Every finding on record at Medicalodges Leavenworth

Based on observation, record review, and interviews, the facility failed to provide R1 with written decisions on the grievances he submitted. Findings included:- R1 admitted to the facility on [DATE]. Upon request, the facility provided R1's grievances for the last 60 days. Review of R1's grievances revealed the following: In a Report of Concern on 04/10/2026, R1 stated the nurse entered his room before 06:00 AM for medications and treatment with advanced knowledge that he was not to be disturbed between 11:00 PM and 06:00 AM, which had been in place since he was admitted . The facility continued to let that happen against R1's will. R1 wanted the facility's response in writing on that grievance and all matters. The Report of Concern documented corrective actions taken, included notifying R1 he would not be getting a written response. R1's response was documented as dissatisfied. In a Report of Concern on 04/13/2026, R1 stated he wanted daily baths from that point forward in the facility's shower room and he requested a written response from the facility. The Report of Concern documented corrective actions taken, included informing R1 he would not be getting a written response from the facility. In a Report of Concern on 05/21/2026, R1 stated he did not receive his scheduled shower on Thursday, which was not the agreement that was set forth and he requested a written response from the facility. The Report of Concern second page, which had boxes for the outcome of the investigation, corrective actions taken, and contacts during the investigation, was blank. On 06/10/2026 at 01:39 PM, R1 laid in bed. He stated he requested written responses to his grievances, but he had never received one. On 06/10/2026 at 03:28 PM, Social Services X stated when a resident filed a grievance, she made copies to give to the appropriate department and Administrative Staff A then logged it on the grievance log. She stated she followed up with the appropriate department to see if they addressed the situation then put the response on the log. She stated she let the resident know what the response was and if they wanted a written response, she typically gave them the written response. Social Services X stated she used to give R1 a written response until she was told not to. She stated she was aware it was a resident right to receive a written response. On 06/10/2026 at 03:41 PM, Administrative Staff A stated when a resident filed a grievance, Social Services X gave the grievance to him and Administrative Nurse D. He stated the grievance was addressed in person or in writing and the grievance log documented whether it was remediated or not. He stated residents received written or verbal summations of the grievance decision. Administrative Staff A stated if a resident had the same grievance over and over again then the facility did not always provide a written response. He stated he did not know it was a resident right to receive a written decision on their grievance. The facility's Grievance Policy and Procedure, revised March 2024, directed the resident had a right to obtain a written decision regarding his or her grievance.

The facility identified a census of 37 residents, with three residents reviewed for misappropriation of resident property (a form of Abuse). Based on record review, observations, and interviews, the facility failed to protect one cognitively impaired resident (R1) from misappropriation of funds. On 07/21/25, it was discovered that Administrative Staff C downloaded R1's credit card account information to their cell phone to make purchases for R1. Administrative Staff C later admitted to purchasing items on R1's card account for themselves. This deficient practice placed R1, a cognitively impaired resident, in immediate Jeopardy, causing R1 emotional distress and a monetary loss of approximately $6000.00. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had a diagnosis of Alzheimer's disease (a common form of dementia characterized by gradual loss of memory, thinking, and reasoning skills).R1's Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 3, which indicated R1 had severely impaired cognition. R1 used a wheelchair for ambulation and required some staff assistance with most activities of daily living (ADL), due to physical limitations. R1's Cognition Care Area Assessment (CAA) dated 01/03/25, recorded R1 could not always tell the difference between what was real and what was a hallucination. When this happened, staff were to stay with the resident and reassure R1 the staff would keep R1 safe.R1's Care Plan, revised 07/14/25, documented R1 had a potential for increased memory loss, due to visual and auditory hallucinations, and other medical conditions. A facility reported incident received on 7/21/25 at 02:19 PM recorded a facility staff member (Administrative Staff C) informed Administrative Staff A, that she [Administrative Staff C] had attached R1's credit card/debit information to her [Administrative Staff C] phone to make purchases for R1, but forgot to remove the card from her phone, which resulted in a charge to R1's account the next time Administrative Staff C used the card for a personal purchase. The report documented Administrative Staff A reviewed R1's bank account statement and discovered several suspicious charges. Administrative Staff A suspended Administrative Staff C and directed her to leave the building and notified law enforcement. The facility investigation lacked documentation regarding the amount of money charged to R1's account. The report also lacked documentation regarding when the personal charges began. A review of R1's account revealed suspicious charges exceeding $5,987.14 noted since February 2025, with most occurring in July 2025. A non-notarized Witness Statement, documented Social Services X delivered R1's mail, and R1 asked Social Services X to open it (a bank statement), because R1 wanted to know the amount in the account. Looking at the account, Social Services X noticed several transactions that did not look like R1's; several were from another town (the town in which Administrative Staff C resided) and Administrative Staff C had R1's credit card in her office. Social Services X asked Administrative Staff C if she used R1's card. Administrative Staff C told Social Services X R1's card info was on her phone, and stated she might have accidentally used it a few times. Social Services X told Administrative Staff C there were more than a few times noted on the bank statement. Social Services X told Administrative Staff C to tell Administrative Staff A. Administrative Staff C begged Social Services not to say anything. On 07/20/25, Social Services X told Administrative Staff C it was not right, and Social Services X would allow Administrative Staff C to tell Administrative Staff A. Administrative Staff C sent Social Services X a message noting Administrative Staff C told Administrative Staff A. On 07/21/25, Administrative Staff A and Social Services X spoke about the incident, and Social Services X provided Administrative Staff A with the bank Statement. A notarized Witness Statement, documented Administrative Staff C ordered food, groceries, and anything R1 needed on Administrative Staff C's phone, because R1's phone stopped working, and Administrative Staff C could not order it on her desktop. When Administrative Staff C went to get a new phone, Administrative Staff C realized she still had R1's card on her phone and never deleted it. Administrative Staff C usually ordered whatever R1 requested, whether Administrative Staff C went and got it or had it delivered. Administrative Staff C forgot to delete the card, ‘a big mistake'. Administrative Staff C took R1 to purchase a new phone as well as catch up on R1's bill and pay off R1's old phone so R1 could have a new working phone. Administrative Staff C always did R1's orders for Walmart, Dillions, DoorDash, and other stores. Administrative Staff C would take money out for R1's (account) and put it in R1's lock box, so R1 would have money on hand. Administrative Staff C would exchange his money for smaller bills, per R1's request, whenever R1 wanted snacks and other items. R1 would gave Administrative Staff C a list, or R1 would come to Administrative Staff C's office and tell her what R1 would like from the store. Many times, R1 would have Administrative Staff C order R1 food from the restaurant and either have it delivered to the facility, as well as go and pick it up for R1 once he placed his order. R1 would sign for his checks, and R1 and Administrative Staff C made sure his bills were paid. Once Administrative Staff C realized R1's card was on her phone, Administrative Staff C immediately deleted it and reported herself to Administrative Staff C. Observation on 07/29/25 at 10:45 AM revealed R1 sat in a wheelchair in his room, dressed appropriately, alert, responding appropriately, pleasant, and cooperative. Interviewed on 07/29/25 at 10:45 AM, R1 stated (regarding unknown charges to his account) he blamed the facility for not overseeing their employees. R1 said, the Poor girl just succumbed to temptation because nobody was watching. R1 said the facility would order things from the store and kept R1's credit card number on file, and the facility staff used that number on file. R1 discovered a reimbursement check from Administrative Staff C and stated R1 did not know he got a check. R1 stated he heard various amounts were charged to his account; $2,500 dollars (partial reimbursement amount) and $10,000. R1 did not know anything about the facility cutting a check like that. R1 thought the facility was still adding everything up. R1 hated to see that girl (Administrative Staff C) go because he liked her. As far as R1 knew, the facility was looking into it. The facility stopped asking R1 questions, and he assumed the facility knew what was happening. R1 revealed he asked the facility how they caught the charges, but they did not tell R1. The facility said they spotted some things in the record, but R1 did not know and hoped the police knew. R1 did not know what the facility was going to do. The facility took care of R1's bills and had access to all of his accounts. R1 did not even have money to go to the vending machines and buy a soda. R1 just lived off the kindness of others. R1 was unsure if the facility had a Resident Funds Account. R1 stated the facility had bottomless access to his bank account.During an interview on 07/29/25 at 11:17 AM, Administrative Staff A stated R1 was his own responsible party and believed he was writing checks to cover his monthly facility liability. Administrative Staff A expressed unawareness that a staff member used the resident's credit card, until informed by Administrative Staff C and Social Services X. Administrative Staff A stated Administrative Staff C was immediately suspended, the Police were notified and met with R1, and R1 wanted charges pressed against Administrative Staff C. Administrative Staff A stated Administrative Staff C did make a partial reimbursement to the resident account in the amount of $2,500.00 dollars on 07/21/25 (copy in file). However, after reviewing R1's bank statement, Administrative Staff A stated the charges Administrative Staff C admitted to did not appear to be the truth, after 50 plus charges, the accidental went out the window. Administrative Staff A did not know the total amount charged to R1's account. We know what Administrative Staff C admitted to and what she admitted to exceeded $10,000 dollars.During an interview on 07/29/25 at 12:11 PM, Social Services X stated that on Friday, 07/18/25, she delivered R1's mail and bank statement. R1 asked Social Services X to open it, and she noticed some transactions which were clearly not R1's: casino, coffee shop, nail salon charges, and some restaurants in another town. Social Services X knew Administrative Staff C went to the casino and lived in the same local town. Social Services X confronted Administrative Staff C, and Administrative Staff C said R1 wanted her to go get something from the store, and Social Services X said No, come here. Social Services X questioned Administrative Staff C if she had used R1's account, and Administrative Staff C said NO. Social Services C said, I have the statement that suggests otherwise. Then, Administrative Staff C said she put credit card information into her phone to purchase online items, and noticed she used R1's credit card a couple of times. Social Services X said Administrative Staff A needed to know, and Administrative Staff C begged Social Services X not to tell. Social Services X said she had to do what was right and noted Administrative Staff C was crying and Social Services X was in disbelief. Social Services X told Administrative Staff C they allow them to let Administrative Staff A know. On Monday (07/21/25) Social Services X had a feeling Administrative Staff C had not told Administrative Staff A, so Social Services X told Administrative Staff A and provided R1's banking statement. Administrative Staff A and Social Services X spoke to R1. On 07/23/25, Social Services X filed an APS report # 2613920. On 07/29/25 at 01:01 PM, Administrative Staff C could not be reached via phone for an interview.During an interview on 07/29/25 at 03:30 PM, Administrative Nurse D stated she did not immediately know of the occurrence but noted it was not facility policy regarding resident personal financial information on a staff member's personal cell phone. The facility's Abuse, Neglect, and Exploitation Policy (ANE), revised [DATE], documented: The residents' right to be free from abuse, neglect, or exploitation, and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The facility ANE policy defined misappropriation of resident property as the patterned and deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy includes necessary elements for screening, training employees regarding Abuse, as well asl methods of prevention, identification, investigation, protection of residents during investigations, and reporting. This same facility policy included a copy of the Elder Justice Act (EJA) in reporting reasonable suspicion of a crime. A printed addendum to the facility policy titled Facility Review of ANE policy documented it was never okay to take funds, or gifts from an resident; staff should not order or purchase items for a resident, or have a residents credit card or any information in your phone, this includes food delivery, direct from a restaurant, uber eats, or Door dash. Staff could not take funds from a resident to purchase items on their behalf, review of the abuse and neglect policy documented it is strictly prohibited to accepts funds or gifts from a resident, employees were not permitted to order or purchase items for a resident, nor should staff possess a residents financial cards or personal information on their electronic devices,, under no circumstances may an employee accept funds form a resident to purchase items on their behalf, and failure to follow company policy and federal regulations will result in immediate corrective action up to and including termination. On 07/29/25 at 04:14 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to protect a cognitively impaired resident from misappropriation of funds and financial which caused R1 to suffer emotional distress and financial loss of approximately $6000.00, placing R1 in immediate jeopardy.The facility implemented immediate corrective actions, which included the following: On 07/21/25, Administrative Staff C was immediately suspended and subsequently terminated. On 07/21/25, an audit of all resident accounts was performed, and no other concerns were noted. On 07/21/25, a meeting with R1 was held wherein the matter was discussed and the facility offered, and R1 accepted counseling to cope with feelings of betrayal and loss of trust. On 07/21/25, the door code was changed to Administrative Staff C's office, and all keys were reclaimed from Administrative Staff C. R1's credit card was returned to him, and the facility took R1 to his bank, where a new, uncorrupted card was issued to him. On 07/21/25, the facility conducted an all-staff in-service regarding the facility ANE policy, timely reporting (of incidents) policy, and review of the Elder Justice Act, with employee signatures of attendance. On 07/22/25, the facility notified law enforcement, who responded and met with R1, and an ongoing criminal investigation began. On 07/25/25, the facility held an impromptu resident council meeting to inform residents there was no gifting of, or sharing of, sensitive information. Due to the corrective actions completed on 07/25/25, before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility identified a census of 34 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care. Findings included: - The facility's January, February, March, and April 2024 nursing schedule lacked evidence of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 02/10/ 24, 02/11/24, 03/09/24, 03/10/24, and 03/22/24. The facility was unable to provide verifiable, auditable evidence of RN coverage. On 09/24/24 at 02:45 PM Administrative Staff C stated the previous director of nursing was the RN coverage for those dates. Administrative Staff C stated the director of nursing was a salaried employee, and she had no documentation to provide to show evidence of her working eight consecutive hours. The facility was unable to provide a policy related to RN coverage. The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week, as required. This placed the residents who resided in the facility at risk of lack of assessment and inappropriate care.

