Every finding on record at Medicalodges Independence

The facility reported a census of 43 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to prevent the potential for food borne bacteria in one of one kitchen and one of one kitchenettes. This placed the residents of the facility at risk for food borne illness. Findings included: - During a tour of the kitchen on 06/16/25 at 08:49 AM, the following areas of concern were noted: 1. The inside of the hand-washing sink had visible dirt and debris. The trash can next to the hand-washing sink had dried food debris stuck on the outside of the plastic can. 2. One three-tiered metal cart, used to transport resident snacks, had multiple areas of rust on the legs as well as a build-up of ground-on food on the wheels. 3. The inside of the three-doored freezer had food debris on the bottom shelf. 4. Two silver-colored skillets hanging by the stove contained multiple scratches in the protective coating causing the skillets to be unsanitizable. 5. The front vent of the three-door reach-in refrigerator had dried-on liquid and the inside of one door contained a long hair stuck to the door by the condensation. 6. Approximately 50 percent (%) of the rubber seal on one door of the three-doored reach-in refrigerator hung loosely. The rubber seal on all three doors contained a thick build-up of food debris. 7. The inside of the three-doored reach-in refrigerator had a copious amount of food debris on the bottom shelf. 8. Two plastic trash cans used in the kitchen had a build-up of dried-on food and liquid. During a tour of the kitchenette refrigerator, on one end of the dining room directly outside of the kitchen, on 06/16/25 at 09:15 AM, the following areas of concern were noted: 1. There was an opened gallon of vanilla ice cream in the refrigerator, unlabeled and undated. 2. There was a paper cup of a frozen solid shake from a local ice cream store, unlabeled and undated. 3. The refrigerator contained an opened container of cottage cheese which was unlabeled and undated. 4. The refrigerator contained a premade salad from a local restaurant which was unlabeled and undated. 5. The refrigerator contained a quart container of butter which was opened and undated. 6. The freezer contained an open box of pizza rolls which was unlabeled and undated. On 06/16/25 at 12:49 PM, Dietary Staff CC confirmed the above concerns needed to be addressed. The Cleaning Rotation guide, revised in 2016, included that microwave ovens, hand-washing sinks and food carts shall be cleaned daily. Trash barrels shall be cleaned weekly. Refrigerators and freezers shall be cleaned monthly.

The facility reported a census of 43 residents; the sample included 14 residents. Based on observation, interview, and record review, the facility failed to verify advanced directives (legal documents in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves) to ensure the outside of hospital Do Not Resuscitate Directive form (DNR- or no code, a legal document or order that means the person does not desire cardiopulmonary resuscitation [CPR] in the event of cardiac arrest) were accurate and legal to reflect Resident (R) 4, R27, and R40's advance directives. This deficient practice placed the residents at risk for impaired rights related to end-of-life care. Findings included: - R4's Electronic Health Record (EHR) included diagnoses of morbid obesity (a serious medical condition characterized by excessive body fat accumulation, significantly impacting health and potentially shortening lifespan), chronic kidney disease (a condition where the kidneys are damaged and lose the ability to filter waste and fluid from the blood), atrial fibrillation (rapid, irregular heartbeat), hyperkalemia (greater than normal amount of potassium in the blood), heart failure (a condition where the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup in the lungs, legs, and other areas), and essential hypertension (high blood pressure). R4's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 14, which indicated intact cognition. R4's Quarterly MDS dated [DATE] documented a BIMS of 14. R4's Care Plan dated [DATE] documented R4 wished to be a DNR. R4's Physician Orders revealed an order for DNR dated [DATE]. R4's EHR Home tab documented R4's code status (full code or DNR) as DNR. R4's EHR, under the scanned documents section, revealed a Do-Not-Resuscitate Directive signed by the resident, with an illegible date. The directive was not signed by the physician. On [DATE] at 08:22 AM, Licensed Nurse (LN) G stated that DNR and full code status were verified in the resident's EHR and by their paper chart. LN G also stated that a DNR should have been signed by the resident and/or their legal representative and the physician. LN G further stated that if a resident left the facility for any appointment or outing a packet was sent with them that included their face sheet indicating code status and their DNR if applicable. On [DATE] at 08:38 AM Administrative Staff A and Administrative Nurse D stated that an advanced directive and/or DNR should have had the resident's signature and physician's signature if resident was cognitively intact or the resident's legal representative's signature and this was done when the resident entered that facility. The staff said the residents also had the ability to enact a DNR once they were moved into the facility. On [DATE] at 08:51 AM, Administrative Nurse D stated that R4's DNR was not signed by a physician so it was not legal. The facility policy Advance Directives, dated 04/2018 stated that indicated that residents have the right to accept or refuse medical or surgical treatment including formulating an advance directive. This policy also indicated that complete copies of the resident's advance directive would be provided and maintained in their clinical record. The policy further indicated that if a resident requested to be a Do Not Resuscitate (DNR), a physician order would be obtained and the advance directive would be reviewed quarterly, with any significant change and upon the resident's request, and the reviews would be documented in their clinical record. The facility policy Advance Directive-Code Status, dated 12/2017 indicated that the policy was to identify and honor the resident's preference regarding advance directives and code status.

The facility reported a census of 43 residents. The sample included 14 residents. Based on interview, observation, and record review, the facility failed to protect and promote the privacy, including during telephone use, for Resident (R) 145, R19 and R44. This deficient practice placed the residents at risk for negative psychosocial effects due to impaired privacy. Findings included: - Observation on 06/17/25 at 09:59 AM, Housekeeping V entered R145's room to perform housekeeping duties without knocking and announcing her presence. R145 was resting on his bed at that time. Observation on 06/17/25 at 10:03 AM, Maintenance U knocked once on R19's door, and without waiting for R19 to respond, walked in and turned the light on, R19 was resting in her bead at that time. On 06/16/25 at 09:20 AM, R4 reported that when she was on the phone, staff would just enter her room and loiter until she was off the phone. On 06/17/25 at 10:09 AM, Certified Nurse Aide (CNA) M stated she would knock and introduce herself and await acknowledgment from the resident before entering the room. CNA M said, if the resident was on the phone she would not enter until they were off the phone or acknowledged it was ok. On 06/17/25 at 10:11 AM, Housekeeping V stated that if there was a resident in the room she planned to work in, she would knock, announce herself, and once acknowledged she would enter the room. Housekeeping V said if the resident was asleep, she quietly entered and quickly performed her tasks. Housekeeping V also stated that if a resident was on the phone, she would just go in and complete her tasks while the resident remained on the phone. On 06/17/25 at 10:27 AM, Licensed Nurse (LN) G stated that before entering a resident's room, she knocked, introduced herself, and announced the reason she was there; she awaited acknowledgment. She said if a resident was on the phone, she would let them know that she would come back later. On 06/17/25 at 11:20 AM, Administrative Staff A reported that if care were performed the curtain would be pulled and doors closed; all staff were to knock, announce themselves, await a response, and re-knock if no response was received before entering the resident's room. Administrative Staff A stated that if the resident were on the phone, then staff should have come back later to allow the resident to have privacy. Administrative Staff A further stated that it was not appropriate to perform housekeeping duties or other resident care duties while the resident was sleeping unless the resident had previously approved of the actions. On 06/17/25 at 11:30 AM, Administrative Nurse D stated that staff were to knock and await permission before they entered a resident's room. Administrative Staff D also stated that if the resident was on the phone, then staff should have come back at a later time unless the resident said it was okay to come in. On 06/17/25 at 04:35 PM, Administrative Staff A reported that the facility did not have a specific policy for resident's rights or privacy, the facility followed the regulations. The facility did not provide a policy related to resident rights and privacy.

The facility had a census of 43 residents. The sample included 14 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to issue written notification as soon as practicable for transfer for Resident (R) 2. The facility additionally failed to notify the Office of the Long Term Care Ombudsman (LTCO). This placed the resident at risk for impaired rights related to returning to the facility. Findings included: - R2's Electronic Health Record (EHR) revealed diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), paroxysmal atrial fibrillation (rapid, irregular heartbeat), atrioventricular block (a condition where the electrical signals that control the heartbeat are partially or completely blocked from traveling between the atria and ventricles), and the presence of cardiac pacemaker (implanted device to regulate the beating of the heart). R2's Discharge with Expected Return Minimum Data Set (MDS) dated 03/01/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact memory. R2's Quarterly MDS dated 05/22/25 documented a BIMS score of 15 and indicated yes for shortness of breath when lying flat for health conditions. R2's Care Plan documented on 05/23/25 that R2 was at risk for potential complications and discomfort related to congestive heart failure. The care plan interventions included the administration of medications as ordered and directed staff to monitor for effectiveness and side effects of the medications. The plan also directed staff to report to the provider any shortness of breath decreased urine output or elevated blood pressure. The Progress Notes dated 03/01/25 at 09:07 AM documented R2 had complaints of chest pain and tightness that radiated down her left arm and neck; she appeared pale in color and displayed shortness of breath. R2 went to the emergency room (ER) for further evaluation. The Progress Notes dated 03/02/25 at 12:25 PM documented that R2 returned to the facility from the hospital. R2's EHR lacked evidence the facility provided written notification of the transfer to R2 and/or her representative. The facility was unable to provide evidence of notification to the LTCO for R2's transfer. On 06/17/25 at 01:25 PM, Administrative Staff A stated that the Ombudsman was provided notification monthly about resident transfers and/or discharges. Administrative Staff A said that the resident and/or legal representative received verbal notification and provided consent via a phone call. Administrative Staff A further stated that transfer packets were sent with the resident whenever they were transferred out, but the documents were never returned by EMS or the hospital. On 06/17/25 at 01:57 PM, Administrative Staff C stated that the LTCO was not been notified because R2 had only transferred out for one day. Administrative Staff C also stated that R2 had not been provided written notification of her transfer by the facility. The facility did not provide a policy related to written notification of resident transfers or discharge to residents and the LTCO.

The facility identified a census of 43 residents. The sample included 14 residents with five residents sampled for quality of care. Based on observation, interview, and record review, the facility failed to provide care and services to monitor medications for Resident (R) 11 when staff failed to monitor for effectiveness and side effects of an antibiotic and failed to follow instructions to discontinue mediations that had potential for increased adverse effects due to the antibiotic. This deficient practice placed R11 at risk for prolonged infection and adverse side effects. Findings: - R11's Electronic Medical Record (EMR) revealed the following diagnoses: end-stage renal disease (ESRD-a terminal disease of the kidneys), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and infected wounds. R11's 04/20/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R11 had dialysis (a procedure where impurities or wastes are removed from the blood)and several wounds. The MDS noted R11 had two unstageable pressure ulcers (the depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus), one deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and three venous ulcers (a stasis wound due to poor circulations). The 04/20/25 Nutritional Status Care Area Assessment (CAA) documented R11 was alert and oriented with intermittent confusion. He had diagnoses of ESRD, diabetes mellitus, and chronic wounds. R11's Care Plan dated 06/16/25 documented R11 was on an antibiotic and had an infection related to wounds. The plan directed staff to administer antibiotics as ordered; monitor for adverse reactions from the antibiotic treatment and continued signs and symptoms of infection; monitor for signs and symptoms of dehydration such and lethargy (extreme weakness), increased weakness, and decreased urine output. R11's Physician's Orders documented an order for atorvastatin (a medication used to lower cholesterol) 40 milligrams (mg) by mouth at bedtime for high cholesterol. R11's Wound Note dated 06/12/25 documented R11 was to start ciprofloxacin (an antibiotic) 250 milligrams (mg) by mouth once a day for 10 days. The note directed to hold while taking the ciprofloxacin. The note directed to start Augmentin 500-125 mg (an antibiotic) one tablet a day for a wound infection for 10 days and directed to take a second tablet after dialysis treatments. R11's Physician's Orders noted an order for ciprofloxacin 250 milligrams (mg) by mouth once a day for 10 days ordered on 06/12/25 for wound infection. R11's Physician's Orders noted an order for Augmentin 500-125 mg, take one tablet a day for a wound infection for 10 days ordered on 06/12/25. Also take one tablet on Monday, Wednesday, and Friday after dialysis. R11's June 2025 Medication Administration Record (MAR) documented atorvastatin calcium 40 mg was given for high cholesterol while he took the ciprofloxacin 250 milligrams on 06/14/25, 06/15/25, 06/16/25, and 06/17/25. R11's clinical record including Progress Notes lacked documentation of routine monitoring of adverse reactions or effectiveness of the antibiotic medications. On 06/18/25 at 09:37 AM, Licensed Nurse (LN) G stated staff should monitor adverse reactions and effectiveness of antibiotics and document every shift for every resident that was taking antibiotics. LN G stated that she was not documenting on R11 but was not surprised there was no documentation of monitoring for R11. LN G said she was not aware that R11's atorvastatin was supposed to be held and said the nurse that was working, or the wound nurse, should have put in the orders. On 06/18/25 at 10:39 AM, Administrative Nurse D stated all residents on antibiotics should be monitored every shift for effectiveness and any adverse reaction to antibiotics. Administrative Nurse D verified the order to hold R11's atorvastatin should have been followed. The Medication Management policy dated 01/2024 documented that each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This included any drug without adequate monitoring. In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences. The facility staff, their physician, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use.

The facility identified a census of 43 residents. The sample included 14 residents with one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record reviews, the facility failed to provide ordered treatments to prevent pressure ulcers and promote healing for Resident (R) 16. This deficient practice placed the resident at risk of developing pressure injuries and delayed wound healing. Findings included: - R16 's Electronic Health Record (EHR) revealed a diagnosis of chronic renal failure (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes). R16's 03/21/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment. The MDS documented R16 had no pressure ulcers but was at risk for pressure injuries. R16's 03/21/25 Pressure Ulcer Care Area Assessment (CAA) documented R16 had no pressure injuries or skin breakdown. He required significant to maximum assistance for bed mobility. R16 was dependent on staff for toileting hygiene and used a wheelchair with staff assistance. The CAA noted R16 had a Braden score 12 which indicated he was at high risk for pressure areas. He had poor intake. R16's 05/29/25 Significant Change MDS documented a BIMS score of four, indicating severely impaired cognition. R16 started hospice services. He had a significant weight loss. R16 had one Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) pressure ulcer and one deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). R16's 05/29/25 Pressure Ulcer CAA documented R16 had a decline in cognition and activities of daily living since admission. His family had elected to implement comfort care provided by the facility in lieu of Hospice. He had two facility-acquired pressure injuries to the bottom of his right foot. R16 triggered for significant weight loss of 38 pounds. He utilized heel protectors. Staff applied Skin-prep (liquid skin protectant) to the pressure injuries. He required two staff to turn and reposition him in bed. He was at risk for further skin breakdown and pressure injuries. R16's Care Plan documented a DTI on his right foot. On 05/06/25 staff were instructed to apply Skin-prep to the ball of R16's right foot. The plan directed staff to apply heel pillow boots to both feet and a padded footboard to R16's bed. On 05/27/25, the plan directed staff to apply Skin-prep to a deep tissue injury on the bottom of the right foot and cover it with border foam dressing. The plan directed staff to apply Skin-prep to the Stage I pressure injury on the bottom of the right foot, and cover with a border foam dressing. The plan directed staff to apply Skin-prep to R16's buttocks and cover the area with a border foam dressing for prevention. R16's Braden Scale for Pressure Ulcer Risk V1.0- - V 1 dated 05/27/25 documented R16 had a pressure risk score of nine which indicated a severe risk for pressure areas. R16's Physician Order noted an order to apply Skin-prep to R16's buttocks and cover with a border foam dressing on Monday, Wednesday, and Friday for prevention; ordered 05/28/25. R16's Physician Order noted an order to apply Skin-prep to R16's right foot and cover with a border foam dressing on Monday, Wednesday, and Friday for deep tissue injury; ordered 05/28/25. R16's Physician Order noted an order for heel protector boots for both feet every shift; ordered 05/28/25. R16's Physician Order noted an order to apply Skin-prep to R16's right foot and cover it with a border foam dressing on Monday, Wednesday, and Friday for a second deep tissue injury; ordered 06/10/25. R16's 06/10/25 Skin/Wound Condition Assessment documented two right plantar foot suspected DTI areas 1.5 centimeters (cm) x 1.5 cm and a second one 1.5cm x 0.5 cm. The oldest pressure area was identified on 04/09/25. On 06/17/25 at 08:57 AM, R16 lay in bed with his boots applied. There was no dressing applied to his feet. On 06/17/25 at 11:35 AM, Certified Nurse Aide (CNA) N and CNA O changed R16's brief. Observation revealed R16's buttock was discolored; he had no dressing on his buttock as ordered. Further observation revealed R16 had no dressing to his feet either. On 06/17/25 at 02:31 PM, Licensed Nurse (LN) G attained the supplies to apply R16's dressings. LN G measured the deep tissue injury wounds on the bottom of R16's feet. The top one was 2.3 cm x 1.8 cm and dark bluish-purple. LN G stated it looked a bit bigger. The bottom wound measured 1.8cm x 0.5 cm and was dark bluish-purple. At 02:51 PM, LN H assisted LN G with the dressing on R16's buttocks. On 06/17/25 at 09:12 AM, CNA N stated that sometimes the dressings were on R16's feet and sometimes there were no dressings applied. On 06/17/25 at 09:14 AM, LN G stated the dressings should be applied to R16's foot and buttocks as ordered. LN G said she would apply the dressings when she was able. On 06/17/25 at 11:35 AM, CNA O stated R16 had not had a treatment or dressing on his buttock for a long time. CNA O said R16 occasionally had a dressing on his feet. On 06/18/25 at 10:39 AM, Administrative Nurse D stated that R16's dressings should have been in place. Administrative Nurse D stated she expected staff to follow treatment orders to prevent further decline. The Wound Prevention and Management Policy dated 12/2018 documented that the purpose of the policy is to identify residents at risk for skin breakdown and develop interventions to decrease the pressure areas and promote healing for residents with identified skin alterations.

