Every finding on record at Medicalodges Eudora

Based on observations, record review, and interviews, the facility failed to ensure an environment free from accident hazards when Certified Nurse Aide (CNA) O did not use a gait belt during a transfer for Resident (R) 2 resulting in a fall where R2 sustained a fracture. The facility further failed to ensure interventions to prevent falls were implemented for R14 and failed to ensure staff used a full body lift safely for R9.Findings included:- R2 admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. R2's Electronic Medical Record (EMR) documented diagnoses of a need for assistance with personal care and lack of coordination. R2's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R2 had impairment of both upper extremity and lower extremity on one side. The MDS noted R2 could walk 10 feet. She required set-up and clean-up assistance with bathing, including tub/shower transfers. R2's Falls Care Area Assessment (CAA) dated 12/23/2025 documented R2 had non-injury falls in the past 6 months. The CAA noted R2 did not always make safe choices with her abilities and with alerting staff of needs. Her medications also increased her fall risk. R2 scored mod/high risk on assessment and interventions were reviewed and ongoing with updates as needed. R2's Quarterly MDS dated 05/28/2026 documented a BIMS of 8, which indicated moderately impaired cognition. The MDS noted she had impairment on both sides of her upper and lower extremities, required partial/moderate assistance with showering, and did not walk. The MDS noted tub/shower transfers were not attempted due to medical condition or safety concerns. R2's Care Plan dated 12/27/2024 documented she needed assistance with activities of daily living (ADL) related to physical limitations. R2 needed assistance from one staff member for dressing and personal care. The plan noted she was at risk for falls and had limitations on the right side of her body. R2's Care Plan dated 01/10/2025 documented she needed assistance with hygiene and peri care. R2's Fall Risk Assessment v1.0 dated 10/22/2025 documented R2 was at moderate risk for falls and noted she had 1 to 2 falls in the previous six months. The assessment noted R2 required hands-on assistance to move from place to place. A Nurse's Note on 02/20/2026 documented that Licensed Nurse (LN) I was alerted that R2 fell in the shower on the back hall and appeared injured. LN I and LN H went to the shower room and saw R2 on the floor with her back to the shower, and her legs pointed towards the door, in a seated position. CNA O informed LN I that she was transferring R2 from the shower chair to the wheelchair and R2's feet slid out from under her. R2 was in too much pain to do a physical exam, but LN I could visibly see that the left leg was about three inches shorter than the right leg while in the seated position on the floor. The note documented that R2 was bare footed on a wet floor, and no gait belt was being used at the time of transfer. LN H's Statement on 02/21/2026 documented LN H was finishing up charting at the front desk when Dietary Staff BB informed LN I that R2 fell and appeared to be injured as R2 was yelling. LN H and LN I went to the 300-hall shower room and found R2 on the floor directly in front of the shower, with her back towards the shower and her feet directly out in front of her, facing the doorway. R2 was in too much pain to get a good look at her left leg. R2 was crying and stated her left leg hurt from her knee to her groin. R2 could not lie flat, so staff assisted her with a gait belt and not bearing weight on her left leg to the wheelchair. The staff called the physician but were unable to get a hold of an on-call provider. Staff called 911, and LN H stayed with R2 until their arrival. CNA O's Statement on 02/21/2026 documented CNA O was giving R2 a shower about 07:00 PM. CNA O had washed R2, washed her hair, and dried R2 off to dress her. R2 stood up out of the shower chair and turned to sit in her wheelchair. CNA O grabbed the towel, and R2 lost her balance and fell backward. CNA O went to get the nurse before getting her up. Dietary Staff BB's Statement on 02/21/2026 documented she heard screaming and crying around 07:30 PM and CNA O came out of the shower room calling for help. Dietary Staff BB entered the shower room and noticed R2 on the floor on her back, with her feet towards the door, crying out. CNA O informed Dietary Staff BB that she was helping transfer R2 from the shower chair to a wheelchair when R2 fell. R2 did not have a gait belt on, and her feet were bare. Dietary Staff BB informed CNA O not to move R2 and alerted LN I and LN H of the incident. A Nurse's Note dated 02/23/2026 documented R2 returned to the facility from the local hospital at 03:29 PM. The note documented R2 had undergone a Gamma nailing (minimally invasive surgical procedure to stabilize severe hip or thigh fractures) and had a surgical incision with staples on her left hip. Observation on 07/21/2026 at 07:58 AM revealed R2 sat in her recliner watching television with her call light within her reach. R2 stated she had already had breakfast. Observation on 07/21/2026 at 02:11 PM revealed R2 slept in her recliner with her walker across the room, and her wheelchair next to her recliner. R2 wore shoes, which were tied. On 07/22/2026, CNA O was unavailable for interview and did not return the call as requested. During an interview on 07/22/2026 at 12:37 PM, LN H stated staff should always use a gait belt for transfers for residents who were at risk for falls. During an interview on 07/22/2026 at 11:23 AM, Administrative Nurse D stated there was not a policy for transferring a resident. Administrative Nurse D stated the staff should have brought the shower chair to the dry area and placed a towel down for R2 to stand up on. Administrative Nurse D stated staff should have placed shoes on R2 for the transfer and should always use a gait belt for transfers. During an interview on 07/22/2026 at 12:50 PM, Administrative Staff A stated there was no policy for transferring residents. Administrative Staff A stated she expected staff to follow the care plan and use a gait belt when indicated and use a gait belt for standing/transfers in the shower. Administrative Staff A confirmed there was no anti-skid/slip tape on the shower floor at the time of the incident. Administrative Staff A stated that, after the incident on 02/20/2026, the CNA was educated with handouts and verbally but confirmed there was no documentation of the education. Administrative Staff A said staff were now required to always carry a gait belt. The facility policy Falls Management dated 12/2022 documented the plan of care was to address individualized resident focus, goals, and interventions directed towards reducing the resident's risk of injury and potential reoccurrence of falls. 2. The EMR for R14 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) with fracture of femur (thigh bone), fracture of lower end of left humerus (upper arm bone), reduced mobility, muscle weakness, and difficulty walking. R14's admission Minimum Data Set (MDS), dated 05/28/2026, documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe impairment in thinking and memory. The assessment documented that she had impairment in one upper extremity, both lower extremities, and used a wheelchair for mobility. She was dependent on staff for putting on footwear, required partial to moderate assistance for sit-to-stand transfers, substantial to maximum assistance for all other activities of daily living (ADL) and all other transfers. R14's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/28/2026, documented she had the presence of inattention and disorganized thinking, had episodes of wandering and rejection of care. R14's Communication CAA, dated 05/28/2026, documented that she had an impaired ability to make herself understood through verbal and non-verbal expression of ideas and wants. It was also documented that she had an impaired ability to understand others. R14's Fall CAA, dated 05/28/2026, documented that she had wandered and that she had had recent falls. It was also documented that she had received antidepressant medication. R14's Care Plan dated 06/03/2026 documented that she had a fall at her previous living placement that resulted in a left hip fracture repair, and she required a non-removable support for her lower left arm. R14 had an intervention dated 06/04/2026 that instructed staff to ensure orthopedic (pertaining to bones) precautions, pertaining to alignment of joints when resting or in her wheelchair, were utilized. Staff was also instructed to provide R14 with constant reminders not to cross her legs. An intervention dated 06/05/2026 directed that she was to have a knee spacer between her knees to support hip alignment when she was in her wheelchair, and when in bed, and another spacer between her lower calf area. An intervention dated 07/13/2026 documented that R14 had a non-injury event on 07/05/2026 and had assist bars placed on her bed, a fall mat on the floor, and an overlay (mattress topper that uses built-in foam bolsters to create raised edges) to define the edges of her bed. Observed on 07/20/2026 at 08:29 AM, R14 was lying on her right side in bed covered with blankets. Her bed was in a low position near the floor. She appeared to be sleeping. Her bed was in the low position, and there was a fall mat on the floor on each side of the bed, but there was no overlay with bolsters on her mattress. Observed on 07/21/2026 at 07:45 AM, R14 resting in bed with her eyes closed. Her bed was in a low position, and there was a fall mat on the floor on each side of the bed, but there was no overlay with bolsters on her mattress. Observed on 07/21/2026 at 12:28 PM, R14 sitting sat up in bed eating a snack with her legs crossed. There was no spacer between her knees or lower calves. On 07/21/2026 at 01:15 PM, Certified Nurse Aide (CNA) M said a mattress overlay with bolsters was not on R14's bed, and she had been unaware that R14 was to have that. She also said that R14 should have had a spacer pillow between her legs. On 07/21/2026 at 01:30 PM, Licensed Nurse (LN) G confirmed R14 was to have an overlay with bolsters on her mattress but did not have one. She also said that R14 should have had a spacer between her knees and not crossing her legs. On 07/21/2026 at 02:00 PM, Administrative Nurse D said the mattress they had did not fit R14's mattress, but she was supposed to have one. She also said that she expected the spacer pillows were to be used but said R14 would remove them. Administrative Nurse D stated she expected staff to get her up or put them back in place when that happened. 3. R9's EMR documented diagnoses that included ischemic stroke, cerebral edema (swelling of the brain), lack of coordination, and muscle weakness. R9's Annual MDS, dated 07/12/2026, documented a BIMS score of 15, which indicated intact cognition. The MDS documented R9 had impairment in one side upper and lower extremities and used a wheelchair for mobility. R9 was dependent on staff for transfers, lower body dressing, and toileting hygiene. He required partial to moderate assistance for eating and oral hygiene, and required substantial to maximum assistance for upper body dressing. The MDS documented that R9 had two or more falls since he was admitted . Observed on 07/21/2026 at 09:45 AM, CNA M and CNA N transferred R9 from his bed to his wheel by Hoyer (total body mechanical lift) lift. CNA M operated the lift and raised R9 from the bed, and CNA N maintained contact with him while he was lifted from the bed. While R9 was suspended in the air over his bed, CNA N took her hands off the resident and moved his wheelchair while CNA M began moving and propelling the lift, while R9 was suspended in the air, towards the wheelchair. CNA N then put her hands back on R9 and guided him. CNA M then removed her hands from the lift, adjusted R9's wheelchair, and lowered him into it while CNA N guided him. On 07/21/2026 at 09:57 AM, CNA M said that two staff were required anytime a resident was transferred with the Hoyer lift. She said that one staff member operated the lift and the second staff member would hold onto the lift sheet and guide the resident. CNA M said that she was unsure if staff were to maintain constant contact with the resident or lift during a transfer. On 07/21/2026 at 01:30 PM, LN G said there would always be two staff members when a resident was transferred with the Hoyer lift; one staff member controlled and operated the lift and was never to take their hands off the lift, and the second guided the resident and was to never take their hands off the resident until the resident had been lowered safely. On 07/21/2026 at 02:00 PM, Administrative Nurse D said there were always two staff members when the Hoyer lift was used; one staff member operated the lift, and the second guided the resident during the transfer. She also said neither staff were to remove their hands ever when transferring a resident with the lift. The facility policy Falls management, dated 12/2022, documented that the plan of care was to address individualized resident focus, goals, and interventions directed towards reducing the resident's risk of injury and potential reoccurrence of falls.

Based on interview, and record review, the facility failed to provide the services of a full-time certified dietary manager for the 41 residents who resided in the facility and received their meals from the kitchen.Findings included:- Record review lacked documentation that Dietary staff BB had her certification as a dietary manager.During an interview on 07/20/2026 at 07:45 AM, Dietary staff BB stated that she was the dietary manager and was not certified yet but was taking classes. Dietary staff BB took over the position in March of 2026 as the last dietary person had walked out. Dietary staff BB stated that she had been an employee at the facility for eight or nine years as a CNA and a CMA, so she was familiar with the residents.During an interview on 07/21/2026 at 09:55 AM, Dietary staff BB stated that she had trained some of the staff in the basics of the kitchen but would ask a nurse or someone with knowledge to answer her questions on food allergies if needed and would research the subject.The facility did not provide a policy upon request.

Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to address quality deficiencies prior to survey. Findings Included: - The facility failed to obtain informed consent from the residents or the residents' legal representatives for the installation of bedrails for Resident (R) 10, R14, R1, and R39. (Refer to F700)The facility failed to properly train staff on the proper use of the Hoyer (total body mechanical lift) lift for safe transfer of residents. R9 was transferred by Hoyer lift, and both staff members removed their hands from the lift and R9 while he was suspended in the air and transferred. (Refer to F689)The facility failed to ensure interventions were being utilized to prevent resident injury and falls. R14 did not have an overlay (mattress topper that uses built-in foam bolsters to create raised edges) on her bed to define the edges as directed by her plan of care. (Refer to F689)Observed on 07/21/2026 at 09:45 AM, Certified Nurse Aide (CNA) M and CNA N transferred R9 from his bed to his wheel by Hoyer (total body mechanical lift) lift. CNA M operated the lift and raised R9 from the bed, and CNA N maintained contact with him while he was lifted from the bed. While R9 was suspended in the air over his bed, CNA N took her hands off the resident and moved his wheelchair while CNA M began moving and propelling the lift, while R9 was suspended in the air, towards the wheelchair. CNA N then put her hands back on R9 and guided him. CNA M then removed her hands from the lift, adjusted R9's wheelchair, and lowered him into it while CNA N guided him.On 0720/2026 at 07:47 AM, Administrative Staff A said that the facility's Quality Assurance Performance Improvement Team (QAPI) team officially meets every quarter at a minimum but usually meets monthly. She said current improvement plans being monitored and tracked included urinary tract infection (UTI) and antibiotic stewardship, staff engagement communication breakout sessions, providing room-to-room activities, handwashing, providing residents with snacks and hydration, and CNA documentation. She said the next QAPI meeting was to be scheduled for 07/28/2026 and they were to discuss and implement an improvement plan for accident and fall prevention.The facility policy Quality Assurance Improvement Plan, dated 01/2025, documented that the facility had a performance improvement program which systematically monitored, analyzed, and improved its performance to improve resident outcomes.

Based on interview, observation, and record review, the facility failed to obtain informed consent from the residents or the resident's legal representative for installation of bedrails for Resident (R) 10, R14, R1 and R39. Findings include:1. The Electronic Health Records (EHR) for R10 included diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side (severe functional limitations, including balance issues, reduced mobility, and possible communication difficulties, requiring a multidisciplinary rehabilitation approach), blindness in right eye, muscle weakness, and acquired absence of right leg below kneeThe Restraint Use Assessment-V3, dated 01/09/2026, documented R10 had quarter bed rails to enhance bed mobility, and they were not considered a restraint.R10's EHR lacked evidence of informed consent for bed rails.Observed on 07/20/26 at 09:15 AM, R10 had upper side rails on each side of her bed.2. The EHR for R14 included diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) with fracture of femur (thigh bone), fracture of lower end of left humerus (upper arm bone), reduced mobility, muscle weakness, and difficulty walking.R14's EHR lacked evidence of a bed rail assessment and informed consent for bed rails.Observed on 07/20/2026 at 08:29 AM, R14 had upper side rails on each side of her bed.3. The EHR for R1 included diagnoses of adult failure to thrive and depression.The Restraint Use Assessment-V3, dated 09/08/2025, documented R1 had quarter rails to enhance his independence with bed mobility and transfers.The Restraint Use Assessment-V3, dated 01/03/2026, documented R1 had quarter rails to enhance his independence with bed mobility and transfers.R14's EHR lacked evidence of informed consent for bed rails.Observed on 07/20/2026 at 09:25 AM, R1 had upper side rails on each side of her bed.4. The EHR for R39 included a diagnosis of adult failure to thrive, depression, and disorientation.The Siderail Assessment V1.0, dated 12/16/2025, documented R39 was not ambulatory with or without assistance, she had impaired memory, cognition, or decision-making, and she had diagnoses or conditions, or received medication that required increased safety measures.R39's EHR lacked evidence of informed consent for bed rails.Observed on 07/20/2026 at 09:56 AM, R39 had upper side rails on each side of her bed.On 07/21/2026 at 01:15 PM, Certified Nurse Aide (CNA) M said approval from therapy had to be obtained before bedrails were used and maintenance attached them. She was unsure if consent was required, but it had to be documented if they were utilized.On 07/21/2026 at 01:30 PM, Licensed Nurse (LN) G said that informed consent along with an assessment were required before bedrails were utilized. She then stated that they had not used bedrails and that the facility had used hand assist rails.On 07/21/2026 at 02:00 PM, Administrative Nurse D said bedrails were not used; assist bars had been utilized. She then stated that informed consent was required before bedrails were used, along with an assessment.The facility policy Side Rail Use and Assessment documented that the purpose of the policy was to ensure the automatic use of side rails of any size or shape was avoided. The policy also documented that the use of side rails was based on residents' assessed medical/psychological needs: it is documented clearly, including risks, benefits, and other alternatives, and periodically reviewed.

Based on observation, record review, and interview, the facility failed to ensure Resident (R)4's call light was within her reach to enable her to call for staff assistance.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness),dementia (a progressive mental disorder characterized by failing memory and confusion) and repeated falls.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. She required substantial to maximum assistance with most activities of daily living (ADL). She had no functional impairment of her upper extremities.R4's Care Plan dated 02/25/2026 documented that R4 will have her call light within her reach and staff will encourage her to use it and ask for assistance.Observation on 07/20/2026 at 07:55 AM revealed R4 in bed asleep. R4's call light was on the nightstand and not within her reach.Observation on 07/21/2026 at 08:07 AM revealed R4 laying in bed awake with blankets on, staring at the window with the blinds closed. There were two call lights draped over the nightstand not within R4's reach. R4's wheelchair was across the room. Her bedside table was over the bed with a cup sitting on it.During an interview on 07/22/2026 at 10:28 AM, Certified Medication Aide (CMA) S stated that the call light needs to be in R4's reach. CMA R says R4 rarely uses the call light, but she will use it if she is fully awake.During an interview on 07/22/2026 at 10:32 AM, Licensed Nurse (LN) G stated that R4 should have her call light within her reach as R4 does use her call light.During an interview on 07/22/2026 at 12:25 PM, Administrative Nurse D stated that all residents should always have their call light in reach.Policy for Providing Quality Care and Accommodation of Needs requested but not received.