The facility had a census of 34 residents. The sample included 12 residents and three Certified Nurse Aides (CNA) were reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure three of the three CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA Q, hired on 06/30/22, had no yearly performance evaluations upon request. CNA R, hired on 03/22/19, had no yearly performance evaluations upon request. CNA MM, hired on 02/08/22, had no yearly performance evaluations upon request. On 09/25/24 at 02:45 PM, Administrative Staff C stated the facility was unable to find any performance evaluations or the required in-service records for the above-mentioned staff. The facility did not provide a policy related to staff competency, staff training, or performance evaluation. The facility failed to ensure three CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 34 residents and one kitchen. Based on interview and record review, the facility failed to provide the services of a full-time certified dietary manager for the 34 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 09/23/24 at 08:13 AM Dietary Staff BB stated he had not started the classes to become the Certified Dietary Manager. Dietary Staff BB stated he was trying to get into a dietary manager's class. He stated the Registered Dietician comes every month, and he was able to notify the Registered Dietician by E-Mail, with changes to diets or menus. On 09/24/24 at 01:10 PM Administrative Staff B stated the facility did not have a Certified Dietary Manager; she stated the dietary manager was enrolled in class. The facility did not provide a policy for a Certified Dietary Manager. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 34 residents in the facility, placing the residents at risk for inadequate nutrition.

The facility identified a census of 34 residents. Based on record review and interviews, the facility failed to designate a staff member employed by the facility at least part-time, with the required qualification and certification as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking, trending, and treatment of infections. Findings included: - During the entrance conference on 09/23/24 at 07:17 AM, Administrative Staff C stated she was acting as the Infection Preventionist (IP) for the facility. She stated she had been onsite in the facility for 45 days. On 09/24/24 at 09:55 AM Administrative Nurse A stated the facility does not have an Infection Prevention person at this time. She stated Administrative Nurse C, a consultant who was not employed directly by the facility, had been conducting the IP duties at this time. The facility's Infection Control Surveillance policy documented the Infection Preventionist was to restore, promote, and maintain the health of the residents while acting as a liaison and source person for all infection control and management activities. The facility failed to designate a staff member employed by the facility at least part-time, who had the required qualification and certification as an Infection Preventionist to be responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking, trending, and treatment of infections.

The facility had a census of 34 residents. Three Certified Nurse Aides (CNAs) were sampled for required in-service training hours. Based on record review and interview, the facility failed to ensure one of the three CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and inadequate care. Findings included: - A review of the information facility's in-service records revealed the following: CNA Q, hired 06/30/22, had not completed any of the required in-services in the past 12 months. On 09/24/24 at 02:45 PM, Administrative Staff C verified CNA Q had not completed the 12-hour required in-services. On 09/25/24 at 01:45 PM Administrative Staff B stated yearly performance reviews were one of the items the new management team was going to work on improving the process. The facility was unable to provide a policy related to staff training. The facility failed to ensure one of the three CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and inadequate care.

The facility identified a census of 34 residents. The sample included 12 residents. The facility identified one medication room and two medication carts, one with scheduled medication and one with narcotics and treatments. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This deficient practice placed the residents at risk for misappropriation and/or diversion of controlled substances. Findings included: - On 09/24/24 at 07:55 AM a review of the July, August, and September 2024 Controlled Medication Shift Count Sheet revealed missing signatures for the on-coming nurse on 07/05, 0714, 07/18, 07/19, 07/20, 07/21, 07/25, 08/01, 08/03, 08/04, 08/07, 09/01, 09/03, 09/07, 09/10, 09/12, 09/16, 09/17, 09/18, 09/20, and 09/21. On 09/24/24 at 07:55 AM, a review of the July, August, and September 2024 Controlled Medication Shift Count Sheet revealed missing signatures for the off-going nurse for 07/06, 07/15, 07/19, 07/20, 07/21, 07/25, 08/01, 08/03, 08/04, 09/03, 09/07, 09/13, 09/17, 9/19, 09/20, and 09/21. On 09/24/24 at 07:59 PM, Licensed Nurse (LN)G stated the procedure for the facility was that nurses were to count the narcotics on their cart with every shift change. On 09/25/24 at 12:41 PM, Administrative Nurse D stated he expected the nurses to count narcotics every time the keys changed hands. The facility's Medication Storage Controlled Medication Storage dated 01/24 documented medications included in the Drug Enforcement Administration or state classification as controlled substances are subject to special handling, storage, disposal, and record-keeping in the nursing care center by federal, state, and other applicable laws and regulations. The facility failed to ensure an accurate reconciliation of controlled medications was completed. This placed residents at risk of medication misappropriation and diversion.