- R21's Electronic Health Record (EHR) revealed a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R21's 04/17/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R21 consumed a therapeutic, regular textured diet. R21 received insulin (a hormone that lowers the level of glucose in the blood) daily. R21's Care Plan documented on 02/08/25 she was at risk for hyperglycemia (high blood sugar) and hypoglycemia ( low blood sugar) related to a diabetes diagnosis and the use of insulin. The plan documented R21 needed to have her insulin administered per physician orders. R21's Physician's Order noted an order for Admelog SoloStar (fast-acting insulin). Inject four units subcutaneously (beneath the skin) before meals related to diabetes. Hold for a blood sugar (BS) of less than 100 milligrams (mg) per deciliter (dL); ordered on 02/08/25. R21's EHR revealed a consultant pharmacist medication review dated 05/23/25 that documented R21 received Admelog outside the ordered parameters on the following dates: 05/01/25 when the BS was 75mg/dL; 05/04/25 when the BS was 93mg/dL; 05/12/25 when the BS was 96mg/dL; and 05/17/25 when the BS was 75 mg/dL. The pharmacist requested that staff ensure the medication was administered per physician's order and that responsible staff received education. A review of staff education provided by Administrative Nurse D revealed that Licensed Nurse (LN) H and LN I received education on 05/27/25 regarding following parameters on insulin. R21's May and June 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) documented the Admelog was administered on 05/30/25 when the BS was 84 mg/dL, and on 06/12/25 when the BS was 94 mg/dL. On 06/01/25 there was no documentation to indicate if it was given or if the BS was obtained. On 06/18/25 at 09:37 AM, Licensed Nurse (LN) G stated that staff were always supposed to look at the medication parameters before giving medications. LN G said that staff had received some training on following medication parameters. On 06/18/25 at 10:39 AM, Administrative Nurse D stated that she expected staff to read and follow parameters when administering any medications. Administrative Nurse D said that education was completed only for the staff that were identified during the pharmacy review for incorrectly administering medications outside of the ordered medication parameters. On 06/18/25 at 10:43 AM, Administrative Nurse E reported that parameter medications were monitored through the medication orders and not care planned, but hyperglycemia (high blood sugar level) and hypoglycemia (low blood sugar) measures were care planned. The Medication Management policy dated 01/2024 documented that each resident's drug regimen was reviewed to ensure it was free from unnecessary drugs. This included any drug without adequate monitoring, in the presence of adverse consequences which indicated the dose should be reduced or the drug eliminated. It further documented that to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, the facility staff, their physician, and the consultant pharmacist would perform ongoing monitoring for appropriate, effective, and safe medication use. The facility reported a census of 43. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure medications were administered within the physician-ordered parameters for Resident (R) 25 and R21. This deficient practice placed the affected residents at risk for adverse medication reactions. Findings include: - R25's Electronic Health Record (EHR) revealed diagnoses of unspecified sequelae 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), essential hypertension (high blood pressure), obstructive sleep apnea (a disorder of sleep characterized by periods without respirations), and renovascular hypertension (a type of high blood pressure caused by narrowing of the arteries that supply blood to the kidneys). R25's admission Minimum Data Set (MDS) dated 09/24/24 documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The Fall Care Area Assessment CAA, dated 09/24/24, documented R25 had a fall within one month before admission and a fall recently since admission; she received high-risk medications. R25's Quarterly MDS dated 03/20/25 documented a BIMS score of 15. R25's Care Plan documented on 06/19/25 that R25 was at risk for falls. The interventions included medications that had a Black Box Warning (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration) or had nursing considerations that needed to be monitored. The plan directed staff to monitor and report any concerns to the physician immediately. R25's EHR documented a Physician's Order for amlodipine 10 mg one time a day. Hold the medication if the systolic blood pressure (SBP- top number, the force the heart exerts on the walls of the arteries each time it beats) is less than 100 millimeters (mm) of mercury (Hg), diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) is less than 60 mmHg or the heart rate (HR) is less than 60 beats per minute (BPM) R25's EHR documented a Physician's Order for metoprolol extended release 50 mg two times a day with instructions to hold the medication if the SBP is less than 100 mmHg, the DBP is less than 60 mmHg or the HR is less than 60 BPM. R25's EHR revealed a consultant pharmacist medication review dated 01/30/25 that documented R25 received amlodipine and metoprolol outside ordered parameters in January 2025. A review of staff education provided by Administrative Nurse D revealed that Certified Medication Aide (CMA) R and CMA S received education on 01/27/25 regarding following blood pressure (BP) parameters for amlodipine and metoprolol. R25's Medication Administration Record (MAR), reviewed from March 2025 through June 2025, recorded R25 received amlodipine and/or metoprolol outside ordered parameters for the following dates: 03/04/25 R25's morning BP was 124/56 mmHg and staff administered amlodipine and metoprolol. 04/05/25 R25's morning BP was 151/56 mmHg and staff administered amlodipine and metoprolol. 04/12/25 R25's evening BP was 137/54 mmHg and staff administered metoprolol. 04/30/25 R25's morning BP was 153/57 mmHg and staff administered the morning amlodipine and metoprolol. 05/18/25 R25's morning BP was 105/58 mmHg and staff administered the morning amlodipine and metoprolol. On 06/18/25 at 09:37 AM, Licensed Nurse (LN) G stated that staff were always supposed to look at the medication parameters before giving medications. LN G said that staff had received some training on following medication parameters. On 06/18/25 at 10:39 AM, Administrative Nurse D stated that she expected staff to read and follow parameters when administering any medications. Administrative Nurse D said that education was completed only for the staff that were identified during the pharmacy review for incorrectly administering medications outside of the ordered medication parameters. On 06/18/25 at 10:43 AM, Administrative Nurse E reported that medications with ordered parameters were monitored through the medication orders. The Medication Management policy dated 01/2024 documented that each resident's drug regimen was reviewed to ensure it was free from unnecessary drugs. This included any drug without adequate monitoring, in the presence of adverse consequences which indicated the dose should be reduced or the drug eliminated. It further documented that to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, the facility staff, their physician, and the consultant pharmacist would perform ongoing monitoring for appropriate, effective, and safe medication use.

The facility reported a census of 36 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 11/27/23 at 11:40 AM, the following areas of concern were noted: 1. Two reach-in freezers contained food debris on the bottom shelf. 2. Six cutting boards had deep grooves, making them unsanitizable. 3. Three kitchen trash cans had dried food debris and liquids on the lids and sides. 4. The flour and sugar plastic bins contained food debris on top of the lids. 5. The resident refrigerator had an undated gallon of vanilla ice cream half full, an undated 25% of a chocolate brownie ice cream cake and an undated three-quart jug of grape juice that was 25% full. On 11/29/23 at 08:01 AM, Dietary staff BB stated any opened food items in the refrigerator should be dated with the open date. Dietary staff BB confirmed the cutting boards had the deep grooves and that the bottom shelf of the freezers contained food debris. Dietary staff BB also confirmed the trash cans should be kept clean. Review of the facility's policy for Cleaning Rotation, 2016, included: Cutting boards will be kept clean and in good repair. Trash barrels shall be cleaned weekly. Freezers and food containers shall be cleaned monthly. Review of the facility's policy for Food Storage, dated 2016, included: Prepared food shall be stored in covered, labeled and dated containers in the refrigerator and/or freezer. The facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria.

The facility reported a census of 36 residents with 15 selected for review which included one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to provide cares to maintain one sampled resident's dignity, Resident (R)92. Findings included: - Review of Resident (R)92's medical record revealed diagnoses included fracture of the right tibia (lower leg bone), chronic (long term) respiratory failure, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], was in progress and not completed. The Base Line Care Plan dated 11/21/23, instructed staff to assist the resident with daily cares and the resident was non weight bearing due to the fracture of her right lower extremity. The care plan instructed staff to keep the head of her bed elevated to assist with breathing. Observation, on 11/27/23 at 12:00 PM, revealed the resident seated in her wheelchair in the dining room. The resident wore a hospital gown, which was loosely tied around her neck and exposed her upper chest. Observation, on 11/27/23 at 02:07 PM, revealed the resident in bed with the head of bed elevated. The resident positioned in a sitting position slumped forward and to the right with the (head) pillow sliding to the top of her head. The resident had a hospital gown on, and the bed blanket pushed to the side, which exposed the resident's incontinence brief. The resident was visible from the hallway, and another resident passing by her open door remarked that the resident had a pillow over her face. Observation, on 11/27/23 at 02:07 PM, Administrative Staff A entered the resident room and Certified Nurse Aide (CNA) PP and MM repositioned the resident and covered the resident's lower torso. Observation, on 11/27/23 at 04:09 PM, revealed CNA PP and MM provided peri care for urinary incontinence and noted the dressing to the resident's coccyx pressure ulcer became saturated with urine. During the peri care, the mid room privacy curtain was drawn however, the privacy curtain that shielded the resident from view when staff opened the room door to the hallway was pushed over on the other side of the room. CNA NN entered the room after knocking, but the resident was not shielded from view. CNA PP exited and entered the room with supplies. Licensed Nurse G entered the room to provide wound care and requested staff to pull the privacy curtain to shield the resident from the door. After completion of the tasks, CNA NN and CNA MM transferred the resident from her bed to her wheelchair and transported the resident to the dining room for the evening meal, still wearing the hospital gown. Observation, on 11/28/23 at 07:46 AM, revealed the resident wearing a hospital gown seated in her wheelchair at the dining room table. Observation, on 11/28/23 at 09:00 AM, revealed the resident attended a therapy session wearing the hospital gown. Observation, on 11/28/23 at 09:36 AM, revealed CNA N and M prepared to transfer the resident from her wheelchair to bed. CNA N stated the resident had no clothing here to wear. Interview with the resident at that time revealed she would like to wear clothing. Interview, on 11/28/23 at 12:07 PM, with Social Service Staff revealed the resident did have two shirts, two pants and two socks per her initial inventory. Social Service Staff X stated the facility did have donated clothing and would find articles of clothing to fit the resident. Interview, on 11/28/23 at 02:08 PM, with Administrative Nurse D, revealed she would expect staff to provide privacy to residents during cares, and if the resident did not have clothing, staff could call family members to bring in clothing or find clothing to fit the resident in the donated supply. The facility policy Resident Rights undated, instructed staff to treat the residents with dignity and individuality including privacy in treatment and in the care of personal needs. The facility failed to ensure privacy for this resident and individuality to promote a home like experience.

The facility reported a census of 36 residents with 15 residents included in the sample. Based on observation, record review, and interview, the facility failed to review and revise the care plan for one of the residents sampled, Resident (R)27 regarding staff instruction on utilizing a gait belt during transfers. Findings included: - The Physician Order Sheet (POS), dated 11/20/23, for Resident (R)27, documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She required extensive assistance of two staff for transfers. She had unsteady balance and was only able to stabilize with staff assistance. She had no impairment in functional range of motion (ROM). The Falls Care Area Assessment (CAA), dated 09/18/23, documented the resident was not steady during transfers and required staff assistance to stabilize. She required extensive assistance of two staff for transfers. The care plan, dated 09/18/23, instructed staff the resident required one to two staff for transfers. The care plan lacked staff instruction on utilizing a gait belt during transfers. Review of the resident's electronic medical record (EMR), from 11/01/23 through 11/28/23, documented the resident required substantial/maximal assistance to dependent assistance of one to two staff for transfers. On 11/28/23 at 08:53 AM, Certified Nurse Aide (CNA) P and CNA O transferred the resident from her wheelchair to her bed. CNA P held onto the back of the resident's pant waist and CNA O held the resident underneath her left arm during the transfer. The resident was able to bear weight but attempted to sit down in the middle of the transfer. The staff failed to use a gait belt during the transfer. On 11/28/23 at 08:53 AM, CNA O confirmed she had not used a gait belt while transferring the resident and should have because the resident would attempt to sit down at times while staff would transfer her. On 11/28/23 at 11:43 AM, CNA Q stated the resident was able to bear weight during transfers but would attempt to sit down while being transferred. Staff should always use a gait belt while transferring her. On 11/28/23 at 02:29 PM, Certified Medication Aide (CMA) R stated the resident would attempt to sit down during transfers. Staff should always use a gait belt while transferring a resident. On 11/28/23 at 11:43 AM, Licensed Nurse (LN) H stated staff were to utilize a gait belt while transferring the resident. LN H stated Administrative Nurse D was responsible for reviewing and revising resident care plans. On 11/29/23 at 12:26 PM, Administrative Nurse D stated it was the expectation for staff to use a gait belt while transferring residents. Administrative Nurse D stated gait belts should be included on the care plans. Review of the facility policy Electronic Care Plan, dated 12/2018, included: The facility was to develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional and social wellbeing for each resident in the facility to include physical functioning and structural problems. The facility failed to review and revise the care plan for this dependent resident to include staff instruction on the use of gait belts during transfers.

