Every finding on record at Phillips County Retirement Center

The facility identified a census of 29 residents with 12 residents included in the sample and three residents reviewed for accident hazards. Based on observation, interview and record review, the facility failed to provide resident centered analysis after falls and interventions aimed to prevent falls for Resident (R)3, who had multiple falls with incomplete investigations of the causal factors and implementation of interventions to prevent further falls.Findings included:- R3's Electronic Health Record (EHR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk).R3's 10/07/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) could not be completed because the resident was rarely or never understood. Per staff assessment, R3 had memory problems and moderately impaired cognition. R3 had physical, verbal and other behavioral symptoms directed towards others that occurred one to three days during the look-back period. R3 rejected care and wandered one to three days during the look-back period. R3 had one non-injury fall and one fall with major injury since the last MDS.R3's 01/07/26 Quarterly MDS documented a BIMS interview could not be completed because the resident was rarely or never understood. Per staff interview, R3 had memory problems and moderately impaired cognition. R3 had physical, verbal and other behavioral symptoms directed towards others that occurred four to six days during the look-back period. R3 rejected care and wandered four to six days during the look-back period. R3 required partial/moderate assistance for sit-to-stand repositioning and transfers and substantial/maximal assistance for walking. R3 self-propelled in a wheelchair. The MDS documented R3 had two or more falls since the previous assessment.The 10/07/25 Cognitive Loss / Dementia Care Area Assessment (CAA) triggered for further development but was not completed.The 10/07/25 Falls CAA triggered for further development but was not completed.R3's Care Plan initiated on 05/16/24 and revised on 01/14/26, documented R3 was at risk for falls and noted the following interventions:Staff would anticipate and meet R3's needs. Staff would be sure R3's call light was within reach and encourage her to use it for assistance as needed. R3 required a prompt response to all requests for assistance. Staff would encourage R3 to participate in activities that promote exercise, physical activity for strengthening and improved mobility.Staff would ensure R3 wore appropriate footwear when ambulating or mobilizing in a wheelchair. Staff would follow the facility fall protocol. Staff would initiate fall risk precautions such as ensure adequate lighting in the resident's room and bathroom at night, ensure the call light was within reach, ensure shoes were on during the day, and slipper socks were on the resident at night, ensure bed brakes were locked, minimize clutter in the room, keep floor surfaces dry during transfers and ambulation, and keep environment the same as much as possible. R3's Care Plan dated 08/09/24, documented R3 had an actual fall and noted staff would continue interventions, currently care planner for R3's at risk status. It further revealed the following interventions.Staff would provide assistance with two staff, a gait belt, and a four-wheeled walker (FWW), initiated on 10/25/24 and revised on 01/15/25.Staff would perform 15-minute visual checks, initiated 11/21/24 and revised on 01/15/25.Staff would ambulate R3 between 09:30 AM and 10:30 AM every day shift, initiated on 11/21/24.Staff would take R3 to the toilet right after evening meal, initiated on 12/12/24Staff would place R3 in a recliner in front of the commons area, initiated on 01/27/25Staff would place Dycem (a non-slip mat used for stabilization and gripping to prevent slipping) in R3's wheelchair, initiated 01/20/25.Staff were re-educated regarding agitated behaviors, initiated on 07/07/25 and revised on 01/26/25.Staff would place a green mattress on the floor against R3's bed, initiated on 08/11/25.Staff would replace R3's bed with a Hi-Low bed, initiated on 08/11/25 and revised on 01/26/26.Staff would walk away and ask a different staff member to assist R3 if she remained agitated after staff approached her, initiated and revised on 08/11/25.Staff were educated to be mindful of floor conditions when plumbers were working where R3 was, initiated on 09/24/25 and revised on 11/03/25.Staff would place grip strips on the floor on the side of the bed to assist the green mattress to stay where it should, initiated and revised on 01/15/26.Staff was re-educated on not leaving R3 alone when she was restless, initiated on 01/27/26.Staff would replace R3's mattress with a scoop mattress, initiated on 01/27/26.Staff were re-educated on the importance of checking on R3 according to her visual checks, initiated on 01/27/26 On 08/05/24 at 06:24 AM, a Post Fall Evaluation documented a noninjury fall at 06:45 AM. The facility's fall investigation report did not contain a root cause analysis (RCA) and Administrative Staff C documented on 08/05/24 an intervention for staff to place grip strips on the floor in front of both recliners.The facility was unable to provide fall investigations or interventions for falls dated 10/04/24, 11/01/24, and 12/23/24.The facility provided fall investigations for the following falls, however the facility investigations lacked casual factors of the