The facility identified a census of 34 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and two residents on transmission-based precautions (TBC-safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility failed to sanitize shared equipment between use. The facility further failed to ensure staff performed adequate hand hygiene, and failed to ensure respiratory equipment was stored in a sanitary manner when not in use. These deficient practices placed the residents at risk for infectious diseases. Findings included: - An initial walkthrough of the facility was completed on 09/23/24 at 07:03 AM. An inspection of Resident (R)22 ' s room revealed no protective equipment (PPE) readily available for EBP. R22 had no signage or indicators R22 was on EBP. R22 had a wound with a wound vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal). An inspection of R4's room revealed no PPE readily available for EBP. R4 had no signage or indicators R4 was on EBP. R4 had an open wound. An inspection of R136's room revealed no PPE readily available for EBP. R136 had no signage or indicators R136 was on EBP. R136 had an open wound. An inspection of R3's room revealed no readily available PPE for EBP. R3 had no signage or indicators R3 was on EBP. R3 had a suprapubic catheter (a tube surgically inserted in the bladder through the abdomen to drain urine) and an open wound. An inspection of R11's room revealed no PPE readily available for EBP. R11 had no signage or indicators R11 was on EBP. R11 had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). On 09/24/24 at 09:20 AM R18's oxygen nasal cannula was draped over the bed rail, and not contained in a sanitary container. On 09/25/24 at 07:03 AM Certified Nurse Aide (CNA) M and CNA P performed hand hygiene and donned a clean pair of gloves upon entering R26's room who was on enhanced barrier precautions related to his urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). CNA M and CNA P did not don a gown while performing catheter care for R26. On 09/25/24 at 08:12 AM Certified Nurse's Aide (CNA) 0 donned gloves to clean R4's front peri-area. CNA N helped CNA O roll R4 to clean R4's buttocks. CNA O doffed gloves, and then donned clean gloves but did not perform hand hygiene. CNA O helped CNA N put R4 in her wheelchair with the Hoyer (total body mechanical lift). CNA O did not perform hand hygiene after peri care, or after putting R4 in her wheelchair. CNA O pushed the Hoyer lift to the hallway and walked to the nursing desk without disinfecting the Hoyer lift. On 09/25/24 at 12:41 PM Administrative Nurse D stated all signs should be on the outside of residents ' rooms that require EHB, and the expectation was for staff to wear the PPE which was indicated for each resident. Administrative Nurse D stated hand hygiene should be done when walking into residents ' rooms, from clean to dirty, and leaving residents ' rooms. Administrative Nurse D stated respiratory equipment should be contained in a bag and should be dated. The facility's Infection Control Surveillance documented the facility was to restore promote and maintain the health of the residents. The facility would provide a sanitary environment to prevent the development and transmission of diseases and infections. The facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility failed to sanitize shared equipment between use. The facility further failed to ensure staff performed adequate hand hygiene, and that respiratory equipment was stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 34 residents. The sample included 12 residents with three residents reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 26 had an anchor for his suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder)on his abdomen per standards of practice to prevent pulling and injury. This deficient practice placed R26 at risk for catheter-related complications. Findings included: - R26's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of urinary retention (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), need for assistance with personal care, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R26 had an indwelling catheter during the observation period. The MDS documented R26 required partial to moderate assistance with toileting hygiene. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R26 had an indwelling catheter during the observation period. The MDS documented R26 was independent with toileting hygiene. R26's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/06/23 documented he had an indwelling catheter and required staff assistance with toileting hygiene and transfers for toileting. R26's Care Plan dated 12/06/22 documented that staff provided catheter care every shift. The plan of care documented that staff would ensure he had a catheter stat-lock on his leg to prevent injury or pulling of the catheter. R26's EMR under the Orders tab revealed the following physician orders: Indwelling catheter French 18 with a five-milliliter (ml) bulb dated 04/08/23. Bactrim DS (antibiotic) oral tablet 800-160 milligrams (mg) (sulfamethoxazole-Trimethoprim) give one tablet by mouth two times a day for seven days related to urinary tract infection (UTI-an infection in any part of the urinary system) dated 09/17/24. On 09/25/24 at 07:03 AM R26 sat in his recliner with his dependent catheter drainage bag with dark amber urine attached to his wheelchair next to the recliner. Certified Nurse Aide (CNA) M and CNA P provided catheter care for R26's suprapubic catheter. R26 stated he did not have a catheter stat-lock at that time. R26 stated the catheter stat-lock was usually placed on his inner left leg and would not stay in place because the catheter tubing was always pulling the stat-lock loose. On 09/25/24 at 07:15 AM, CNA P stated she would apply the stat-lock after she clarified the placement with the charge nurse. On 09/25/24 at 12:32 PM, Licensed Nurse (LN) G stated catheter care was provided every shift. LN G stated a suprapubic catheter's stat-lock should be placed on the abdomen to prevent pulling on the catheter tube. On 09/25/24 at 12:42 PM, Administrative Nurse D stated he expected there to be a stat-lock placed on the resident's abdomen for a suprapubic catheter to prevent any injuries from the tubing being pulled or dislodged. The facility was unable to provide a policy related to catheter care. The facility failed to ensure the standard of practice was followed for the placement of an anchor for R26's suprapubic catheter tubing on his abdomen to prevent pulling or injury. This deficient practice placed R26 at risk for catheter-related complications.

The facility identified a census of 34 residents. The sample included 12 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident(R) 27's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask and nasal cannula was stored in a sanitary manner. This placed R27 at an increased risk for respiratory infection and complications. Findings included: - R27's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of pressure-induced deep tissue damage of left heel, reduced mobility, need for assistance with personal cares, muscle weakness, obesity, osteomyelitis (local or generalized infection of the bone and bone marrow), hypertension (HTN-elevated blood pressure), sleep apnea (a disorder of sleep characterized by periods without respirations), and ), depression (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R27 required a non-invasive mechanical ventilator. The MDS documented R27 was dependent on staff for all activities of daily living (ADLs) except eating. R27's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 03/15/24 documented R27 required staff assistance for all ADLs due to impaired balance and transition during transfers. The CAA documented R27 had an ADL decline, due to falls, incontinence, and skin breakdown. R27's Care Plan dated 03/29/23 documented R27 had sleep apnea and used a C-PAP at night. The nurse staff was to change and clean the filters on the CPAP per recommendations. R27's plan of care documented nursing staff was to clean the mask, headgear, and tubing weekly. R27's plan of care documented nursing staff was to ensure R27's mask was in place at night, had a leak-free seal, and was set at 12 liters of continuous oxygen during bedtime. Staff were to assist R27 with donning and doffing the CPAP. R37's EMR under the Orders tab revealed the following physician orders: Clean C-PAP mask, filter, and machine, rinse tubing and rinse and refill humidifier bottle if applicable every Wednesday dated 08/28/24. CPAP at 12 continuous at bedtime related to sleep apnea dated 03/29/24. On 09/23/24 at 07:29 AM, R27 sat up in his bed playing on his laptop. R27's CPAP mask was laid on the bedside table, not in a sanitary container. On 9/24/24 at 08:09 AM R27 sat up in his bed reading on his laptop. R27's CPAP mask was laid on his bedside table, and R27's CPAP was not stored in a sanitary container. On 09/25/24 at 12:24 PM, Certified Nurse's Aide (CNA)M stated all respiratory equipment should be stored in a plastic bag with the date on the bag. On 09/25/24 at 12:30 PM, Licensed Nurse (LN)G stated all respiratory equipment was stored in a plastic bag, the bag is dated and changed weekly. On 09/25/24 at 12:41 PM, Administrative Nurse D stated respiratory equipment was stored in a container or bag. He stated respiratory tubing was dated and changed weekly and all respiratory masks were to be contained. The facility did not provide a policy related to the care and sanitary storage of respiratory equipment. The facility failed to ensure R27's CPAP mask was stored in a sanitary manner. This placed R27 at increased risk for respiratory infection and complications.