The facility reported a census of 36 residents with 15 selected for review which included two residents reviewed for pressure ulcers. Based on observation, interview and record review the facility failed to ensure staff provided measures for pressure ulcer treatment/prevention for one Resident #92, of the two residents reviewed for pressure ulcers. Findings included: - Review of Resident (R)92's medical record revealed diagnoses included fracture of the right tibia (lower leg bone), chronic (long term) respiratory failure, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], was in progress and not completed. The Base Line Care Plan dated 11/21/23, instructed staff to float the resident's heels on a pillow while in bed due to alteration in skin integrity due to a stage three pressure ulcer (full thickness tissue injury that extends into subcutaneous tissue) to her left buttocks, and to use a wheelchair cushion when in the wheelchair. A Physician Order, dated 11/21/23, instructed staff to cleanse the stage three pressure ulcer to the left buttocks with wound cleanser, apply Prisma (a collagen substance used for wound healing) moistened with saline and to cover it with a bordered foam dressing every Monday, Wednesday, Friday and as needed for soiling or dislodgement. The Skin Condition Note, dated 11/21/23, documented a stage three pressure injury to left buttock which measured 1.2 by 0.7 by 0.2 centimeter (cm) with pale pink tissue and mild serous drainage. Observation, on 11/27/23 at 02:07 PM, revealed the resident positioned on her back in bed with the head of bed elevated. The resident had a brace on her right leg from knee to ankle and both heels lay directly on the bed without an off-loading device or the planned pillow to reduce pressure. Observation, on 11/27/23 at 04:09 PM, revealed Certified Nurse Aide (CNA) MM and CNA NN, provided peri care to the resident. The resident's brief was saturated with urine, and the pressure ulcer dressing to her left buttocks was saturated with urine and loose. Licensed Nurse (LN) G removed the dressing and revealed a red excoriated area approximately three centimeters in diameter with an open area approximately 0.5 cm in diameter with yellow slough (dead skin). LN G then cleansed the area with wound cleanser, applied the Prisma moistened with saline to the wound bed and covered the area with a bordered foam dressing. CNA MM and CNA NN transferred the resident to her wheelchair which lacked a pressure relieving cushion and took the resident to the common dining area for supper. Observation, on 11/28/23 at 07:36 AM, revealed the resident seated in the common dining table eating breakfast. The resident lacked a pressure relieving cushion to her wheelchair. Observation, on 11/28/23 at 09:36 AM, revealed CNA M and CNA N transferred the resident from her wheelchair to her bed with the mechanical lift. CNA N checked the resident for incontinence and found the resident without incontinence or the pressure ulcer dressing to her left buttocks. CNA N stated the previous shift got the resident up in her wheelchair for breakfast and they did not know why the resident did not have a dressing to her pressure ulcer. CNA N did not provide an off-loading device for the resident's heels. Interview, on 11/28/23 at 11:20 AM, with LN G, revealed the resident should have her heels off loaded (pillow to reduce pressure) and a pressure reducing cushion in her wheelchair. LN G examined the resident's heels at that time and found her right heel with redness and minimal blanching. Interview, on 11/28/23 at 11:50 AM, with Administrative Nurse E, confirmed staff should off load the resident's heels with a pillow and place a pressure relieving cushion in her wheelchair. The facility policy Wound Prevention and Management, dated 12/18/23, instructed staff to provide a pressure reducing cushion to residents who utilize wheelchairs a mode of transportation and to provide positioning devices such as pillows or foam wedges to prevent direct and skin to skin contact for residents identified at risk for pressure injury and to promote healing. The facility failed to provide a pressure reducing cushion to this resident's wheelchair, failed to provide heel offloading devices as planned for promotion of healing and prevention of further pressure injury.

The facility reported a census of 36 residents with 15 residents sampled, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to properly reposition one dependent Resident (R)4, failed to lower the bed into the low position for one dependent R 32, and failed to utilize a gait belt while transferring one dependent R 27 from her wheelchair to her bed. Findings included: - Review of Resident (R)32's electronic medical record (EMR) revealed diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required extensive assistance of two staff for bed mobility, had impairment on both sides of his upper and lower extremities. and had no falls since the prior assessment. The Fall Care Area Assessment (CAA) dated 06/13/23, documented the resident was at risk for falls due to a history of a cerebrovascular accident (CVA-(stroke) - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He required extensive assistance of two staff for bed mobility, he had impairment on one side of his upper and lower extremities and had no falls since his prior assessment. The fall care plan, revised 09/13/23, instructed staff the resident had limitations on the left side of his body. Staff were to ensure he had his call light within reach while in bed. Review of the resident's EMR revealed fall assessments which placed the resident at a moderate risk for falls, dated 10/18/23 and 09/21/23. The EMR revealed a fall assessment which placed the resident at a high risk for falls, dated 10/03/23. Review of a fall report, provided by the facility, dated 10/03/23, documented staff discovered the resident lying on his back on the floor mat underneath his bed. The resident's bed was in the high position. Staff assessed the resident and he had no injuries from the fall from his bed. Staff assisted him back into bed with the Hoyer (full body) mechanical lift. Staff were re-educated to ensure the resident's bed was in the lowest possible position following cares. On 11/29/23 at 09:11 AM, Certified Nurse Aide (CNA) Q stated the resident's bed needs to always be in the lowest position when he was in the bed. On 11/28/23 at 09:25 AM, Licensed Nurse (LN) G stated the staff were to ensure the resident's bed was in the low position following cares. On 11/28/23 at 11:43 AM, LN H stated staff were to always ensure the resident's bed was in the low position while the resident was in bed. On 11/29/23 at 12:26 PM, Administrative Nurse D stated it was the expectation for staff to keep the resident's bed in the lowest position while he was in the bed. The staff member had left the resident in his bed with the bed in the high position when the fall occurred on 10/03/23. The resident rolled out of the bed, landing on the floor mat. He had no injuries from the fall. The facility lacked a policy for keeping resident beds in the low position. The facility failed to lower the bed to the lowest position after providing cares to the resident, - The Physician Order Sheet (POS), dated 11/20/23, for Resident (R)27, documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She required extensive assistance of two staff for transfers. She had unsteady balance and was only able to stabilize with staff assistance. She had no impairment in functional range of motion (ROM). The Falls Care Area Assessment (CAA), dated 09/18/23, documented the resident was not steady during transfers and required staff assistance to stabilize. She required extensive assistance of two staff for transfers. The care plan, dated 09/18/23, instructed staff the resident required one to two staff for transfers. Review of the resident's electronic medical record (EMR), from 11/01/23 through 11/28/23, documented the resident required substantial/maximal assistance to dependent assistance of one to two staff for transfers. On 11/28/23 at 08:53 AM, Certified Nurse Aide (CNA) P and CNA O transferred the resident from her wheelchair to her bed. CNA P held onto the back of the resident's pant waist and CNA O held the resident underneath her left arm during the transfer. The resident was able to bear weight but attempted to sit down in the middle of the transfer. The staff failed to use a gait belt during the transfer. On 11/28/23 at 08:53 AM, CNA O confirmed she had not used a gait belt while transferring the resident and should have because the resident would attempt to sit down at times while staff would transfer her. On 11/28/23 at 11:43 AM, CNA Q stated the resident was able to bear weight during transfers but would attempt to sit down while being transferred. Staff should always use a gait belt while transferring her. On 11/28/23 at 02:29 PM, Certified Medication Aide (CMA) R stated the resident would attempt to sit down during transfers. Staff should always use a gait belt while transferring a resident. On 11/28/23 at 11:43 AM, Licensed Nurse (LN) H stated staff were to utilize a gait belt while transferring the resident. On 11/29/23 at 12:26 PM, Administrative Nurse D stated it was the expectation for staff to use a gait belt while transferring residents. The facility policy for Assisting with Transfers to/from a Chair, undated, included: When transferring a resident from a chair staff shall use a gait belt to help assist with the transfer. The facility failed to utilize a gait belt while transferring this dependent resident, to ensure proper transfers. 28560 - Review of Resident (R)4's medical record, revealed diagnoses included cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), abnormal posture, restlessness, and agitation. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated normal cognitive function. The resident required partial to moderate assistance for transfers. The resident used a wheelchair for mobility. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/13/23, assess the resident had cerebral palsy with spastic movements of her body. The resident required extensive to total assistance with her cares. The resident was mobile using her wheelchair. The Quarterly MDS, dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. The resident had impairment in functional range of motion in both upper and lower extremities bilaterally and required partial to moderate assistance for transfers. The resident utilized a wheelchair for mobility. The Care Plan reviewed 11/13/23, instructed staff the resident was independent with wheelchair locomotion. The resident required assistance of two for bed mobility and transfers. Observation, on 11/27/23 at 10:30 AM, revealed the resident sliding down in her wheelchair in the common living area. Activity Staff Z placed his forearms under the resident's axilla (armpits) and pulled her up in the chair while standing behind her wheelchair. Activity Staff Z did not apply a gait belt. Observation, on 11/28/23 at 09:09 AM, revealed the resident positioned in her wheelchair propelling herself with her feet. CNA M assisted the resident to her room, and the resident was able to hold her feet off the floor. Certified Nurse Aide (CNA) M and CNA N placed a gait belt on the resident and assisted her to transfer from her wheelchair to the toilet. CNA M stated the resident usually used her feet to propel herself in her wheelchair. Observation, on 11/29/23 at 10:18 AM, revealed the resident sliding down in her wheelchair in the common dining room CNA O repositioned the resident by standing behind her in the wheelchair and pulled her up by her pants. Interview, on 11/29/23 at 10:18 AM, with CNA O, revealed staff repositioned the resident in her wheelchair by pulling her up by her pants or under her armpits. Interview, on 11/29/23 at 10:25 AM, with Consulting Therapy Staff GG, revealed staff should apply a gait belt on the resident and two staff should assist the resident either with a grab bar for her to hold onto while standing or staff to stand on either side while instructing her for repositioning. Interview on 11/29/23 at 11:30 AM, with Administrative Nurse D, revealed she would expect staff to transfer the resident in a safe manner to prevent potential injury. The facility policy Assisting with Transfers to/from a Chair, dated 2021, instructed staff to gather supplies which included a gait belt, support the persons privacy, safety, comfort, and dignity. The policy instructed staff to review the plan of care for level of assistance required. The facility failed to provide safe repositioning techniques for this resident who required partial to moderate assistance with with repositioning in her wheelchair to prevent potential injury.

The facility reported a census of 36 residents with 15 selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure monitoring for adverse effects of psychotropic medications for two of the five sampled residents, Residents (R) 10 and R13, to ensure no unnecessary medication usage. Findings included: - Review of resident's (R)10's medical record revealed diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion) and paranoid personality (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking). The Significant Change Minimal Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment with fluctuating inattention and disorganized thinking. The resident received antipsychotics on a regular basis. The Psychotropic Drug Use Care Area Assessment (CAA), dated 04/05/23, assessed the resident received Seroquel (an antipsychotic) for paranoid personality disorder and dementia. Staff monitored the resident for adverse reactions and target behaviors. The Care Plan, reviewed 10/06/23, instructed staff the resident received Seroquel for panic, fear, agitation and wandering. It instructed the staff to provide interventions for behaviors which included one on one attention, activity, room temperature adjustment, change in position, back rub, and redirection. On 01/25/23 the physician order instructed staff to administer Seroquel 50 milligrams three times a day for dementia. Review of the DISCUS (Dyskinesia {abnormal, uncontrolled movement} Identification System Condensed User Scale) assessments revealed staff completed the DISCUS assessment on 06/30/22, 02/01/23 and 11/15/23 all with scores of 0 which indicated no adverse symptoms noted. Observation, on 11/28/23 at 07:58 AM, revealed the resident seated on the side of her bed asleep. Interview with Certified Nurse Aide (CNA) N revealed the resident became agitated during morning cares so staff would return to the resident when she was calmer. Observation, on 11/28/23 at 09:00 AM, revealed CNA N attempted to assist the resident with morning care and the resident flailed her arms at CNA N. Interview, on 11/29/23 at 11:30 AM, with Administrative Staff D, revealed the facility did try a gradual dose reduction of the resident's Seroquel which resulted in escalation of behaviors. Administrative Staff D stated staff should complete the DISCUS assessments quarterly and confirmed the assessments lacked completion quarterly. The facility policy Behavior Management and Psychotropic Medications, revised 12/2022, instructed staff to complete the DISCUS assessments on admission, readmission, quarterly and with significant change. The facility failed to ensure accurate monitoring of this resident for adverse effects of antipsychotic medications to ensure no unnecessary psychotropic medication usage. - Review of Resident (R) 13's medical record revealed diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The resident did not receive antipsychotics on a routine basis. The Psychotropic Drug Use Care Area Assessment (CAA), dated 06/06/23, assessed the resident received psychotropic medications. The Care Plan, reviewed 09/12/23, assessed the resident received therapeutic psychotropic medications for panic, fear, and anxiety with the staff instructed to provide interventions for behaviors. On 08/02/23, the physician instructed staff to administer Risperidone, one milligram, twice a day, for dementia with anxiety. Review of the DISCUS (Dyskinesia {abnormal, uncontrolled movement} Identification System Condensed User Scale) assessments revealed staff completed the DISCUS assessment on 05/31/23 with a score of 0 indicated no adverse symptoms noted. Observation, on 11/27/23 at 03:36 PM, revealed the resident receiving a haircut in the beauty shop. The resident was cooperative with instructions. Interview, on 11/29/23 at 12:39 PM, with Administrative Nurse D Administrative Staff D stated staff should complete the DISCUS assessments quarterly and confirmed the assessments lacked completion quarterly. The facility policy Behavior Management and Psychotropic Medications, revised 12/2022, instructed staff to complete the DISCUS assessments on admission, readmission, quarterly and with significant change. The facility failed to ensure staff monitored this resident for adverse effects of antipsychotic medications to ensure no unnecessary psychotropic medication usage.

The facility reported a census of 36 residents with 15 selected for review which included one resident reviewed for antibiotic usage. Based on observation, interview and record review, the facility failed ensure appropriate antibiotic use for one Resident (R)35 resident. Findings included: - Review of Resident (R)35's medical record revealed diagnoses included fracture right and left lower legs, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and traumatic brain injury. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated normal cognitive function. The resident was frequently incontinent of urine. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 09/25/23 assess the resident was frequently incontinent of bladder and used a bed pan for elimination abut could not always wait for staff assistance. The Care Plan, reviewed 09/19/23, instructed staff to assist the resident with toileting, to check and change the resident every two hours, and provide peri care. Staff instructed to report changes in odor or color of urine to the nurse as the resident has a history of urinary tract infection. Review of the medical record revealed a urine culture laboratory report dated 09/24/23, with greater than 100,000 Klebsiella pneumonia bacteria. On 09/27/23, the physician order instructed staff to administer Cipro, 500 milligrams (mg), daily for seven days. On 10/05/23, the physician order instructed staff to administer Macrobid 100 mg, daily for recurrent urinary tract infections. On 10/09/23, the physician order instructed staff to apply Nystatin powder to the moisture associated skin damage/excoriation to the resident's left and right buttocks. Review of the October and November 2023 Infection Tracking Logs revealed the facility's lack of inclusion of R 35's Cipro and Macrobid antibiotic orders. Interview, on 11/27/23 at 10:30 AM, with the resident, revealed she had been on a low dose antibiotic for chronic urinary tract infections but did not know if she was still on it. Interview, on 11/29/23 at 11:30 AM, with Administrative Nurse D, revealed R35's Cipro was ordered for the acute urinary tract infection and Macrobid ordered for prophylaxis of chronic urinary tract infections and they did not trigger in the data collection system for antibiotic stewardship. Administrative Nurse D stated staff to encourage fluids and request cranberry products from the physician for treatment of chronic urinary tract infections as well as prompt toileting opportunities. The facility policy Antibiotic Use Protocol dated 06/2017, instructed staff to provide nonpharmacological interventions (cranberry juice, increase fluids) for asymptomatic infections of for prophylaxis and document in the clinical record. Nursing staff to review documentation in the clinical record supporting antibiotic use signs and symptoms and conduct a root cause analysis for antibiotic use. The facility failed to assess the administration of an antibiotic for this resident's chronic urinary tract infection to determine the efficacy of implementation of nonpharmacological interventions to prevent inappropriate long-term use of antibiotics.

