident with moving all extremities ? offer fluids to the resident during routine care and with meals ? monitor for signs and symptoms of wound infection ? monitor resident ' s skin integrity during personal cares, report any abnormalities to charge nurse ? consult the wound care nurse as needed to identify the resident ' s skin risks and monitor current treatment to left ankle ? open area on left buttocks healed on 3/22/11, open scar tissue from incontinence ? complete wound care per orders to left ankle as ordered. ? wound care nurse to monitor for appropriate treatment according to condition ? [MEDICATION NAME] daily may cause excessive bleeding or bruising, and monitor for signs or symptoms of excessive bleeding/bruising ? use special care when transferring the resident to be sure arms and legs are free of hitting any objects when lifting and sitting down. ? attempt to protect feet with blue pressure relief boots as resident allows when up in the chair or bed, and resident refused at times ? air mattress with 2 full padded rails on bed for skin protection, and monitor for gaps between mattress and side rails ? monitor for signs and symptoms of nonverbal signs of pain ? check for wetness and change on rounds every 2-3 hours and as needed, and change adult brief as needed ? provide perineal care after each incontinent episode ? note any changes in the amount of urine frequency, color or odor ? 5/10/11 If resident refused to wear padded boots, the resident had crocheted boots they may wear The ADL care plan dated 3/21/11 directed staff: ? resident wore adult briefs for protection, incontinent due to urgency and retention, and incontinent of bowel, assist with perineal care after each incontinent episode ? when transferring use the mechanical lift and 2 staff, due to resident ' s weakness/debility and left [MEDICAL CONDITION] ? reposition every 2-3 hours and as requested or needed, and the resident was able to use the right side rail for bed positioning. ? resident ' s knees were contracted on both sides, staff to monitor for reddened areas and attempt to reposition as needed ? use a pink tilt recliner for positioning and mobility. ? resident depended on staff to propel to various locations in the facility, and check for proper body alignment ? air mattress to bed for skin protection with 2 full padded rails, monitor for gaps between the mattress and rails to prevent entrapment The Resident Profile (certified nursing assistant (CNA) care guide) dated 3/21/11 directed, the resident had an air mattress, blue boots on in bed and chair as tolerated, would refuse at times, and brief for incontinence of bladder and bowel. It further directed staff to check and change (the resident ' s brief) every 2-3 hours and as needed. The Braden Scale for Predicting Pressure Sore Risk dated 3/5/11 recorded the resident at high risk for the development of a pressure sore. The Braden Scale scores of 10-12 indicated high risk, and the resident ' s score was 11. During perineal care observation on 5/18/11 at 1:23 P.M., the resident had an open bleeding area on his/her upper left buttocks, and an open bleeding area on his/her upper right buttocks. Observation on 5/18/11 at 1:38 P.M., 2:15 P.M., 3:00 P.M., 3:23 P.M., 3:57 P.M., 4:08 P.M., 4:15 P.M. and 4:38 P.M. (3 hours), revealed the resident in same position in his/her wheelchair and did not have repositioning or incontinence check by staff during that time. Upon request on 5/18/11 at 4:40 P.M., licensed staff D assessed the resident ' s buttocks wounds. Staff D measured the open wound on the left buttocks at 0.4 centimeters (cm.) wide by 0.4 cm. long surrounded by an area of purple-red colored skin which measured 7.0 cm. wide by 5.0 cm. long. Licensed staff D measured the open bleeding wound on the right buttocks at 1.1 cm. wide by 1.7 cm. long surrounded by an area of purple-red colored skin which measured 9.0 cm. wide by 4.0 cm. long. Observation and palpation at that time of the resident ' s air filled wheelchair cushion revealed the front of the cushion contained air and was approximately 4 inches tall. The rear portion of the cushion was approximately ? inches tall. The cushion shape created a hollow where the resident ' s buttocks rested. During interview on 5/18/11 at 4:46 P.M., licensed staff D identified the resident ' s open wounds as Stage 2 pressure ulcers. Licensed staff D further stated they were not aware the resident had the pressure ulcers on his/her buttocks, and staff had not reported it to them. Licensed staff D acknowledged the resident ' s wheelchair air cushion was flat and would have staff re-inflate it. The Skin Condition Assessments completed by the wound nurse on 5/17/11, 5/10/11, 5/3/11, 4/27/11, 4/20/11, 4/17/11 and 4/5/11 lacked documentation of the resident ' s pressure ulcers. The skin assessment dated [DATE] recorded the resident ' s " buttocks healed pink and intact " . The nurse ' s notes from 4/7/11 to 5/17/11 lacked documentation of the resident ' s pressure ulcers. During interview on 5/18/11 at 1:39 P.M., direct care staff F stated the resident had open areas on his/her buttocks for " at least a couple of weeks " , and did not report it to the licensed staff because licensed staff already knew about the wounds. During interview on 5/18/11 at 1:40 P.M., direct care staff G stated they did not know exactly when the resident ' s wounds opened this time and the wounds opened and closed several times. Direct care staff G stated they did not report the wounds to the licensed staff, and the licensed staff already knew the resident ' s wounds were open. Direct care staff G continued the resident told staff when he/she had to have the brief changed and they did not use a check and change schedule for the resident. During interview on 5/18/11 at 3:46 P.M., licensed staff C stated the resident did not have any skin problems at this time. During interview on 5/18/11 4:59 P.M., direct care staff H stated the resident had open areas on his/her buttocks on 5/13/11 and the open areas were ongoing. Direct care staff H further stated they did not report the open areas and the licensed staff knew about them. During interview on 5/18/11 at 5:03 P.M., licensed staff B stated when a resident had a skin problem; the CNAs should record it on the skin condition worksheet and report it to the licensed staff. Licensed staff B further stated the licensed staff should sign the skin condition worksheet and report the skin problem to the wound nurse. Licensed staff B continued the resident had fragile skin and staff should reposition the resident every 90 minutes, and no longer than every 2 hours. The facility failed to provide care to prevent the development of 2 pressure ulcers for this dependent resident.