The facility identified a census of 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the medication regimen review (MRR) was addressed by the physician for Resident (R) 3 and R26. The facility also failed to ensure the Consultant Pharmacist (CP) identified and recommended a gradual dose reduction (GDR) for R3's psychotropic (alters mood or thought) medications. The facility further failed to ensure the CP identified and reported irregularities for R9's non-Center for Medicaid and Medicare (CMS) approved indication for an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and lack of physician documentation for ongoing use without a gradual dose reduction (GDR)attempted. These deficient practices placed the residents at risk for unnecessary medication use, side effects, and physical complications. Findings included: - R3's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), mild cognitive impairment, cognitive-communication deficient, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R3 had received an antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), hypnotic (a class of medications used to induce sleep), and opioid (a class of controlled drugs used to treat pain) during the observation period. The MDS documented no gradual dose reduction, or a drug regimen review was completed during the observation period. R3's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/06/24 documented he refused his medication at times. R3's Care Plan dated 09/22/22 documented the pharmacist would review R3's medication monthly and as needed. R3's EMR under the Orders tab revealed the following physician orders: Ambien (hypnotic) tablet 10 milligrams (mg) (Zolpidem Tartrate) give one tablet by mouth at bedtime for difficulty sleeping 10/14/22. A review of R3's Monthly Medication Review (MMR) from September 2023 through August 2024 revealed the MMRs dated 05/09/24, 06/26/24, and 07/15/24 lacked evidence that the physician had reviewed or addressed the CP's recommendations. The MMRs lacked evidence the CP had identified and recommended a GDR for R3's hypnotic medication Ambien. The facility was unable to provide evidence of physician documentation of the CP's recommendations and physician documentation of the continued use of Ambien. On 09/23/24 at 02:56 PM, R3 sat with his eyes closed in his wheelchair at the table in the smoking room. On 09/25/24 at 12:32 PM, Licensed Nurse (LN) G stated she would expect the consultant pharmacist to identify when a GDR was needed. LN G stated she would then notify the physician of any changes that needed to be made. On 09/25/24 at 12:45 PM, Administrative Staff C stated she was unable to locate the physician's responses for the CP's recommendations for several months after the previous director of nursing had left the facility. Administrative Staff C stated she had started in August 2024 to address the CP's MMR with the physician. The facility's Medication Regimen Review and Reporting policy dated 01/2024 documented Medication Regimen Review (MRR) or Drug Regimen Review was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes, minimizing adverse consequences, and potential risks associated with medication. The MRR included a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involved collaborating with other members of the interdisciplinary team (IDT), including the resident, their family, and/or the resident's representative. The facility failed to ensure the CP identified and recommended a GDR for R3's Ambien. The facility also failed to ensure the physician had reviewed and addressed the CP's MMRs for R3. This placed R3 at risk for unnecessary medication administration and possible adverse side effects. - R26's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of urinary retention (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), need for assistance with personal care, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R26 had received an antidepressant (a class of medications used to treat mood disorders), insulin (a hormone that lowers the level of glucose in the blood), and an opioid (a class of controlled drugs used to treat pain) medication during the observation period. The MDS documented that a medication regimen (MRR) was not completed during the observation period for R26. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R26 had received an antidepressant medication, insulin, and opioid medication during the observation period. The MDS documented a MRR was not completed for R26 during the observation period. R26's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/06/23 documented he had received high-risk medications. R26's Care Plan dated 12/06/22 documented the pharmacist would review his medications monthly and as needed. The plan of care documented the pharmacist, and the physician would review R26's medications per facility protocol and as needed. A review of R26's Monthly Medication Review (MMR) from September 2023 through August 2024 revealed the MMRs dated 02/14/24, 03/07/24, and 06/26/24 lacked evidence that the physician had reviewed or addressed the CP's recommendations. The facility was unable to provide evidence of physician documentation of the CP's recommendations. On 09/24/24 at 07:59 AM R26 propelled himself into the dining room in his wheelchair. On 09/25/24 at 12:32 PM, Licensed Nurse (LN) G stated she would expect the consultant pharmacist to identify when a GDR was needed. LN G stated she would then notify the physician of any changes that needed to be made. On 09/25/24 at 12:45 PM, Administrative Staff C stated she was unable to locate the physician's responses for the CP's recommendations for several months after the previous director of nursing had left the facility. Administrative Staff C stated she had started in August 2024 to address the CP's MMR with the physician. The facility's Medication Regimen Review and Reporting policy dated 01/2024 documented Medication Regimen Review (MRR) or Drug Regimen Review was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes, minimizing adverse consequences, and potential risks associated with medication. The MRR included a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involved collaborating with other members of the interdisciplinary team (IDT), including the resident, their family, and/or the resident's representative. The facility failed to ensure the CP's monthly recommendations had been reviewed or addressed by the physician for R26. This deficient practice placed R26 at risk for unnecessary medications and adverse side effects. - R9's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and cognitive communication deficit. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented that R9 had received antipsychotic medication and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. The MDS documented no GDR was completed during the observation period for R9. The Quarterly MDS dated [DATE] documented a BIMS score of one which indicated severely impaired cognition. The MDS documented that R9 had received antipsychotic medication and antidepressant medication. The MDS documented no GDR was attempted during the observation period. R9's Psychotropic Drug Use Care Area Assessment (CAA) dated 03/13/24 documented she had received psychotropic medication and that the physician and the pharmacist would review her medication. R9's Care Plan dated 03/13/24 documented the pharmacy and the physician would consult to consider a dose reduction when clinically appropriate. R9's EMR under the Orders tab revealed the following physician orders: Risperdal (antipsychotic) tablet (risperidone), give 0.25 milligram (mg) by mouth three times a day related to bipolar disorder dated 05/06/24. A review of R9's Monthly Medication Review (MMR) from September 2023 through August 2024 lacked evidence the CP identified and reported the lack of an approved CMS indication for R9's Risperdal. R9's clinical record lacked physician documentation of a rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Risperdal and for the continued use of psychotropic medication. The facility was unable to provide evidence of the above physician documentation. On 09/23/24 at 04:36 PM, R9 walked unassisted around the common area outside the dining room. On 09/25/24 at 12:32 PM, Licensed Nurse (LN) G stated she would expect the consultant pharmacist to identify when a GDR was needed. LN G stated she would then notify the physician of any changes that needed to be made. On 09/25/24 at 12:42 PM, Administrative Nurse D stated antipsychotic medication required a GDR and an approved indication for administration. Administrative Nurse D stated he would expect the consultant pharmacist to make the recommendation and the physician to review the recommendation and make any changes needed. The facility's Medication Regimen Review and Reporting policy dated 01/2024 documented Medication Regimen Review (MRR) or Drug Regimen Review was a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes, minimizing adverse consequences, and potential risks associated with medication. The MRR includes a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT, including the residents, their families, and/or resident representatives. The facility failed to ensure the CP identified and reported that R9 had a nonCMS-approved indication for use for antipsychotic medications. This placed R9 at risk for unnecessary medication administration and possible adverse side effects.

The facility identified a census of 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9 had a Center for Medicare and Medicaid Services (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) or the required physician documentation. The facility further failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale for R9 and R3. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects. Findings included: - R9's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and cognitive communication deficit. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented that R9 had received antipsychotic medication and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. The MDS documented no GDR was completed during the observation period for R9. The Quarterly MDS dated [DATE] documented a BIMS score of one which indicated severely impaired cognition. The MDS documented that R9 had received antipsychotic medication and antidepressant medication. The MDS documented no GDR was attempted during the observation period. R9's Psychotropic Drug Use Care Area Assessment (CAA) dated 03/13/24 documented she had received psychotropic medication and that the physician and the pharmacist would review her medication. R9's Care Plan dated 03/13/24 documented the pharmacy and the physician would consult to consider a dose reduction when clinically appropriate. R9's EMR under the Orders tab revealed the following physician orders: Risperdal (antipsychotic) tablet (risperidone), give 0.25 milligram (mg) by mouth three times a day related to bipolar disorder dated 05/06/24. R9's clinical record lacked physician documentation of a rationale for a non-approved CMS indication for the continued use of the antipsychotic medication Risperdal and for the continued use of psychotropic medication with no gradual dose reduction. The facility was unable to provide evidence of the above physician documentation. On 09/23/24 at 04:36 PM, R9 walked unassisted around the common area outside the dining room. On 09/25/24 at 12:32 PM, Licensed Nurse (LN) G stated she would expect the consultant pharmacist to identify when a GDR was needed. LN G stated she would then notify the physician of any changes that needed to be made. On 09/25/24 at 12:42 PM, Administrative Nurse D stated antipsychotic medication required a GDR and approved indication for administration. Administrative Nurse D stated he would expect the consultant pharmacist to make the recommendation and the physician to review the recommendation, and then any changes needed. The facility's Behavior Management and Psychotropic Medications policy last revised 12/2022 documented to enhance the quality of life through behavioral interventions minimized psychotropic medication use and off -label use of medication prescribed that affects brain activity and monitoring for adverse effects. Residents would be assessed for appropriate diagnosis, utilization, adverse effects, and target behaviors related to psychotropic medication use and off-label use of medication prescribed that affects brain activity. The Consultant Pharmacist was to complete a Medication Regimen Review monthly and provide information to the physician and facility regarding gradual dose reduction or continued use when indicated, an appropriate diagnosis, and monitoring of target behaviors. The facility failed to ensure R9 had a CMS-approved indication or the required physician documentation for use for antipsychotic medications without GDR attempts. This placed R9 at risk for unnecessary medication administration and possible adverse side effects. - R3's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), mild cognitive impairment, cognitive-communication deficient, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R3 had received an antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), hypnotic (a class of medications used to induce sleep), and opioid (a class of controlled drugs used to treat pain) during the observation period. The MDS documented no gradual dose reduction, or a drug regimen review was completed during the observation period. R3's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/06/24 documented he refused his medication at times. R3's Care Plan dated 09/22/22 documented the pharmacist would review R3's medication monthly and as needed. R3's EMR under the Orders tab revealed the following physician orders: Ambien (hypnotic) tablet 10 milligrams (mg) (Zolpidem Tartrate) give one tablet by mouth at bedtime for difficulty sleeping dated 10/14/22. R3's EMR lacked evidence a GDR was attempted or documented as contraindicated by the physician. On 09/23/24 at 02:56 PM, R3 sat with his eyes closed in his wheelchair at the table in the smoking room. On 09/25/24 at 12:42 PM, Administrative Nurse D stated a GDR should be attempted. The facility's Behavior Management and Psychotropic Medications policy last revised 12/2022 documented to enhance the quality of life through behavioral interventions to minimize psychotropic medication use and off label the use of medication prescribed that affects brain activity and monitoring for adverse effects. Residents would be assessed for appropriate diagnosis, utilization, adverse effects, and target behaviors related to psychotropic medication use and off-label use of medication prescribed that affects brain activity. The Consultant Pharmacist was to complete a Medication Regimen Review monthly and provide information to the physician and facility regarding gradual dose reduction or continued use when indicated, an appropriate diagnosis, and monitoring of target behaviors. The facility failed to ensure R3 had a GDR or the required physician documentation for the use of hypnotic medications without GDR attempts. This placed R3 at risk for unnecessary medication administration and possible adverse side effects.