The facility reported a census of 40 residents. Based on record review and interview, the facility failed to maintain an accurate accounting system of the residents' controlled narcotic medications, to enable an accurate reconciliation (a system of record keeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered, and/or, including the process of disposition) and to prevent potential loss or diversion of the narcotic medications. The facility failure to maintain this system resulted in one card with 31 tablets of Resident (R)1's MS Contin (morphine narcotic medication) missing from the facility. The failure has the potential to affect all residents that recieved controlled medications. Findings Included: - Resident (R)1's signed Physician Order Sheet (POS), dated 09/06/23, documented the resident admitted on [DATE]. The resident's diagnoses included cerebral infarction (medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), chronic pain syndrome (life altering and life-long pain), low back pain (pain between the lower edge of the ribs and the buttocks), and cervicalgia (pain in spine around and below your head). R1's, 09/06/23 signed Physician Order Sheet included a physician order for MS Contin (morphine) (opioid agonist) tablet, 30 milligrams (mg), administer one tablet by mouth, every 12 hours, for pain, with the start date of 09/21/23. Review of the Controlled Medication Inventory Sheet, from 08/24/23 through 10/05/23, revealed the lack of documentation at each shift change to determine how many controlled medications were in the medication cart. The inventory sheets also lacked the end of each shift nurse signatures to verify reconciliation of the controlled medications completed with two nurses'. Review of the facility's investigation revealed on 09/21/23, Licensed Nurse (LN) H received R1's medications in the mail and signed for them from the postal service. She took the medication behind the nurses station and made count sheets. The medications included MS Contin, with a card with 31 tabs, another card of 31 cards, and a card with one single tab of MS Contin. She reported she filled out each narcotic card with an individual narcotic count sheet. The facility discovered the medication missing when they thought the resident was close to needing the medication refilled at the pharmacy. When the pharmacy reported they filled the medication on 09/20/23, the pharmacy sent a total of 63 tablets. Administrative nurse D searched for the missing narcotic and was unable to locate the missing narcotic or the controlled medication inventory sheet. Due to the lack of a log for the total number of cards in the facility, the facility was unable to determine on what date the card of 31 tablets of MS Contin became missing. Review of the Medication Administration Record (MAR) from 09/21/23 through 10/09/23 revealed staff documented administration of the resident's MS Contin twice a day as ordered by the physician. On 10/09/23 at 10:40 AM, LN G verified observation of LN H when she placed the three controlled substance cards of MS Contin in the medication cart for R1 on 09/21/23. LN G verified that she did not reconcile the controlled medications at the end of each shift with the oncoming nurse for each of the residents with narcotic medications. On 10/09/23 at 09:15 AM, Administrative Staff A reported being advised that R1's medication card identified as number three, for MS Contin (31 tablets) and the narcotic sheet that was to accompany the medication, were discovered missing from the facility on 10/03/23. On 10/11/23 at 01:41 PM, LN J explained she requested a refill on 10/03/23 from an unidentified hospice nurse for R1's MS Contin. LN J reported the hospice nurse advised her that the medication was filled and mailed by the pharmacy on 09/20/23. She then reported to Administrative Nurse D that she was unable to locate one of three cards and the count sheet. On 10/09/23 at 11:00 AM, LN I verified that the nursing staff do not reconcile the number of controlled medications at shift change with the oncoming nurse. On 10/09/23 at 10:25 AM, Administrative Nurse D reported the nurses should be reconciling the controlled medications at shift change and both nurses should then sign the Controlled Medication Inventory Sheet. The nurses should add controlled medications to the sheet when received and subtract the medications when administration completed, was discontinued, or the resident discharged . The facility Controlled Medication Reconciliation policy, dated 10/2014, revealed the Controlled Medication Inventory sheet maintains a log of the total number of cards in the medication cart. The policy documented that when a medication was received, the medication will be recorded on the sheet and the licensed nurse will sign the entry. At each shift change or change in licensed nurse responsibility for the medication cart the oncoming licensed nurse will count and reconcile the medication cart. The facility failed to maintain an accurate accounting system of the residents' controlled narcotic medications, to enable an accurate reconciliation and to prevent potential loss or diversion of the narcotic medications. The facility failure to accurately maintain this system resulted in one card with 31 tablets of Resident (R)1's MS Contin (morphine narcotic medication) discovered missing from the facility. The failure has the potential to affect all residents that recieved controlled medications.

The facility reported a census of 45 residents, based on observation, record review, and interview, the facility failed to maintain an effective pest control program to ensure no bed bugs were in the residents' environment. Findings included: - On 10/26/22 at 11:04 AM Resident (R)6 reported the staff killed a bed bug that had been on her yesterday. The Task tab for R6 revealed she received a shower on 10/19/22, 10/26/22, and lacked documentation of a shower on 10/25/22. On 10/26/22 at 11:18 AM Administrative Staff A stated the pest control company did a whole treatment to that room on 10/11/22 because there was a sighting of a bed bug. The staff did see one yesterday, but the pest control was already due to come back tomorrow and was off today. Administrative Staff A stated the staff had notified her of a sighting yesterday, however, did not know if it was a bed bug or not, she had the housekeeper check the room for bed bugs and none were found. Administrative Staff A stated R6 had not had a shower since the sighting, however she was due for one today. Administrative Staff A stated she did not think that R6 had been out of her room, however her roommate had been. Administrative Staff A stated when questioned how the room was being monitored for bed bugs, the housekeepers have to report any sightings so pest control can focus on that during visits or in between and the nurse does weekly skin assessments and monitors for bed bugs as well. On 10/26/22 at 12:04 PM observed R6 sitting in the dining room in her wheelchair at a table with two other residents. On 10/26/22 at 12:40 PM Administrative Nurse D stated when asked what was done after the bed bug sighting, she was out of the facility on 10/25/22 and was not aware until today, and Administrative Staff A would know what was done. On 10/26/22 at 12:43 PM Certified Nurse Aide (CNA) M stated she worked on 10/25/22 and was aware of a bed bug sighting by a housekeeper and maintenance informed and did not see anything when he looked around. CNA M stated she had assisted R6 up and the bed bug was found on the floor, it was alive and crawling, and this occurred after lunch time. CNA M stated her shift ended at 02:00 PM and R6 did not receive a shower on her shift but did get a shower the first thing this morning. On 10/26/22 at 12:54 PM Housekeeping Staff U stated she worked until 03:30 PM yesterday and was not aware of a bed bug sighting, she did not receive bags of linen from that room that she was aware of. Housekeeping Staff U stated she worked earlier in the month on that hall when pest control sprayed the room, and the two residents were kept out of the room until the room was ready. 10/26/22 at 01:05 PM Housekeeping Staff V stated another housekeeper found a bed beg in a room and reported to him and he reported to Administrative Staff A. Housekeeping Staff V stated he looked at the pest and identified it as a bed bug, killed it, and told Administrative Staff V, then sent pest control an email, who was off today and had sprayed the same room two weeks ago. Two weeks ago, we removed the residents from the room and they were given a shower and stayed out of the room for three to four hours. We had not seen any further bed bugs since that time and believe they are coming in with a visitor that was here the day before yesterday. The policy is when a bed bug was found, the resident would be taken to the shower and placed in an empty room if we had one, leaving everything in the room, however we do not have an empty room at this time. Administrative Staff A stated there was not any bites on the resident's skin when inspected. Housekeeping Staff V stated he had a few of her clothing items back in laundry but not all of them. On 10/26/22 at 01:22 AM R6 stated the staff did not shower her after the bed bug sighted, the staff showered her today first thing this morning before breakfast, got her another gown, wiped down her bed, and shut the door, and looked at her skin. R6 stated the staff never asked her to stay in her room after the bed bug was first sighted. On 10/26/22 at 04:50 PM CNA N stated she worked on that hall on 10/25/22 and she did not personally give R6 a shower, the evening shift does not do showers, and she arrived for duty at 04:00 PM. On 10/26/22 at 04:52 PM Certified Medication Aide (CMA) R stated she worked as a CNA on the same hall on 10/25/22 and she did not give R6 a shower and thought the day shift did. CMA R stated R6's door to her room was shut when she arrived for duty and was told a bed bug had been found. CMA R stated R6 stayed in her room during her shift and her roommate did come out of the room for dinner. On 10/27/22 at 08:56 AM observed R6 in her room on her bed and her roommate was sitting up in a wheelchair. On 10/27/22 at 09:20 am CNAO stated R6 had not received a shower on her shift after the bed bug was found, however the roommate received one around 02:00 PM. The day the bed bug was found R6 was in the dining room at lunch time and was not aware if her bed had been stripped or clothes from the laundry put on her instead of clothes from the room. On 10/27/22 at 02:15 PM Pest Control Consultant GG stated there was an occurrence of bed bugs on 10/11/22 and the first time since providing services to the facility since the end of July 2022, he had just arrived and had not inspected the room yet. On 10/27/22 at 02:20 PM Pest Control Consultant GG stated he had seen one bed bug so far, on the seam of the mattress where the zipper was and based on size it was an adult bed bug. Since eggs are translucent and cannot be seen, Pest Control Consultant GG stated double bagging linens and running through the dryer twice would be recommended and treatment to the room. When the staff has had a sighting of a bed bug, any staff entering room should wear a shoe cover and an isolation type gown. The residents would need to be removed from the room to properly treat it and would need to remain out of the room at least two hours to give the chemical enough time to dry. On 10/26/22 at 02:34 PM Licensed Nurse (LN) H stated she was not on duty on 10/25/22 and if she ever found a bed bug she would kill it then report the sighting to maintenance and Administrative Staff A. The resident would be removed from the room, showered, and placed in their clothes that had been put in the dryer, and if the resident had a roommate the same thing would be done. The bed would need to be stripped and all linens and clothing items in closets and drawers would need to be washed and dried. LN H stated the resident(s) would be placed in another room and if one not available would have to stay out of the room until it could be sprayed, but normally the room would be treated right away. LN H stated she was not aware there had been a bed bug sighting in R6's room. On 10/27/22 at 04:15 PM Administrative Staff A stated linens in the room of the bed bug sighting had not been placed into the dryer until pest control was here today, and both residents received a shower and kept out of room while treated and could go back in after the room was dry. The Service Inspection Report by pest control dated 10/27/22 revealed upon entering facility spoke with Administrative A about a bed bug found, upon inspection found a full-grown adult bed bug on the seam of resident mattress. Had the nursing staff move resident from her bed so that treatment could be applied. The chemical was to dry two to four hours before allowing R6 back into bed. The facility policy Bed Bug Protocol dated 06/2019 instructed upon discovery of, evidence of, or suspected bed bugs, shower resident and dress in clean clothes directly from the laundry prior to moving resident to another room. Move the resident and only necessary items while treatment was occurring. Clothing was to be bagged and laundered before moving to another room. Bag resident clothes and belongings, and dry in dryer for a full cycle on high heat. Wash clothes and belongings if needed (do not wash prior to drying). Bag or seal in an airtight container all personal items not in use that cannot be treated and that wish to be kept. Items should be kept sealed for an extended period (months). Bag all infested bedding and trash and tie gooseneck fashion and/or tape closed. Launder bedding and dispose of trash in an outdoor trash bin. Beds and DME equipment such as wheelchairs and walkers are to be left in the room for treatment. Bed bugs can hide in the tubing of the frames. Environmental services was to close and seal off the room for the duration of the treatment and inspection period when possible. The policy failed to provide instruction if another room was not available and if pest control services could not provide service for several days. The facility failed to shower and dress R6 in clean clothes after sighting of the bed bug, failed to bag clothes and belongings after the sighting and place them in the dryer, and allowed the resident and her roommate to exit the room and go to the dining room prior to inspection and treatment by pest control, which found a live adult bed bug on the resident mattress. The facility failed to place the residents on transmission-based precautions until pest control could provide service. The lack of facility response placed the other residents at risk for acquiring bed bugs as both residents in the room required staff assistance for cares.

The facility reported a census of 45 residents. Based on observation, record review, and interview, the facility failed to maintain a medication error rate of less than five percent. Observation of 25 physician ordered medications revealed two medications administered in error, resulting in a medication error rate of eight percent. The errors effected Resident (R)7 and R9. Additionally, on a separate occurrence, the facility failed to administer the correct insulin to R1. Findings included: - Observation on [DATE] at 11:35 AM, Licensed Nurse (LN) G administered R7 [MEDICATION(S)] insulin per pen per physician order. The pen lacked an open and expiration date. This practice places resident at risk for receiving expired insulin. On [DATE] at 11:38 AM, LN G stated insulin pens should have an open and expiration date and the [MEDICATION(S)] pen for R7 did not. On [DATE] at 12:28 PM, observation of the medication cart revealed 16 insulin pens lacked an open date and one pen had a date of ,d+[DATE] however the date was not written on the available open or expired space on the sticker on the pen. On [DATE] at 12:38 PM, Administrative Staff A stated the insulin pens should have an open and an expiration date. The Medication Administration Record (MAR) dated [DATE] for R8 revealed instructions to administer folate (vitamin), one milligram (mg), one tablet. On [DATE] at 09:33 AM, Certified Medication Aide (CMA) S provided one tab of folate to R8. The bottle she dispensed the medication from contained 400 microgram (mcg) tablets. On [DATE] at 09:52 AM, CMA S informed Licensed Nurse (LN) H of the difference in dosage on the MAR and the bottle, LN H confirmed CMA S could have administered two-and-a half tabs for the correct dose but would see if one mg tabs were available. The facility administered [MEDICATION(S)] that lacked and open date and the incorrect dosage of Folate resulting in two medication administration errors. On [DATE] at 02:03 PM, Administrative Staff A stated she expected the staff to follow the rights for medication administration, right person, right medication, right dose, right time and right route. The facility policy Medication Administration Subcutaneous Insulin dated ,d+[DATE] revealed the policy was for the staff to administer subcutaneous insulin as ordered and in a safe, accurate, and effective manner. The staff were to date the vial or device after first use. The facility policy Medication Administration General Guidelines dated ,d+[DATE] revealed prior to administration, review and confirm medication orders for each individual resident on the MAR. Compare the medication and dosage schedule on the resident's MAR with the medication label. Verify medication is correct three times before administering the medication; when pulling medication package from the med cart, when dose is prepared, before dose administered. The facility failed to ensure the medication order matched the medication label and failed to ensure the insulin pen had an open date prior to administration, resulting in medication errors on ,d+[DATE] observations, an eight percent medication error rate. Furthermore, the facility failed to ensure the insulin pens had an open date placed when first used. - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated [DATE] for R1 revealed the staff were to check her blood sugar and give her the physician ordered amount of insulin. The Medication Administration Record (MAR) dated ,d+[DATE], included instructions for: 1. [MEDICATION(S)] (rapid acting insulin) Flex Pen Solution Pen-injector, (insulin [MEDICATION(S)]), inject 10 units, subcutaneously (under the skin), two times a day, related to diabetes mellitus, starting on [DATE], and scheduled at noon and the PM pass (02:00 PM to 07:00 PM). 2. [MEDICATION(S)] (long-acting insulin) FlexTouch Solution Pen-injector, 100 unit/mL (insulin Detemir), inject 20 units, subcutaneously, two times a day, related to diabetes mellitus, starting on [DATE] and scheduled at HS pass (resident's bedtime). The Progress Notes dated [DATE] at 10:42 PM by Licensed Nurse (LN) I, for R1 revealed R1 given [MEDICATION(S)], 20 units. R1's blood sugar was 130 and physician notified and gave orders to give a protein shake and check her blood sugar every hour and give the scheduled [MEDICATION(S)] insulin. The Progress Notes dated [DATE] at 11:03 PM revealed R1's blood sugar level was 83 and was given a protein shake. The Progress Note dated [DATE] at 12:32 AM revealed R1's blood sugar level was 129. On [DATE] at 02:03 PM Administrative Nurse A stated she received a call from (LN) J, which was training LN I, to report LN I administered [MEDICATION(S)] 20 units, instead of the [MEDICATION(S)] insulin. LN I realized she administered the wrong insulin and reported to LN J. On [DATE] at 02:03 PM Administrative Staff A stated she expected the staff to follow the rights for medication administration, right person, right medication, right dose, right time and right route. The facility policy Medication Administration General Guidelines dated ,d+[DATE] revealed prior to administration, review and confirm medication orders for each individual resident on the MAR. Compare the medication and dosage schedule on the resident's MAR with the medication label. Verify medication is correct three times before administering the medication; when pulling medication package from the med cart, when dose is prepared, before dose administered. The facility failed to ensure the right insulin and right dose administered to R1 resulting in physician notification with new orders for protein shake and hourly blood sugar monitoring. The medication error could have resulted in [CONDITION(S)] (low blood sugar) resulting in further treatment necessary.