falls and failed to implement interventions in a timely manner. The falls were dated as follows:10/03/24 at 03:30 PM with an intervention on 10/25/24 for staff to assist R3 with the use of a gait belt and walker, initiated 22 days after the fall.11/02/24 at 10:52 PM with an intervention on 11/21/24 for staff to assist R3 to the toilet after the evening meal, initiated 19 days after the fall.12/22/24 at 02:10 PM with an intervention on 01/09/25 to check R3 every 15 minutes, initiated 18 days after the fall.12/22/24 at 01:45 PM with intervention on 01/09/25 to place R3 in a recliner in the commons area and provide a different wheelchair.12/28/24 at 11:45 AM with an intervention on 01/09/25 to place R3 in a low bed. On 12/23/24 at 06:39 AM, a Post Fall Evaluation documented a noninjury fall at 06:40 AM. The facility did not provide a fall investigation.On 12/25/24 at 11:01 PM, a Communication - with Physician note documented R3 had increased pain to her pelvic area, right hip and lower back, and she walked with a mild limp. Staff documented there was no bruising or swelling to the pelvic area or shortening or rotation of either leg.R3's EHR, under the scanned documents tab, revealed an order dated 12/26/24 from R3's physician to obtain a pelvis and lumbar (lower back) spine x-rays. The document was signed off by an unknown staff member and Administrative Nurse D on 12/31/24.On 12/27/24 at 09:27 AM, a Nurse's Note documented the facility received a fax response, and it was sent to radiology (x-ray).On 12/27/24 at 10:59 AM, a Psychosocial Note documented R3 was transported to the hospital for x-rays accompanied by family.R3's EHR scanned documents dated 12/27/24 revealed radiology results for the pelvis x-ray exam performed on 12/27/24 at 11:16 AM, which documented a right greater trochanteric (hip) fracture. The document was signed by the radiologist on 12/24/24 at 11:30 PM. The document was signed by R3's physician on 12/30/24.On 12/27/24 at 12:47 PM, a Nurse's Note documented the facility received a telephone call from the hospital to inform them R3 needed to be sent to the Emergency Department (ED) due to a hip fracture. Staff informed R3's representative and transported R3 back to the hospital. Staff documented the reports indicated surgical intervention was likely needed and R3 had family members in the facility who would accompany staff and R3 to the ED.On 12/27/24 at 11:05 PM, a Nurse's Note documented R3 returned to the facility at 06:00 PM with instructions from the ED that the resident's hip fracture did not require surgical intervention and included instructions for R3 to utilize a walker/wheelchair for locomotion, take Tylenol (acetaminophen) as needed (PRN) for pain, and instruction to follow up with her physician in 10 days.On 12/28/24 at 01:44 PM, an Incident Note documented R3 had an unwitnessed fall in her room at approximately 11:45 AM and was assessed to have shortening and subluxation (rotation) of the right leg. R3 was unable to keep her leg straight and was transported to the ED for evaluation.On 12/28/24 at 02:16 PM, R3's EHR Nurse's Note documented the facility called the ED for a status update for R3 and was informed R3's fracture was worse, and the ED was working to transfer R3 to a different facility for additional treatment.On 12/28/24 at 05:17 PM, R3's EHR Nurse's Note documented the facility received a call from the ED and was notified R3 was transferred to a different hospital than originally planned because R3's fracture was complicated and further fractured and dislocated.On 12/31/24 at 01:42 PM, R3's EHR Nurse's Note documented R3 returned to the facility from the hospital in the facility van with assistance from two staff in a wheelchair. R3 had a surgical dressing on her right hip/thigh and knee with orders to monitor her daily for signs of infection and to keep the dressing intact.On 01/03/25 at 12:23 AM, the facility's fall report documented the resident had a fall with minor injury. The EHR progress notes did not contain an entry that documented the fall. The fall report did not contain a root cause analysis and Administrative Staff C documented on 01/09/25 an intervention was initiated to educate staff regarding the resident's skin integrity and transfer protocols.On 02/12/25 at 07:23 PM, R3's EHR Nurse's Note documented the resident had a fall with major injury at 05:10 PM. R3 was assisted to her wheelchair and transported back to her room, where she was assessed for injury, had left leg pain, and was identified with outward rotation. Facility staff contacted Emergency Medical Services (EMS) for transport to the ED for evaluation. The facility's fall investigation did not contain a root cause analysis and Administrative Staff C documented a 02/13/25 intervention for staff to know R3 was sent to the hospital for surgery and then would be released to swing bed (a type of hospital setting that allows persons to transition from hospital treatment to recovery). The care plan team would assess R3 upon return to the facility for any applicable interventions.Review of the Post Fall Evaluations revealed R3 also had falls on 07/10/25, 09/23/25, 10/25/25, 12/05/25, 12/14/25 and 01/08/26.On 03/09/26 at 10:40 AM, R3 rested in a recliner in the common area with her eyes closed.On 03/09/26 at 02:00 PM, R3 sat in her wheelchair and self-propelled herself in the common area with peers and staff present.On 03/10/26 at 06:24 AM, R3 rested in her