The facility identified a census of 34 residents. The sample included 12 residents with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration regarding Resident (R) 8's care between the nursing home and the hospice 24 hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided to these residents by hospice. This deficient practice created a risk of missed opportunities for services and delayed physical, mental, and psychosocial needs for R8. Findings included: - R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and altered mental status. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R8 had received hospice care while at the facility during the observation period. R8's Pain Care Area Assessment (CAA) dated 09/04/24 documented R8 had reported he was in constant pain and required assistance with his activities of daily living. R8's Care Plan dated 10/30/23 documented the facility and the hospice provider would coordinate R8's care and services. The plan of care documented R8 wanted the staff to be aware of his code status. The plan of care dated 04/05/24 documented that the hospice provider's certified nurse aide (CNA) would visit twice weekly to assist R8 with bathing. The plan of care documented the hospice nurse would visit weekly. The plan of care lacked documentation regarding the medications covered by hospice and what personal care items were provided by hospice as well as the medical equipment provided by hospice. R8's EMR under the Orders tab revealed the following physician orders: Admit to hospice services dated 09/01/24. On 09/23/24 at 02:37 PM, R8 sat in his recliner next to his bedside table in his room. On 09/25/24 at 12:25 PM, Certified Nurse Aide (CNA) M stated would show up on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA M stated she was not sure if the Kardex listed the medical equipment that hospice had provided or which days the hospice CNA came to the facility to help R8 with bathing. On 09/25/24 at 12:32 PM, Licensed Nurse (LN) M stated everyone had access to the resident's care plans and the Kardex. LN G stated the resident's plan of care should contain the medical equipment hospice had provided, medication covered by the hospice provider, and frequency of visits for the hospice support staff. On 09/25/24 at 12:472 PM, Administrative Nurse D stated everyone had access to the resident's care plan or Kardex. Administrative Nurse D stated the plan of care should have the equipment and medication that the hospice provided for R8. The facility was unable to provide a policy related to the collaboration of care with the hospice provider. The facility failed to ensure a collaborative process was in place to communicate necessary information regarding R8's care between the nursing home and the hospice 24 hours a day, seven days a week including documentation of these communications, which had the potential for negative outcomes for R8.

The facility identified a census of 34 residents. The sample included 12 residents with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to implement pressure-reducing interventions for Resident (R) 16. This placed R16 at an increased risk for pressure ulcer development and worsening of present pressure ulcers. Findings included: - R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and myocardial infarction (heart attack and leukemia (malignant disease affecting bone marrow). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R16 was at risk for developing pressure ulcers. The MDS documented R16 had one or more unhealed pressure ulcers Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) or higher and a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters). The MDS documented R16 has a pressure-reducing device for his chair and a pressure-reducing mattress for his bed. The MDS documented R16 had impairments on both sides of his body and was dependent on staff for toileting. The MDS documented R16 needed substantial to maximum assistance rolling left to right. R16's Pressure Ulcer Care Area assessment dated [DATE] documented that R16 had pressure ulcer risk, with contributing factors that included urinary and bowel incontinence and decreased mobility. R16 required two staff substantial assistance with activities of daily living (ADLs) including transfers. R16's Care Plan dated 06/21/24 documented R16 was at risk for impaired skin integrity and pressure ulcer development related to impaired moisture-associated skin damage. Staff was to encourage eating, and padding was applied to R16's right foot pedal for protection, to enable his pressure wound to heal. R16's plan of care directed that his heels were to float on a pillow while he was in bed. R16's EMR under the Orders tab revealed the following physician's orders: Apply [NAME] (wound coverage dressing) gentle border dressing 3x3 to left heel daily, every day shift, for skin condition dated 06/20/24. Right heel apply Skin-prep (liquid skin barrier) daily dated 07/27/24. Coccyx (area at the base of the spine) /bilateral sacrum: cleanse with wound cleanser and apply house stock barrier cream every day shift, for wounds, and every two hours as needed for soiling dated 09/05/24. Clean left heel with wound cleanser, pat dry, apply calcium alginate (dressing which forms a soft, gel that absorbs when it comes into contact with wound exudate). Cover with a foam dressing dated 09/05/24. On 09/24 /24 at 01:24 AM, R16 lay on his back in bed. R16's heels lay directly on the mattress, and R16's blue foam boots lay on his bedside table. On 09/25/24 at 12:24 PM, Certified Nurse's Aide (CNA)M stated everyone had access to the care plan for each resident, she stated she could pull up Kardex (a nursing tool that gives a brief overview of the care needs of each resident) in the EMR to see what each resident needed for cares, CNA M stated if a resident needed something specific the CNAs would be told in the daily report before there shift started. On 09/25/24 at 12:30 PM, Licensed Nurse (LN)G stated all nursing staff had access to the care plans. LN G stated the CNAs can ask nursing, or log into the EMR and view the Kardex. LN G stated nursing usually communicated important information about a resident with the CNAs in daily reports. On 09/25/24 at 12:41 PM, Administrative Nurse D stated he was sure all nursing staff had access to the care plan and would be able to see that a resident needed his heels floated while in bed. The facility's 'Wound Prevention and Management policy revisited on 12/18 documented a systematic approach for identifying residents at risk for skin breakdown and developing interventions to decrease the incidence of residents who develop pressure ulcers while providing guidelines for optimal care to promote healing for residents with all identified skin alterations. The facility failed to ensure R16's heels were floating on a pillow while he was in bed. This placed R16 at increased risk for pressure ulcer development and worsening of the left heel pressure wound.

The facility identified a census of 35 residents. The sample included three residents reviewed for abuse and/or neglect. Based on record review, and interview the facility failed report an allegation of abuse to the State Agency (SA) for Resident (R)1 within the required timeframe. This placed R1 at risk for ongoing abuse and/or neglect. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of senile degeneration of brain, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and insomnia (inability to sleep). The Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility on [DATE]. Review of the Assessments tab recorded a Clinical Health Review completed on 08/22/23 which documented no skin concerns or discoloration. Review of the Tasks: Monitory Skin Observation completed 08/22/23 through 08/27/23 documented no red areas, discolorations or skin concerns. The Admission Progress Note dated 08/22/23 at 05:04 PM documented R1 arrived at the facility. R1's skin assessment documented her skin was warm, dry and intact upon admission. The Discharge Note dated 08/27/22 at 04:56 PM documented R1 discharged with family and had bruising noted to forearms. The progress notes lacked any event, agitation, or incident that indicated bruising could have occurred. The EMR lacked further documentation of description or measurements of the bruising noted to R1's forearms. The facility lacked any investigation or witness statements related to the bruising of unknown origin to R1's forearms. On 09/13/23 at 12:15 PM Licensed Nurse (LN) G stated when she discharged R, she noted the bruising on R1's forearm. LN G further stated that the bruising appeared to be around 10 to 12 hours old based on the coloring and it was on both of R1's forearms. LN G revealed that R1 was not combative and said she felt the staff nurses would have relayed in report if the residnet was combative. LN G stated she had never been told or heard that R1 had been combative or resistant of cares from staff. On 09/18/23 at 02:00 PM Administrative Nurse D stated that R1's bruise was technically an injury of unknown origin. Administrative Nurse D stated the situation was complicated and she attempted to investigate the bruising, but the concern was brought to her attention two weeks after R1 discharged . Administrative Nurse D had no explanation for missing the documentation about R1's bruised forearms. Administrative Nurse D stated R1's representative reported a concern about R1's bruised forearms on 09/05/23. Administrative Nurse D revealed she had not started an official investigation and had just recently got back with R1's family member on 09/15/23. Administrative Nurse D initially stated she did not report the event because she could not verify the bruising, but when asked if the allegations should have been reported to the SA, Administrative Nurse D stated it should have been. On 09/18/23 at 02:51 PM Administrative Staff A stated she learned R1 had a bruise on her arms when R1's representative informed Administrative Nurse D about the bruises a couple of weeks afterwards. Administrative Staff A revealed that she attempted to think of what could have happened to R1. Administrative Staff A said that when the bruise was brought up, it should have been investigated. Administrative Staff A further revealed that R1's bruising should have been reported to the SA. The facility's Abuse, Neglect and Exploitation revised 10/2022 documented it was a policy of the facility to keep residents free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The policy documented investigations are to be handled by Administrative Staff A or Administrative Nurse D. The investigation is to be thorough, timely and credible investigation of all incidents to rule out abuse, neglect, or misappropriately of funds or property. The facility failed to identify a report of bruising of unknown origin as an allegation of abuse and report to the SA as required. This placed R1 at risk for ongoing abuse and /or neglect.

The facility identified a census of 35 residents. The sample included three residents reviewed for abuse and/or neglect. Based on record review, and interview the facility failed to investigate bruising of unknown origin for Resident (R)1. This placed R1 at risk for unidentified and ongoing abuse and/or neglect. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of senile degeneration of brain, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and insomnia (inability to sleep). The Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility on [DATE]. Review of the Assessments tab recorded a Clinical Health Review completed on 08/22/23 which documented no skin concerns or discoloration. Review of the Tasks: Monitory Skin Observation completed 08/22/23 through 08/27/23 documented no red areas, discolorations or skin concerns. The Admission Progress Note dated 08/22/23 at 05:04 PM documented R1 arrived at the facility. R1's skin assessment documented her skin was warm, dry and intact upon admission. The Discharge Note dated 08/27/22 at 04:56 PM documented R1 discharged with family and had bruising noted to forearms. The progress notes lacked any event, agitation, or incident that indicated bruising could have occurred. The EMR lacked further documentation of description or measurements of the bruising noted to R1's forearms. The facility lacked any investigation or witness statements related to the bruising of unknown origin to R1's forearms. On 09/13/23 at 12:15 PM Licensed Nurse (LN) G stated when she discharged R, she noted the bruising on R1's forearm. LN G further stated that the bruising appeared to be around 10 to 12 hours old based on the coloring and it was on both of R1's forearms. LN G revealed that R1 was not combative and said she felt the staff nurses would have relayed in report if the residnet was combative. LN G stated she had never been told or heard that R1 had been combative or resistant of cares from staff. On 09/18/23 at 02:00 PM Administrative Nurse D stated that R1's bruise was technically an injury of unknown origin. Administrative Nurse D stated the situation was complicated and she attempted to investigate the bruising, but the concern was brought to her attention two weeks after R1 discharged . Administrative Nurse D had no explanation for missing the documentation about R1's bruised forearms. Administrative Nurse D stated R1's representative reported a concern about R1's bruised forearms on 09/05/23. Administrative Nurse D revealed she had not started an official investigation and had just recently got back with R1's family member on 09/15/23. Administrative Nurse D initially stated she did not report the event because she could not verify the bruising, but when asked if the allegations should have been reported to the SA, Administrative Nurse D stated it should have been. On 09/18/23 at 02:51 PM Administrative Staff A stated she learned R1 had a bruise on her arms when R1's representative informed Administrative Nurse D about the bruises a couple of weeks afterwards. Administrative Staff A revealed that she attempted to think of what could have happened to R1. Administrative Staff A said that when the bruise was brought up, it should have been investigated. Administrative Staff A further revealed that R1's bruising should have been reported to the SA. The facility's Abuse, Neglect and Exploitation revised 10/2022 documented it was a policy of the facility to keep residents free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The policy documented investigations are to be handled by Administrative Staff A or Administrative Nurse D. The investigation is to be thorough, timely and credible investigation of all incidents to rule out abuse, neglect, or misappropriately of funds or property. The facility failed to investigate bruising of unknown origin for R1 placing R1 at risk for unidentified and ongoing abuse and/or neglect.