Based on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R)5's Electronic Medical Record (EMR) contained appropriate documentation for a schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diagnosis.Findings included:- R5's EMR revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), schizoaffective disorder, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods).R5's 01/19/2026 admission Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of ten, which indicated moderately impaired cognition. R5's MDS did not show a diagnosis of schizophrenia.The Functional Abilities Care Assessment (CAA) dated 01/19/2026 documented R5 was cognitively impaired and required assistance with activities of daily living and with cueing and prompting.R5's Quarterly MDS, dated 03/05/2026, documented a medical disorder of schizophrenia.The Medication Administration Record (MAR) dated January 2026 documented Seroquel/quetiapine (antipsychotic) given for mood.The MAR dated February, March, April, June & July 2026 documented Seroquel/quetiapine was given for schizoaffective disorder.A U.S. Department of Veterans Affairs (VA) medical history report dated 10/28/2025 did not document a diagnosis of schizoaffective disorder.R5's 01/15/2026 Antipsychotic Medication Informed Consent lacked schizoaffective disorder as a reason for the use of medications.On 02/05/2026, the physician signed a Medication Review Report, dated 02/02/2026 through 02/28/2026, which showed the antipsychotic medication Seroquel/quetiapine was ordered but did not document schizoaffective disorder as a diagnosis in the diagnosis summary.On 03/05/2026, the physician signed a Medication Review Report, dated 03/04/2026 through 03/31/2026, which documented the antipsychotic medication Seroquel/quetiapine fumarate was ordered and documented schizoaffective disorder as a diagnosis in the diagnosis summary.R5's 01/18/2026 Care Plan lacked documentation regarding schizoaffective disorder.R5's 02/20/2026 Nursing Progress Note documented that the resident was okay and slept through the night as usual.R5's 02/27/2026 Pharmacy Note to Attending Physician documented a request to the physician to add the diagnosis schizoaffective disorder.R5's EMR lacked physician documentation of specific behaviors, clinical findings, and assessments supporting the addition of the schizoaffective diagnosis.During an observation on 07/20/2026, R5 was lying in bed watching television.During an interview on 07/22/2025 at 08:45 AM, Administrative Nurse D reported that R5 admitted to their facility with a diagnosis of schizophrenia from the VA and further stated the diagnosis may have come from a medical team that comes into the facility and visits patients that are receiving antipsychotic medications.The facility's medication error reporting and adverse drug reaction prevention and detection policy dated 2007, documented that the interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. The policy further documented that an active diagnosis/indication (and documented objective findings, if necessary) supports the use of the medication

Based on observation, interviews and record reviews, the facility failed to ensure appropriate care and services to promote wound healing for Resident (R) 36 when staff failed to use the correct physician's treatment order.Findings included:- R36's Electronic Health Record (EHR) documented diagnoses that included left ankle and foot osteomyelitis (local or generalized infection of the bone and bone marrow), elevated white blood cell count, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to the body), chronic kidney disease, atrial fibrillation (rapid, irregular heartbeat), bradycardia (low heart rate, less than 60 beats per minute), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), absence of three toes on the left foot.R36's 07/16/2026 admission Minimum Data Set (MDS) documented R36 had an infection of the foot and a surgical wound. The MDS further documented R36 was receiving surgical wound care.R36's Care Plan documented she was receiving daily wound dressings to the surgical site to the left foot. The plan further documented R36 was receiving intravenous (IV-administered directly into the bloodstream via a vein) antibiotic treatment.R36's skin condition progress note dated 07/11/2026 documented a surgical incision site with seven staples to the left foot. The surgical incision was from an amputation (surgical removal of a body part) of the third toe. The skin condition progress notes further documented the surgical incision was to be cleansed with normal saline (NS-saline water solution for medical use) and an Aquacel AG (brand name of a specific type of wound dressing) applied over the surgical incision.R36's physician's order dated 07/10/2026 documented nursing staff was to cleanse the wound with NS and then apply Aquacel AG to R36's left third toe site over the surgical staples. Staff was then to apply gauze or an ABD pad (large pad to absorb drainage) to the surgical site.Observation on 07/21/2026 at 08:43 AM showed R36 lying on his bed with Licensed Nurse G at bedside. Licensed Nurse (LN) G performed the dressing change and applied [NAME] Collagen (Brand name of a specific type of dressing) to the wound instead of the ordered Aquacel AG.On 07/21/2026 at 08:46 AM, R36 stated there was no pain in the surgical site; the infection in the surgical site was the problem.On 07/22/2026 at 11:09 AM, LN G stated the nurse should follow the physician's treatment order and stated the Aquacel AG was not available, so the [NAME] Collagen was substituted.On 07/22/2026 at 01:23 PM, Administrative Nurse D stated she expected staff to follow the physician orders for wound treatments. Administrative Nurse D said LN G should have called the physician to obtain an order for a different treatment when the ordered treatment was not available.The facility prevention and wound management policy documented that the facility will provide a systematic approach for identifying residents at risk for skin breakdown and develop interventions to decrease the incidence of residents who develop pressure ulcers while providing guidelines for optimal care to promote healing for residents with all identified skin alterations.

Based on observation, interview, and record review, the facility failed to ensure adequate services for respiratory care when staff failed to provide Resident (R) 44 with as needed (PRN) breathing treatments as ordered for shortness of air (SOA)/shortness of breath (SOB). Findings included:- The Electronic Health Records (EHR) for R44 included diagnoses of acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and obstructive sleep apnea.R44's admission Minimum Data Set (MDS), dated for 01/22/2026, documented a Brief Interview for Mental Status (BIMS) of 15, which indicated cognitively intact. The MDS documented that R44 required setup or cleanup assistance for eating, partial to moderate assistance for oral hygiene, refused the bathing assessment, and required substantial to maximum assistance for all other activities of daily living (ADL). The MDS documented that she had SOB or trouble breathing when she laid flat and that she used a non-invasive mechanical ventilator.R44's Quarterly MDS, dated 06/25/2026, documented a BIMS of 13. The MDS documented that she had COPD and respiratory failure.R44's Care Plan, dated 02/03/2026, documented she took medication to manage chronic and acute pain in her back and feet. Staff were instructed to monitor for signs of overdose that included breathing difficulties and respiratory arrest (completely stopped breathing).R44's Care Plan, dated 02/09/2026, documented she was on a recommended fluid limitation for her health. Staff was instructed to observe any changes in blood pressure, urine output, skin turgor, cognitive status, and activity tolerance.R44's Care Plan did not have documentation related to her COPD or her PRN breathing treatments.R44's EHR documented a Physician's Order, dated 01/14/2026, for ipratropium-albuterol inhalation solution (a combination bronchodilator used to prevent and treat airway narrowing in COPD patients) 0.5-2.5 milligrams (MG)/three milliliters (ML), one vial inhaled orally every six hours as needed for SOB.The 06/24/2026 at 04:10 PM Wellness Meeting Note documented R44 did not participate in any activities that shift, as she normally did, and did not have much of an appetite. R44 had complaints of pain in her low back and felt short of air and requested to speak with the provider.The 06/24/2026 at 08:18 PM Orders Note documented that R44 had been seen by the provider, and a two-view chest x-ray had been ordered for SOA.The 06/27/2026 at 11:12 AM Transfer Note documented that when the nurse went into R44's room, she was leaning over and soaked with sweat and urine. The note documented that she could not tell the nurse where her pain was and had a temperature of 103.0 degrees Fahrenheit. The provider was notified, and R44 was sent to the hospital for further evaluation.R44's June 2026 Medication Administration Record (MAR) documented that the only PRN breathing treatment was administered on 06/13/2026. There were no documented refusals.Observed on 07/21/2026 at 12:38 PM, R1 was lying in bed awake. Upon opening the door, a strong urine smell wafted out of the room.On 07/21/2026 at 01:15 PM, Certified Nurse Aide (CNA) M said she would have known if a resident was SOA/SOB if their breathing was not normal for them, or they had audible wheezing. She would then notify the nurse.On 07/21/2026 at 01:30 PM, Licensed Nurse (LN) G said if the CNA reported a resident had difficulty breathing or wheezing, she would have attempted to give them a breathing treatment, especially if there was a standing order. She also said she would have attempted to give them a breathing treatment if they had SOA/SOB; if they refused, she would have documented it and notified the provider.On 07/21/2026 at 02:00 PM, Administrative Nurse D said that if a resident had SOA/SOB and they had orders for PRN breathing treatments, she expected the nurse to have at least attempted to give them the treatment. She said if they refused, she expected them to document the refusal and notify the provider.The facility policy Clinical Resources for Implementing Standards of Care, dated 11/2024, documented that clinical resources would be used as guidelines for implementation of standard of care practices for the delivery of services to residents.

Based on observation, record review and interviews, the facility failed to ensure Resident (R)33 remained free from a significant medication error when staff failed to follow the physician prescribed administration schedule for R33's Carbidopa-Levodopa (medication used to control tremors shaking associated with Parkinson's disease).Findings included:-R33's Electronic Medical Record (EMR) documented R33 had diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The admission Minimum Data Set (MDS), dated 04/09/2026, documented R33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R33 required staff assistance for toileting, bathing, dressing, and transfer.The Functional Abilities Care Area Assessment (CAA), dated 04/20/2026, documented R33 required staff assistance with activities of daily living (ADLs) due to weakness.The Medication Administration Record (MAR), dated July 2026, documented carbidopa-levodopa 25 milligrams-100 milligrams by mouth four times daily was started on 04/02/2026.The 04/02/2026 order details report documented the facility time code for administration of the carbidopa-levodopa four times a day at 06:00 AM; 10:00 AM; 02:00 PM, and 08:00 PM daily.The hospital discharge physician orders dated 07/07/2026, when R33 returned to the facility, showed the order for carbidopa-levodopa to be administered four times daily at 07:00 AM; 11:00 AM; 03:00 PM and 07:00 PM.On 07/21/2026 at 12:28 PM, observation revealed R33 sitting in a recliner and stated she had just finished her lunch and was waiting for her afternoon medications.On 07/20/2026 at 03:53 PM, R33 stated she was very distressed with the facility for not following the doctor's orders for the times she was supposed to receive her carbidopa-levodopa every day. She stated the physician had emphasized the importance of the administration times. R33 stated she had discussed this issue with the facility staff, but nothing changed. R33 stated that sometimes staff woke her at 05:00AM to administer the morning dose.On 07/21/2026 at 04:08 PM, Certified Medication Aide (CMA) R reported she administered the 03:00 PM Carbidopa-Levodopa at 01:38 PM.On 07/22/2026 at 12:35 PM, CMA R stated the MAR tells staff what time to administer the carbidopa-levodopa and verified the MAR showed the medication was due daily at 07:00 AM, 11:00 AM, 03:00 PM, and 08:00 PM. The night nurse administers the 07:00 AM dose before they leave work at 06:00 AM each day.On 07/22/2026 at 12:49 PM, Licensed Nurse (LN) H reported the night shift nurse administers the morning dose of R33's carbidopa-levodopa prior to the end of their shift at 06:00 AM each day, and the CMA administers the remaining doses each day.On 07/22/2026 at 12:40 PM, Administrative Nurse D reports the physician's order for the carbidopa-levodopa medication administration should follow the physician's order and the facility's medication administration policy.The medication error reporting and adverse drug reaction prevention and detection policy dated 2007 showed the facility utilizes a system to assure that medication usage is evaluated on an ongoing basis.

Based on observation, interview, and record review, the facility failed to ensure the posted nurse staffing contained the required information when staff failed to include the resident census or posted an inaccurate census.Findings included:- Observation on 07/20/2026 at 07:38 AM revealed the Daily Staff Posting posted nurse staffing sheets for 07/19/2026 and 07/20/2026. The sheets did not have the census or the actual hours worked posted on the form.Review of the Daily Staff Posting sheets revealed the sheet had a line for the facility name and date, but not for the census. The sheet had the nurse staff breakdown by shifts (First, Second, and Third) and further by eight-hour shift and/or twelve-hour shifts. Review of the July 2026 staffing sheets revealed each sheet lacked the required information, including census and the actual hours worked for each Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nurse Aide (CNA/Certified Medication Aide (CMA). On 07/22/2026 at 01:17 PM, Administrative Nurse D stated the daily posting form should be filled out completely and accurately.On 07/22/2026 at 01:18 PM, Administrative Staff A stated all the required areas for the daily staffing should be completed each dayThe facility's Benefit Improvements Protection Act (BIPA) Nurse Staff Posting policy, revised 12/2019, indicated the facility will post staffing data each shift for the direct care and licensed nurses. The policy indicated the daily posted staffing will identify the census at the beginning of each shift to track the necessary staffing required.

Based on observations, record review, and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M used a gait belt and two-person assist during toileting and toileting hygiene for Resident (R) 1 to prevent accidents. On 04/17/2026 at approximately 01:15 PM, CNA M assisted R1 with toileting. When R1 stood up in front of the toilet for CNA M to clean bowel movement off of her, R1 stated she needed to sit down and proceeded to sit back down onto the edge of the toilet. R1 slipped off the toilet edge and onto the floor. R1's right leg bent backwards at the knee with her ankle positioned at the height of her upper body. CNA M called for help, and Licensed Nurse (LN) G responded. The facility called for assistance from Emergency Medical Services (EMS) to assist R1 off the floor, which they were able to do after they provided medication. EMS partially reset R1's right leg, then transported her to the hospital, where she was found to have an acute comminuted (break or splinter of the bone into more than two fragments) distal (away from the farthest point of origin or attachment) femoral (thigh bone) fracture and required surgical intervention. Findings included:- R1 admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of need for assistance with personal care, generalized muscle weakness, and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had impairment on both sides of her lower extremities. R1 required substantial/maximal assistance with toileting hygiene and partial/moderate assistance to stand. R1 had no falls since the last assessment. R1's Significant Change MDS dated [DATE] documented R1 had a BIMS score of 13, which indicated intact cognition. R1 had impairment on both sides of her lower extremities. R1 was dependent on staff for toileting hygiene, and standing was not attempted due to a medical condition or safety concerns. R1 had no falls since her re-entry to the facility. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 05/14/2026 documented R1 required substantial assistance with ADL completion and directed caregivers of her wants and needs. R1's 06/23/2021 Care Plan documented she needed staff assistance with ADL related to physical limitations. The Care Plan documented an intervention, dated 09/11/2024, that R1 was incontinent and could not take herself to the bathroom and perform her own hygiene. R1 needed two-staff assistance with her toileting needs, such as using a bedpan, toileting hygiene, or changing her brief. The facility's Investigation dated 04/20/2026, documented on 04/17/2026 at approximately 01:15 PM, CNA N reported to Administrative Nurse D that R1 fell. Administrative Nurse D entered R1's room to discover LN G and CNA M in R1's bathroom. Feces covered the floor and the toilet riser. R1 laid on the floor while CNA M supported her head, and LN G left to call EMS. R1's left ankle bled, and Administrative Nurse D applied pressure with gauze. While Administrative Nurse D applied pressure to R1's left ankle, she observed R1's right leg was deformed with her right knee twisted and bent backwards. R1 transferred to the hospital and was admitted for a right leg femur fracture. The facility's investigation documented CNA M failed to utilize a gait belt during the transfer. CNA M self-terminated her employment, and the facility completed nursing staff education regarding gait-belt usage. The facility concluded the root cause analysis of R1's fall was her deconditioning and weakness from her recent hospital stay with an environmental contributing factor of feces covering the floor and toilet riser. R1's EMR documented the following: A Nurse's Note on 04/17/2026 at 06:30 AM documented at approximately 06:30 AM, the CNA called the nurse for help. The nurse entered R1's room and observed R1 sitting upright on the floor with her back supported by the bed and her legs straight in front of her. R1 stated she did not fall, she tried to go to the bathroom, and while the CNA helped transfer her from the bed to the wheelchair, her legs gave up, and she slipped onto the floor. A Fall Note on 04/17/2026 at 02:37 PM documented the CNA assisted R1 in the bathroom, and she stood up for the CNA to clean her then stated to the CNA that she had to sit down. R1 sat down on the edge of the toilet, then proceeded to fall from the toilet to the floor. When the nurse arrived, R1 sat on the floor directly in front of her toilet and leaned to her right side. The CNA helped keep R1's head from resting on the toilet. R1 had stool on the floor, and she continued to defecate. R1's right leg appeared deformed as it was bent completely backwards at the knee and she sat on that leg. The nurse called for EMS to transport R1 to the hospital. A Computed Tomography (CT scan- a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) of the right lower extremity without intravenous (IV-administered directly into the bloodstream via a vein) contrast results on 04/17/2026 at 09:47 PM, documented diffuse osseous demineralization (progressive loss of minerals from bone tissue which reduced bone density and strength) and an acute, comminuted distal femoral fracture that had intra-articular extension (extends to the joint) to the knee. CNA M's notarized Witness Statement dated 05/01/2026 revealed on 04/17/2026 at around 01:15 PM, she toileted R1 in her bathroom. Once she finished cleaning feces on R1's legs and stomach, CNA M asked R1 to stand up so she could wipe her bottom. R1 stood up, and CNA M wiped her a few times before R1 stated she needed to sit down. CNA M stated R1 sat down on the edge of the toilet, and her bottom slipped off the edge and R1 slid onto the floor with her back to the toilet. R1's right leg was bent behind her with her right ankle positioned up to her right armpit. CNA M stated she immediately yelled for help and LN G entered with CNA N. LN G's Witness Statement, not dated, revealed on 04/17/2026, CNA M called her to R1's room. LN G entered R1's room and saw R1 sat on the floor directly in front of her toilet and leaned to her right side while CNA M helped keep R1's head from resting on the toilet. R1 had stool on the floor and continued to defecate. LN G stated R1's right leg appeared deformed as it was bent completely backwards at the knee and R1 sat on her right leg. LN G called EMS to transport R1 to the hospital. Administrative Nurse D's Witness Statement, not dated, revealed on 04/17/2026, CNA N approached her and said LN G needed her in R1's room. Administrative Nurse D entered R1's room and found R1 on the floor while CNA M held her head for support. R1 laid on her right side against the toilet and noted feces on the floor. R1's left ankle bled, and Administrative Nurse D applied pressure to her left ankle then noticed R1's right leg was deformed with her right knee twisted and bent backwards. EMS arrived and gave R1 IV pain and sedation medications, then relocated R1's knee and leg. EMS transported R1 to the hospital. On 06/04/2026 at 11:39 AM, R1 laid in bed with her eyes closed. On 06/04/2026 at 12:27 PM, CNA O stated she had access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident) that directed a resident's care. She confirmed R1's Care Plan directed R1 needed two staff assistance with toileting hygiene. CNA O stated she knew R1's fall occurred in her bathroom with one CNA and no gait belt usage. She stated she kept residents safe during transfers by using two staff, if their care plan directed they needed two staff, and she always used a gait belt, even with stand-by assist transfers. On 06/04/2026 at 12:46 PM, LN H stated staff knew how much assistance a resident needed by their care plan or Kardex. She confirmed R1's Care Plan directed she needed two staff assistance with toileting hygiene. LN H stated she worked on 04/17/2026 and went to R1's room to assist. She said R1 was on the floor in front of the toilet while CNA M sat on the floor and cradled her head in her lap. LN H stated R1 laid to her right with the toilet to her left, and LN H did not initially see R1's right leg. She said R1 rolled over a bit and R1's right heel was close to her right armpit. The facility contacted EMS and EMS attempted to see if they could reduce R1's right leg and splint it. LN H stated EMS gave R1 IV medications, and after a period of time, EMS talked R1 through the reduction process and was able to reduce her right leg enough to get her out of the bathroom and onto the gurney. LN H said she did not see a gait belt on R1 when she initially walked in and R1's pants were not pulled up and there was bowel movement all over the bathroom floor. LN H stated she ensured safe transfers by using a gait belt and two-staff if the care plan documented the resident required two staff assistance. On 06/04/2026 at 12:59 PM, Administrative Nurse E stated R1 would tell staff when she needed more help than one staff member with transferring from her wheelchair to a chair in the day area. She confirmed after reading R1's Care Plan that R1 would have needed two-staff assistance with toileting hygiene on 04/17/2026. She stated she expected staff to use the number of staff directed on the care plan and to use a gait belt with all transfers. The facility's Falls Management policy, revised December 2022, revealed the care plan documented fall risk interventions, and the facility communicated fall prevention interventions to facility staff through the plan of care. The facility did not have a policy on safe transfers. The facility identified, implemented, and completed the following corrective measures:1. CNA M self-terminated with her last day as 04/17/2026.2. The facility updated R1's care plan on 04/21/2026 for transfer status.3. The facility completed gait belt usage education with nursing staff on 04/28/2026 and again on 05/14/2026. Due to the facility's completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a G (isolated, actual harm that was not immediate jeopardy).