The facility reported a census of 45 residents. Based on observation, record review, and interview, the facility failed to ensure 15 insulin pens, when opened, included an open date when first used so the staff could determine the medications' expiration dates. This insulin pens lacking an open date included Resident (R)9, R6, R10, R7, R4, R11, and R12. Findings included: - Observation on [DATE] at 11:35 AM Licensed Nurse (LN) G administered R7 [MEDICATION(S)] insulin per pen per physician order. The pen lacked an open and expiration date. On [DATE] at 11:38 AM LN G stated insulin pens should have an open and expiration date and the [MEDICATION(S)] pen for R7 did not. On [DATE] at 11:45 AM LN G removed [MEDICATION(S)] [MEDICATION(S)] pen out of the medication cart for R11 to administer, the insulin pen lacked an open or expiration date. On [DATE] at 12:06 PM LN G removed R9's insulin pen from the medication cart to administer and lacked an open or expiration date. On [DATE] at 12:18 PM LN G removed R6's insulin pen from the medication cart to administer and lacked an open or expiration date. On [DATE] at 12:26 PM LN G removed R10's insulin pen to administer, pen lacked an open and expiration date. On [DATE] at 12:28 PM observation of the medication cart revealed additional pens that lacked an opened date and one pen had a date of ,d+[DATE] however the date was not written on the available open or expired space on the sticker on the pen. On [DATE] at 12:38 PM Administrative Staff A stated the insulin pens should have an open and an expiration date. The facility policy Medication Administration Subcutaneous Insulin dated ,d+[DATE] revealed the policy was for the staff to administer subcutaneous insulin as ordered and in a safe, accurate, and effective manner. The staff were to date the vial or device after first use. The facility failed to ensure 15 insulin pens for seven residents, when opened, included an opened date when first used so the staff could determine the medications' expiration dates.

The facility reported a census of 39 residents with three identified as elopement risks and the sample included those three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent one cognitively impaired Resident (R) 1, identified as an elopement and fall risk, from leaving the facility through an exit door, without staff knowledge, on 06/24/22 between 05:50 PM and 06:00 PM. R1 stated previously that day to Licensed Nurse (LN) G that he planned to leave through the front door. When R1 exited the facility, the door alarm did not sound as there were visitors exiting the building during the time of the elopement. At approximately 06:00 PM, R4 reported to Certified Medication Aide (CMA) R that she observed R1 outside the facility. The facility staff immediately left the building and observed R1 next to a fence in the neighbor's back yard. R1 ran away from the staff, around the house and sat on the front porch. The staff escorted R1 back into the facility at approximately 06:03 PM. The temperature outside was 98 degrees and R1 was outside approximately 10 minutes. This deficient practice placed the resident in immediate jeopardy. Findings included: - R1's signed Physician Orders (PO), dated 03/30/22, documented the resident with a diagnosis of dementia without behavioral disturbance (chronic disorder of the mental processes caused by brain disease or injury marked by memory disorders, personality changes and impaired reasoning). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 5, which indicated severely impaired cognition. R1 was independent with Activities of Daily Living (ADLs) and walked with a cane. The ADL function/rehabilitation Care Area Assessment (CAA), dated 03/30/22, documented the resident was independent with locomotion and transfers. He walked with a cane with a steady gait and had a diagnosis of dementia. The Cognitive Loss/Dementia CAA, dated 03/30/22, documented R1 was alert and oriented to self, situation, and at times, place. The Falls CAA, dated 03/30/22, documented R1 was at risk for falls due to dementia. The Care Plan, updated 03/30/22, revealed the resident was at high risk to leave the facility on the elopement assessment on 03/17/22. The staff were advised if the resident showed exit seeking behaviors such as packing belongings, it was a sign the resident was thinking about leaving. Staff were to place the resident on safety checks if he exhibited exit seeking behaviors such as pacing, sitting close to the door, packing belongings, or voicing a desire to leave the facility. The resident ambulated with a cane and was able to transfer himself independently. He was at risk for falls and had a deficit in cognitive functioning due to dementia. Staff were to cue and prompt the resident as he had impairment with memory and decision making. Review of an Elopement Risk Assessment, dated 06/24/22, (post elopement), documented the resident with a score of 35 or at high risk of elopement. The facility placed R1 on 1:1 monitoring until placement was found in a different facility. A Social Service Quarterly Note, dated 06/23/22 at 03:59 PM, by Social Services Staff X, revealed R1 was alert and oriented to himself. Resident had severe impairment of his short-term memory. His long-term memory came and went and his ability to focus on tasks at hand varied at times. He had poor decision-making skills on a regular basis. R1 communicated verbally and had difficulty making accurate statements regarding his needs or concerns. R1 had a BIMS score of 8 (moderately impaired cognition). Resident had mood and behavior issues, confused regarding his situation, and at times difficult to redirect. He varied on a regular basis regarding his acceptance of his placement at the facility being long term. R1 ambulated on his own and used a cane generally. He was also able to transfer on his own. A Nurse's Note, dated 06/24/22 at 02:54 PM by LN G, revealed the resident stated in front of the staff that he was going to walk out that door. The resident continued to keep walking and talking on the phone. A RISK Progress Note, dated 06/24/22 at 11:43 PM by Administrative Nurse D, revealed the staff notified her at 06:03 PM that the resident was outside the building at the next-door neighbor's house. R4 turned on her call light and reported to the staff that she saw the resident outside of her window. Staff immediately went outside and R1 started running away from them when they saw him. The staff assisted the resident back into the facility and placed him on 1:1 monitoring until other facility placement was found. R1 was wearing a flannel shirt, blue jeans, gray slippers, and a ball cap. Review of Accuweather.com's weather history for June 24, 2022, revealed the weather was 98 degrees when the resident eloped from the facility. A Witness Statement, dated 06/24/22 by LN G, documented she last saw the resident sitting in a chair in front of his room at 05:50 PM. She was walking to the nurse's station when CMA R yelled that R1 was outside the facility. LN G ran out the front door and observed the resident who started running as soon as he saw the staff. They followed him to the front of the neighbor's house where he stopped, and they convinced him to go back into the facility. A Witness Statement, dated 06/24/22 by CMA R, documented around 06:00 PM, a resident yelled at her to come to their room. The resident informed her there was a resident outside. The CMA R ran up the hall yelling at the nurses at the nurse's station that R1 was outside the building. They immediately ran out and caught up with the resident at the neighbor's front porch. Observation and interview, on 06/28/22 at 03:09 PM, with Administrative Nurse D, revealed the resident eloped through the front door without the alarm sounding. He walked to the parking lot and through to a fence in the backyard of a neighbor's house. He then ran from the fence, across the driveway, around the house, and to a front porch where he sat down. Administrative Nurse D stated that nobody was at the front door when the resident eloped. It was determined he followed visitors out the door as the door alarm did not sound. None of the staff saw him leave. When staff found out the resident was outside, they immediately went out and saw the resident by the fence at the neighbor's house next to the parking lot. R1 saw the staff and started running towards the front of the neighbor's house. The staff found him sitting on the porch and he stated that he felt like he was in prison and wanted out. R1 willingly went back into the facility and was outside for approximately 10 minutes. Administrative Nurse D stated that the resident had not tried to leave before but talked about leaving to the staff at various times before the elopement. Interview, on 06/29/22 at 08:26 AM, LN H revealed in the evenings he would get more confused, agitated, and hard to re-direct. The resident liked to sit by the front door, but never tried to get out until he eloped on 06/24/22. The elopement was the actual first attempt with exit seeking and getting out the door. Nobody saw him leave. Interview, on 06/29/22 at 11:18 AM, R4 revealed she remembered seeing R1 outside her window. She always looked out her window and had a good view. The day R1 eloped, he walked by her window really fast and was looking over his shoulder to see if anybody was following him. R4 reported to the staff who recognized him when she saw him outside the window of R4's room. R4 stated she saw R1 running when he saw the staff coming after him, but they caught up with him. The staff brought him back into the facility and he didn't put up a fight. The facility's policy Resident Elopement Policy & Procedure, revised 07/26/21, documented .the facility strives to promote a safe and secure environment to help minimize risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so .Elopement occurs when a resident leaves the premises or a safe area without the necessary supervision .Staff are to investigate and report instances of potential elopement . The facility failed to provide adequate supervision to prevent one cognitively impaired Resident (R) 1, who was identified as an elopement and fall risk, from leaving the facility through an exit door, without staff knowledge, on 06/24/22 between 05:50 PM and 06:00 PM. R1 stated previously that day to Licensed Nurse (LN) G that he planned to leave through the front door. When R1 exited the facility, the door alarm did not sound as there were visitors exiting the building during the time of the elopement. At approximately 06:00 PM, R4 reported to Certified Medication Aide (CMA) R that she observed R1 outside the facility. The facility staff immediately left the building and observed R1 next to a fence in the neighbor's back yard. R1 ran away from the staff, around the house and sat on the front porch. The staff escorted R1 back into the facility at approximately 06:03 PM. The temperature outside was 98 degrees and R1 was outside approximately 10 minutes. This deficient practice placed the resident in immediate jeopardy. This deficiency was cited as past non-compliance as the facility completed the following as of 06/26/22 at 10:00 PM: 1. Door functions on all exit doors checked right after the elopement. 2. The Maintenance Director called in to re-inspect the door locking mechanisms and change the combinations for all keypads on 06/24/22 at 07:35 PM. 3. The facility staff checked the front door signage instructing visitors not to let residents out of the facility and they were in place. 4. Staff placed the resident on 1:1 status as soon as staff returned him into the facility. The resident left the faciity on [DATE] at 08:40 PM to admit to a BHU. 5. Immediate education started on 06/24/22 at 06:03 PM for staff on taking immediate action and reviewing care plans for individuals exhibiting exit seeking behaviors. 6. QAPI meeting held with the Director of Nursing (DON) and the Medical Director (MD) on 06/24/22 at 08:26 PM. 7. All staff educated on elopement policy, residents at risk review, intervention review for at risk residents, notification review when residents have exit seeking behaviors, and risk assessment charting, which started on 06/24/22 at 06:15 PM and completed on 06/26/22 at 10:00 PM.

The facility reported a census of 31 residents. Based on observation, interview, and record review, the facility failed to ensure ongoing antibiotic stewardship to ensure appropriate antibiotic use. Findings included: - Review of the December 2021 Infection Control Surveillance Log, revealed three residents with urinary tract infection and one resident had a culture for urinary tract infection with no reported causative organism. This resident was treated with [MEDICATION(S)] and [MEDICATION(S)] (antibiotics). Review of the January 2022 Infection Control Surveillance Log, revealed seven residents with urinary tract infections and two of the seven with causative organisms documented. All residents were treated with antibiotics. Review of the February 2022 Infection Control Surveillance Log, revealed seven residents with urinary tract infections with one of the seven residents with the causative organism documented. All residents were treated with antibiotics. Review of the March 2022 Infection Control Surveillance Log, revealed four residents with urinary tract infections with the causative organism identified for one of the four residents. All four residents were treated with antibiotics. The April 2022 Infection Control Surveillance Log, was not started. (as of 04/06/22). Interview, on 04/06/22 at 02:00 PM, with Administrative Nurse D, revealed she did not complete the March 2022 Infection Control Surveillance Log. Administrative Nurse D stated she looks at culture results as the results are available but does not record them on the Infection Control surveillance Log until the end of the month. Furthermore, Administrative Nurse D stated the facility utilized the McGeer's criteria (a tool used for identification of symptoms of infection for antibiotic use) for monitoring antibiotic compliance but the use of this compliance for the infections was not documented in the medical record or Infection Control Surveillance Log. Administrative Nurse D stated this was a component that needed to be documented. Interview, on 04/06/22 at 03:45 PM, with Licensed Nurse (LN) G, revealed she did not know what McGeer's Criteria was, but used standard of care for resident assessment when a resident needed antibiotics. Interview, on 04/07/22 at 08:15 AM, with LN I, revealed she was not familiar with McGeer's Criteria for assessing residents with suspicion of an infection. The facility policy Antibiotic Use Protocol revised 12-2018, instructed staff the Director of Nursing or designee, to review documentation in the clinical record supporting antibiotic use signs and symptoms meeting infection criteria. Furthermore, the policy guides staff to analyze and conduct root cause analysis, determine prescribing patterns, reduction of antibiotics, training and educational efforts towards performance improvement. The facility failed to perform ongoing antibiotic stewardship to ensure appropriate antibiotic use and determine trends and tracking of infections in the facility. - Review of resident (R) 11's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment, and admitted to the facility with a deep tissue injury. The Pressure Ulcer Care Area Assessment (CAA), dated 02/28/22, assessed the resident admitted to the facility with a deep tissue injury (an injury caused by pressure and lack of blood flow) to his left heel. The Care Plan, reviewed 02/17/22, instructed staff to provide appropriate pressure relieving devices and heel protectors. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wound Consultant Oder, dated 03/17/22, instructed staff to administer [MEDICATION(S)] (an antibiotic) twice a day for 10 days and to discontinue the [MEDICATION(S)]. A Wound Consultant Note, dated 03/18/22, assessed the resident had a deep tissue injury that evolved and required debridement (removal of dead tissue). A Physician Order, dated 04/02/22 instructed staff to administer [MEDICATION(S)] (an antibiotic) 100 mg twice a day for 10 days for [CONDITION(S)] in heel ulcer. A Wound Consultant Order, dated 04/06/22, instructed staff to administer [MEDICATION(S)], twice a day for 10 days, then start [MEDICATION(S)] 100 mg twice a day for 10 days. Interview , on 04/07/22 at 10:30 AM, with Administrative Nurse E, revealed the wound culture results went to the attending physician (who did not order the cultures) and to the wound consultant, and the resident's antibiotic orders were changed. The March 2022 Infection Control Surveillance Log, indicated the resident had purulent drainage from a skin infection and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This log lacked indication of the subsequent order for [MEDICATION(S)], and the facility lacked an April log, to monitor for the conflicting antibiotic orders. The facility policy Antibiotic Use Protocol revised 12-2018, instructed staff the Director of Nursing or designee, to review documentation in the clinical record supporting antibiotic use signs and symptoms meeting infection criteria. Furthermore, the policy guides staff to analyze and conduct root cause analysis, determine prescribing patterns, reduction of antibiotics, training and educational efforts towards performance improvement. The facility failed to perform ongoing antibiotic stewardship to ensure appropriate antibiotic use for this resident with [CONDITION(S)] in his heel wound.