The facility identified a census of 31 residents. The sample included four residents. Based on record review, interviews, and observations, the facility failed to ensure that Licensed Nurse (LN) staff followed standards of practice regarding reconciliation of controlled narcotic substances when staff signed the narcotic control log verifying removal and destruction of fentanyl (controlled pain medication with high likelihood for abuse) patches without actually visualizing or verifying and another occasion when staff wasted a fentanyl patch with no witness. This deficient practice placed the four residents identified by the facility as using fentanyl patches at risk for unnecessary side effects related to fentanyl and risk of diversion/misappropriation of fentanyl patches. Findings included: - Review of the R1's fentanyl Narcotics Count Sheet documented on 08/12/23 at 07:00 AM Licensed Nurse (LN) H wasted a fentanyl patch with no witness signature verifying the waste and destruction of the patch. On 08/12/23 at 08:00 AM R1 had a fentanyl patch applied to his right should and LN J removed the patch that was applied on 08/12/23 at 08:00 AM and both LN J and LN K verified by signing that it was removed and destroyed by both nurses. Review of the R1's fentanyl Narcotics Count Sheet documented on 08/18/23 at 08:00 AM, R1 had a fentanyl patch applied to his right shoulder. On 08/21/23 at 09:00 AM R1 had a fentanyl patch applied to his lower back and LN G and LN H removed the patch that was applied on 08/18/23 at 09:00 AM and both LN G and LN H verified by signing that it was removed and destroyed by both nurses. The facility's Risk Investigation 2958 documented on 08/23/23 Certified Medication Aide (CMA) R noted that R1 had a fentanyl patch dated 08/18/23 to R1's right upper shoulder and a second fentanyl patch to his left back dated 08/21/23. CMA R alerted LN I to this occurrence. LN I assessed R1, removed the older fentanyl patch and destroyed it with two LN. LN G's notarized Witness Statement dated 08/25/23 documented LN G had the assistance of an unidentified staff member to have R1 lean forward and pulled up R1's shirt to look for previously placed fentanyl patch. LN G documented she was unable to locate the previously placed fentanyl patch. LN G documented her application of the new fentanyl patch as well as the placement. LN G passed on the incident with R1 and the fentanyl patches to LN H at shift change. On 08/28/23 at 12:10 PM LN G stated she placed a new patch on R1. LN G revealed that she failed to locate the previously placed patch but signed that the previously placed patch was removed. LN G revealed that LN H came on shift and was informed by LN G that the previously placed fentanyl patch for R1 was not located. LN G further stated she made a mistake and should have documented the previously placed was not located. On 08/28/23 at 01:33 PM LN H stated she relieved LN G. LN H revealed that typically when a narcotic was pulled and needed to be wasted, it was held until there were two licensed nurses present to waste it. LN G lacked a narcotic patch that needed to be wasted, but LN H revealed that was something LN H did not think about. LN H stated she signed that the previously placed fentanyl patch was wasted without seeing the patch. LN H revealed that on 08/12/23 a new fentanyl patch for R1 was opened by mistake. LN H further revealed that LN J wasted the opened Fentanyl patch with LN H and that both LN H and LN J must have forgotten to sign the narcotic count sheet. On 08/28/23 at 02:08 PM LN J stated that the night shift nurse, LN H, reported in shift change LN H pulled a fentanyl patch for the wrong person. LN J stated she could not recall how it was wasted. On 08/28/23 at 02:14 PM LN K stated she witnessed the previously placed fentanyl patch, that was removed from R1, being wasted with LN J on 08/12/23. LN K revealed she could not recall ever witnessing an unused fentanyl patch being wasted without being used. LN K questioned why any nurse would need to waste an unused fentanyl patch. On 08/28/23 at 02:35 PM Administrative Nurse D stated she expected both nurses to visually confirm the medication being wasted before the actual medication destruction and signing the narcotic sheet that it was visually observed being wasted by both nurses. The facility's Controlled Medication Reconciliation policy dated 10/2014 directed the purpose was to maintain an accurate accounting of all controlled medications and to deter diversion. A controlled medication inventory sheet would be utilized to deter diversion. The facility failed to ensure that LN staff followed standards of practice regarding reconciliation of controlled narcotic substances when staff signed the narcotic control log verifying removal and destruction of fentanyl patches without actually visualizing or verifying and another occasion when staff wasted a fentanyl patch with no witness.This deficient practice placed the four residents identified by the facility as using fentanyl patches at risk for unnecessary side effects related to fentanyl and risk of diversion/misappropriation of fentanyl patches.

The facility identified a census of 31 residents. The sample included four residents reviewed for fentanyl (controlled narcotic medication with high risk for abuse) patch use. Based on interview, record review, and observation, the facility failed to ensure Licensed Nurse (LN) staff possessed the skills necessary to provide competent nursing services for Resident (R)1 when staff placed a new fentanyl patch without ensuring removal of the previous patch. This deficient practice placed the resident at risk for incompetent nursing care, and unnecessary side effects related to fentanyl. Findings included: - R1's Electronic Medical Record (EMR) documented under the Diagnoses tab the following diagnoses: Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), chronic pain syndrome, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five which indicated severely impaired cognition. R1 required extensive assistance of two staff members for bed mobility, transfers, dressing, and toilet use. R1 required extensive assistance of one staff member for personal hygiene, and locomotion on and off the unit. R1 received antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), and opioid (a broad group of pain-relieving drugs that work by interacting with opioid receptors in the cells) medications seven out of the last seven days. The Pain Care Area Assessment (CAA) dated 08/16/23 documented R1 had complaints of pain during his interview. R1 had orders for scheduled pain medication and received medications for complaints of pain. The Activity of Daily Living (ADL) CAA dated 08//16/23 documented R1 required assistance with ADLs related to impaired balance and transition during transfers. R1 needed extensive to total assistance with most ADLs and R1 transferred using the sit to stand lift with two staff members assistance. The Therapeutic Psychotropic Care Plan intervention dated 08/14/23 documented an intervention that Administrative Nurse D provided education to staff member, and no adverse reactions were noted at that time. An intervention dated 08/23/23 documented Administrative Nurse D provided education to all nursing staff; no adverse reactions noted at that time. The Orders tab recorded the following physician order dated 05/21/23: fentanyl patch 72 hour 25 micrograms (mcg) per hour (hr) apply one patch transdermally (entering the bloodstream by absorption through the skin) one time a day every three days for moderate pain. A Nurses Note dated 08/22/23 at 09:07 AM documented staff notified R1's representative of medications held due to R1 was lethargic. A Nurses Note dated 08/23/23 at 09:00 AM documented R1 had a medication error. R1 displayed no adverse reactions, vital signs were within baseline, and he was awake and alert. Staff notified the physician, administrative staff, and R1's representative. Review of the R1's fentanyl Narcotics Count Sheet documented on 08/18/23 at 08:00 AM, R1 had a fentanyl patch applied to his right shoulder. On 08/21/23 at 09:00 AM R1 had a fentanyl patch applied to his lower back. The sheet recorded LN G and LN H removed the patch that was applied on 08/18/23 at 09:00 AM and both LN G and LN H verified by signing that it was removed and destroyed by both nurses. The facility's Risk Investigation 2958 documented on 08/23/23 Certified Medication Aide (CMA) R noted that R1 had a fentanyl patch dated 08/18/23 to R1's right upper shoulder and a second fentanyl patch to his left back dated 08/21/23. CMA R alerted LN I to this occurrence. LN I assessed R1, removed the older fentanyl patch and destroyed it with two LN. LN G's notarized Witness Statement dated 08/25/23 documented LN G had the assistance of an unidentified staff member to have R1 lean forward and pulled up R1's shirt to look for previously placed fentanyl patch. LN G documented she was unable to locate the previously placed fentanyl patch. LN G documented her application of the new fentanyl patch as well as the placement. LN G passed on the incident with R1 and the fentanyl patches to LN H at shift change. Review of the R1's fentanyl Narcotics Count Sheet documented on 08/18/23 at 08:00 AM, R1 had a fentanyl patch applied to his right shoulder. On 08/21/23 at 09:00 AM R1 had a fentanyl patch applied to his lower back. The sheet recorded LN G and LN H removed the patch that was applied on 08/18/23 at 09:00 AM and both LN G and LN H verified by signing that it was removed and destroyed by both nurses. On 08/28/23 at 10:58 AM R1 sat in his recliner in his room with his feet elevated. R1 had his eyes closed but aroused easily to a knock on his door. R1 stated he felt good and was ready for lunch. On 08/28/23 at 12:10 PM LN G stated she placed a new patch on R1. LN G revealed that she failed to locate the previously placed patch but signed that the previously placed patch was removed. LN G revealed that LN H came on shift and was informed by LN G that the previously placed fentanyl patch for R1 was not located. LN G further stated she made a mistake and should have documented the previously placed was not located. On 08/28/23 at 01:33 PM LN H stated she relieved LN G and LN G lacked a narcotic patch that needed to be wasted. LN H revealed that was something she did not did not think about at that time. LN H stated she signed that the previously placed fentanyl patch was wasted without seeing the patch. On 08/28/23 at 04:21 PM Consultant GG stated that the residents with fentanyl patches typically had an order placed to check patch placement each shift. The facility's Controlled Medication Reconciliation policy dated 10/2014 directed the purpose was to maintain an accurate accounting of all controlled medications and to deter diversion. A controlled medication inventory sheet would be utilized to deter diversion. The facility failed ensure LN staff possessed the skills necessary to provide competent nursing services for R1 when staff placed a new fentanyl patch without ensuring removal of the previous patch. The facility further failed to assure the nursing staff followed standards of practice when staff signed the narcotic control log verifying removal and destruction of fentanyl patches without actually visualizing or verifying. This deficient practice placed the resident at risk for incompetent nursing care, unnecessary side effects related to fentanyl and risk of diversion or misappropriation of fentanyl patches.