The facility reported a census of 38 residents. The sample included three residents, reviewed for elopement/elopement risk. Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision for cognitively impaired Resident (R) 1, who was at moderate risk for elopement. On 08/25/25 at approximately 12:50 PM, Administrative Staff B opened the facility door to allow R1 and R3 outside to sit on the patio. Administrative Staff B told Licensed Nurse (LN) G R1 was outside, seated in her electric wheelchair. At 02:10 PM, Emergency Medical Services (EMS) alerted the facility that they responded to a 911 call and found R1 on the ground approximately one-half mile from the facility. R1 hit a curb in her electric wheelchair, fell, and hit her head. The facility staff were unaware R1 had left the facility until they received the EMS call. The facility's failure to prevent a cognitively impaired resident from leaving the facility grounds without staff supervision placed R1 in immediate jeopardy.Findings included:- The electronic medical record (EMR), documented R1 admitted to the facility on [DATE]. The EMR documented R1's diagnoses included hepatic encephalopathy, (a serious condition that occurs when the liver is unable to filter toxins from the blood, and this buildup of toxins affects the brain's ability to function), cerebral vascular accident with residual effects (commonly known as a stroke when a blood vessel blockage or rupture disrupts blood flow to the brain), aphasia (an acquired communication disorder that results in loss of the ability to produce or understand language), and unspecified mood disorder symptoms (a mental health condition, often used when an individual experiences significant impairment or distress in daily functioning but does not neatly fit into other categories, such as depression, or bipolar disorder). The Annual Minimum Data Set (MDS) dated [DATE] documented R1 scored seven on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R1 did not experience mood, wandering, or other behavior disorders during the assessment period and received antidepressant medications.The 05/09/25 Care Area Assessment (CAA) (an analysis of resident characteristics) documented R1 had a cognitive deficit but could make her needs known, R1 had diagnoses of hemiplegia and hemiparesis (paralysis on one side of the body), could stand with assist, required assistance of two staff with bed mobility, used a slide board for transfers, did not have a history of falls, and had bowel and bladder incontinence. The CAA recorded R1 used an electric wheelchair and chose not to use the toilet (check and change).A 08/08/25 Quarterly MDS documented a BIMS score of nine, which indicated moderately impaired cognition.The 09/10/25 Significant Change MDS documented a decrease in R1's BIMS score of six, indicating moderately impaired cognitive decline, from the assessments on 05/09/25 and 08/08/25. R1 scored an 11 on a mood screening tool, noting R1 had little interest or pleasure in doing things, felt tired or had little energy most days, and had a poor appetite. The 09/10/25 Communication CAA recorded R1's decreased cognition.R1's Care Plan dated 08/22/25 documented R1's inability to ambulate, required use of an electric wheelchair, and directed staff to provide assistance with setup in the wheelchair and ensure its functional operation. R1 used a slide board for transfers. The care plan recorded R1 was a fall risk, had no recent falls, and outlined appropriate interventions. R1's care plan lacked documentation to identify R1 as an elopement risk and/or interventions to identify or prevent an elopement from the facility. R1's care plan did not address R1's ability to participate in unsupervised activities outside the facility. R1's revised Care Plan dated 08/25/25 recorded R1 used a regular wheelchair and required staff assistance with ambulation. A transfer method was not addressed on R1's revised care plan. The care plan, recorded R1 was identified at a high risk for wandering and directed staff to interpret behaviors from R1's viewpoint, coordinate information with the hospital for medical care, observe for triggers, assist R1 during increased times of wandering, assist with identifying and communicate to others, and upon return from hospital continue with oversight and referrals for physical, psychosocial, and medication evaluations. R1's revised Care Plan lacked documentation related to R1's outdoor privileges. A Nurses Progress Note dated 08/25/25 at 04:27 PM recorded the facility received a call from County EMS at approximately 02:05 PM, stating that the resident fell while out in the community. The nurse's note recorded there were witnesses, and EMS was told R1 had fell out of her chair and had a head injury and a laceration. EMS stated R1 was able to tell them that she lived in a facility. EMS also reported that they would be transporting the resident to the hospital for treatment of the head injury.A facility self-report #2600022 received on 08/25/25 recorded R1 eloped from the facility on 08/25/25. The report documented R1 was last seen around 12:45 PM or 12:50 PM, seated on the front porch/patio after a staff member assisted R1 outside with another resident (R3). The facility received a call from EMS at approximately 02:10 PM, stating they found a person (identified as R1) in the community, after community members called EMS, stating a person had hit the curb with her electric wheelchair and had fallen to the ground. EMS transported R1 to the hospital for evaluation and treatment. The report documented per the 08/02/25 assessment, R1 was not at risk for elopement, which contradicted the 08/02/25 Elopement Risk Assessment, which indicated R1 was at moderate risk for elopement. The report noted the other resident (R3) went back into the facility, leaving R1 alone. It is unknown how long R1 was alone. The weather was sunny and mild, with a temperature in the mid-70s. The Facility Investigation lacked documentation to address why R1 was outside unattended, who found the resident, what witnesses said, an interview with resident (R3) who was outside with R1, where and how specifically R1 was found, what route was taken by R1, how far R1 traveled from the facility, what environmental hazards were present, what R1 wore, and/or any ongoing communication with the hospital.A Skin Assessment dated 08/02/25, before R1's elopement and fall, recorded R1 had bruises on both breasts and around the breast. An Elopement Risk Assessment dated 08/02/25 recorded a score of 10, which placed R1 at moderate risk for elopement.A Skin Assessment done on R1's reentry, dated 09/03/25, recorded R1 had bruises all over due to her fall that resulted in her hospital admission. R1 had bruises to the right peri-orbital (eye socket), right cheek, shoulder, top of breast, forearm, upper arm, back of hand, knee, and forehead. This also included the left foot top, left forearm, scar on the 1st, 2nd, and 3rd fingers, and blanchable redness on the buttocks.The 09/03/25 reentry Elopement Risk Assessment recorded a score of 11, which continued R1's moderate risk for elopement status.The 08/25/25 Hospital emergency room Report documented R1 presented as trauma transfer from (another hospital), after a fall from her motorized wheelchair. The patient did not know why she is in the hospital and does not remember falling. R1 is only oriented to self and place and not to reason. A Computerized Tomography (CT) head scan was obtained at 04:25 PM on 08/25/25, which was significant for an acute right-sided subdural hematoma (bleeding near the brain that can happen after a head injury). The patient was also hypoxic (a deficiency in the amount of oxygen reaching the tissues).On 09/22/25 at approximately 08:00 AM observation of the area where R1 was found, approximately a half mile from the facility, revealed a main road in town, near a restaurant and bank, with changing slopes, cement curbing, and walkways, grassy and paved areas, varying speed limits and traffic patterns, stop signs, stop lights, lane changes, and other potential environmental hazards for a cognitively impaired dependent resident.According to Weather Underground (www.wunderground.com) on 08/25/25 at 12:53 PM, the temperature was 70 Degrees Fahrenheit with calm winds and fair skies.On 09/22/25 at 11:10 AM, observation revealed R1 in her room with a faded bruise and a pen-point puncture wound to her right temple.An undated Witness Statement documented Administrative Staff B opened the door for R1 to go outside along with another resident (R3). R1 stated she did not inform the nurse she was going outside. Administrative Staff B stated she would inform the nurse, and informed LN G, R1 was on the front porch, and LN G said, Ok. Administrative Staff B then told another staff member that the issue of the resident signing out needed to be addressed in the resident council. This was approximately 12:50 PM. LN G's undated Witness Statement documented at 01:00 PM, Administrative Staff B notified her that R1 was outside. At 02:05 PM or 02:10 PM, the front hall nurse, LN H, received a call from the county EMS stating R1 fell outside the facility, sustained a head injury, and was being transported for emergency treatment. LN H's statement documented notifications made to the facility's Administrative Staff A, interim, Administrative Nurse D, residents' responsible party, and R1's physician and or nurse practitioner. An undated Witness Statement documented LN H received a phone call from county EMS at 02:02 PM inquiring if R1 resided at the facility. LN H questioned the inquiry, and after EMS explained the resident fell and sustained a head injury, LN H provided information regarding R1's cognition and medications. EMS reported R1 would be transported to the hospital or a head trauma unit. On 09/22/25 at 11:10 AM, R1 stated she remembered using her electric wheelchair to travel from the facility, but did not know where she was going or why. R1 did not remember falling from her electric wheelchair. R1 stated she remembered being hungry at the time, but did not remember hitting a curb or being in the hospital. R1 did not remember hurting herself (pointing to a bruise on her right temple). R1 denied any mistreatment by staff or other residents.On 09/23/25 at 11:06 AM, CNA N stated R1 did not go outside often.During a phone interview on 09/23/25 at 11:15 AM, Administrative Staff B stated R1 would go outside on occasion (usually with other residents). She wanted to purchase some potato chips from the vending machine, but then saw other residents going out and said, Oh, I'm gonna go outside, instead. She seemed ok, there was nothing out of the ordinary. R1 did not seem agitated or anxious.On 09/23/25 at 11:28 AM, CNA O stated she worked that day but on a different hall. CNA O stated she knew R1 would like to sit in the front of the building occasionally, but it was not frequent. The resident would ride around in her electric wheelchair, but CNA O never saw her leave the facility grounds.On 09/22/25 at 04:39 PM, LN G stated Administrative Staff B reported R1 was out on the patio. At around 02:00 PM, EMS called and stated the resident was located away from the facility.On 09/22/25 at 04:59 PM, LN G stated she did not know how R1 was found away from the facility, on the ground. LN G stated R1's bruise and puncture-like wound was likely from the fall, noting it was much larger when R1 first returned from the hospital but has decreased a lot.On 09/22/25 at 12:54 PM, Administrative Staff A stated R1 would go in and out of the building depending on her mood. Administrative Staff A stated she did not know of R1 ever exiting the building without staff knowledge before. She confirmed R1 was found lying on the ground, near a restaurant. Administrative Staff A stated she was unaware of where R1 was going or why. R1 returned from the hospital with a puncture-like wound to her upper right temple. Administrative Staff A noted all residents were assessed for elopement risk after this incident, and an all-staff in-service was conducted. R1's sibling and the responsible party did not want R1 to use the electric wheelchair, which was discontinued on 09/04/25. Administrative staff B stated staff care planned R1 as at moderate risk for elopement, noted all doors had key pads, and R1 was not able to exit on her own without a power chair. The facility's Resident Elopement Policy and Procedure policy, revised 12/2022, documented the facility's intent to promote a safe and secure environment to help minimize the risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. Residents are to be assessed for elopement risk within the first 24 hours of admission, quarterly, and annually, for behaviors indicating potential elopement risk and with any significant change. Assessments are to be documented in the clinical record. If an identified risk is present, the interventions implemented are to be documented on the resident's care plan. On 09/23/25 at 01:59 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to prevent a cognitively impaired resident from leaving the facility grounds without staff supervision. The residenet fell while out unsupervised and sustained a head injury, placed R1 in immediate jeopardy.The deficient practice was determined as Past Non-Compliance on 08/25/25 when the facility implemented the following corrective actions:Notifications made to the resident's PCP and DPOAStatement obtained from staff members (see witness statements, Emergency QAPI meeting held with Dr [NAME], Medical Director, Director of Nursing, and ED on 08/25/25 Emergency resident council meeting on 08/25/25Staff meeting held on 08/25/25, on the elopement policy and procedure. Maintenance Director completed checks on all Exit doors, 08/25/25The resident elopement book was reviewed, The facility implemented a list of Residents with a BIMS score of 13 and above to exit the facility without supervision. The facility completed corrective actions by 08/25/25, prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance and remained at the scope and severity of a J.