The facility reported a census of 41 residents, with 24 residents with blood sugar monitoring and three residents sampled for review. Based on interview and record review, the facility failed to monitor and report blood sugars that were out of parameters for Resident (R) 1. The facility placed the resident in immediate jeopardy when the glucometer (instrument used to calculate blood glucose) panel read High, which indicated a blood sugar (BS) over 600 mg/dl (milligrams/deciliter) from 06/19/2020, until R1 was sent to the hospital on [DATE] at 12:15 PM for treatment of [REDACTED]. Ketosis is the accumulation of substances called [MEDICATION NAME] and [MEDICATION NAME] bodies in the blood. Acidosis is increased acidity of the blood.) and septic shock (a condition sometimes occurring in [MEDICAL CONDITION], in which the blood pressure falls and the organs of the body fail to receive sufficient oxygen). Findings include: - The signed Physician order [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE]. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required total assistance with eating. He required extensive two-person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. He required a feeding tube (a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) that included 50% or more of his calories and 501 cubic centimeter (CC) of fluids. The Activity of Daily Living Functional/Rehabilitation Care Area Assessment (CAA), dated 06/01/20, revealed R1 was alert and oriented to person, place, time, and situation. He had a BIMS score of 15. The resident was in the hospital with a [DIAGNOSES REDACTED]. He had a feeding tube placed while in the hospital and received nothing by mouth. R1 needed extensive assistance for bed mobility, transfers with use of a sit to stand lift, wheelchair locomotion, dressing, toilet use, and personal hygiene. He was totally dependent upon staff for nutrition via a feeding tube. The Discharge MDS, dated [DATE], documented the resident had an unplanned admission to an acute hospital. The Care Plan for diabetes mellitus with uncontrolled blood sugars, dated 05/25/20, instructed staff to test R1's blood sugar five times a day and directed staff to fax the BS (blood sugar) to his Primary Care Physician (PCP) daily every night shift after the last feeding of the night. Updated 06/22/20, instructed staff to notify the PCP if the blood sugar was below 70 mg/dl or above 350 mg/dl. Monitor blood sugars as ordered and report any unusual fluctuations to the physician. Observe for signs and symptoms (excessive thirst, excessive appetite, excessive voiding, altered level of consciousness, mood changes, excessive perspiration, weight changes, circulatory changes) of hypo/[MEDICAL CONDITION] and report changes to the charge nurse and physician as needed. On 06/19/20, R1 was seen by the PCP. Review of the clinical records revealed there was a new order for staff to check his BS five times a day, every third day for one month. Review of Faxes sent to the PCP revealed on Friday 06/19/20 at 12:20 AM, Licensed Nurse (LN) G faxed the physician the resident's blood sugars as follows: At 09:23 AM, the resident's BS was 153 mg/dl. At 12:02 PM, the resident's BS was 194 mg/dl. At 08:55 PM, the resident's BS was 340 mg/dl. At 11:05 PM, the resident's BS was High, on the glucometer, that indicated the resident's blood sugar was over 600 mg/dl. On 06/20/20 at 06:56 AM, LN G performed the resident's blood glucose test. The glucometer indicated High. At 07:05 AM, she faxed the blood glucose reading to the physician. The record lacked telephone notification of the high blood glucose. Review of the Clinical Record lacked documentation of follow up blood sugars and assessments related to elevated blood sugars after two high readings on 06/19/20 at 11:05 PM and on 06/20/20 at 07:00 AM. The next time staff checked the blood sugar was on 06/22/20 at 08:05 AM, two days later, when blood sugars continued to read High. On 06/22/20 at 08:26 AM the physician ordered the following: 1. [MEDICATION NAME], 50 units, one time for BS reading of High. 2. Obtain BS before every tube feeding. 3. Fax BS to the physician daily. On 06/22/20 at 10:30 AM, a Nurse's Note recorded the BS reading was High. On 06/22/20 at 10:37 AM, the physician ordered [MEDICATION NAME] 50 units subcutaneous one time only and to hold the resident's tube feeding. On 06/22/20 at 12:15 PM, the Nurse's Progress Note documented R1 transferred to the hospital, related to high blood sugars and lethargy (altered level of consciousness). On 06/22/20, the Facility Investigation documented LN G stated she had taken two BS readings on her shift and both read High on the glucometer. The medical records from the Emergency Department Record documented on 06/22/2020 at 12:28 PM, R1 arrived at the emergency department with [DIAGNOSES REDACTED]. Presenting complaint included the sending facility checked the resident's blood sugar this morning, the first reading was high and he was given 50 units of [MEDICATION NAME]. Rechecked blood sugar at 11:30 AM also read high. They gave 50 units of [MEDICATION NAME]. The resident was typically alert, oriented, and able to transfer himself. He was not able to talk or transfer himself at this time. Emergency Medical System (EMS) personnel stated he was not alert and unable to do a stroke scale (a tool used by healthcare providers to objectively quantify the impairment caused by a stroke). His blood sugar read high and unable to give a number. The resident appeared ill, was lethargic, and oriented to nothing. He received Regular 10 units of insulin and then started an insulin intravenous (IV) drip. On 07/27/20 at 09:17 AM, LN H stated when a glucometer read High, this meant the blood sugar was over 600 mg/dl. When a blood sugar was out of parameters, the expectation would be to call the physician with the results. On 07/27/20 at 12:30 AM, Administrative Nurse D stated it was her expectation that the physician be notified by phone and not faxed with out of parameter blood sugars. On 07/28/20 at 10:13 AM, Physician GG stated his expectation was for staff to notify him, by phone, with any blood sugars out of parameters The facility's Diabetic Hypo/Hyperglycemic Protocol, revised 12/17, documented if a resident had a blood sugar greater than 400 mg/dl, or out of range of physician ordered parameters, the physician would be notified. The procedure for an elevated blood sugar included to contact the physician for additional orders if blood sugar remained above 400 mg/dl. If the resident does not have an order for [REDACTED]. The facility failed to assess, monitor, and notify the physician by phone for R1, who had blood sugars that registered over 600 mg/dl from 06/19/20 until 06/22/20, a total of three days, that placed the resident in immediate jeopardy. The resident became lethargic and the physician ordered for him to be transferred to local hospital for treatment of [REDACTED]. Failure to closely monitor and notify the physician of the elevated blood sugars increased the resident's likelihood of a serious outcome of diabetic coma. The deficient practice cited as past non-compliance on 06/22/20 at 04:00 PM when the facility completed the following: Immediate nursing education completed for proper notification, following blood sugar parameters [MEDICAL CONDITION] education. All diabetic residents were audited to ensure parameters were in place. Emergency Quality Assurance Performance Improvement (QAPI) meeting held to review action plan including education completed and audits. Audits will be completed on all diabetic residents to ensure parameters and physician notifications are being followed. Residents care plan has been reviewed and updated.

The facility reported a census of 43 residents, with 3 selected for sample review. Based on interview and record review, the facility failed to ensure 1 (#1) of the 3 residents reviewed for neglect, received assistance to reposition and toilet cares, in a manner to prevent the development of pressure ulcers. The resident experienced an oval shaped deep tissue injury to the buttocks, after staff left the resident on a fracture bedpan (a shallow waste receptacle, not as deep as a regular bedpan) for several hours. Findings included: - Resident #1's admission Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 15/15, indicating intact cognition, had little interest in doing things, and lacked energy or appetite. The resident required extensive assistance for repositioning and toileting needs; was at risk for the development of pressure ulcers, and admitted on [DATE], with a stage II pressure ulcer. The resident received a turning and repositioning program, nutritional program, pressure ulcer care, and pressure relieving devices. A quarterly Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 13/15, indicating intact cognition, and with little change in the resident's physical and emotional status. The assessment identified a sacrum pressure ulcer, present on admission, as healed. A Care Area Assessment for pressure ulcers, dated 11/25/16, included: The resident required extensive assistance for most ADL (activities of daily living) care, including bed mobility and transfers and exhibited reddened areas to the buttocks upon admission. The Care Area Assessment for ADLs, dated 11/25/16 included: The resident with very limited mobility at this time, transferred using a mechanical Hoyer lift, and required extensive assist of two for transfers. The care plan, dated 3/1/17, included the following interventions: The resident required extensive assistance of 2 staff for turning and repositioning. Reposition every hour. Required a mechanical lift for transfers with 2 staff's assistance. Provide a bedpan for continence of bowel and bladder. The resident calls for assistance as needed. Keep linens clean and dry. If experiencing intermittent confusion, offer assistance with toileting every 2 hours. Float heels on pillow while in bed. Addition, dated 2/21/17, use a positioning pillow or wedge when in bed. Addition, dated 3/1/17, when using the bedpan, if the resident fails to call within 15 minutes for assistance, return to check if the resident finished. Reposition the resident at that time. Review of the resident's skin assessments included: On 2/21/17: Lacked identification of any current pressure ulcers. On 2/28/17: 1.) Left heel purple and intact, lacked blistering. 2.) A defined purple/red ring in color noted around bilateral buttocks. Depression felt over purple areas but skin remained intact at this time. 3.) The center appeared reddened with an open area over the resident's sacrum with scant sanguineous drainage noted. On 3/8/17: 1.) Right buttock, pressure ulcer, measured 10 cm (centimeter) by 0.7 cm, SDTI (suspected deep tissue injury). Wound purple/intact. Peri wound blanching. 2.) Left buttock, pressure ulcer, measured 21 cm x 2.5 cm, SDTI. Wound purple/intact. Peri wound blanching. 3.) Right heel, pressure ulcer, 2 cm x 1 cm, SDTI. Heel purple and intact. Peri wound blanching. 4.) Left heel, pressure ulcer, 0.5 cm x 1 cm, SDTI. Heel purple and intact. No blistering noted at this time. Peri wound blanching. 5.) Sacral wound open, wound bed pink/moist. This lacked actual measurements of this area. Interview on 4/14/17 at 12:45 PM, with an anonymous caller, identified a concern regarding the resident receiving the care needed. The caller reported the staff placed the resident on a fracture bedpan (a shallow waste receptacle, not as deep as a regular bedpan) before 5:00 AM and the resident remained on the bedpan for approximately 7-8 hours because the staff on duty failed to reposition and/or remove the resident from the bedpan. Licensed nursing staff C reported, on 4/14/17 at 1:28 PM, he/she did not recall receiving any significant changes in the resident at the 6 AM, shift change report on the morning of 2/28/17. The staff reported he/she completed a head to toe assessment of the resident during breakfast time, and that the resident responded per normal for the resident, at that time. The staff reported they did not assess anything out of the normal for the resident. The staff reported he/she did not recall seeing the resident the remainder of the morning, as the resident chose to remain in his/her room for meals. The staff verified the wound care nurse reported the change in the resident's clinical condition to him/her, around 1 PM, during the resident's skin assessment, and at that time staff C assessed the resident for the change in mentation. On 4/14/17 at 2:06 PM, direct care staff F reported he/she worked as a float (working on both halls) on the day the resident was left on the bedpan. The staff recalled only interacting with the resident on one occasion, prior to lunch, when the staff inquired what the resident wanted for lunch. After lunch, the staff reported being called to the resident's room, as the resident did not have his/her heels off-loaded and the wedge in place for positioning. At that time, staff F and H repositioned the resident and noted the fracture bedpan under the resident. Staff informed the wound care nurse, at that time, and removed the pan, noting the bedpan left a mark on the resident's buttocks, in the shape of the bedpan. On 4/14/17 at 2:09 PM, direct care staff G reported the resident was very alert and instructed us on what his/her care needs were. The change in his/her condition was very sudden. Prior to the day before ([DATE]) the resident always helped a lot with his/her care. The resident always used the bedpan for toileting, and did not get out of bed much. The resident always allowed repositioning, didn't refuse cares, and usually remained in the position staff assisted him/her into. On 4/14/17 3:45 PM, licensed nursing staff D, reported being the nurse responsible for wound care. The staff reported that on 2/28/17 staff D went to the resident's room for his/her skin assessment and observed, immediately, that the resident did not have his/her heels off-loaded, nor was the wedge in place. At that time, staff D went to find the CNA (certified nursing aid) staff regarding the proper positioning of the resident. Staff D returned to the resident's room with direct care staff F and H and provided re-education regarding off-loading of the heels and use of the wedge for pressure relief. Staff F and H repositioned the resident and noted the fracture bedpan in place. Staff D completed the wound assessment (see measurements above), and then notified the charge nurse of the resident's change in mentation, reporting the resident seemed to be reaching out to items in the air, not seen by others. Administrative nursing staff B reported on 4/14/17 at 4:00 PM, when made aware of the resident's skin condition, he/she immediately began an investigation into the incident. The staff verified the resident was known by staff to call and request assistance for his/her care needs, however, the staff were still expected to check on the resident and provide repositioning every 1-2 hours and to offer toileting. On 4/25/17 at 4:45 PM, per telephone interview with the primary care physician extender I, revealed he/she had knowledge of the incident when the resident was left on the bedpan for hours. He/She explained this resident should not have been left on the bedpan like that. The facility failed to ensure the staff provided care and services and prevent neglect from occurring when the resident remained on a bedpan from approximately 4:30 AM to 1:30 PM, (9 hours). The resident developed a suspected deep tissue injury as a result of the neglect. The investigation revealed the facility was in past-noncompliance as of 2/28/17, as the facility: 1.) All nursing staff were educated on turning and repositioning; following the care plans; report between shift; accurate documentation, and toileting and bedpan placement 's ensuring residents removed. This in-servicing began at 2:00 PM and was completed by 10:00 PM on 2/28/17. 2.) Reassessments and care plan updates completed on 2/28/17, for all residents that required assistance with repositioning and/or use of a bedpan. 3.) Follow-up and monitoring will be reviewed by the DON and/or designee who will do random checks on nursing staff daily for proper positioning and turning for 90 days. 4.) An emergency QAPI meeting was held with the team and the medical director (per phone) on 2/28/17 at 4:30 PM and this will be monitored at the next scheduled QAPI meeting.

The facility reported a census of 48 residents. Based on observation, interview and record review, the facility failed to honor 1 or 48 resident's wishes regarding code status (#1). Resident #1 became unresponsive, and staff began CPR (cardiac-pulmonary resuscitation) without first identifying the resident's wishes to be a DNR (do not resuscitate). The staff performed CPR on the resident until EMS (Emergency Medical Services) arrived and determined the resident was a DNR. The resident was deceased . The facility also failed to maintain an accurate system to ensure staff were aware of the code status of residents, including residents # 5, 6, 7, 8, and 9, in the facility. The facility failed to have systems in place to ensure availability of qualified staff to perform CPR 24 hours a day/7 days a week for the 30 full code residents, and identified 30 with a full code status (chose to receive resuscitation cardiac/respiratory arrest, cessation of a heartbeat and respirations). This placed all residents in the facility in immediate jeopardy. Findings included: - Review of resident #1's signed physician orders, dated [DATE], included a DNR (Do Not Resuscitate) order dated [DATE]. The admission Minimum Data Set, dated dated [DATE], identified the resident's cognition was intact with a Brief Interview for Mental Status of ,[DATE]. The care plan, dated [DATE] included the resident was a DNR code status and did not want CPR performed. The nurses notes, dated [DATE] at 6:45 PM, documented licensed nursing staff D dialed EMS to call for EMS transport to the emergency department of the hospital for the resident's change in condition. At 9:29 PM, while dialing for the EMS, direct care staff G, alerted the nurse that the resident stopped breathing. Licensed nursing staff D and C rushed to the resident's room, from the nurse's desk and began CPR. The notes documented the staff continued CPR until EMS arrived and took over CPR, at 9:35 PM. Staff then researched to find the resident requested DNR status. Staff notified EMS and they stopped CPR, without the resident resuming a heart rhythm. At 9:45 PM, the resident was pronounced dead. Review of the resident's clinical record evidenced a Pre-Hospital DNR Request Form, dated [DATE], signed by the resident and the SSD (social services designee) of the facility. Licensed nursing staff E reported on [DATE] at 1:45 PM, the location of the resident's code status was available in the chart or in the computer. On [DATE] at 9:33 AM, direct care staff G reported he/she assisted the resident, on [DATE]. The nurse left the room to begin the process of sending the resident to the hospital, when staff G noted the resident became unconscious and appeared to stop breathing. Staff G stepped into the hallway and called out to the nurse, at the desk. The staff reported that someone in the room asked about the resident's code status and no one knew what it was. Staff G reported it was hectic at the time, no one thought about checking on the CNA tablet in the room, and staff initiated CPR. When asked about training, staff G reported he/she did not recall receiving any training regarding code status, and the staff member was not currently certified in CPR. On [DATE] at 10:04 AM, direct care staff I reported he/she immediately notified the nurse when finding a resident non-responsive, and then would start CPR. The staff stated to look for a resident's code status, the staff needed to look in the computer or the clinical record. On [DATE] at 10:10 AM, direct care staff J reported if he/she found a resident unresponsive, that he/she would immediately notify the charge nurse. Staff J verified staff should look in the computer/tablets or in the chart to verify a resident's code status. On [DATE] at 10:14 AM, direct care staff K reported looking on the tablet was the quickest way for the CNA's to check code status. Staff K reported if he/she found a resident non-responsive they would immediately notify the charge nurse. Licensed nursing staff C reported on [DATE] at 8:50 AM, he/she was going off duty, on [DATE] when the resident coded. The nurse reported being at the desk, with staff D, when a staff member called from the hallway that the resident stopped breathing. Staff C reported they grabbed the crash cart and headed towards the resident's room and the staff members then began CPR. When asked about code status, the staff member indicated that while performing the CPR the staff notified EMS and continued the CPR until EMS arrived. After EMS arrived, then staff checked the resident's code status and determined the resident was a DNR. He/she notified EMS, and they stopped CPR. Licensed nursing staff D reported on [DATE] at 9:12 PM, that he/she was the charge nurse on duty the evening of [DATE]. Staff had gone to the nurse's desk area to begin the paperwork, including printing of the transfer form, from the computer, and making the phone call to EMS for transport. Direct care staff G stepped into the hall and called out the resident had stopped breathing. I ran to the resident's room, while in the room, licensed staff C asked if the resident was a DNR and staff D indicated they did not know, so staff began CPR. Staff called EMS during CPR, with CPR being performed by staff until EMS arrived. After arrival of the EMS personnel, staff D reported they immediately went and checked on the resident's code status, then informed EMS of the resident's DNR status. CPR was then stopped and the resident never revived. Direct care staff F reported on [DATE] at 10:18 AM, the staff look under Advanced Directives in the chart or in the computer for code status. The staff further noted, the direct care staff also had code status in the tablets, under the resident's profile. On [DATE] at 11:30 AM, activity/social services staff L reported he/she was responsible for obtaining code status upon admission, reviewing the code status during the care planning conferences, and ensuring no changes are needed to the advance directives. When the signed copy is returned from the physician that is placed on the residents chart, and notification is made to medical records for input into the computer. On [DATE] at 11:45 AM, administrative nursing staff B reported the expectation of licensed staff during an incident when a resident stopped breathing, included the licensed staff to direct and delegate tasks. The staff should always check code status, prior to beginning CPR, if indicated. The licensed staff are responsible for notification to 911, or delegation of the task. Staff confirmed the last training session for code status and response was in December, 2015 when staff received training on what to do and identifying code status in the tablets, computers, or charts. The facility policy, Advance Directives-Code Status, dated ,[DATE] included: To identify and honor resident preferences regarding advance directives and code status. The policy included: Resident advance directives, if formulated and preference for code status are to be obtained upon admission. Residents who have not formulated an advance directive and who do not have a DNR order will be considered a Full Code. A physician order [REDACTED]. Resident advance directives and preference for code status are to be reviewed quarterly, with significant change and upon the resident's request. Reviews are to be documented in the clinical record. The facility is to maintain a record of each employee's CPR certification and expiration date. CPR certified employees are to be available at all times. The resident's code status is located in the following areas of the clinical record: Face Sheet Condition Alert Sheet Physician Orders Advance Directives PCC Resident header (point click care software on the resident's profile page) POC Resident header(point of care software on the resident's opening page) EMAR Resident header (electronic medication administration record) Care Plan Kardex (a program describing the resident's care needs) The facility failed to ensure resident #1's end of life wishes were respected and honored, when the facility staff failed to verify the resident's code status, before initiating CPR on this resident who previously expressed the desire to be a DNR per facility policy. On [DATE] at 11:50 AM administrative staff A verified the facility lacked a tracking system for monitoring of staff CPR certification, to ensure a CPR certified staff member was on duty every shift/every day. Furthermore, the facility failed to maintain a system to ensure staff were aware of the resident's wishes for end of life care, when the staff failed to ensure advance directives were in place, as requested by the residents of the facility. Concerns with the following included, during the record review: #5 - no designation in the chart, the computer indicated full code status; however the follow-up book had a resident/representative signed DNR, dated [DATE], and faxed to the physician on [DATE]. #6 - the chart lacked designation of code status, the computer identified the resident as a full code; however, the follow-up book identified a DNR signed by the resident/representative on [DATE], however, lacked a signature by the physician, faxed on [DATE] to the physician. The record lacked evidence of any follow-up since staff sent the initial fax. #7 - the chart lacked designation of code status and the computer identified the resident as a full code, however, the follow-up book identified a DNR form, dated and signed by the physician on [DATE]. The form lacked a resident/representative signature. #8- the chart evidenced a DNR status, with the computer indicating the resident as a full code. The follow-up book evidenced a DNR signature by the physician, dated [DATE]. However, a note at the bottom, dated [DATE] identified that due to involuntary admit the resident would be a full code. #9 - The chart evidenced the resident as DNR, and the computer identified the resident with a full code status. The revocation portion of the form identified an unreadable signature, however lacked a date. This deficient practice placed the residents in the facility in immediate jeopardy, for the facility system failure relating to identifying resident code statuses in a timely manner, for failure to ensure a system to identify the staffing included a CPR certified staff member 24 hours/7 days a week, which left the residents of the facility in immediate jeopardy of not receiving the code status they desired, at the end of life. The facility abated the immediate jeopardy on [DATE] at 2:58 PM, when the facility in-serviced all of the nursing staff related to the system to identify the residents code status. The facility also reviewed and corrected all of the residents documented code status,' in both the computer and the clinical chart, to ensure the staff's timely knowledge of correct code status for each resident of the facility. This deficient practice remained at the scope and severity of F.