The facility identified a census of 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to ensure the privacy of protected health information (PHI) for 39 residents. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Findings Included: - On 04/04/23 at 07:10AM an initial walk-through of the facility revealed a treatment cart with three used COVID-19 (highly contagious, potentially life-threatening respiratory virus) test swabs on top of the cart in the main entry area next to the dining hall. A resident census was left unsecured and in full view on top of the treatment cart which revealed the COVID-19 status of all 39 residents in the facility. On 04/10/23 at 07:00AM a treatment cart was placed at the entrance of the facility which contained a list on top of the cart residents awaiting COVID-19 results, unattended and in full view. On 04/10/23 at 12:03PM Licensed Nurse (LN) G stated all PHI related to the resident's care should not be left out for others to view. She stated the information should be put up in a secured area when not in use. On 04/10/23 at 01:21PM Administrative Nurse D stated staff were expected to ensure the privacy of each resident and secure sensitive information when not in use. On 04/10/23 at 03:000AM, Administrative Staff A stated the facility followed regulations. The facility did not provide a policy related to Resident Rights as requested on 04/11/23. The facility failed to ensure the privacy of PHI for 39 residents. This deficient practice placed the residents at risk for decreased psychosocial wellbeing.

The facility identified a census of 46 residents. The facility reported 15 residents received altered texture diets. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to serve an altered texture diet to one resident (#1). Resident #1 choked on 6/19/18 after eating ham and bean soup and required the [MEDICATION NAME] maneuver (a technique of abdominal thrusts to stop choking). Findings included: - The electronic medical record for resident #1 included a [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident required supervision for eating and received a mechanically altered diet (a diet of soft foods altered with a machine, with food cut up or ground into small pieces). The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident required supervision for eating and received a mechanically altered diet. The Care Area Assessments dated 5/11/18 documented the resident required assistance with Activities of Daily Living (ADLs) and for staff to provide the ordered diet and supervise the resident while eating. The care plan dated 8/18/18 directed staff to provide the resident's diet as ordered and to supervise the resident while he/she ate the meal. The physician's orders [REDACTED]. The undated diet card for this resident documented the resident's diet order as a mechanically soft diet with honey thickened liquids. The menu for the lunch meal on 6/19/18 included ham and bean soup. The recipe to alter the soup for a mechanical soft diet directed staff to grind the ham. The nurse's note dated 6/19/18 at 12:00 PM documented the resident choked on his/her meal. Staff stood the resident and gave multiple abdominal thrusts to the resident. After the resident began breathing, staff placed oxygen on the resident. Staff obtained the resident's vital signs (pulse, blood pressure, respiratory rate, temperature, and oxygen level), which measured within normal limits. The resident stated he/she choked on the soup. Staff notified the resident's representative, the physician, the director of nursing, and the administrator. The witness statement dated 6/20/18 from dietary staff CC documented staff CC did not follow the instructions to grind the ham in the soup before staff served it to the resident. On 10/15/18 at 12:17 PM, the resident laid in bed and was alert and calm. On 10/15/18 at 12:18 PM, the resident stated he/she choked in (MONTH) on the soup that staff served him/her at the lunch meal. On 10/15/18 at 12:48 PM, dietary staff CC stated the resident's diet order was on the resident's diet card. On 10/15/18 at 2:49 PM, direct care staff M stated he/she checked the resident's meal and diet card before he/she served it to ensure the meal was correct according to the resident's ordered diet. On 10/15/18 at 3:10 PM, dietary staff BB stated the resident's diet order was for a mechanical soft diet with honey thickened liquids. Staff BB said staff CC did not grind the ham in the soup or thicken the liquid before direct care staff served it to the resident. On 10/16/18 at 4:08 PM, administrative nursing staff E stated he/she expected staff to check the resident's diet order on the diet card before they served food to the residents. On 10/16/18 at 4:44 PM, dietary staff CC was unavailable for an additional interview. The facility's policy Diet Orders, undated, lacked documentation about serving the resident's diet according to the diet order. The facility failed to provide this resident with a diet according to the physician's orders [REDACTED]. This deficient practice placed the resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 6/19/18 when the facility provided staff with an in-service about residents who received modified diets, including serving ground meat and thickened liquids when required, cutting up food, and ensuring the food on the meal tray matched the diet card.

The facility identified a census of 46 residents. The facility reported 4 residents had food allergies [REDACTED]. Based on observation, record review, and interview, the facility failed served an entree including a documented food allergy to one resident (#2). Resident #2 experienced redness around his/her mouth and tongue on 10/1/18 after he/she ate tuna. This deficient practice placed residents #2 in immediate jeopardy. Findings included: - The electronic medical record for resident #2 included a [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The resident required supervision for eating and received a therapeutic diet. The Care Area Assessments (CAAs) dated 7/21/18 for cognition documented the resident had short-term and long-term memory problems. The CAA for ADLs documented he/she required supervision while eating and had a seafood allergy. The care plan, revised 8/16/18, documented the resident had a seafood allergy and directed staff to supervise the resident while he/she ate. The resident's diet card, undated, documented an allergy to fish. The dietary profile, dated 7/17/18, documented the resident had an allergy to fish. The nurse's note dated 10/1/2018 at 6:12 PM documented the resident consumed tuna with dinner this evening and had a documented allergy to seafood. Staff noted redness around the resident's mouth and tongue. Staff notified the resident's physician. On 10/15/18 at 11:33 AM, the resident laid in bed with eyes closed. On 10/15/18 at 12:48 PM, dietary staff CC stated the resident's food allergies [REDACTED]. He/she stated if a resident ordered a food he/she had an allergy to, then staff would not serve it. On 10/15/18 at 2:49 PM, direct care staff M stated he/she checked the resident's meal and diet card before he/she served it to ensure the resident did not receive a food he/she had an allergy to the food. On 10/16/18 at 4:08 PM, administrative nursing staff E stated he/she expected staff to check the resident's diet card for food allergies [REDACTED]. On 10/18/2018 9:05 AM, dietary staff DD stated the diet card documented the resident's food allergies [REDACTED]. Staff DD stated he/she did not have the resident's diet card at that time. The facility failed to provide a policy about food service and food allergies [REDACTED].>The facility failed to serve a meal free of allergens to this cognitively impaired resident. After ingesting the food allergen, the resident experienced redness to his/her mouth and tongue. This deficient practice placed the resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 10/10/18 when the facility provided staff with an in-service about serving the resident food according to their ordered diet, which diets could be refused by the resident, to offer an alternative if the resident refused the menu for that meal, and to follow the dietary restrictions listed on the diet card to include food allergies [REDACTED].>