The facility identified a census of 45 residents, with three residents reviewed for abuse. Based on record review, observations, and interviews, the facility failed to prevent the mental abuse of cognitively impaired and dependent residents, Residents (R) 2, R3, and R4. In May 2025, Hospitality Aide P took demeaning and humiliating photos of the residents in compromising positions, without their consent, knowledge, or permission. Hospitality Aide P kept the images on her personal cell phone and later texted them to at least one other staff member. It is unknown if Hospitality Aide P distributed the images beyond this incident. This deficient practice violated the rights of R2, R3, and R4 and placed the residents in immediate jeopardy, based on reasonable person concept, for the negative psychosocial impact of fear, humiliation, privacy violation, and dehumanization.Findings included:- R2's Annual Minimum Data Set (MDS) dated [DATE] did not record a Brief Interview for Mental Status (BIMS) score. However, the facility indicated in a facility incident (FRI #6430) that the resident had a BIMS of 7, which indicated R2 had severely impaired cognition. The MDS documented R2 was 5 feet 3 inches in height and weighed 118 pounds (Lbs.). R2 was assessed to be incontinent of bowel and bladder, had functional impairment on one side, ambulated with the use of a wheelchair, and was dependent on staff for all activities of daily living (ADL) except for eating, which required cueing and encouragement. Facility Reported Incident number 6430 documented Administrative Staff A received three separate emailed photographic images on 07/04/25 at 08:15 AM from Certified Nurse Aide (CNA) M, a former employee. Administrative Staff A identified R2, R3, and R4 as residents in the photos. The images depicted R2 lying in bed on the left side and unclothed from the waist down. The image of R3 depicted the resident lying in bed, with her head tilted to the side. The image of R4 revealed the resident lying on her back while CNA O stood on and at the head of R4s bed, using a draw sheet to assist the resident up in bed. The report documented the facility notified law enforcement, began an investigation, and implemented an immediate plan of correction. The facility investigation documented substantiated abuse, based on the photographs received, the reports provided, and the involved residents' inability to give consent. On 07/16/25, a review of the photographs depicted the following:R2 lying in bed on her left side, seemingly sleeping, wearing a flannel-type nightgown, to the waist. R2's legs were retracted in a fetal-like position, and R2's right hip and legs were exposed and visible. R2's face was evident in the photo.R3 lying in bed on her right side, from the mid chest up, head tilted to the side, dressed and seemingly sleeping. The resident's face was evident in the photo.R4 lying on her back while CNA O stood on and at the head of R4's bed, using a draw sheet to assist the resident up bed. The photograph showed the resident from the waist up, wearing a blouse, and the lower left leg was exposed. The residents' alertness could not be determined; however, R4's face was visible, as well as CNA O's entire body. The facility investigation did not contain CNA M's Witness Statement (former employee). The 07/04/25 unnotarized Witness Statement from Hospitality Aide P documented, Hospitality Aide P sent pictures to CNA M (her relative) after she received the photos of residents from CNA M. Hospitality Aide P stated she did not know photographs were not allowed at that time. Hospitality Aide P stated she would not have taken a picture of a resident's face. The 07/04/25 unnotarized Witness Statement from CNA/Certified Medication Aide (CMA) O documented the pictures were taken. CNA/CMA O asked for the photographs to be deleted and thought it was taken care of. CNA/CMA O further stated she should have reported. Review of the Electronic Medical Record revealed all three residents were cognitively impaired and dependent on staff for cares.R2's Annual Minimum Data Set (MDS) dated [DATE] did not record a Brief Interview for Mental Status (BIMS) score. [However, the facility indicated in a facility incident (FRI #6430) that the resident had a BIMS of 7, which indicated R2 had severely impaired cognition]. The MDS documented R2 was five feet three inches tall, weighed 118 pounds lbs., was incontinent of bowel and bladder, had functional impairment on one side, ambulated with the use of a wheelchair, and was dependent on staff for all activities of daily living (ADL) except for eating.R3's Quarterly Minimum Data Set (MDS) dated [DATE] recorded a BIMS score of zero, which indicated severely impaired cognition. The MDS documented R3 was five feet tall, weighed 109 pounds (lbs.), was incontinent of bowel and bladder, had functional impairment on both sides, ambulated with the use of a wheelchair, and was dependent on staff for all activities of daily living (ADL).R4's Quarterly Minimum Data Set (MDS) dated [DATE] recorded a BIMS score of zero, which indicated severely impaired cognition. The MDS documented R4 was five feet six inches tall, weighed 174 lbs., was frequently incontinent of bowel and bladder, had functional impairment on one side, ambulated with the use of a wheelchair, and was dependent on staff for most activities of daily living (ADL). Observation on 07/16/25 at 01:32 PM revealed R2 laid on her right side in a low bed with a fall mat next to the bed. R2 was alert to verbal and answered yes/no questions. R2 did not know or remember being photographed, and stated she was doing ok.On 07/16/25 at 11:30 AM, Administrative Nurse E stated she was relatively new to the facility but was aware of the facility's reported incident involving R2, R3, and R4, regarding photographs taken. Administrative Nurse E acknowledged the inappropriate behaviors of former staff and noted immediate in-service regarding abuse, neglect, and exploitation of residents and the violation of photographing and or recording residents in any way. Administrative Nurse E stated the facility required each staff member to read and sign the facility policy on 07/04/25 and could return until they completed the task. During a telephone interview on 07/17/25 at 12:30 PM, Administrative Staff A stated she received the photos from a former employee, CNA M, who was related to Hospitality Aide P. According to CNA M, Hospitality Aide P took the photos sometime in May 2025. According to Hospitality Aide P, she admitted to taking photographs of residents, only after receiving photographs from CNA M. Both staff members stated they knew of the pictures. Hospitality Aide P said she sent pictures of the residents to her relative (CNA M) because her sister had sent pictures of the residents to her. Hospitality Aide P said she did not know it was not allowed. Neither former staff member would say why they took the photographs of the residents. Administrative Staff A stated it was reported CNA M and Hospitality Aide P were arguing. Administrator A stated that the staff involved were immediately suspended and eventually terminated. Law Enforcement came out on July 4th and were unsure of criminal charges at the time, but returned stating there may be criminal charges, and the facility submitted all the information related to the incident. Administrative Staff A stated the facility notified the State Agency and the resident's physicians, and Administrative Staff A met with the resident's family's responsible parties in person. Administrative Staff A noted R2, R3, and R4 were assessed for injuries, with none found. Additionally, alert and oriented residents were interviewed and stated they had not been photographed. Administrative Staff A stated the Hospitality Aide P should not have been in a resident's room during personal cares.The facility's Abuse, Neglect, and Exploitation Policy (ANE), revised in October 2022, documented the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. It is the facility's Policy to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift and immediate action to adjudicate alleged resident abuse and neglect. Section 18.4 Of this policy, titled, social media, Networking and Blogging documented: The use of recording devices in all of our facilities is restricted as we are required to maintain, confidentiality for patients and employees, even incidental or casual use of recording devices is prohibited due to the potential violation of personal rights, Personal health information or the disclosure of proprietary information. Currently, only Administrators and Regional [NAME] Presidents are authorized to take pictures, video, or create any type of recording.The IJ template was given to Administrative Staff A on 07/16/25 at 06:35 PM.The immediate jeopardy was removed on 07/04/25 when the facility implemented corrective actions as follows, which were completed on 07/09/25:The facility provided ANE and cell phone usage policy training to all onsite staff on 07/04/25, completed by 07/09/25 for all staff, and staff were not permitted to work their next shift without having the re-education.Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility identified a census of 49 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care. Findings included: - The facility's January, February, March, and April 2024 nursing schedule lacked evidence of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 01/20/24, 01/21/24, 02/17/24, 03/3/24, 03/16/24, and 04/7/24. The facility was unable to provide verifiable, auditable evidence of RN coverage. On 08/13/24 at 01:29 PM, Administrative Staff A stated she was unable to show evidence of RN coverage for the above days. The facility did not provide a policy related to Registered Nurse coverage. The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week, as required. This placed the residents who resided in the facility at risk of lack of assessment and inappropriate care.

The facility identified a census of 49 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA M, hired on 06/13/13, had no yearly performance evaluation upon request. CNA N, hired on 06/16/22, had no yearly performance evaluation upon request. CNA/Certified Medication Aide (CMA) R, hired 09/17/18, had no yearly performance evaluation upon request. CNA P, hired on 04/18/22, had no yearly performance evaluation upon request. CNA O, hired on 03/15/23, had no yearly performance evaluation upon request. On 08/14/24 at 10:05 AM, Administrative Staff A stated the director of nursing was responsible for performing the yearly performance evaluations for the nursing staff. On 08/14/24 at 01:00 PM, Administrative Nurse D stated she was responsible for the yearly performance evaluations for the nursing staff. Administrative Nurse D stated she had not performed the yearly performance evaluation yet. The facility was unable to provide a policy related to yearly performance evaluations. The facility failed to ensure any of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 49 residents and one kitchen. Based on interviews and record reviews, the facility failed to provide the services of a full-time certified dietary manager for the 49 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 08/12/24 at 02:25 PM, Dietary Staff BB stated he had been with the facility a few days. He stated he had completed the classes but had not scheduled to take his certification exam. On 08/13/24 at 09:35 AM Dietary Staff BB stated the Registered Dietician (RD) came to the facility monthly. He stated staff could call the RD with any concerns. On 08/13/24 at 10:00 PM Administrative Staff A stated the facility had a certified dietary manager, but she had taken a different position and no longer worked in the kitchen. The facility did not provide a policy for the dietary manager position. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food, placing the residents at risk for inadequate nutrition.

The facility identified a census of 49 residents. Based on interviews, and record review the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit accurate registered nurse (RN) coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staff. Findings included: - The PBJ report provided by the CMS for Fiscal Year (FY) 2023 quarter three, quarter four, and quarter one FY 2024 documented no triggered areas. The facility was unable to provide RN punch times for staff hours on 01/20/24, 01/21/24, 02/12/24, 02/17/24, 02/24/24, 03/3/24, 03/16/24, 04/7/24 as requested. On 08/14/24 at 02:00 PM Administrative Staff A stated she was unable to provide punch times for RN staff on the dates above. Administrative Staff A stated the facility did not have a policy regarding the PBJ reporting. Administrative Staff A stated the facility followed the Centers for Medicaid and Medicare (CMS) guidelines for payroll reporting. The facility did not provide a policy for PBJ reporting. The facility failed to ensure accurate staffing hour information was submitted to the federal regulatory agency through PBJ when the facility failed to submit accurate RN coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staff.

The facility had a census of 49 residents. Five Certified Nurse Aides (CNAs) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - A review of the information facility's in-service records revealed the following CNAs were employed with the facility for more than 12 months: CNA M, hired on 06/13/13, had not completed any of the required in-services in the past 12 months. CNA O, hired 03/15/23, had completed six hours of the required yearly in-services in the past 12 months. CNA P, hired on 04/18/22, had completed six hours of the required yearly in-services in the past 12 months. On 08/14/24 at 01:00 PM, Administrative Nurse D stated human resources help ensure the nursing staff completes their 12 hours of required in-services are completed annually. She stated the required ins-services are assigned to certain courses and should be completed monthly. The facility was unable to provide a policy related to staff training. The facility failed to ensure three of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care.

The facility identified a census of 49 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the need for a physician-documented rationale for non-approved Center for Medicare and Medicaid Services (CMS) indications for the use of antipsychotic medications (class of medications used to treat major mental conditions which cause a break from reality) for Resident (R) 35, R20, R19, and R27. This deficient practice placed these residents at risk for adverse medication effects and medication errors. Findings included: - R35's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), insomnia (inability to sleep), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R35 received antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), antipsychotic medication, anticoagulant (class of medications used to prevent the formation of blood clots), diuretic (medication to promote the formation and excretion of urine), hypnotic (a class of medications used to induce sleep), and opioid (a class of medication used to treat pain) during the observation period. The MDS documented that a gradual dose reduction was not completed and lacked documentation a Monthly Medication Review (MMR) was completed during the observation period. The MDS documented R35 had dementia. The Quarterly MDS dated [DATE] documented a BIMS score of 10 which indicated moderately impaired cognition. The MDS documented that R35 had received antianxiety medication, antidepressant medication, antipsychotic medication, anticoagulant (medication, diuretic medication, hypnotic medication, and opioid medication during the observation period. The MDS documented that a gradual dose reduction was not completed and lacked documentation an MMR was completed during the observation period. R35's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/09/24 documented R35 received antipsychotic medication, antianxiety medication, antidepressant medication, and hypnotic medication. R35's Care Plan revised on 08/04/24 documented that staff would administer medications as ordered. R35's EMR under the Orders tab revealed the following physician orders: Trazodone hcl tablet (antidepressant) 150 mg give one tablet by mouth at bedtime related to insomnia dated 01/17/23. Abilify (antipsychotic) oral tablet 30mg give one tablet by mouth one time a day related to unspecified mood disorder dated 01/23/23. Belsomra tablet (hypnotic) 10mg give one tablet by mouth at bedtime related to insomnia dated 06/03/23. Clonazepam (antianxiety) oral tablet 0.5mg give one tablet by mouth three times a day related to insomnia dated 09/27/23. A review of the Monthly Medication Review (MMR) from August 2023 to July 2024 lacked evidence of CP recommendations for physician documentation for the rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Abilify for R35. On 08/14/24 at 07:38 AM R35 walked with his walker in the hallway from his room to the dining room unassisted. His gait was steady, and he wore a pair of tennis shoes. On 08/14/24 at 12:40 PM, Licensed Nurse (LN) G stated she would fax the MMR to the physician, note the new orders, and make the changes upon the returned faxes from the physician. LN G stated she did talk with the physician to clarify the indication for the residents who received antipsychotic medications. LN G stated the approved indication for antipsychotic medication was for behaviors and mood disorders. On 08/14/24 at 01:00 PM, Administrative Nurse D stated she realized the process for MMR had not been successful with tracking the physician responses. Administrative Nurse D stated she realized on 08/14/24 that the process for the facility's monitoring antipsychotic medication had not been utilized correctly. The facility was unable to provide a policy related to the process of CP reporting irregularities. The facility failed to ensure the CP identified and reported the non-approved CMS indication for the use of antipsychotic medication. This deficient practice placed R35 at risk for unnecessary medications and related complications. - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), aphasia (a condition with disordered or absent language function), muscle weakness, and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Significant Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated intact severely impaired cognition. The MDS documented that a staff interview for cognition was not completed. The MDS documented R20 had received diuretic (medication to promote the formation and excretion of urine) medication, antidepressant (class of medications used to treat mood disorders) medication, and antipsychotic (class of medications used to treat major mental conditions which cause a break from reality). The MDS documented that a gradual dose reduction was not completed and lacked documentation a Monthly Medication Review (MMR) was completed during the observation period. The MDS documented R20 had Alzheimer's disease. R20's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/26/24 documented she received antipsychotic medication for anxiety. R20's Care Plan dated 08/06/24 documented that staff would administer her medications as ordered by the physician. R20's EMR under the Orders tab revealed the following physician orders: Risperdal (antipsychotic)tablet 0.5 milligrams (mg) give 0.5 mg by mouth at bedtime related to anxiety 07/20/22. A review of the Monthly Medication Review (MMR) from August 2023 to July 2024 lacked evidence of recommendations for physician documentation for a rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Risperdal for R20. The December 2023 MMR revealed a recommendation for a dose reduction of antipsychotic medication Risperdal, mood stabilizer Depakote, and antidepressant medications citalopram and mirtazapine. The physician's response dated 12/27/23 to the CP's recommendation was to discontinue the antidepressant citalopram. The response did not address the other medications or include a rationale for continued use. The facility was unable to provide a physician-documented rationale for no GDR for Risperdal, Depakote, and mirtazapine. On 08/13/24 at 02:55 PM, R20 lay on her bed asleep with the head of her bed elevated. R20's call light was within reach. On 08/14/24 at 12:40 PM, Licensed Nurse (LN) G stated she would fax the MMR to the physician, note the new orders, and make the changes upon the returned faxes from the physician. LN G stated she did talk with the physician to clarify the indication for the residents who received antipsychotic medications. LN G stated the approved indication for antipsychotic medication was for behaviors and mood disorders. On 08/14/24 at 01:00 PM, Administrative Nurse D stated she was aware of the physician's orders on November 2023 MMR and that R35 had continued to receive the medications and was a medication error. Administrative Nurse D stated she had realized the process for MMR had not been successful in tracking the physician responses. Administrative Nurse D stated she realized on 08/14/24 that the process for the facility's monitoring antipsychotic medication had not been utilized correctly. The facility was unable to provide a policy related to the process of CP reporting irregularities. The facility failed to ensure the CP identified and reported the non-approved CMS indication for the use of antipsychotic medication for R20. The facility also failed to ensure the physician provided a documented rationale or risk-versus-benefit of continued use of R20's psychotropic medications without GDRs. This deficient practice placed R20 at risk for unnecessary medications and adverse side effects. 41713 - R19's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hallucinations (sensing things while awake that appear to be real, but the mind created), psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), and hypertension (HTN-elevated blood pressure). R19's Significant Change Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R19 required partial to moderated assistance from staff for activities of daily living (ADLs) and required substantial to maximal staff assistance with toileting. R19 received an antipsychotic on a routine basis as well as an antianxiety and antidepressant medication. No gradual dose reduction (GDR) had been attempted, and the MDS documented it was contraindicated. R19's Quarterly MDS dated [DATE] documented a BIMS score of three which indicated severely impaired cognition. R19 required partial to moderated assistance from staff for ADLs and required substantial to maximal staff assistance with toileting and bathing. R19 received an antipsychotic on a routine basis as well as an antianxiety and antidepressant medication. No GDR had been attempted and it was recorded as clinically contraindicated. The Psychotropic Drug Use Care Area Assessment (CAA) for R19 documented he triggered due to psychotropic drug use. He received antipsychotic, antianxiety, and antidepressant medications. R19's Care Plan directed staff he took Seroquel (an antipsychotic medication) for paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) and hallucinations. The staff was directed to provide medications as ordered. R19's Orders tab of the EMR documented an order dated 01/10/22 for Seroquel, take one 50 milligram (mg) tablet by mouth at bedtime for psychotic disorder with hallucinations. R19's Orders tab of the EMR documented an order dated 03/05/22 for Seroquel, take one 25 mg tablet by mouth at bedtime for psychotic disorder with hallucinations. A review of the consultant pharmacist's monthly Medication Regimen Reviews (MRR) from January 2023 to the present lacked documentation of a recommendation for a CMS-approved indication for use for Seroquel. On 08/14/24 at 01:00 PM, Administrative Nurse D stated she realized the process for MMR had not been successful in tracking the physician responses. Administrative Nurse D stated she realized on 08/14/24 that the process for the facility's monitoring antipsychotic medication had not been utilized correctly. The facility was unable to provide a policy related to the process of CP reporting irregularities. The facility failed to ensure the CP identified and reported the non-approved CMS indication for the use of antipsychotic medication for R19. This placed R19 at risk for unnecessary medication administration and possible adverse side effects. - R27's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, and confusion), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R27's Annual Minimum Data Set (MDS) dated [DATE] documented R27 had a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. R27 displayed inattention and disorganized thinking that was present and fluctuated. R27 utilized a walker and a wheelchair for mobility. R27 was dependent on staff for all activities of daily living (ADLs) and functional abilities. R27 received an antipsychotic medication on a routine basis. A GDR had not been attempted and had not been documented by the physician as being contraindicated. R27 was on hospice services. R27's Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. R27 displayed inattention and disorganized thinking that was continuously present. R27 utilized a walker and a wheelchair for mobility. R27 was dependent on staff for all ADLs and functional abilities. R27 received an antipsychotic medication on a routine basis. A GDR had not been attempted and had been documented by the physician as being contraindicated. R27 was on hospice services. R27's Psychotropic Drug Use Care Area Assessment (CAA) dated 02/28/24 documented that she currently an antianxiety (class of medications that calm and relax people) and an antidepressant (class of medications used to treat mood disorders) medication with no adverse effects due to medication. R27 was noted with multiple falls during the lookback period since the last assessment. R27 was wandering at times. R27 had severely impaired cognition, and long-term and short-term deficits along with impaired decision-making, inattention, and disorganized thinking. R27 had a current diagnosis of dementia and had some refusal of care. Staff was to reapproach and encourage R27 with ADLs and daily care. Staff was to monitor for changes and notify the physician or psychiatrist to avoid complications and minimize risk. R27's Care Plan last revised 05/08/24 directed staff that she took Seroquel, an antipsychotic, for the behavior of agitation and lashing out at staff. The staff was directed to give medications as the physician ordered. Staff was directed to observe and report any changes in R27's cognitive status. R27's Orders tab of the EMR documented an order dated 08/17/23 for Seroquel 50 milligrams (mg) one tablet one time a day. The order lacked a diagnosis for use. R27's Orders tab of the EMR documented an order dated 02/21/24 for Seroquel 25 milligrams (mg) one table at bedtime for anxious behavior related to major depressive disorder and anxiety. A review of the consultant pharmacist's monthly medication regimen reviews (MRR) from August 2023 to present lacked documentation of a recommendation for a CMS-approved indication for the use of an antipsychotic medication. A 04/30/24 physician's response to the consultant pharmacist's 04/26/24 recommendation for a GDR for R27's antipsychotic Seroquel documented R27 had a good response to the medications. R27 was on hospice and was currently stable on the medication. R27 was monitored regularly by both facility staff and hospice. A change or reduction was likely to cause a reduced quality of life and increased symptoms. On 08/14/24 at 07:36 AM R27 sat in her Broda (specialized wheelchair with the ability to tilt and recline) at the dining table. Staff assisted R27 with eating. R27 displayed no behaviors. On 08/14/24 at 01:00 PM, Administrative Nurse D stated she realized the process for MMR had not been successful in tracking the physician responses. Administrative Nurse D stated she realized on 08/14/24 that the process for the facility's monitoring antipsychotic medication had not been utilized correctly. The facility was unable to provide a policy related to the process of CP reporting irregularities. The facility failed to ensure the CP identified and reported the non-approved CMS indication for the use of antipsychotic medication for R27. This placed R27 at risk for unnecessary medication administration and possible adverse side effects.