The facility identified a census of 43 residents. Based on observation, record review and staff interview, the facility failed to provide supervision to prevent an injury accident for 1 (#1) of three sampled residents for falls. Findings included: - The Physician order [REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] identified the resident had long and short term memory impairment and moderate impairment with decision-making. The resident needed supervision with bed mobility, locomotion on the unit and eating, he/she did not walk, needed extensive assistance with transfers, locomotion off the unit, dressing, toilet use and bathing. The resident required partial physical support for standing but had good sitting balance. He/she fell within the last 30 days. The resident received anti-depressant, anti-anxiety and anti-psychotic medications daily. The Resident Assessment Protocol (RAP) dated 8/9/10 for activities of daily living (ADL) identified the resident received physical and occupational therapy (PT/OT) 3-5 times weekly for strengthening, endurance and balance. The resident required staff assistance of one with activities of daily living (ADLs). The RAP dated 8/9/10 for falls documented the causative factors for falls were previous falls, weakness, dementia, and he/she received psychotropic medications. Interventions for falls were a floor alarm in the room, auto lock brakes to his/her wheel chair, and a Wanderguard. The resident received psychotropic medications. The mini mental assessment dated [DATE] revealed the resident had significant cognitive impairment. The fall assessment dated [DATE] revealed a score of 24 which indicated the resident was at high risk for falls. The resident profile sheet dated 8/10/10 for falls identified the resident had previous falls, weakness, and received psychotropic medications. Interventions for fall prevention were auto lock brakes to the wheel chair, PT/OT 3-5 times weekly for strengthening, balance and endurance, and staff placed the resident on the Orange Alert Fall Program. The Orange Alert Fall Program Policy dated January 28, 2009 identified the procedure to "Assess all residents on admission and at least quarterly for the need for increased supervision due to increased fall risk. Alert all staff to the need for increased supervision of a resident by identifying the resident with orange". The care plan for ADLs dated 8/10/10 documented staff ensured the call light was in easy reach and reminded the resident to use it. He/she required assistance of one person for transfers, received PT/OT 3-5 times weekly for strengthening, balance and endurance. The care plan for falls dated 8/10/10 documented staff placed a floor alarm in his/her room and checked for proper function to alert staff if resident attempted to get up without assistance. The resident required the assistance of one staff with all transfers. The resident attempted to get up on his/her own and transferred self. The updated plan of care dated 8/23/10 identified additional staff interventions to prevent falls were the bed alarm, bedrails, and a Wanderguard. The resident required one staff for transfer assistance. The mini mental assessment dated [DATE] revealed the resident had significant cognitive impairment. The fall assessment dated [DATE] revealed the resident's score was 27 and he/she remained at a high risk for falls. According to a late entry in the nurses notes dated 9/2/10 on 8/27/10 at 7:00 A.M. the resident fell and put him/herself into the wheel chair. There was blood on the bathroom floor and on the resident's face and under his/her nose. The resident became unresponsive for approximately five minutes. Staff transferred the resident to the hospital. The emergency room note dated 8/27/10 said the doctor evaluated the resident for multiple trauma. The resident had black and blue ecchymosis over the right shoulder and an abrasion on his/her nose. The x-ray revealed the resident received a nondisplaced fracture of the right proximal humerus. Treatment included a swath and a sling. An interview on 9/22/10 at 9:35 A.M. with direct care staff A said he/she got the resident up on the morning of 8/27/10 and assisted him/her to the bathroom. He/she parked the wheel chair at ninety degree angle to the resident who sat on the toilet. Direct care staff A said they left the room to assist a student with another resident. He/she estimated they were out of the room approximately five minutes. When he/she entered the room, the resident sat in the wheel chair in the bathroom with his/her head down. He/she said they noted the resident's face was bloody. The resident said he/she fell on to the floor. The resident stated they were sick, the facial color was pale and the resident lost consciousness. Direct care staff A said he/she hollered for assistance. When assistance arrived, three staff members lifted the resident to the bed. He/she verified the resident was a one person transfer, he/she was on the Orange Alert Fall Program which meant a resident needed additional supervision. He/she said it was a facility policy that staff would not leave a resident unattended while in the bathroom. He/she said staff sent the resident to the hospital. An interview on 9/22/10 at 10:05 A.M. with licensed staff A said it was the facility's practice that staff would not leave a resident assessed at a high risk for falls unattended in the bathroom. He/she said the resident did not have a bed alarm as stated on the care plan but did have a floor alarm. An interview on 9/22/10 at 2:20 P.M. with administrative staff A said according to the facility policy, staff would not leave a resident assessed at a high risk for falls in the bathroom unattended. The facility failed to provide supervision to prevent an avoidable accident for this cognitively impaired resident who sustained a fractured humerus and required hospitalization .