The facility identified a census of 64 residents. The sample included 5 residents. Based on observation, interview and record review, the facility failed to provide services necessary to avoid physical harm to other residents by failing to implement effective interventions after the facility readmitted resident #2 to the facility from a geriatric psychiatric unit after he/she physically assaulted another resident with a leg brace and other multiple residents. Findings included: - Resident #2's Physician order [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) of 12/31/11 identified the resident with a Brief Interview for Mental Status score of 3 that indicated severe cognitive impairment. The MDS noted the resident utilized a walker or wheelchair for mobility and received antipsychotic and antidepressant medications. The MDS recorded no physical or verbal behaviors in the look back period. The behavioral symptom Care Area Assessment (CAA) with an ARD of 7/12/11 identified the resident as very combative and exhibited both verbal and physical abuse to both residents and staff. The [MEDICAL CONDITION] drug use CAA with an ARD of 7/12/11 noted the resident received [MEDICATION NAME] (an antipsychotic), [MEDICATION NAME] (dementia agent) and [MEDICATION NAME] (an antipsychotic). The 8/12/11 untimed social services note revealed he/she witnessed the resident hit and kick another resident in the hall of the facility because he/she blamed the other resident for being in the way. The 12/14/11 untimed nurses notes revealed the resident kicked a staff member and hit him/her in the lower jaw area. The note further documented the following "safety concern": Resident is increasingly becoming a danger to staff and other residents related to increased behaviors and aggressiveness. The note further revealed the resident still had strength and the capability to cause harm. The note also revealed the resident's behaviors had minimal to no change since the last hospitalization . The 2/3/12 at 8:40 A.M. nurses notes revealed at approximately 4:15 A.M., the resident transferred him/herself out of bed to the wheelchair, propelled self and wandered into another resident's room. The resident turned on the call light and when staff went to answer it, staff observed resident #2 swing a metal leg brace at and hit the resident on the head, hand and stomach. At that time, the staff removed resident #2 from the area. The facility reported incident revealed the resident sustained [REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] 50mg po every morning and evening and 75 mg at bedtime for dementia with behavioral disturbance. The 2/3/12 psychiatric evaluation identified the resident with dementia Alzheimer vascular type with [MEDICAL CONDITION], depression, behavioral disturbance, anxiety disorder not otherwise specified, and impulse control disorder not otherwise specified. A letter dated 2/9/12 from the resident's physician identified in June, 2011, the resident was physically abusive with staff having bit a nurse breaking the skin. The resident readmitted to the outside facility behavioral unit in November 2011 after he/she refused care and exhibited physical abuse toward staff. The resident readmitted to the outside facility behavioral unit in December 2011 after he/she exhibited physically abusive behaviors toward other residents at the facility. The physician further noted the most recent incident on 2/3/12 when he/she entered another resident's room and beat him/her while he/she laid in bed. The physician identified the most recent admission to the behavioral unit as the resident's fourth admission since June of 2011. The physician further noted the following: "Due to his/her history of physical abuse of staff and other patients that reside at this facility, it is not safe for him/her to continue residing at this facility. This resident would be better suited at a more secure facility where his/her behaviors can be better managed and controlled". The 2/9/12 untimed physician's progress note identified the resident as delusional with a history of physical abuse where he/she hit another resident. The progress note revealed the resident needed to transfer and documented "Plan transfer out of the facility". The temporary care plan dated 2/17/12 identified the resident as alert but not oriented and independent with wheelchair locomotion at times. This care plan instructed staff to report any physical or verbal behaviors to the nurse and to perform hourly checks on the resident and document the checks in a binder located on the back of the resident's wheelchair. The revised 2/23/12 care plan addressed the resident's verbal and physical aggression related to delusional disorder and dementia instructed the staff to remove the resident from a public area when the resident exhibited disruptive/unacceptable behaviors, talk with him/her in a low pitch, calm voice to decrease/eliminate undesired behaviors and provide diversional activity. The care plan further instructed the staff to remove the resident to a quiet area if he/she would, spend time with the resident and reassure him/her, do not invade the his/her personal space and if unable to calm him/her down, leave and return at a later time if he/she is not demonstrating harm to him/herself or others. Interventions on 2/7/12 noted the resident started on [MEDICATION NAME] for behavior management and on 2/23/12 for staff to serve meals in his/her room for decreased stimulation. Observation on 2/23/12 at 9:02 A.M. revealed the resident as he/she laid in bed with his/her eyes closed. The 2/20/12 at 4:47 P.M. nurse's note revealed the resident kicked at other residents as they walked by. The 2/22/12 at 4:42 P.M. nurse's note identified the resident in another resident's room and tried to hit the nurse's hand when they removed him/her from that room. The 2/24/12 at 11:10 P.M. nurse's note identified the resident as confused and noted he/she wandered in other resident's rooms. The 2/25/12 at 2:50 A.M. nurse's note documented the resident in another resident's room and grabbed his/her leg. The other resident yelled at the resident to get out of his/her room. The staff responded and removed the resident from the other resident's room. On 2/23/12 at 8:10 A.M., administrative nursing staff B revealed the resident returned to the facility after inpatient stay on behavioral unit. He/she further noted the resident was on "hourly checks". A notebook for the documentation of the hourly checks located on the back of the resident's wheelchair revealed documentation the staff last checked the resident at 6:00 A.M. that morning. Further review of the log revealed inconsistent documentation of the hourly checks. On 2/23/12 at 10:12 A.M. direct care staff F, who was assigned to care for the resident state he/she was unaware of the hourly checks until he/she just read about it up at the desk. On 2/23/12 at 10:15 A.M., administrative nursing staff B acknowledged the inconsistent documentation of hourly checks. On 2/23/12 at 9:35 A.M., administrative staff A revealed the facility issued the resident's family member a 30 day discharge notice on 2/20/12 and noted the facility was working with the family to find suitable placement for the resident. On 2/27/12 at 2:48 P.M., licensed nursing staff D revealed the resident had exhibited aggressive behaviors towards other residents for approximately the past 18 months. He/she further noted the resident was in and out of the behavioral unit mainly due to his/her aggressive behaviors toward others. Licensed nursing staff D further noted the resident was generally more aggressive towards staff upon return from the behavioral unit. The updated 6/8/07 facility policy entitled "Abuse, Neglect and Exploitation" identified neglect as the failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness and noted all of the residents have the right to be free from abuse to include verbal, physical and mental abuse. On 2/23/12 at 1:46 P.M. an unsampled resident revealed he/she tried to stay away from this resident and will go the other way when he/she sees him/her. The facility failed to provide an environment free from verbal, physical and mental abuse by failing to adequately supervise this resident with a history of multiple physical abuse incidents with other residents and failed to ensure other residents in the facility felt safe.

The facility identified a census of 60 residents. The sample included 3 residents. Based on observation, interview and record review the facility failed to initiate nutritional interventions for 1 (#1) resident of 3 residents sampled for weight loss. Findings included: - Resident #1, admitted [DATE], had [DIAGNOSES REDACTED]., vitamin D deficiency, constipation, anxiety state, benign loc [MEDICAL CONDITION] prostate without urinary obstruction, major [MEDICAL CONDITIONS] disorder, chronic ischemic [MEDICAL CONDITIONS], posttraumatic stress disorder, generalized [MEDICAL CONDITION], hypertension, headache and [MEDICAL CONDITION] as listed on the Physician order [REDACTED]. The admission Minimum Data Set 3.0 dated 7/28/11 recorded a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment, required assistance with activities of daily living (ADL), needed only setup assistance with eating, weighed 176 pounds, and was not on a planned weight change program. The temporary care plan dated 7/18/11 recorded that the resident needed set up assistance with eating. The temporary careplan lacked any further nutritional interventions. The careplan dated 8/18/11 for inappropriate behaviors recorded I may say inappropriate things, may be physically inappropriate at times and have a behavior of " air boxing " at times when I am agitated or frustrated. There was no behavior of refusal of cares noted. The careplan for being at risk for some nutritional issues dated 8/19/11 recorded the resident would maintain his/her weight plus or minus 5 pounds, has dentures, but did not like to wear them, and received a regular mechanical soft diet. The careplan for requiring assistance with his/her ADL ' s dated 8/19/11 recorded the resident was able to feed himself/herself, but needed staff to assist him/her with meal set up. An interview on 11/2/11 with administrative staff C said the facility did not assess calorie counts and the facility had not completed one for this resident. The weights for the resident included: 7/18/11=177 8/1/11=176 8/13/11= 171 8/15 /11=171 8/20/11= 166 8/22/11= 166 consisting of a 11 pound weight loss or 6.2% in 1 month. The Nuring Home Evaluation form completed by the physician and dated 8/3/11 recorded the resident ' s weight was 177 pounds on admission. The dietary assessment completed by consultant staff A and dated 8/9/11 recorded the current weight of 177 pounds. Resident was WNL (within normal limits) of recommended IBW( ideal body weight) and height. IBW 178 pounds plus or minus 10% with BMI (body mass index) of 24 indicating adequate weight. Feeding ability self with set up and encouragement. Current weight of 177 pounds WNL. [MEDICATION NAME] WNL at 3.6. Fed self with minimum assist. Snacks offered. Skin intact at this time. The dietary assessment completed by consultant staff A and dated 8/25/11 recorded current weekly weight reported as 166 pounds indicating weight loss of 11 pounds in a month. Resident IBW 178. Resident with current UTI (urinary tract infection) and on antibiotic which may affect oral intake and thus wt. Received mechanical soft diet. Skin intact at this time. [MEDICATION NAME] WNL at 3.8. Due to complaint of weight decrease recommend MVI, fortified mechanical soft diet and house supplement twice daily. Nurses notes dated 8/22/11 recorded weekly weights reviewed. Dietician to evaluate. An observation on 10/31/11 at 12:45 P.M. the resident sat in the main dining room feeding him/herself. Plate of food included bread, and fried chicken and 3 blue covered drinking mugs sitting in front of him/her on table. The resident ate extremely slow. The staff sat down briefly and offered mug to the resident and he/she began drinking. An observation on 11/1/11 between 12:30-1:10 P.M. resident feed him/herself in the main dining room hamburger, bread, and dessert. The resident ate about 25% of the hamburger. Direct care staff offer to help and cue the resident to eat. At 1:10 P.M. staff took his/her tray leaving his/her two blue mugs which were about 50% drank. An interview on 10/31/11 at 2:30 P.M. with consultant staff A revealed trying everything with him/her. Thinks it might be starting to turn weight loss around. Gets Two cal. Put food on bread and he/she will eat it. Resident adamant that staff would not assist/feed him. Had discussed problem with the physician but more with former administrative staff D about interventions. An interview on 11/1/11 at 2:30 P.M. with administrative staff A stated that new admissions receive weekly weights for four weeks. A Weekly Weights/Nutritional Risk policy dated 11/1/2000 revealed the purpose was to identify residents at risk for weight loss and poor nutrition. Staff document weekly weight in the treatment record. Staff will weigh new admissions within four hours of admission and weekly for four weeks to establish a baseline weight and monitor for loss. The facility failed to assess and implement timely interventions to prevent a significant weight loss in this resident.