The facility identified a census of 49 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 27, R19, R20, and R35 had an approved Centers for Medicaid and Medicare (CMS) indication or the required physician documentation for antipsychotic medications(class of medications used to treat major mental conditions which cause a break from reality). The facility failed to ensure a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for continued use or gradual dose reduction (GDR). This placed the affected residents at risk for unnecessary psychotropic medication and possible adverse side effects. Findings included: - R27's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, and confusion), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R27's Annual Minimum Data Set (MDS) dated [DATE] documented R27 had a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. R27 displayed inattention and disorganized thinking that was present and fluctuated. R27 utilized a walker and a wheelchair for mobility. R27 was dependent on staff for all activities of daily living (ADLs) and functional abilities. R27 received an antipsychotic medication on a routine basis. A GDR had not been attempted and had not been documented by the physician as being contraindicated. R27 was on hospice services. R27's Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. R27 displayed inattention and disorganized thinking that was continuously present. R27 utilized a walker and a wheelchair for mobility. R27 was dependent on staff for all ADLs and functional abilities. R27 received an antipsychotic medication on a routine basis. A GDR had not been attempted and had been documented by the physician as being contraindicated. R27 was on hospice services. R27's Psychotropic Drug Use Care Area Assessment (CAA) dated 02/28/24 documented she currently received antianxiety (a class of medications that calm and relax people) and an antidepressant (class of medications used to treat mood disorders) with no adverse effects due to medication. R27 was noted with multiple falls during the lookback period since the last assessment. R27 was wandering at times. R27 had severely impaired cognition, and long-term and short-term deficits along with impaired decision-making, inattention, and disorganized thinking. R27 had a current diagnosis of dementia and had some refusal of care. Staff was to reapproach and encourage R27 with ADLs and daily care. Staff was to monitor for changes and notify the physician or psychiatrist to avoid complications and minimize risk. R27's Care Plan last revised 05/08/24 directed staff that she took Seroquel, an antipsychotic, for the behavior of agitation and lashing out at staff. The staff was directed to give medications as the physician ordered. Staff was directed to observe and report any changes in R27's cognitive status. R27's Orders tab of the EMR documented an order dated 08/17/23 for Seroquel 50 milligrams (mg) one tablet one time a day. The order lacked a diagnosis for use. R27's Orders tab of the EMR documented an order dated 02/21/24 for Seroquel 25 milligrams (mg) one table at bedtime for anxious behavior related to major depressive disorder and anxiety. A 04/30/24 physician's response to the consultant pharmacist's recommendation for a GDR for R27's antipsychotic Seroquel documented R27 had a good response to the medications. R27 was on hospice and was currently stable on the medication. R27 was monitored regularly by both facility staff and hospice. A change or reduction was likely to cause a reduced quality of life and increased symptoms. On 08/14/24 at 07:36 AM R27 sat in her Broda (specialized wheelchair with the ability to tilt and recline) at the dining table. Staff assisted R27 with eating. R27 displayed no behaviors. On 08/14/24 at 12:37 PM, Licensed Nurse (LN) G stated that all medications should have an appropriate indication listed for use on the order. LN G had not realized that R27's Seroquel order did not have an indication listed. LN G stated she knew that antipsychotic medications required a specific diagnosis for use. On 08/14/24 at 12:58 PM Administrative Nurse D stated that the facility physician had been at the facility that day and he had changed some of the diagnoses on psychotropic medications but had been less successful with getting R27's diagnosis changed or a rationale for the use of her Seroquel by her psychiatry physician. Administrative Nurse D stated that she had never noticed that R27's Seroquel medication order lacked a diagnosis or indication for use. The Behavior Management & Psychotropic Medications policy last revised in December 2022 documented that residents are to be assessed for appropriate diagnosis, utilization, adverse effects, and target behaviors related to psychotropic medication use and off-label use of medication prescribed that affect brain activity. Psychotropic medications and off-label use of medication prescribed that affect brain activity were not to be initiated without prior communication between the physician, resident, or responsible party and the facility's interdisciplinary team. Off-label and as-needed (PRN) use of psychotropic medications and off-label use of medication prescribed that affects brain activity were discouraged for elderly residents with dementia. Physician orders to automatically reduce and discontinue an existing or newly initiated antipsychotic medication and off-label use of medication that affects brain activity were to be considered at the time the order was received. The facility failed to ensure R27 had an appropriate CMS-approved indication for use for antipsychotic medication. This placed R27 at risk for unnecessary medication administration and possible adverse side effects. - R19's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hallucinations (sensing things while awake that appear to be real, but the mind created), psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), and hypertension (HTN-elevated blood pressure). R19's Significant Change Minimum Data Set (MDS) dated [DATE] documented he had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R19 required partial to moderated assistance from staff for activities of daily living (ADLs) and required substantial to maximal staff assistance with toileting. R19 received an antipsychotic on a routine basis as well as an antianxiety and antidepressant medication. No gradual dose reduction (GDR) had been attempted, and the MDS documented it was contraindicated. R19's Quarterly MDS dated [DATE] documented a BIMS score of three which indicated severely impaired cognition. R19 required partial to moderated assistance from staff for ADLs and required substantial to maximal staff assistance with toileting and bathing. R19 received an antipsychotic on a routine basis as well as an antianxiety and antidepressant medication. No GDR had been attempted and it was recorded as clinically contraindicated. The Psychotropic Drug Use Care Area Assessment (CAA) for R19 documented he triggered due to psychotropic drug use. He received antipsychotic, antianxiety, and antidepressant medications. R19's Care Plan directed staff he took Seroquel (an antipsychotic medication) for paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) and hallucinations. The staff was directed to provide medications as ordered. R19's Orders tab of the EMR documented an order dated 01/10/22 for Seroquel, take one 50 milligram (mg) tablet by mouth at bedtime for psychotic disorder with hallucinations. R19's Orders tab of the EMR documented an order dated 03/05/22 for Seroquel, take one 25 mg tablet by mouth at bedtime for psychotic disorder with hallucinations. On 08/14/24 at 12:37 PM, Licensed Nurse (LN) G stated that all medications should have an appropriate indication listed for use on the order. LN G stated she knew that antipsychotic medications required a specific diagnosis for use. On 08/14/24 at 12:58 PM Administrative Nurse D stated that the facility physician had been at the facility that day and he had changed some of the diagnoses on psychotropic medications which included R19. The facility's Behavior Management and Psychotropic Medication revised 12/22 documented that residents were to be assessed for appropriate diagnosis, utilization, adverse effects, and target behaviors related to psychotropic medication use and off-label use of medication prescribed that affect brain activity. The facility was to assess for trauma-informed care experiences upon admission. The facility was to review residents exhibiting new or prolonged behaviors weekly. The facility's psychotropic medication regimens are to be reviewed routinely by the consultant pharmacist. Target behaviors were to be identified and monitored for residents receiving psychotropic medications and/or off-label use of medication prescribed that affects brain activity for the purposes of gradual dose reductions and the need for continued use. Each resident's plan of care will address individualized focus, goals, and interventions directed towards managing the resident's target behaviors, non-pharmacological interventions, psychotropic medication use, and gradual dose reductions and/or supporting documentation for continued use. Psychotropic medications and off-label use of medication prescribed that affect brain activity are not to be initiated without prior communication between the physician, resident, or responsible party and the facility's interdisciplinary team. Off-label and as-needed (PRN) use of psychotropic medications and off-label use of medication prescribed that affect brain activity are to be discouraged for elderly residents with dementia. Physician orders to automatically reduce and discontinue an existing or newly initiated antipsychotic medication and off-label use of medication that affects brain activity are to be considered at the time the order is received. The facility failed to ensure R19 had a CMS-approved indication, or the required physician documentation, for use for antipsychotic medication. This placed R19 at risk for unnecessary medication administration and possible adverse side effects. 41037 - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), aphasia (a condition with disordered or absent language function), muscle weakness, and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Significant Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated intact severely impaired cognition. The MDS documented that a staff interview for cognition was not completed. The MDS documented R20 had received diuretic (medication to promote the formation and excretion of urine) medication, antidepressant (class of medications used to treat mood disorders) medication, and antipsychotic (class of medications used to treat major mental conditions which cause a break from reality). The MDS documented that a gradual dose reduction was not completed and lacked documentation a Monthly Medication Review (MMR) was completed during the observation period. The MDS documented R20 had Alzheimer's disease. R20's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/26/24 documented she received antipsychotic medication for anxiety. R20's Care Plan dated 08/06/24 documented that staff would administer her medications as ordered by the physician. R20's EMR under the Orders tab revealed the following physician orders: Risperdal (antipsychotic)tablet 0.5 milligrams (mg) give 0.5 mg by mouth at bedtime related to anxiety 07/20/22. A review of the Monthly Medication Review (MMR) from August 2023 to July 2024 lacked evidence of recommendations for physician documentation for a rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Risperdal for R20. The December 2023 MMR revealed a recommendation for a dose reduction of antipsychotic medication Risperdal, mood stabilizer Depakote, and antidepressant medications citalopram and mirtazapine. The physician's response dated 12/27/23 was to discontinue the antidepressant citalopram. The response did not address the other medications or include a rationale for continued use. The facility was unable to provide a physician-documented rationale for no GDR for Risperdal, Depakote, and mirtazapine. On 08/13/24 at 02:55 PM, R20 lay on her bed asleep with the head of her bed elevated. R20's call light was within reach. On 08/14/24 at 12:40 PM, Licensed Nurse (LN) G stated she did talk with the physician to clarify the indication for the residents who received antipsychotic medications. LN G stated an approved indication for antipsychotic medication was behaviors and mood disorder. On 08/14/24 at 01:00 PM, Administrative Nurse D stated she realized on 08/14/24 that the process for the facility's monitoring antipsychotic medication had not been utilized correctly. The facility's Behavior Management and Psychotropic Medication policy revised 12/2022 documented that residents were to be assessed for appropriate diagnosis, utilization, adverse effects, and target behaviors related to psychotropic medication use and off-label use of medication prescribed that affect brain activity. The facility was to assess for trauma-informed care experiences upon admission. The facility was to review residents exhibiting new or prolonged behaviors weekly. The facility's psychotropic medication regimens are to be reviewed routinely by the consultant pharmacist. Target behaviors were to be identified and monitored for residents receiving psychotropic medications and/or off-label use of medication prescribed that affects brain activity for the purposes of gradual dose reductions and the need for continued use. Each resident's plan of care would address individualized focus, goals, and interventions directed towards managing the resident's target behaviors, non-pharmacological interventions, psychotropic medication use, and gradual dose reductions and/or supporting documentation for continued use. Psychotropic medications and off-label use of medication prescribed that affect brain activity are not to be initiated without prior communication between the physician, resident, or responsible party and the facility's interdisciplinary team. Off-label and as-needed (PRN) use of psychotropic medications and off-label use of medication prescribed that affect brain activity are to be discouraged for elderly residents with dementia. Physician orders to automatically reduce and discontinue an existing or newly initiated antipsychotic medication and off-label use of medication that affects brain activity are to be considered at the time the order is received. The facility failed to ensure R20 had a CMS-approved indication for the use of an antipsychotic or the required physician documentation. The facility further failed to ensure a GDR was attempted or documented as contraindicated by the physician with a supporting rationale. These deficient practices placed R20 at risk for unnecessary medications and adverse side effects. - R35's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), insomnia (inability to sleep), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R35 received antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), antipsychotic medication, anticoagulant (class of medications used to prevent the formation of blood clots), diuretic (medication to promote the formation and excretion of urine), hypnotic (a class of medications used to induce sleep), and opioid (a class of medication used to treat pain) during the observation period. The MDS documented that a gradual dose reduction was not completed and lacked documentation a Monthly Medication Review (MMR) was completed during the observation period. The MDS documented R35 had dementia. The Quarterly MDS dated [DATE] documented a BIMS score of 10 which indicated moderately impaired cognition. The MDS documented that R35 received antianxiety medication, antidepressant medication, antipsychotic medication, anticoagulant (medication, diuretic medication, hypnotic medication, and opioid medication during the observation period. The MDS documented that a gradual dose reduction was not completed and lacked documentation an MMR was completed during the observation period. R35's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/09/24 documented R35 received antipsychotic medication, antianxiety medication, antidepressant medication, and hypnotic medication. R35's Care Plan revised on 08/04/24 documented that staff would administer medications as ordered. R35's EMR under the Orders tab revealed the following physician orders: Trazodone hcl tablet (antidepressant) 150 mg give one tablet by mouth at bedtime related to insomnia dated 01/17/23. Abilify (antipsychotic) oral tablet 30mg give one tablet by mouth one time a day related to unspecified mood disorder dated 01/23/23. Belsomra tablet (hypnotic) 10mg give one tablet by mouth at bedtime related to insomnia dated 06/03/23. Clonazepam (antianxiety) oral tablet 0.5mg give one tablet by mouth three times a day related to insomnia dated 09/27/23. Sertraline hcl (antidepressant) oral tablet 50mg give one tablet by mouth one time a day for depression dated 03/20/24. A review of the Monthly Medication Review (MMR) from August 2023 to July 2024 lacked evidence of recommendations for physician documentation for a rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Abilify for R35. R35's clinical record lacked physician documentation of a rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Abilify and for the continued use of psychotropic medication with no gradual dose reduction for clonazepam, Belsomra, and Trazodone. The facility was unable to provide evidence of the above physician documentation. On 08/14/24 at 07:38 AM R35 walked with his walker in the hallway from his room to the dining room unassisted. His gait was steady, and he wore a pair of tennis shoes. On 08/14/24 at 12:40 PM, Licensed Nurse (LN) G stated she did talk with the physician to clarify the indication for the residents who received antipsychotic medications. LN G stated an approved indication for antipsychotic medication was behaviors and mood disorder. On 08/14/24 at 01:00 PM, Administrative Nurse D stated she realized on 08/14/24 that the process for the facility's monitoring antipsychotic medication had not been utilized correctly. The facility's Behavior Management and Psychotropic Medication policy revised 12/2022 documented that residents were to be assessed for appropriate diagnosis, utilization, adverse effects, and target behaviors related to psychotropic medication use and off-label use of medication prescribed that affect brain activity. The facility was to assess for trauma-informed care experiences upon admission. The facility was to review residents exhibiting new or prolonged behaviors weekly. The facility's psychotropic medication regimens are to be reviewed routinely by the consultant pharmacist. Target behaviors were to be identified and monitored for residents receiving psychotropic medications and/or off-label use of medication prescribed that affects brain activity for the purposes of gradual dose reductions and the need for continued use. Each resident's plan of care would address individualized focus, goals, and interventions directed towards managing the resident's target behaviors, non-pharmacological interventions, psychotropic medication use, and gradual dose reductions and/or supporting documentation for continued use. Psychotropic medications and off-label use of medication prescribed that affect brain activity are not to be initiated without prior communication between the physician, resident, or responsible party and the facility's interdisciplinary team. Off-label and as-needed (PRN) use of psychotropic medications and off-label use of medication prescribed that affect brain activity are to be discouraged for elderly residents with dementia. Physician orders to automatically reduce and discontinue an existing or newly initiated antipsychotic medication and off-label use of medication that affects brain activity are to be considered at the time the order is received. The facility failed to ensure R35 had a CMS-approved indication for the use of an antipsychotic or the required physician documentation. The facility further failed to ensure a GDR was attempted or documented as contraindicated by the physician with a supporting rationale. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects.

The facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to implement, immediate interventions which included offloading actions such as heel boots of heel floating when Resident (R) 50 developed a stage two pressure injury (pressure injury which expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin) As a result of the deficient practice R50's original blister (stage two pressure injury) worsened to a full thickness wound which became infected and required acute management and care. Findings included: - The electronic medical record (EMR) for R50 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R50 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R50 required supervision to limited assistance of one staff for activities of daily living (ADLs). R50 had impairment of one side of her upper extremity and used a walker and a wheelchair for mobility. R50 was at risk for pressure ulcers, had no pressure wounds, venous wounds or skin tears upon admission. R50 had a pressure reducing device for her bed. The Quarterly MDS dated [DATE] documented R50 had a BIMS score of 13, which indicated intact cognition. R50 required limited assistance of one to two staff for ADLs and was not at risk for pressure ulcers. The Pressure Ulcer/Injury Care Area Assessment (CAA) for R50 dated 05/31/22 documented she required assistance with bed mobility and was identified to be at risk for pressure ulcer/injury development. R50 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Braden Scale (an assessment that evaluates a person's risk for developing a pressure ulcer) score was 18 and R50 was at mild risk of developing a pressure ulcer. The 05/31/22 Quarterly Braden Scale score of 21 and was a low risk of developing a pressure ulcer. The Skin Breakdown Care Plan for R50 revised on 09/05/22 directed staff that R50 used a pressure reducing/relieving mattress on her bed. Staff was to assess R50's skin and report any noted changes. Staff was to assist R50 in keeping her skin clean and dry. Staff was to monitor and report any changes, skin tears, or bruising while providing daily cares, and/or assisting with bathing. Staff was to encourage R50 to consume all the offered foods/fluids to assist in maintaining adequate nutrition/hydration. On 10/26/22 the Skin Breakdown Care Plan was revised with the following interventions: R50 had a blister on her right heel and staff was to encourage R50 to not wear shoes until blister resolved. R50 had and air boot that she was given at the ER. R50, always wore the boot, per her preference. R50 had been referred to wound consultants for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Under the Assessments tab a Skin/Wound Condition assessment dated [DATE]noted a new blister to R50's right heel (no measurements). A Provider Progress Note document dated 10/13/22 documented R50 was seenforseen for pain to her right ankle with swelling and blistering. The assessment revealed [CONDITION(S)] to right lower extremity, a blister to right heel/ankle. The plan/orders were to obtain a venous doppler of the right lower extremity for [CONDITION(S)]. An order to apply skin prep to blister on right ankle and heel twice daily until healed. A Provider Progress Note dated 10/20/22 documented R50 was seen for an acute follow-up. R50's blister to right heel had popped. New order to apply triple antibiotic ointment to the right heel twice daily until healed. On 10/21/2022 at 10:25 AM a Nurse's Note documented R50 was seen on rounds for 10/20/22. A new order for triple antibiotic ointment (TAO) to right heel blister. Lipid levels and magnesium levels to be drawn on 10/24/22. A 10/22/2022 at 12:50 AM Nurse's Note documented right heel blister had broken. There was noted clear drainage to dressing, no odor. The skin surrounding blister had light redness and skin peeling. Encourage R50 to leave the socks off during the day and in bed for drying out the area. A Change in Condition Note dated 10/23/22 at 07:39 AM for R50 documented the blister like area was intact yesterday and now the area had become open with increased redness and swelling. An 'Orders Note on 10/23/22 at 07:55 AM documented a new order obtained from R50's physician. May send R50 to ER acute care center for evaluation and treatment due to related change in the wound to foot with increased pain, redness and swelling. A Nurse's Note dated 10/23/22 at 08:21 AM documented R50 left via emergency medical services (EMS) and was being transported to the hospital. All paperwork sent with the resident. Report was called to the hospital. An Orders Note dated 10/23/22 at 01:34 PM documented R50 had returned from the hospital via EMS transportation. New orders were called in by the attending physician at the hospital to get lab drawn in three days and after antibiotic therapy had been completed. R50 was ordered [MEDICATION(S)] (a medication used to treat bacterial infections) 750 mg by mouth every 48 hours x 7 days. R50 received the first dose at the hospital. The wound to the right heel was dressed with a dry dressing and padded with Kerlix. The hospital provided an air-boot for comfort. R50 was not to stand or walk on the boot. An Infection Note dated 10/24/22 at 10:52 AM documented R50 had no observed reaction to [MEDICATION(S)]. The right heel dressing was changed with no odor noted, redness surrounded wound bed. There was a small amount of drainage observed on the old dressing. R50 stated wound a little sore when touched. A Wound Care Plus note dated 10/25/22 documented: preliminary impression of this skin breakdown/ulceration was as follows - the ulcer was mixed etiology including pressure. Further workup will determine primary etiology. The wound (document stated left medial heel) was debrided with a total area of 36 square centimeter (cm). Wound imaging for bacterial presence noted the presence of bacteria was identified indicative of bacterial burden. The plan/wound order post debridement was to cleanse wound with Hypochlorous Acid (a weak acid used in wound treatment). Use to irrigate or scrub the wound bed. Apply A & D ointment (A protective skin barrier that seals out wetness) and skin prep around wound. Xeroform (a dressing/cover used to protect wounds) gauze cut to fit into wound edges, a super absorbent pad secured with conforming gauze (Kerlix). Dressing was to be changed daily and as needed for soiling, saturation, or unscheduled removal. A Skin/Wound Condition assessment dated [DATE] at 04:00 PM documented R50 had a wound to left heel (original wound was the right heel) blister that measured 5.0 centimeters (cm) in length by 7.2 cm width, and a depth of 0.2 cm. Right heel blister was open draining a small amount of serosanguineous (fluid containing blood) drainage. Resident seen by Wound Care Plus (WCP) this afternoon. The wound was examined, debrided (removal of damaged skin) by wound care plus with loose macerated (softening and breaking down of the skin from prolonged exposure to moisture) skin removed. Red epithelial (skin) over half of wound with some slough (dead tissue, usually cream or yellow in color) and eschar (dead tissue) noted after debridement. The skin surrounding the wound was red and darker red in color with maceration. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover the xeroform with an ABD bandage and kerlix. Preventive measures currently being utilized: wheelchair cushion, pressure reducing mattress, float heels, and special boots. An Infection Note dated 10/27/22 at 08:04 AM documented R50 continued taking [MEDICATION(S)] for right heel infection and was afebrile. R50 was encouraged to elevate her right foot while laying down. Dressing to wound was intact, clean, and dry. An Infection Note dated 11/01/22 at 10:51PM documented R50 had completed antibiotic treatment on 10/29/22 for heel wound. No adverse reactions noted or reported. R50's wound dressing was clean, dry and intact. A Wound Care Plus Note for R50 dated 11/01/22 at 01:28 PM documented wound one right medial heel was a full thickness undiagnosed wound and was non-healed. The wound had deteriorated since previous visit. Wound was debrided. A tissue culture was performed. Wound orders for right heel included to cleanse wound with hypochlorous acid to irrigate or scrub wound bed. Apply [MEDICATION(S)] (a medicated ointment used to treat infection) ointment to affected area. Continue the xeroform gauze and Kerlix daily. A Skin/Wound Condition assessment dated [DATE] at 11:51 AM documented a right heel blister wound that measured 5.2 cm in length, 7.8 cm in width, and 0.2 cm in depth. The right heel blister area was debrided by Wound Care Plus. The wound bed post-debridement was 50 percent red granulation (tissue formed during wound healing) tissue with some slough and eschar. The surrounding skin has maceration and rubor (reddening). The right foot was cool to touch. [MEDICATION(S)] (a medication used to treat and prevent infection) 100 milligrams (mg) by mouth twice a day (BID) was ordered for wound infection. An Infection Note dated 11/02/22 at 11:39 PM documented R50 started [MEDICATION(S)] 100 mg BID for seven days for right heel wound. No adverse reaction noted. The right heel dressing was clean, dry and intact. R50 voiced pain to right heel she rated a five out of 10. R50 was given Tylenol 650 mg per physician order. An Infection Note dated 11/07/22 at 11:08 AM documented R50 continued [MEDICATION(S)] for right heel wound. Right heel dressing was changed this morning with moderate amount of serosanguineous drainage noted to old bandage noted. No odor present to wound, the surrounding wound bed skin continued to be red and warm to touch. R50 stated her pain level at a six of ten and tolerable even after as needed Tylenol (pain reliever/fever reducer) had been given. A Skin/Wound Condition assessment dated [DATE] at 10:56 AM documented the right heel blister wound measured 3.5 cm in length, 5.0 cm in width and had a depth of 0.3 cm. The blister wound was open with a moderate amount of serous (a clear to pale yellow watery fluid) drainage with no odor present. The wound bed had pan and darker red granulation tissue, eschar present to top of wound. The area surrounding wound was normal in color and temperature. No changes in treatment were made. On 11/02/22 at 11:37 AM R50 sat in her wheelchair in her room, her right foot had noted [CONDITION(S)] to top of foot, the foot was wrapped with Kerlix from about mid foot back to her heel and ankle area. There is a soft heel/foot protector boot on. The right leg was resting on the wheelchair foot pedal. On 11/07/22 at 08:35 AM R50 sat in her wheelchair in the lobby her right foot was elevated on an adjustable foot pedal, her heel protector boot on, the foot was wrapped with Kerlix. There was [CONDITION(S)] noted to the top of the foot. On 11/08/22 at 09:31 AM Administrative Nurse E did the dressing change for R50's wound. Administrative Nurse E measured the wound bed using a disposable paper wound tape. The wound measured 3.5 cm length by 5.0 cm width and a depth of 0.3 cm. The wound was cleaned and dressed in new xeroform and ABD pad and Kerlix. R50 tolerated procedure with minimal pain. On 11/08/22 at 02:08 PM Certified Medication Aide (CMA) S stated if she noted any skin changes during a bath or dressing a resident, she would notify the nurse immediately. CMA S stated R50 had been wearing her diabetic shoes and was up and about walking using a walker prior to the development of the blister/wound. CMA S was not aware of any specific intervention for her feet/heels prior to the blister. On 11/08/22 at 02:32 PM LN H stated that the MDS nurse and IDT team revised the care plans, and the staff nurses could revise the care plan with new interventions as needed. LN H stated R50 had interventions to monitor the skin. LN H was not aware of an intervention specific to R50's feet or heels. On 11/08/22 at 03:23 PM Administrative Nurse E stated R50's blister to right foot/heel was first noticed on 10/12/22 and a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN E stated when she looked at the wound on 10/24/22 the skin was macerated and had leakage from the blister, so at that time she spoke to the physician to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LN E stated the wound had been diagnosed as an undiagnosed skin wound. On 11/08/22 at 03:42 PM Administrative Nurse D stated the care plans should have interventions in place for each resident for basic skin care to avoid pressure ulcer development. Administrative Nurse D stated a resident's care plan should be revised to address skin concerns. Administrative Nurse D stated she was not certain if R50 had any prior interventions in place for her feet/heels before the blister developed. Administrative Nurse D stated that R50 had been in the hospital a short time ago for her pancreatitis (inflammation of the pancreas) and stayed in bed a lot after she returned to the facility. Administrative Nurse D stated that R50 did walk about the facility prior to the development of the heel blister and did wear her diabetic shoes. The facility policy Wound Prevention and Management last revised May 2017 documented the plan of care would address problems, goals and interventions directed towards prevention of pressure ulcers and/or skin integrity concerns identified. IF identified risk was present the interventions would be implemented for residents at risk and placed on the care plan. The facility failed to implement, monitor and modify interventions and failed to provide treatment and services for resident (R)50 to avoid the development of a pressure wound. This deficient practice placed R50 at risk for further skin breakdown and infection/injury. The facility failed to implement immediate interventions which included offloading actions such as heel boots of heel floating when R50 developed a stage two pressure injury. As a result of the deficient practice R50's original blister worsened to a full thickness wound which became infected and required acute management and care. - R19's electronic medical record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented that R19 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R19 was at risk for pressure ulcers during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of three which indicated severely impaired cognition. The MDS documented that R19 required extensive assistance of two staff members for ADL's. The MDS documented R19 was at risk for pressure ulcers during the look back period. R19's Pressure Ulcer Care Area Assessment (CAA) dated 06/14/22 documented R19 was at risk for pressure ulcer and deep tissue injuries related incontinence and extensive assistance for bed mobility. R19's Care Plan last revised 04/20/20 documented staff would provide appropriate pressure relieving devices to the bed, wheelchair and/or R19 personal chair. Review of the EMR under Orders tab revealed physician orders: 7/30/20 Apply heel protectors and leave on at all times except for bath date. On 11/07/22 at 01:06 PM R19 sat in a wheelchair as she propelled herself with her right hand, left foot was elevated on extended leg rest on the wheel chair. R19 was not wearing heel protectors. On 11/08/22 at 01:50 PM, Certified Medication Aide (CMA) R stated the care plan would list the pressure relieving devices for each resident. CMA R stated staff observed each residents skin when providing care and during bathing. On 11/08/22 at 02:33 PM Licensed Nurse (LN) H stated skin assessments were completed weekly and documented under assessments in the EMR. LN H stated R19 was to wear heel protectors to prevent pressure ulcers. On 11/08/22 at 03:44 PM Administrative Nurse D stated she was not sure whether R19 was always to wear the heel protectors, she would have to review R19's clinical record. The facility's Wound Prevention and Management last revised May 2017 documented interventions would be implemented for residents at risk and placed on the care plan. The facility failed to ensure R19 was provided with pressure reducing heel protectors were in place at all times to assist with prevention of pressure ulcers on R19's heels. This deficient practice placed R19 at risk development of pressure ulcer/deep tissue injuries.

The facility identified a census of 63 residents. The sample included seven residents. Based on record review, observation, and interview, the facility failed to protect Resident (R)1 from misappropriation of his money when a facility employee wrote and cashed nine checks without R1's permission or knowledge from his personal checking account. The first documented episode of misappropriation was (MONTH) 11, 2019. Subsequent occurrences were documented through (MONTH) 23, 2019 totaling 55,200.00 dollars ($). This left R1 feeling angry, confused, fearful, and betrayed. The deficient practice placed R1 in immediate jeopardy beginning on 4/11/19. Findings included: - R1's 2019 Electronic Medical Record (EMR), under the [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Significant Change MDS dated [DATE] documented a BIMS score of 13 which indicated intact cognition. The Care Area Assessment (CAA) dated 09/10/19 for Communication documented that R1 understood verbal content. It also recorded his speech was garbled and could be difficult to understand at times. The Care Plan, revised on 04/15/19, documented that R1 may have difficulty articulating his needs due to dysphasia (language disorder marked by deficiency in the ability to speak, due to brain disease or damage). It directed staff to allow R1 time to respond to questions and requests, restate requests if R1 was unable to respond, and provide cueing if needed. It also directed staff to use simple sentences. Review of the Kansas General Durable Power of Attorney form revealed the form was completed, signed and notarized on 10/4/19. This form granted R1's representative authority in all R1's financial matters. Review of canceled checks, provided by both R1's representative and the facility, revealed the following checks which were made out to Administrative Staff B (the alleged perpetrator -AP), and signed and cashed by Administrative Staff B: 2072 4/11/19 $9500.00 2071 5/8/19 $3500.00 2108 5/24/19 $5500.00 2112 6/24/19 $4500.00 2113 7/11/19 $5750.00 2115 7/26/19 $5500.00 2118 8/23/19 $5500.00 2119 9/23/19 $5450.00 Review of the canceled checks also revealed check 2103, made out to Gameball for $10,000.00 on 4/24/19. The memo line for the check recorded it was for a fundraiser. Review of canceled checks provided by the facility and R1's representative revealed R1 paid for his services provided by the facility with checks from the same account, though made out specifically to the facility. On 11/7/19 R1's Durable Power of Attorney (DPOA) notified the presiding law enforcement agency of the theft and/or unauthorized use of the checks from R1's checking account. Per a late entry Social Service Progress Note, dated 11/12/19 at 10:18 AM, Consultant Therapist (CT) II notified Social Services (SS) X that R1 reported he had checks missing and the police were going to be coming to the facility to speak to R1 regarding the missing checks. The note further recorded SS X called R1's DPO[NAME] R1's DPOA informed SS X that $53,000.00 in checks have been written on R1's account. The note recorded SS X asked R1's DPOA who the checks were made out to and the DPOA stated the checks were made payable to Administrative Staff B. The note documented that SS X informed Administrative Staff A and other facility and corporate members immediately after the phone call with R1's DPOA ended. Per the facility Investigation Report, on 11/12/19 at approximately 3:00 PM, CT II reported to SS X that R1 reported a former employee, Administrative Staff B, wrote unauthorized checks off his account and he wanted to speak to the police. The report indicated R1's DPOA was notified and the DPOA sent copies of the canceled checks to the facility. The report documented Administrative Staff A reported the situation to law enforcement and the appropriate state agency on 11/12/19. Per Social Service Progress Note, dated 11/13/19 at 10:29 AM, SS X and Administrative Staff A met with R1 and asked him if he ever wrote checks to Administrative Staff B. R1 reported that he never wrote checks to her. On 11/18/19 at 1:30 PM, R1 stated he never gave Administrative Staff B permission to get his checkbook or write checks on his account to herself. R1 stated that he did not know if the money that Administrative Staff B took from him would be lost permanently. R1 further stated he was not aware of checks being written for the facility. R1 stated he never thought anything like this would happen. R1 verbalized he felt uncertain about what to do about the situation. He was noted to become angry when asked about check #2103 that had Fundraiser noted on the Memo line, to which he stated in a raised voice that he had never donated to that fundraiser and he knew that it was Administrative Staff B. After the conversation, R1 slumped over, dropped his shoulders, and rubbed his forehead. On 11/20/19 at 5:35 PM, R1 sat in his wheelchair in his room. He stated he was feeling ok but also reported that he was afraid about his future and what would happen to him. He also expressed concern as to how he was going to be able to continue to provide for himself for the rest of my life due to the financial loss. R1 was tearful as he made this statement. On 11/18/19 at 3:05 PM Administrative Staff A stated that upon learning of the checks that Administrative Staff B wrote from R1's account, the facility reported it to the state agency, the police department, and spoke to the Attorney General. Administrative Staff A reported the facility conducted an in-service with the residents to discuss misappropriation of property and had also performed education with staff. She said the facility conducted audits of resident accounts to make sure there were not any other unexplained transactions with the accounts, expenses, and financials. Administrative Staff A reported the facility would be notifying all families and DPOAs. Administrative Staff A reported Administrative Staff B had been placed on suspension on 10/1/19 for violating employee confidentiality and terminated from the facility on 10/4/19 for the same offense as well as other infractions which included not following facility policy regarding hiring practices. On 11/18/19 at 3:48 PM, a staff member who desired to remain anonymous stated that Administrative Staff B knew how much money R1 had in his checking account and discussed the amounts with other staff members. He/she stated that Administrative Staff B would go down to R1's room and get his checkbook when a payment to the facility was needed. He/she further revealed that the facility was aware that Administrative Staff B accessed and wrote R1's checks. On 11/19/19 at 1:55 PM Consultant GG stated she was unaware that Administrative Staff B had access to R1's checkbook. She stated she did not know that Administrative Staff B wrote checks off R1's accounts for any purpose. She further stated that after learning that Administrative Staff B wrote unauthorized checks from R1's accounts for personal use, the facility completed an audit to ensure that checks made out to the facility were deposited into the facility bank account and applied to R1's balance. Consultant GG confirmed that resident checks to cover monies owed to the facility would not be made out directly to a staff member. The facility policy Abuse, Neglect and Exploitation dated (MONTH) (YEAR) documented the resident has the right to be free from misappropriation of resident property and the facility would take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The facility failed to protect R1 from misappropriation of resident's money when a facility employee stole R1's checks and wrote checks for her personal use for $55,200.00. The first recorded stolen check was written on (MONTH) 11, 2019 for $9,500.00 with multiple checks written subsequently in large amounts. This failure affected R1 which caused him to feel angry, fearful, confused, and betrayed and placed R1 in immediate jeopardy. The facility removed the immediacy by completing the following on 11/20/19: The AP was terminated from employment by the facility on 10/4/19. R1's checkbook is now maintained by his DPO[NAME] All residents were reviewed by the facility to assess for misappropriation of funds, checkbooks and valuable. A full audit of all resident trust accounts was performed. All residents have been educated about misappropriation, exploitation and informed of their rights. A safe was purchased and placed in the facility to allow residents a secure place to store valuables if the resident desired. All staff were educated on Abuse, Neglect and Exploitation which included specific information and training regarding misappropriation of resident's property and funds. The facility Quality Assurance Performance Improvement team held a meeting and established ongoing measures for protection of residents against misappropriation. The deficient practice remained at a scope and severity of a G .