The facility identified a census of 44 with a sample of 19 residents, which included 3 residents reviewed for Range of Motion (ROM). Based on observation, interview and record review, the facility failed to ensure restorative services to prevent an unavoidable decline in range of motion of the hands, for 1 resident (#17), of the 3 with ROM services reviewed. Findings included: - The physician orders [REDACTED]. The annual MDS (minimum data set), dated 5/28/13, revealed the resident with a BIMS (brief interview for mental status) score of 03, severely impaired cognition. The resident had no impairment in functional limitation in ROM (Range of Motion) to the upper extremities. The resident did not receive Occupational Therapy (OT) or Physical Therapy (PT) but did receive Restorative AROM (Active Range of Motion) 6 out of 7 days. The quarterly MDS 3.0, dated 11/23/13, revealed the resident with severely impaired cognition by staff assessment. The resident had no impairment in functional limitation in ROM (Range of Motion) to the upper extremities. The resident received OT 40 minutes per day, 7 days per week. The care plan, last updated 2/12/14, documented Restorative Nursing Program - AROM (Active Range of Motion) both hands open as far as possible x (times) 5 per day. Gentle PROM (Passive Range of Motion) both shoulders overhead x 5 per day. Gentle PROM right elbow as straight as possible x 5 per day. Splint/Brace: cones in both hands x 2 hours after breakfast and lunch. The Restorative Care Program, dated 12/19/13, documented the resident discharged from OT with Restorative recommendations: Goals for restorative program: prevent upper extremity contractures. Approach for implementation of above goals: 1) Gentle PROM both shoulders overhead x five. 2) gentle PROM right elbow as straight as possible x five. 3) Both hands open as far as possible x five. 4) Cones in both hands x two hours after breakfast. Cones in both hands x 2 hours after lunch. Precautions: Perform exercises in supine (on back) in bed. The Restorative Aide Notes documented the following: 12/28/14...Resident refuses exercises at times. 1/10/14...Has not made progress this week. refused exercises most of the week. 1/17/14...Has not participated much this week. 1/25/14...Participated at times in these exercises, actively resists exercises at times. 1/31/14...Allows exercises to be performed at times but does refuse and/or actively resist staff attempts to perform these tasks. 2/8/14...Allows staff to perform these tasks, most of the time without any resistance. 2/14/14...Allowed RA (Restorative Aide) to perform PROM this week. 2/22/14...Allows RA to perform tasks when (he/she) is not able to participate. The Intervention Task Report for January and February, 2014, for restorative exercises documented the resident as follows: The resident did not receive restorative care 22 days, 15 days documented RR and 7 days documented NA, out of the 49 total days available for restorative care in January and February, 2014. On 26 days, the resident completed 2-10 minutes of exercises, never reaching the 15 minutes required per facility policy. The Key documented NA means no Restorative performed; Number is minutes performed. RR means resident refused. Restorative Services were not performed on Sundays. On 2/24/14 at 12:32 PM, The resident sat in a Broda chair in the living room with the TV on, cones noted in hands, bilaterally, leaning to the right side, with the chair padded on the right side. On 2/25/14 at 10:12 AM, observation revealed the resident rested in the bed with the lights off. Direct Care Staff I placed cones in the resident's hands. The resident was resistant to the cone placement. The residents closed his/her hands tightly with wrists turned in toward chest with facial grimacing and pulled his/her hands away. Direct Care Staff I was able to place cones in the resident's hands. On 2/25/14 at 2:17 PM, Direct Care Staff I entered the resident's room with the resident awake in the bed. Staff I attempted to do ROM exercises with the resident with minimal resistance. The resident pulled slightly against the staff. Staff I made no attempts to identify the cause of the resident's resistance and stated, "You don't want to exercise? Ok" and left room at this time. On 2/26/14 at 9:47 AM, Direct Care Staff I entered the residents room with the resident in bed. Staff I instructed the resident they were going to do exercises. The resident closed his/her hands tightly with his/her wrists turned toward the chest, and arms pulled tight toward chest. Staff I began with the left hand, open/close x 5 (hand opened approximately 50 %) the resident's arms and upper body shook and pulled arms toward his/her chest with this exercise. Direct care staff I moved to the resident's right hand but was unable to perform due to resistance. When the residents hands shook, Staff I stated, "Are you okay? Do you want me to quit?", then Staff I proceeded with the right elbow extension x 1, Staff then held the residents left hand and began talking to the resident about things on the wall, began left elbow extension x 5. Moved back to right arm elbow extension x 5. Right shoulder overhead x 5. Left shoulder overhead x 5. Then staff placed hand cones bilaterally. Staff I stated that the cones are place on the days he/she worked, which is 3 days a week, and only after breakfast for 2 hours. Staff I denied the cones are to be placed in the resident's hands again after lunch. On 2/25/14 at 10:07 AM, Direct Care Staff I stated the resident received Restorative 3 times per week, and they put hand rolls in for 2 hours each day after breakfast. Staff I also did extension of the resident's elbows, and the shoulders, and work the hands and use a lotion massage. Some days he/she does great, but about 50% of the time he/she resisted, so Staff I always went back later and tried, sometimes that worked. On 2/25/14 at 2:20 PM, Direct Care Staff I stated that the resident was often (40-50%) resistant to care. Staff I charted daily on the residents seen, even if they refused. At the end of the week, Staff I documented a summary note on the resident's restorative progress. Staff did not offer the resident encouragement or inquire as to why the resident was resistant when the resident resisted care and said he/she would just document this as refused and come back tomorrow since he/she just had to see the resident 3 times per week. Staff stated that he/she would not attempt restorative care again today because it was late in the day and he/she still had charting to do and then it was time to go home. On 2/26/14 at 8:43 AM, Therapy Staff K stated that the RA (restorative aide) used to come on a regular basis with questions about progress when the residents resisted. Staff K reported the facility scheduled the RA so heavy to work in the dining room as an aide assisting with feeding that the RA did not have time to do the restorative and Staff K never hear from the RA anymore. Staff K stated the facility identified upper extremity contractures for sure. Staff K confirmed writing the restorative care program and that it lacked how many times per week it is to be performed. Staff K confirmed the resident should receive restorative at least 3-5 times per week. The RA seemed to just give up easily on doing the exercises. When the RA started doing restorative, Staff K worked with the RA a lot on being assertive, but reported the RA is very timid. Licensed Nursing Staff M, on 2/25/14 at 3:17 PM, stated the residents hands had contractures and feet are a little bit dropped. I believe the resident is getting restorative, and has hand rolls...I'm not 100% sure. On 2/26/14 at 10:31 AM, Administrative Nursing Staff C stated the RA made a weekly note and reports to the restorative nurse if the resident is cooperating or not and all of their findings for the week. Staff C confirmed that according to the Occupational Therapy Assistant, the resident had full open hands on 12/18/13 and wrote exercises for the hands to prevent contractures. Staff C confirmed the resident currently with upper extremity contractures and that the resident had a decline. If the RA is meeting any resistance with care, the RA needed to report that to the restorative nurse, who is Administrative Nursing Staff E and had been in that role for 1 month. On 2/26/14 at 10:53 AM, Administrative Nursing Staff E stated that he/she has been told he/she is going to be the Restorative nurse, and had training scheduled on 3/25/14, but is not actively performing the role yet or making any decisions on his/her own for any residents. If the RA comes to me, I defer them to Administrative Nurse C, because he/she is who did it before me. I am not familiar to the residents on the program, or their progress, or decline for that matter. I am not familiar with how the resident is doing. On 2/26/14 at 11:08 AM, Therapy Staff K stated that he/she looked at the resident yesterday and the resident has full hand contractures at this time. When Staff K discharged the resident from occupational therapy in December 2013, 2 months ago, the resident had open hands. The resident has had a huge decline. The resident also has leg contractures, the facility is not currently doing anything for the residents leg contractures. On 2/26/14 at 12:11 PM, Direct Care Staff I stated he/she felt like the resident is resistant to care at least 50% of the time. When this happens, Staff I has never gone to the charge nurse and reported it. Staff I had never tried anything different in the approach when the resident is resistant, and does feel like the resident may be in pain at times. Staff I had never requested anything for pain from the nurse or tried warm moist packs prior to performing PROM. Staff I stated, "I don't report to anybody, I think there is a nurse in charge of the program but I'm not sure who. I just make my weekly notes and I assume somebody is reviewing them." The facility provided Policy for Restorative Program, dated 5/16/12, documented: Philosophy: To maintain range of motion for each resident to reach and maintain the highest level of functioning. Protocol:...7.) Restorative programs should occur at a minimum of 15 minutes per day six days a week. 8.) the Restorative Nurse will monitor the program for each resident and note any changes or concerns in restorative note in PCC (point click care). RA nurse will notify appropriate entities as per standards of practice. The RA nurse will report to Risk Meeting weekly on these changes or concerns with interventions and reassessment. The facility provided Rehab Resident Screen dated 2/27/14 documented order received for OT/PT. Attempted evaluation on 2/26/14, patient uncooperative and resistant to assessment of upper extremities...The resident screened by OTA...bilateral hands fully open, but with signs and symptoms of pain, grimace and increased resistance at approximately -30 degrees of full extension at right hand. The facility failed to provide the planned RA program for the resident, failed to identify the cause of the resident's frequent refusals of exercises, failed to designate a registered nurse to oversee the restorative program, failed to identify a decline in the resident's ROM and the resident's hands became contracted from full ability on 12/18/13, to only partial open ability on 2/26/14.