ML Eudora 692 The facility identified a census of 59 residents. The sample included 23 residents with three residents sampled for nutrition. Based on observation, record review, and interview, the facility failed to prevent a significant weight loss of 7.52% in 30 days and 8.37% loss over 3 months for Resident (R) 6, who was totally dependent upon staff for all food and fluid intake. Findings included: - The Electronic Medical Record (EMR) under the [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented severe cognitive impairment per staff interview for R6. The MDS documented that R6 required total assistance of one staff person for eating. The MDS recorded R6 weighed 98 pounds (lbs). The MDS documented no weight loss, but she was on a physician prescribed weight gain program . The quarterly MDS dated [DATE] documented severe cognitive impairment per staff interview for R6. The MDS documented that she required extensive assistance of one staff person for eating. The MDS documented no weight loss and documented the resident weighed 90 lbs. The Care Area Assessment (CAA) dated 01/18/19 for nutrition documented that R6 required extensive assistance with meals. It directed staff to encourage nutritional supplements and eating due to a history of weight loss. The CAA documented that R6 gained weight over the previous review period as a result of a physician ordered weight gain. The resident currently weighed 98lbs. and received a mechanically altered diet. The CAA recorded the resident required staff assistance and encouragement to maintain nutritional status and staff should offer fluids frequently. The Care Plan, dated 07/04/19, for weight loss directed staff to refer R6 to the registered dietician (RD) as needed. The care plan lacked parameters for when to determine a RD consult was needed. The current diet order was for fortified foods, mechanical soft with ground meat, and nectar thickened liquids. The resident was to receive 90 milliliters (ml) of [MEDICATION NAME] (nutritionally complete, high calorie formula designed to meet the increased protein and calorie needs of stressed patients) supplement between meals. The care plan directed staff that R6 enjoyed chocolate wafers and diet coke. The care plan also directed staff to offer her chocolate wafers and coke if her intake was poor. The care plan indicated she would consume her meals better when staff interacted with her during the dining process. The care plan dated 09/23/19 for Activities of Daily Living (ADL) directed staff that R6 required total assistance from staff with eating. The EMR recorded a physician's orders [REDACTED]. The physician discontinued the order on 04/26/2019. The record lacked evidence of a current physician's orders [REDACTED]. The EMR recorded a physician's orders [REDACTED]. The order also directed the resident may have soft food options as tolerated. On 07/8/2019 at 10:48 AM a Dietary Progress Note in the EMR entered by Dietary BB documented R6's weight was 98 lbs. and over the last 90 days, her weight was stable. It recorded she had a regular diet with mechanical soft texture. She required full assistance with meals and would normally have her eyes closed. It recorded she ate well with 75-100% intake at most meals. She liked chocolate and a diet cola for snacks . On 07/26/2019 at 09:36 AM, the EMR recorded a Weight Change Note with a Weight Warning which alerted staff that R6's recorded weight value was 94 lbs. (recorded in vitals on 7/24/19 at 04:20 PM) and this was down 3% over the last 30 days. It further recorded the resident had adequate intake during meals and staff assisted her in the dining room. It documented staff offered snacks throughout the day. It also recorded R6 had [MEDICAL CONDITION] (fluid accumulation) to her lower extremities. It directed that R6's weight and intake would be monitored. Review of the (MONTH) 2019 intake record under the Tasks tab in the EMR revealed R6 ate less than 51% percent of her meals 19 times. Additionally, the record revealed missing documentation of intake for 20 meals, all but one was evening meals. The intake record for snacks lacked documentation that staff offered a snack for seven snack times in month of (MONTH) 2019 . Review of the (MONTH) 2019 intake record in the EMR revealed R6 ate less than 51% percent at 25 meals. It additionally revealed missing documentation for 21 meals, all but four were evening meals. It lacked documentation that staff offered a snack for seven snack times in month of (MONTH) 2019. On 09/27/19 at 01:13 PM a Dietary Progress Note entered by Dietary BB recorded R6 weighed 90 lbs., which was a seven lb. loss over the last 90 days. It further recorded her weight was stable. It documented R6 was a full assist at meals, ate with her eyes closed, and ate 75-100% at most meals. It recorded she liked chocolate and diet cola for snacks . The (MONTH) 2019 intake record in the EMR revealed 12 meals where R6 consumed less than 51% and 26 meals which had no documentation. Only eight evening meals were recorded with intake. The snack record lacked documentation a snack was offered on 14 scheduled snack times in (MONTH) 2019. Review of the (MONTH) 2019 intake record, dates 10/1/19-10/20/19, revealed R6 ate less than 51% for 24 meals. Additionally, the record lacked documentation of intake for 15 meals, all but one was evening meals. The snack record lacked documentation a snack was offered on three scheduled snack times in (MONTH) 2019. The clinical record under the vital sign tab documented weights of 97.1 lbs. on 09/18/19; 97 lbs. on 09/23/19; 90 lbs. on 09/25/19; 94.04 lbs. on 10/02/19; 91.04 lbs. on 10/09/19; and 89.8 lbs. on 10/16/19. This reflects a 7.52 % loss over a period of 30 days. On 10/16/19 at 11:22 AM staff propelled R6 in her wheel chair to the dining room by . At 11:43 AM staff positioned the resident at the dining table. At 11:46 AM, a glass of nectar thickened apple juice and nectar thickened water was on the table though no drinks were offered at that time. Staff served her lunch at 12:06 PM. Staff assisted R6 with several bites of food, then she coughed, and staff offered a sip of thickened liquids from the cup . Another staff person then assisted R6 starting at 01:10 PM. At 01:16 PM, the staff assisting R6 stated she was full and stated she had consumed 25-50% of her meal. Observation of the meal revealed R6 consumed approximately 10% of the ground meat with gravy and a few bites of green bean and potato casserole. On 10/17/19 at 09:25 AM R6 sat in a recliner across from the nurse's station, eyes closed. On 10/21/19 at 03:48 PM, R6 sat in her wheelchair at the nursing station. Staff offered and assisted R6 with nectar thick liquids though no snack was offered . During an interview on 10/17/19 at 11:51 AM Dietary BB stated that the food items are fortified with margarine, milk, heavy cream, or sour cream. R6 received super cereal (hot cereal fortified with margarine for extra calories) at breakfast and the staff would give her whatever she wanted to eat. During an interview on 10/21/19 at 01:54 PM, Dietary BB stated that he and the RD discussed the weights weekly during the weight meeting and would come up with the interventions for identified weight loss and then he would care plan the interventions . He said that he was aware R6 had lost weight and stated that is why she received fortified foods. He also stated that part of the problem was that R6 slept through meals. During an interview on 10/21/19 at 02:27 P, Certified Nurse Assistant (CNA) N stated that R6 had not fed herself for the 18 months she had worked with her. CNA N was unaware of what weight loss interventions were in place for R6. During interview on 10/21/19 at 04:15 PM, Licensed Nurse (LN) K stated that R6 had not fed herself in the past 12 months that she had worked with her. LN K stated that the weight loss interventions in place for R6 are fortified foods and med pass. She further stated that she became aware of any new weight loss interventions when the physician ordered them. LN K also stated R6 received treatment for [REDACTED]. During an interview on 10/21/19 at 04:23 PM, Administrative Nurse D stated that staff would stay and assist R6 until she was finished eating. Administrative Nurse D stated that she was not sure what weight loss interventions were in place for R6. She said the RD and dietary manager review the weights two to three times monthly to review the interventions. During an interview on 10/22/19 at 11:17 AM, Consultant HH, stated that she last evaluated R6 (MONTH) (YEAR). She stated that R6 had not been referred to speech therapy for therapy related to swallowing difficulties or weight loss . During an interview on 10/22/19 at 02:45 PM, Consultant II stated she reviewed the residents that had weight loss from a report she through Point Click Care (electronic medical record system) at the facility during her visit. She then wrote her recommendations and sent them to the Director of Nursing (DON), MDS Coordinator, the Administrator, Certified Dietary Manager (CDM) and Assistant Director of Nursing (ADON). The CDM updated the care plan with the new weight loss recommendations or interventions. She could not find where R6 had a significant weight loss. She stated that a significant weight loss is 5% in one month and 7.5% in 90 days. She could not find an intervention started on or around 07/26/19 when R6 triggered for a weight warning of loss of 3% in 30 days. She stated that she would prefer to address weights before it became a significant weight loss. The Fortified Foods, Two Calorie Med Pass, Other Supplements and Snacks policy with a revision date of 05/19, documented any resident at risk or with poor nutritional intake, declining intake, weight loss, and or pressure ulcers will be referred to the RD . The RD would determine if the resident required additional protein and or calories, then document the need for the interventions and initiate orders for any that required a physician's approval before usage and update care plan as needed or provide information to the dietary manager so the care plan can be updated. A review would be conducted on a quarterly basis by the RD or dining services manager to monitor and assess those receiving fortified foods, [MEDICATION NAME], Med Pass, and other supplements. The facility failed to identify a weight loss pattern and implement interventions aimed to prevent a significant loss for one totally dependent resident, which resulted in a loss of 7.52% in one month and 8.37% over 3 months.

The facility had a census of 59 residents. The sample included 13 residents. Based upon observation, record review and interviews the facility failed to provide services and treatment to prevent the development of pressure ulcers for 2 (#40, #44) of 2 residents sampled for pressure ulcers. Findings included: - Resident #40's quarterly Minimum Data Set (MDS) 3.0 dated 2/15/14 identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene and limited staff assistance with walking in the room/corridor. The MDS coded the resident was frequently incontinent of urine, was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, utilized a pressure relieving device for his/her bed and wheelchair and was not on a turning/repositioning program. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 12/2/13 documented the resident required staff assistance with most ADLs. The resident's Pressure Ulcer CAA dated 12/2/13 included the resident was at risk for skin breakdown. The resident required staff assistance with toileting and bed mobility and was incontinent of bowel and bladder. The resident had a history of [REDACTED]. The resident's care plan with a print date of 12/2/13 included the resident required staff assistance with ADLs, required extensive staff assistance of 2 with bed mobility and staff placed a lift sheet under the resident to prevent shearing when staff lifted the resident up in bed. Staff offered to reposition the resident every 2 hours and staff floated the resident's heels when in bed. The resident was incontinent of bowel and bladder and utilized a Pummel cushion (a cushion with a raised area in the middle to help with positioning) in his/her wheelchair and had a pressure relieving device on his/her bed. The resident's care plan did not address the resident currently had pressure ulcers. A nurse's note (NN) dated 1/10/14 and timed 3:28 P.M. documented the resident had a sheared (mechanical forces contributing to pressure ulcer formation) area on his/her right buttock that measured 1.0 (centimeter) cm by 0.5 cm and staff repositioned the resident frequently when in bed to offload pressure to the resident's buttock. The clinical record lacked evidence the facility implemented additional interventions after the development of this pressure ulcer. A NN dated 1/14/14 and timed 6:38 A.M. documented the resident had a sheared area to his/her right buttock that measured 0.1 cm by 0.5 cm by 0.1 cm and staff applied barrier cream with Zinc. A NN dated 2/4/14 and timed 11:09 A.M. documented the resident's right buttock had a sheared area that measured 0.5 cm by 1.2 cm with minimal depth. The resident's left buttock had a sheared area that measured 0.5 cm by 0.7 cm with minimal depth. A NN dated 2/18/14 and timed 10:36 A.M. documented the resident's right buttock healed. The resident's left buttock had a shearing wound that measured 0.6 cm by 0.5 cm by 0.1 cm. A NN dated 2/24/14 and timed 3:48 P.M. documented staff informed the resident's physician the resident had a sheared area on his/her right buttock and a Stage 2 pressure ulcer on his/her coccyx. The resident's physician gave an order for [REDACTED]. A NN dated 2/27/14 and timed 2:19 A.M. documented the resident's coccyx/lower back had a reddened area that measured 7.0 cm by 8.0 cm with a red/white area near the upper border on a bony prominence that measured 1.0 cm by 1.0 cm. The sheared area on the resident's left buttock measured 0.1 cm by 0.4 cm. A NN dated 3/4/14 and timed 10:47 A.M. documented the resident spent most of his/her day in the wheelchair or bed. A NN dated 3/6/14 timed 7:09 A.M. documented the resident had no open areas. A NN dated 3/13/14 and timed 1:31 A.M.. documented the sheared area on the resident's left sacrum measured 0.3 cm by 0.3 cm. A NN dated 3/26/14 and timed 1:25 P.M. documented the shearing on the resident's sacrum resolved and staff continued to apply barrier cream due to the resident's fragile skin. A NN dated 4/24/14 and timed 2:02 A.M. documented the resident's lower lumbar had a reddened area that measured 10.0 cm by 7.0 cm. A circular reddened area with darkened borders that measured 1.5 cm diameter on his/her right coccyx, and slight generalized redness to his/her left coccyx area and the resident was incontinent of bowel and bladder. A NN dated 4/24/14 and timed 8:58 A.M. documented the top of the resident's right buttock had a sheared area that measured 2.1 cm by 1.5 cm by 1.0 cm and a Stage 2 pressure ulcer on his/her coccyx that measured 0.2 cm by 0.2 cm by 0.1 cm. The resident spent most of the day in his/her bed or wheelchair, was incontinent of bowel and bladder and required extensive staff assistance with most ADLs. The resident's clinical record lacked evidence to support the facility had determined the resident's tissue tolerance (ability of the skin and underlying tissue to tolerate exposure to pressure without adverse effects). Observation on 4/24/14 at 8:45 A.M., 8:50 A.M., 9:00 A.M., 9:10 A.M., 9:25 A.M., 9:30 A.M., 9:43 A.M., 9:45 A.M., 10:00 A.M., 10:06 A.M., 10:13 A.M., 10:19 A.M., 10:28 A.M. 10:38 A.M., 10:47 A.M., 10:53 A.M., 11:00 A.M., 11:10 A.M., 11:15 A.M., 11:21 A.M., 11:33 A.M., 11:35 A.M. and 12:05 P.M. (a duration of 3 hours and 20 minutes) the resident sat in his/her wheelchair without a change in position). On 4/24/14 at 12:05 P.M. the surveyor asked licensed nurse I if he/she could observe the resident's skin. At 12:10 P.M. direct care staff GG propelled the resident from the dining room to his/her room. Observation revealed the resident was incontinent of urine and the resident had a Stage 2 pressure ulcer on his/her right buttock that measured approximately 2.0 cm by 1.0 cm and a pinpoint Stage 2 pressure ulcer on his/her coccyx. Further observation revealed no dressing on the pressure ulcers. During interview with direct care staff GG at that time, he/she stated staff only repositioned the resident when he/she was in bed. On 4/24/14 at 12:30 P.M. the resident sat in his/her wheelchair at a dining room table. The resident continued in the wheelchair at the dining room table at 1:00 P.M., 1:15 P.M., 1:28 P.M., 1:37 P.M., 1:47 P.M., 1:57 P.M., 2:14 P.M., 2:20 P.M., 2:30 P.M., 2:38 P.M., 2:48 P.M., 3:00 P.M., 3:10 P.M., 3:20 P.M., 3:25 P.M., 3:30 P.M., 3:50 P.M. and 4:00 P.M. (a duration of 3 hours and 30 minutes) without a change in position. On 4/28/14 at 8:15 A.M. and 9:10 A.M. the resident laid in bed. Observation revealed the resident did not have on heel protectors and the resident's feet were not offloaded. On 4/24/14 at 3:56 P.M. direct care staff HH stated staff repositioned the resident every 2 hours when in bed, staff lifted the resident in bed with a draw sheet, the resident did not utilize heel protectors but staff placed a pillow under the resident's right hip to keep the resident off his/her right side. On 4/28/14 at 1:44 P.M. administrative nursing staff D stated the resident was not on a turning/repositioning program but according to standard of practice staff should turn/reposition the resident every 2 hours. On 4/28/14 at 2:34 P.M. licensed nurse F stated the resident was at risk for pressure ulcers and staff repositioned the resident every 2 hours. The resident currently had a pressure ulcer on his/her right coccyx and staff applied barrier cream to the pressure ulcers. On 4/28/14 at 3:00 P.M. administrative nursing staff confirmed the resident's care plan did not include the resident's current pressure ulcers. The 2009 International Guidelines for Pressure Ulcer Treatment included to limit the time an individual spent in a chair without pressure relief and to position the individual off the pressure ulcers whenever possible. The facility failed to timely assess this resident for the prevention of pressure ulcers and failed to prevent the development of multiple avoidable pressure ulcers. The facility also failed to provide interventions as planned after the development of pressure ulcers. - Resident #44's annual Minimum Data Set ((MDS) dated [DATE] identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status, had no behaviors, was totally dependent upon staff with bed mobility, and locomotion on/off the unit, toilet use, required extensive staff assistance with transfers, dressing, eating and the activity of walking in the room/corridor occurred only once or twice. The resident was frequently incontinent of urine, was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, utilized a pressure relieving device on his/her bed and wheelchair and was not on a turning/repositioning program. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 3/6/14 documented the resident required extensive to total staff assistance with most ADLs. The resident required extensive assist of 2 with transfers, was able to walk very short distances in his/her room, was unable to self propel his/her wheelchair and was totally dependent upon staff for locomotion. The resident's Urinary Incontinence CAA dated 3/6/14 documented the resident was frequently incontinent of bowel and bladder. The resident's Pressure Ulcer CAA dated 3/6/14 documented on 2/20/14 the resident scored 13 on the Braden Scale (tool used to predict the development of pressure ulcers) which placed the resident at risk for the development of pressure ulcers. The resident required extensive staff assistance of 2 with repositioning when in bed and the resident without unhealed pressure ulcers. The resident's care plan with a print date of 12/2/13 included the resident required assistance of 2 staff for ADL's and personal care, staff repositioned the resident every 2 hours and floated the resident's heels when in bed. On 4/23/14 at 10:40 A.M., 10:45 A.M., 10:50 A.M., 10:56 A.M., 11:01 A.M., 11:10 A.M. and 11:20 A.M. the resident sat in the activity/day area of the facility in his/her wheelchair. At 11:24 A.M. staff propelled the resident to a dining room table in the assisted dining room for the lunch meal. Prior to staff propelling the resident to the dining room table (2) staff straightened the resident in the wheelchair but did not lift the resident from the wheelchair. The resident continue to sit in the wheelchair at the dining room table at 11:33 A.M., 11:42 A.M., 11:53 A.M., 12:00 P.M. 12:10 P.M., 12:19 P.M., 12:25 P.M., 12:28 P.M., 12:37 P.M., 12:45 P.M. and 12:49 P.M. At 12:59 P.M. the resident in his/her wheelchair in front of the nursing station on the hall he/she resided without a change in his/her position. On 4/24/14 at 8:05 A.M., 8:10 A.M., and 8:22 A.M. the resident sat in his/her wheelchair at a dining room table. At 8:29 A.M., 8:35 A.M., 8:40 A.M., 8:44 A.M., 8:50 A.M., 9:00 A.M., 9:10 A.M., 9:25 A.M., 9:30 A.M., 9:43 A.M., 9:45 A.M., 10:00 A.M., 10:06 A.M., 10:13 A.M., 10:19 A.M., 10:28 A.M., 10:38 A.M., 10:47 A.M., 10:53 A.M., 11:00 A.M., 11:10 A.M., 11:15 A.M., 11:21 A.M., and 11:25 A.M. (duration of 3 hours and 20 minutes). The staff did not reposition the resident. On 4/24/14 at 11:33 A.M. direct care staff GG propelled the resident from the day room to a dining room table for the lunch meal. At that time the surveyor asked to check the resident's skin. Direct care staff GG propelled the resident from the dining room table to a common bath on the northeast hall. Observation revealed the resident's skin was intact. Further observation revealed the resident was incontinent of urine. During interview with direct care staff at that time he/she stated he/she did not get the resident up that morning but staff placed the resident in the wheelchair around 8:00 A.M. that morning. Direct care staff GG stated the resident sat in the wheelchair form 8:00 A.M. until now. Direct care staff GG stated the resident was not on a repositioning/turning program. On 4/24/14 at 3:50 P.M. direct care staff HH stated staff checked on the resident every 2 hours during rounds and he/she did not know if the resident was on a repositioning/turning program. On 4/28/14 at 1:44 P.M. administrative nursing staff stated the resident was at risk for the development of pressure ulcers, the resident was not on a turning/repositioning program; however according to standard of practice staff should reposition the resident every 2 hours. The facility failed to reposition this severely cognitively impaired dependent resident at risk for the development of pressure ulcers as planned.