The facility reported a census of 51 residents. The 23 residents selected for review included 3 reviewed for nutrition. Based on observation, interview, and record review, the facility failed to ensure 2 of the 3 residents reviewed for nutrition remained within acceptable parameters of nutritional status as possible, including resident (#8) who experienced a 16 % weight loss in 4 months and #24, who experienced a 17 % weight loss in just over 6 months. Findings included: - Review of resident #8's face sheet revealed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission MDS (minimum data set assessment), dated 7/4/12, scored a BIMS (brief interview for mental status) of 9, indicating moderate cognition impairment, independent with eating after set-up help, coughing or choking during meals or when swallowing medication, weight of 135 pounds, weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and not on a physician's orders [REDACTED]. The 7/9/12 CAAS (care area assessment summary), for ADL (activities of daily living needs) functional/rehabilitation potential documented, "Needs assistance for ADLs because (the resident) needs assistance from staff with ADLs." The nutritional status, documented, "Triggers because he/she is above his/her IBW (ideal body weight). IBW = 110. He/She has a BMI (body mass index) of 21.6. He/She has a good appetite. Able to feed self after set-up by staff." The resident's quarterly MDS, dated [DATE], recorded a BIMS of 6, indicating severe cognitive impairment, independent with eating after set-up help, no swallowing disorders identified, weight of 123 pounds, weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and not on a physician's orders [REDACTED]. The admission nursing assessment, dated 6/27/12, documented an admission weight of 144.8 pounds. The assessment further included documentation, "... Slight [MEDICAL CONDITION] noted to bilateral hands..." Further nursing assessment note, dated 6/30/12, three days after admission, documented, "... Resident has no [MEDICAL CONDITION]" The 10/10/12 plan of care, included, "Nutrition - I am currently on a liberalized diet. I like to choose what I want to eat. I usually eat my meals in my room and I do not need any assistance. When I come to the dining room, I prefer to stay in my room." The Nutrition/Hydration Goal documented, "My weight will be stable and I will have no aspiration over the next 90 days." A physician order [REDACTED]. Continue on puree diet with nectar thickened liquids." A physician order [REDACTED]. Continue on pureed diet." Dietary notes, dated 7/13/12, documented, "Resident picks food from menu. Current weight 144. IBW (ideal body weight) 107-131 pounds." A fax to the physician, dated 7/19/12, documented, "FYI (for your information): Resident was admitted on [DATE], with admit weight of 144.8 pounds. July weight was 133.8 pounds. Lost 11 pounds. Resident was receiving ST (speech therapy) and diet was changed to pureed with honey thickened liquids. Resident was refusing to eat. Resident and DPOA (durable power of attorney) were given risks of not following ST recommendations. They opted to not follow recommendations. Waiver was signed. Resident is now eating in the main dining room and staff reports an improvement in meal consumption." Review of the registered dietitian's notes dated 9/27/12, revealed the recommendation list from the dietitian visit lacked any recommendations for this resident. Dietary notes dated 10/1/12, documented, "Resident comes to dining room for meals, picks from menu, feeds self, eats well most of the time. Current weight is 123 pounds." The facility weights record documented the following weights: On 6/27/12, weight on admission of 144.8 pounds. On 7/1/12, weight of 135 pounds. On 7/11/12, weight of 133.8 pounds. On 7/18/12, weight of 133.8 pounds. On 7/25/12, weight of 133 pounds. (11.8 pound loss= 8.1% in 1 month.) On 8/1/12, weight of 131.4 pounds. On 8/9/12, weight of 131.4 pounds. On 8/15/22, weight of 129.8 pounds. On 9/1/12, weight of 128.4 pounds. (16.4 pound loss = 11.3 % in 2 months.) On 9/6/12, weight of 127 pounds. On 9/11/12, weight of 125.6 pounds. On 9/19/12, weight of 123.4 pounds. On 9/25/12, weight of 123.2 pounds. On 10/1/12, weight of 123 pounds. On 11/1/12, weight of 121.4 pounds. (23.4 pound loss = 16.1 % in a little over 4 months.) The meal intake record for September, 2012, revealed staff documented the resident consumed 10-100% of the 3 meals consumed, with no supplements recorded as taken. Review of this 9/12 meal intake record revealed it lacked documentation of any meal intake for 11 meals. The meal intake record for October, 2012, revealed staff documented the resident consumed 25 to 100% of the 3 meals consumed, with no supplement recorded as taken. Review of this 10/12 meal intake record revealed it lacked documentation of any meal intake for 3 meals. Review of the resident's 10/12 MAR (medication administration record) lacked evidence the resident received a planned supplement. The physician signed recertification record, dated 10/10/12, which contained a diet order for a liberalized, puree texture diet with honey thickened liquids. On 10/30/12 at 5:05 PM, the resident sat in the dining room in the wheelchair. Staff served the resident a cheeseburger, chips, muffin, and cantaloupe. The resident ate independently. At 5:30 PM, observation revealed the resident ate all except 1/2 of the bun. The resident's diet card with the meal, documented the resident received, a "Regular diet." On 10/31/12 at 7:30 AM, the resident sat in the wheelchair in the dining room. At 7:48 AM, staff served the resident breakfast of coffee, water, 2 sausage links, scrambled eggs, and toast. The resident ate independently. At 8:21 AM, the resident completed 100% of the food. On 10/31/12 at 11:35 AM, the resident sat in the dining room in the wheelchair with eyes closed. A cup of coffee, water, and ice tea sat in front of the resident on the table. At 12:11 PM, staff served the resident rice, 3 meat balls, peas, and fruit cobbler. The resident ate independently. At 12:23 PM, the resident completed all but the rice. The resident drank 2 cups of coffee and left the dining room at 12:43 PM. On 10/31/12 at 3 PM, the resident and a visitor sat in the living area of the facility and asked for something to drink and direct care staff S told them, the staff couldn't serve them, unless they went into the dining room. At that time, direct care staff S reported, "I was told due to the new carpet, the residents could not eat or drink in the living area." When asked if (the staff member) ate or drank in (the staff's) living area at home with carpet, (the staff member) stated, "I do." On 10/31/12 at 7:58 AM, licensed nursing staff V reported, "I don't think (the resident) has lost weight. (The resident) eats regular food if (the resident) eats in the dining room. I think he/she has a pretty good appetite. He/She eats independently and receives no supplement." On 10/31/12 at 11 AM, licensed nursing staff B reported the registered dietitian notes should be in the computer. Staff B explained, "I know the registered dietitian was having some trouble getting his/her name on his/her reports in the computer." At that time, the surveyor requested staff B to contact the registered dietician for additional documentation to be faxed to the facility. On 10/31/12 at 1:55 PM, licensed nursing staff B reported they could not find anything documented from the registered dietitian and he/she currently out of town. On 11/1/12 at 2:53 PM, licensed nursing staff K stated, "The registered dietitian made no recommendations on the visit of 8/29/12." On 11/2/12 at 11:30 AM, licensed nursing staff M stated, "It looks like (the resident) has had a steady weight loss. Our protocol is if not eating 50% of the meal, offer the house supplement. Weights are reviewed and the doctor notified. (The resident) feeds themselves. The resident has no order for a supplement." On 11/2/12 at 1:55 PM, direct care staff D stated, "I don't think (the resident) has lost weight. He/She comes and gets his/her own snacks." On 11/2/12 at 4:00 PM, licensed nursing staff B and R reported they felt they were on top of their residents with weight loss, as the facility conducted weekly meetings, and just had a meeting this morning and was discussing the resident. However, nurse B did not explain any interventions the staff implemented to correct this resident's continued weight loss. Licensed nurse B then reviewed the weekly committee notes and reported the resident was first admitted on a pureed diet with thickened liquids as recommended by ST and the resident wouldn't eat the pureed food. On 7/10/12, the resident signed a waiver for responsibility as he/she stated he/she would not eat the pureed diet or drink the thickened liquids. The facility undated policy and procedure, "Resident Controlled Liberalized Diets," documented, "Purpose: The purpose of liberalized diets is to allow residents to 1) control food choices to stimulate appetite for improved nutritional status, 2) provide an expanded selective menu with more variety and popular food for increased patient satisfaction,... Procedure: 4) Residents not on the liberalized diet program may, after a nutrition evaluation by the dietician, be recommend that the patient be transitioned to the liberalized diet program..." The facility failed to identify this resident's continued weight loss and develop interventions to maintain or increase the resident's weight, and failed to provide supplements if the resident's intake failed to equal at least 50 % of the meal served. From 6/27/12 to 11/1/12, the resident lost 23.4 pounds (16.16%). - Review of resident #24's face sheet revealed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED].), and behavior disorder. The resident's annual MDS (minimum data set assessment) dated 12/27/11, identified the resident with short and long term memory problems, modified independence with decision making skills, and indicators of [MEDICAL CONDITION] of disorganized thinking behavior continuously present. The assessment of mood coded the resident as being short tempered, easily annoyed 2-6 days, required supervision and set up help with bed mobility, transfers, walking in the room/corridor, locomotion on and off the unit, dressing, independent after set up help with eating, no swallowing disorders, current weight of 106 pounds, no weight loss coded, and no nutritional approaches identified. Licensed nursing staff A, responsible for the resident assessments, reported on 11/1/12 at 10:44 AM, that the CAAS (care area assessment summary), due 12/27/11, as not available including areas for; Cognitive Loss/Dementia, ADL (activities of daily living needs) Functional/Rehabilitation Potential, and Nutritional Status. The resident's 9/26/12 quarterly MDS, identified the resident with short and long term memory problems, severely impaired decision making skills, no indicators of [MEDICAL CONDITION], staff assessment of mood coded the resident as being short tempered, easily annoyed 2-6 days, no behaviors, independent with bed mobility, transfers, walking in the room/corridor, locomotion on and off the unit, required supervision and set up help with eating, no swallowing disorders, weight of 88 pounds, weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months coded, and with no nutritional approaches identified. The resident's MDS dated [DATE], documented short and long term memory problems, severely impaired decision making skills, indicators of [MEDICAL CONDITION], of inattention and disorganized thinking, and with behavior present but fluctuates. The assessment of the resident's mood coded the resident being short tempered, and easily annoyed 2- 6 days. The resident's bed mobility, transfers, walking in the room/corridor, locomotion on and off the unit required extensive assistance of 1 staff, and the resident required limited assistance of 1 staff for eating, no swallowing disorder, weight of 83 pounds, weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and no nutritional approaches identified. The 7/3/12 plan of care, documented, "Discussed continued weight loss with (the resident's child). End of life planning discussed. Would do hospice when time comes. On a liberalized diet. At times am able to answer yes or no to the food I do and do not want. Sometimes I do not have a good appetite and will not eat much. Eat meals in the dining room and staff reminds me when I forget." The plan further documented, "Nutrition/Hydration Goal: Will have no weight loss over the next 90 days." An updated entry on the care plan, dated 9/26/12, documented, "Due to continued weight loss, family input and staff observation, the kitchen will continue to offer larger portions at breakfast which is when (the resident) has a history of eating the best and continue to offer snacks throughout the day. We will start offering breakfast foods at all meals due to eating breakfast better." A physician order [REDACTED]. The annual registered dietitian assessment, dated 2/22/12, documented, "... Liberalized diet ordered. Meal consumption varies and inadequate at times... [MEDICATION NAME] (medication appetite stimulant), Vitamin E supplementation ordered... Weight 104 pounds. 2/11 weight 102 pounds... Food choices are available per selective dining...Additional nutritional intervention is not necessary at this time... No change noted." The South hall ADL (activities of daily living needs) record, dated 5/3/12, revealed it lacked evidence the resident was included in the assisted or encouraged dining on the evening shift. Certified dietary manager notes, dated 5/15/12, no time, documented, "Resident eats in dining room, gets assist with picking food, eats fair, feeds self. Current weight 95 pounds, IBW (ideal body weight) 126-154 pounds." Nurses notes, dated 6/5/12, no time, documented, "Resident has lost 9.4 pounds in 2 months. Resident started on [MEDICATION NAME] (medication to increase appetite), 20 mg (milligrams), daily, on 4/18/12. He/She has been refusing his/her meds frequently. Time change for meds have been ineffective. Resident is confused and difficult to redirect at meal times. Staff encourages resident to eat at each meal. Continue with weekly weights. DPOA (durable power of attorney) and doctor notified with no new orders at this time." Nurses notes, dated 6/6/12 at 3 PM, documented, "Restorative staff encouraged resident at both breakfast and lunch to eat. Refused lunch but ate almost all of breakfast." Dietary notes, dated 6/26/12, documented, "Resident has not been eating well lately. Staff has been assisting when resident will let them." Nurses notes, dated 8/24/12 at 9:43 AM, documented, "DC (discontinue) [MEDICATION NAME]. DPOA states that resident has never been a big eater especially after breakfast. Has never weight much over 120 pounds in his/her entire life. Nurses notes, dated 8/26/12 at 10:25 AM, documented, "Continues with good appetite at breakfast. Feeds self in dining room. Has been asking and receiving additional food with breakfast. Appetite appears to decrease with lunch and supper. Staff provides supervision and encouragement with meals." Registered dietitian notes, dated 9/27/12, documented, "...Weight of 87.6 pounds... History of weight loss, now fluctuation 87-90 pounds... Sanctuary evaluation recommended due to increase agitation. [MEDICATION NAME] (medication appetite stimulant) ordered. House supplement continues TID (three times per day) for nutritional support. Meal consumption varies, inadequate at times. Encourage 100% meal consumption. Appropriate nutritional intervention is being provided. Weekly weights are being monitored." The facility documented a list of computerized weight list for the resident as follows: On 4/2/12, weight of 101 pounds. On 5/2/12, weight of 95 pounds. (6 pound loss = 5.9 % in 1 month.) On 6/1/12, weight of 91.6 pounds. On 7/2/12, weight of 90 pounds. (11 pound loss = 10.9 % in 3 months.) On 8/1/12, weight of 91.4 pounds. On 9/1/12, weight of 89.2 pounds. On 9/25/12, weight of 87.6 pounds and transferred to (a geriatric psych hospital), returning to the facility on [DATE], with the same documented weight of 87.6 pounds. On 10/23/12, weight of 83 pounds. (18 pound loss from 4/2/12 until 10/23/12 = 17.8 % in just over 6 months.) physician's orders [REDACTED]. The October, 2012, MAR (medication administration record), revealed staff failed to document the house supplement as given following the resident's hospitalization return on 10/13/12, as ordered by the physician. On 10/31/12 at 8:21 AM, observation revealed the resident in the dining room in a regular dining room chair. At 8:32 AM, staff served the resident 120 cc (cubic centimeters) of orange juice. At 8:36 AM, the resident was drinking 120 cc of a house supplement. A plate in front of the resident held a pancake and syrup, however, the resident did not start to eat it. At 8:43 AM, direct care staff U sat beside the resident and assisted the resident to drink the orange juice and 1 bite of the pancake. At 8:52 AM, dietary staff C removed the uneaten pancake and served the resident an english muffin with cheese and sausage. At 8:53 AM, direct care staff U placed 1/4 of the sandwich in the resident's left hand and encouraged the resident to eat. At 9:06 AM, the resident began coughing at intervals. At 9:30 AM, the resident remained in the dining room and had eaten only about 1/4 of the sandwich. The diet card with the meal documented a diet of, "Regular." At 9:36 AM, consultant therapy staff EE applied a gait belt to the resident and assisted the resident to walk from the dining room to the therapy room. The staff failed to provide the resident with double portions of this breakfast meal. On 10/31/12 at 12:15 PM, the resident sat at the dining room table in a regular dining room chair. At 12:35 PM, resident remained at the table and not served. At 12:50 PM, staff served the resident glasses of water and cranberry juice. Dietary staff GG asked the resident what he/she wanted to eat. At 12:51 PM, staff served the resident a ham and cheese sandwich. At 12:57 PM, direct care staff T provided the resident a 120 cc house supplement and gave the resident 1/2 of the sandwich. At 1:07 PM, the resident ate 1/2 the sandwich and all of juice. At 1:15 PM, consultant therapy staff HH sat down beside the resident and encouraged the resident to eat the sandwich. At 1:35 PM, consultant staff HH applied a gait belt and walked the resident from the dining room. However, no other staff provided or offered the resident a dessert or anything else to eat, prior to leaving the dining room. The staff failed to provide the resident with any breakfast foods during this mealtime. On 11/1/12 at 7:48 AM, observation revealed the resident in the dining room at the table, with a bacon and fried egg sandwich, crust removed, glasses with water and orange juice in front of the resident. OT (occupational therapy) staff sat beside the resident. At 8:14 AM, the resident remained in the dining room and had eaten 1/2 of the sandwich. At 8:40 AM, the resident remained in the dining room, with only 1/2 of the sandwich eaten, but had drank all of the juice and half of the water. Resident held (the resident's) head in (the resident's) left hand. At 9:01 AM, the resident remained in the dining room, and appeared asleep. The resident drank all of the water but had had not eaten any more of the sandwich. At 9:12 AM, direct care staff G applied a gait belt to the resident and assisted the resident to walk from the dining room to the bathroom. The staff failed to provide the resident with the double portions during this breakfast meal. On 10/31/12 at 7:58 AM, licensed nursing staff V reported the resident is losing some weight and needs encouragement to eat. The resident's speech is garbled. "If we offer (the resident) something in the evening, (the resident) will eat a sandwich sometimes. (The resident) is on house supplement TID (three times per day) and [MEDICATION NAME] (medication appetite stimulant)." On 11/1/12 at 7:42 AM, dietary staff BB, when asked if any resident is planned to have double portions at breakfast, stated, "If they ask they can have it." Also, at that time, dietary staff GG stated the residents could have double portions if they ask. The previous observations of the resident's meals, revealed the staff failed to provide the resident with double portions at breakfast. On 11/1/12 at 10:55 AM, direct care staff D reported when questioned, if staff D had provided the resident any snacks this morning, (staff D) stated, "(The resident) had a late breakfast. (The resident) nibbles. (The resident) has not been eating well. We don't force (the resident) to eat. Sometimes (the resident) will eat crackers. Most of the residents eat during activities and go to the dining room. Not sure about any weight loss." On 11/2/12 at 11:55 AM, licensed nursing staff M stated prior to going to the hospital and even now, the resident does not eat well. It looks like the resident lost weight leaving and coming back. The resident enjoys pancakes, is on [MEDICATION NAME] at one time. The resident wouldn't take medicine at times. The family and doctor are aware of it, and the resident is on a supplement. On 11/2/12 at 4:00 PM, licensed nursing staff B and R reported feeling they were on top of their residents with weight loss, as the facility conducted weekly meetings and just had a meeting this morning. Staff B stated they had discussed this resident's weight loss in the weekly weight meeting and then planned to serve the resident double portions at breakfast as that was the best meal the resident ate. When asked staff B why the resident was not getting double portions at breakfast, staff B did not have an explanation. The facility failed to ensure this resident received the planned interventions of double portions of breakfasts, and breakfasts food at all meals, to improve the resident's nutritional status and maintain body weight. The resident sustained [REDACTED].