The facility identified a census of 69 residents. The sample included 14 residents. Based on observation, interview and record review, the facility failed to assess a change in status in a timely manner for 1 (#1010) of 3 residents sampled for hospitalization , resulting in an inpatient stay with three blood [MEDICAL CONDITION] received. Findings included: - Resident #1010's December 2011 physician's orders [REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment with an Assessment Reference Date (ARD) of 10/1/11 identified the resident with a Brief Interview for Mental Status (BIMS) score of 14 that indicated intact cognition, required limited staff assistance of one for bed mobility, transfers, walking in the room or corridor, locomotion on and off of the unit, and required extensive staff assistance of one for dressing, toilet use, personal hygiene, and bathing. The MDS documented the resident with occasional bladder incontinence and always continent of bowel. The revised 12/7/11 care plan identified the resident had recent [MEDICAL CONDITION] (GI) and instructed the staff to monitor the resident for any frank red blood, black tarry stools, or coffee ground emesis and notify the physician if present. The care plan further identified the discontinuation of Aspirin and the addition of Aspirin to the resident's allergy list and the completion of labs ordered by the physician with the physician notified of the results. Review of the care plan prior to the 12/7/11 lacked any information regarding the resident's aspirin usage with the potential for bleeding. The nurses notes documented the following: 11/26/11 timed 5:44 P.M. Temperature 96.5. Staff reported to this writer this morning of resident having loose dark tarry stool. This afternoon, staff reported resident with weakness and unsteady on his/her feet. Resident stated he/she does not feel well, but unable to say how he/she felt. Will continue to monitor. 11/27/11 timed 4:36 A.M. Resident up to bathroom with assist tonight with no weakness observed. No loose stools reported tonight. 11/27/11 timed 12:37 P.M. I was called to resident's room by a Certified Nurse's Assistant. (CNA). Resident was sitting on the toilet leaned back. He/she stated they did not feel well. He/she was assisted to bed by 2 CNA's with a gait belt. Blood Pressure (BP) 101/57, pulse 61, respirations 18, temperature 97.4. Oxygen saturation 85% on room air. Blood sugar 244. The resident had not eaten this morning and the medications were given about 10:00 A.M. Took blood pressure again, it was 87/57 and the staff called the physician. Received orders to: 1) Hold [MEDICATION NAME] until seen by physician on Tuesday or sooner, if needed. 2) Hold [MEDICATION NAME] if systolic is < 100. 3) Get labs 11/28/11, Complete Blood Count (CBC) and Chemistry Profile. 4) Blood sugar daily times one week. Notified daughter of episode and new orders. 11/28/11 timed 4:31 A.M. BP 118/52. Resident up once with assistance to the bathroom. No complaints of weakness or discomfort. 11/28/11 timed 2:35 P.M. Resident complained of not feeling well today. CNA called me to the resident's room to observe the resident's stool. Resident had what appeared to be a black tarry stool in toilet. Vital signs were obtained: temperature 97.2, BP 129/72, pulse 79, respirations 18, and oxygen saturation 95% on 1.5 liters of oxygen. Skin was pale in color. Lab called critical hemoglobin at 1:50 P.M. of 5.5 (normal range 12.0-16.0). Physician notified and stated send the resident to the emergency room for evaluation. Physician also notified of the resident's positive urine culture.[MEDICATION NAME](an antibiotic) 250 mg (milligrams) ordered by mouth twice daily. Emergency Medical Services notified via 911 and arrived at 2:15 P.M. Resident taken to hospital via ambulance at 2:35 P.M. 11/28/11 timed 10:44 P.M. Spoke with a representative at the hospital who informed this writer the resident was admitted to the hospital with [REDACTED]. In a notarized statement, licensed nursing staff C revealed staff notified him/her the resident had loose, tarry stools on the morning of both 11/25/11 and 11/26/11. Licensed nursing staff C further noted the resident told him/her they were not feeling well, but was unable to describe how he/she felt. Then later the afternoon of 11/26/11, licensed nursing staff C reported the resident was weak. Licensed nursing staff C noted he/she informed the oncoming nurse. In a notarized statement, direct care staff I revealed that on 11/25/11 he/she assisted the resident to the toilet and noted the resident had black tarry stools. He she noted that after he/she got the resident back to bed, he she reported this to licensed nursing staff C and told him/her the soiled brief was in the trash in the bathing unit if he/she wanted to view it. Direct care staff I documented licensed nursing staff C did not go look at the soiled brief that contained the black tarry stool. Direct care staff I noted licensed nursing staff C verbalized it was "probably a GI bleed," and walked away. Direct care staff H's notarized statement, he/she revealed that he/she assisted the resident to the bathroom a total of 4 times on 11/25/11 and 11/26/11. He/she further documented the resident was very weak and had black tarry stools each time. Direct care Staff H noted he/she reported the findings to licensed nursing staff C each time and "nothing was done about it", noting licensed nursing staff C did not go look at the stools or the resident, and did not ask direct care staff H to save the stools for him/her to view the next time. On 12/21/11 at 2:10 P.M., direct care staff F revealed that on the morning of 11/27/11, the resident requested to go to the bathroom. Direct care staff F assisted the resident to the bathroom. When the resident had finished, direct care staff F revealed he/she provided peri-care and pulled up his/her brief. The resident then said he/she was dizzy and did not feel right. Direct care staff F noted he/she sat the resident back down on the toilet, at which time the resident began convulsing and "was shaking everywhere, turned very pale, had no color, even in her lips, and was unresponsive and drooling". Direct care staff F revealed he/she immediately turned on the emergency bathroom call light. Direct care staff F took his/her cell phone out of his/her pocket and called the facility. Licensed nursing staff D answered the phone and said he/she would be right there. Direct care staff F noted the resident was still shaking and convulsing while he/she waited for help to arrive. Direct care staff G arrived first, followed shortly by licensed nursing staff D. Direct care staff F noted the resident was still unresponsive and drooling, but had stopped convulsing. Licensed nursing staff D directed direct care staff F and G to transfer the resident with a gait belt into the wheelchair in the bathroom and then into the bed. The resident began to respond a little and was slurring his/her words. Color still was not normal. Licensed nursing staff D took the resident's vital signs and his/her oxygen saturation was low and read in the 80's and oxygen was put on the resident at 2 liters per nasal cannula. Licensed nursing staff D also checked the resident's blood sugar, that registered around 245. Licensed nursing staff D notified the physician and obtained orders, but the resident was not sent out to the hospital at that time. Direct care staff F did not see any black tarry stools on that date of 11/27/11, but was told in report the resident had been having dark, loose stools that did not look right. On 12/21/11 at 3:20 P.M., licensed nursing staff E revealed he/she did not work 11/25-11/27/11, but when he/she returned to work on 11/28/11 he/she learned in report the resident had been having some tarry stools. Licensed nursing staff E revealed he/she went down to the resident's room and assessed the resident. He/she noted a black tarry stool was in the toilet. He/she noted that the lab had drawn blood that morning. The lab notified the facility of a critical lab value, as the hemoglobin was 5.5. He/she then notified the physician and the resident's family member and sent the resident out to the hospital. Review of the hospital records revealed the resident was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The hospital History and Physical dated 11/28/11 documented the resident was noted by nursing staff at the nursing home to have a melanotic tarry stool. A CBC revealed a hemoglobin of 5.5. The resident's family members stated that the resident had been weak for several months but this had been getting progressively worse. The resident complained of being so weak, he/she could not walk. The resident was on [MEDICATION NAME] (an antihypertensive agent) until yesterday morning when he/she went to the bathroom, got very weak and his/her BP was low. Medications included Aspirin 81 mg by mouth daily. The physician diagnosed the resident with probable upper GI bleed with melanotic stools and acute blood loss [MEDICAL CONDITION] with orders to place the resident on a telemetry unit for monitoring, vital signs every 4 hours, transfuse 2 units of packed red blood cells overnight, placed on a [MEDICATION NAME] (a proton pump inhibitor) infusion, continue home medications, except for Aspirin, place on intravenous fluids of normal saline at 75 cc (cubic centimeters) per hour, heme-test (check for blood) all stools, and repeat CBC in the morning. On 12/21/11 at 3:52 P.M., administrative staff A revealed administrative nursing staff B received a report of concern filed by several certified nursing assistant's on 11/28/11 or 11/29/11 that nursing did not respond to the reports of black, tarry stools and weakness for this resident. Administrative staff A revealed administrative nursing staff B shared this with him/her and an indepth investigation was launched, that resulted in the suspension of licensed nursing staff C from 11/29/11 thru 12/4/11. Administrative staff A noted that when the employee returned to work on 12/5/11, consultant nurse J spent the entire day working with the employee on assessment skills. On 12/21/11 at 5:09 P.M., administrative nursing staff B acknowledged the lack of nursing assessment for this resident with weakness and black, tarry stools. On 12/21/11 at 5:22 P.M., consultant staff J acknowledged the lack of assessment and documentation for this resident with weakness and black, tarry stools. Observation on 12/21/11 at 5:42 P.M. revealed the resident sat in a wheelchair in his/her room. The 2010 facility provided policy entitled " INTERACT" (Interventions to Reduce Acute Care Transfers) recognized persistent bleeding from the rectum (melena) or bleeding accompanied by significant orthostatic blood pressure drop as a change in condition that required immediate physician notification. The facility failed to accurately assess the resident in a timely manner and notify the physician of the black, tarry stools and progressive weakness that ultimately resulted in hospitalization .

The facility reported a census of 69 residents divided on four separate nursing units. The facility identified 44 residents as independently mobile. Based on observation, record review and interview, the facility failed to maintain safe water temperatures in the open and accessible therapy gym. This potential hazard created immediate jeopardy for injury to the cognitively impaired independently mobile residents in the facility. Findings included: - On 10/18/11 at 9:58 A.M., during initial facility tour, observation revealed the water temperature in the facility therapy gym recorded at 139.2 degrees Fahrenheit. Three to four residents were present in the gymnasium along with two staff members. At this time, therapy staff, U said the door to the therapy gym remained open even in the evenings for resident use when no therapists are present. On 10/18/11 at 10:25 A.M. recheck of this same faucet yielded a temperature of 139.1 degrees Fahrenheit. On 10/18/11 at 10:55 environmental staff H obtained an initial hot water temperature of 106 degrees Fahrenheit. Environmental staff H was asked to place the pointed end of his/her thermometer (where probe was) under the water flow, after which it registered 141.4 degrees Fahrenheit. At this time, (10/18/11 at 10:55 A.M.) environmental staff H contacted environmental staff who instructed him/her to turn the water to this sink off immediately. On 10/18/11 at 11:00 A.M. Environmental staff T stated that, "we check temperatures weekly, but the therapy room is just an area that we never even thought about." Environmental Staff T subsequently provided documentation of weekly water checks for the previous 6 months for laundry, kitchen and resident rooms; however the therapy sink was not included on this documentation. On 10/18/11 at 11:00 A.M. environmental staff T identified the problem as a failed mixing valve on the boiler, which supplied the therapy room and staff break room area. The facility did not provide a policy that addressed checking water temperatures in resident rooms and common areas or any other part of the building. On 10/17/11 at 12:10 P.M. administrative staff A acknowledged the immediate jeopardy this hazard posed to residents and stated they would provide immediate correction. Recheck of the water temperature in the therapy gym on 10/19/11 at 4:00 P.M. recorded a temperature of 106 degrees Fahrenheit. The immediate jeopardy was abated on 10/18/11 at 10:15. A.M. based on the facilities written correction plan that included: "Water in the therapy room was shut off immediately- water was shut off at approximately 10:15 A.M. A mixing/tempering valve was added at the problem location (sink in therapy room) at approximately 12:30 P.M. on 10/18/11." By locking the therapy room door when the therapist or staff members were not present. "Environmental services director added a valve at the problem site (12:30 p.m. on 10/18/11). New tempering/ mixing valves were ordered 10/18/11 at 1:30 P.M. to replace the faulty valve on the line that supplied the area that included the problem site, A new valve will be shipped today with delivery anticipated 10/19/11." "Temperatures thru out the building will be checked frequently in the next 72 hours to ensure there are no other problem areas. Ongoing." "Environmental services have reviewed the log to verify that all faucets are accounted for and will continue to do routine temperature checks per schedule." The citation remains at a scope and severity of a E. The facility failed to maintain water temperatures within acceptable range of 120 degrees Fahrenheit or lower.