bed with her eyes closed. Her bed was in the lowest position with the mattress beside the bed on the floor.On 03/10/26 at 11:02 AM, R3 rested in a recliner in the common area with her eyes closed.On 03/10/26 at 09:48 AM, Certified Medication Aide (CMA) R stated after a fall was over and the resident was taken care of, fall interventions were added by Administrative Staff C and Administrative Nurse D. CMA R stated some interventions were communicated to staff on the Treatment Administration Record (TAR) such as the 15-minute visual checks, or the interventions would be passed on in shift report for a couple of days. CMA R said she did not have access to the care plan in the EHR and could only look in the EHR at the TAR.On 03/10/25 at 09:51 AM, Licensed Nurse (LN) G stated fall reports were routed to Administrative Staff C, and interventions to implement to prevent additional falls were created by Administrative Staff C and Administrative Nurse D. LN G stated the nurses working the floor did not create any interventions to prevent falls and did not have access to the resident's care plan. LN G stated there was an intervention book kept in the nurses' station for each resident and stated that staff did not know what the interventions for falls were until Administrative Nurse D and Administrative Staff C let the staff know, and then passed it on in shift change report.On 03/10/26 at 10:01 AM, Certified Nurse Aide (CNA) M stated staff did not have access to the care plan book most of the time since it was stored in Administrative Staff C's office. CNA M stated that after a fall, when staff filled out the paperwork, they documented what they thought an intervention could be, but the decision was ultimately up to Administrative Nurse D and Administrative Staff C. CNA M stated CNA staff do not have access to the care plan in the EHR.On 03/10/26 at 10:12 AM, Administrative Nurse D stated staff would have a meeting and develop an intervention (to prevent further falls) until the interdisciplinary team (IDT - a team of facility staff consisting of members of various departments including but not limited to; dietary, nursing, maintenance, therapy, etc.) could meet and develop an intervention to be placed on the care plan in the EHR. After a fall, the facility's IDT team which was composed of Administrative Staff C, Administrative Nurse D and Consultant GG would hold a meeting and develop a care plan intervention. Administrative Nurse D stated Administrative Staff C was responsible to update the care plan and communicate any changes to staff, who would then transmit the information via shift change report. Administrative Nurse D stated the care delivered by the staff was driven by the care plan and was unsure of the licensure/certification of Administrative Staff C and that this process was in place prior to her being hired by the facility. Administrative Nurse D stated that she was currently in school and was not able to regularly hold or attend IDT meetings to discuss falls in the facility. Administrative Nurse D stated prior to 08/2025 when she started school, IDT meetings were held once per week, but currently they were held whenever possible due to work/school scheduling conflicts. Administrative Nurse D stated that after a fall, the IDT team should meet within 24 to 48 hours to investigate the fall and develop care plan interventions and communicate that with staff.On 03/10/26 at 12:45 PM, Administrative Staff C stated she was a CNA and was in charge of the care plan interventions with Administrative Nurse D related to falls with consultation with Consultant GG. Administrative Staff C said she was in charge of the care plans and she would generate the focus, and Administrative Nurse D would input the interventions to generate the cares. Administrative Staff C said she and Administrative Nurse D would perform the root cause analysis of a fall investigation. Administrative staff attempted to have an IDT meeting every morning when Administrative Nurse D was in the building, but a resident could go two to four weeks between the fall and an intervention being developed and added to the care plan. Administrative Staff C stated floor nurses had the ability to add interventions to the care plan, but not the authority to perform this action. Administrative Staff C said that staff knew what interventions to implement after Administrative Staff C and Administrative Nurse D figured it out and it was communicated to all the staff via shift report. Administrative Staff C said she had the ability and authority to make care plan revisions without the knowledge or approval of the DON. Administrative Staff C said that after a fall, an intervention log was generated and a copy was placed in the red intervention book in the nurses' station and also placed in the falls tab on the care plan. This list was discussed with Consultant GG when she came to visit. Administrative Staff C said fall reports were routed to her and she assessed the situation to determine an appropriate intervention.On 03/10/26 at 01:51 PM, Administrative Nurse D recognized the fall investigations were incomplete and/or missing and did not contain a root cause analysis of why the fall occurred. Further, Administrative Nurse D identified the notes documented on the last page of each fall investigation were the intervention that was developed and should have been added to the care plan. Administrative Nurse D stated she expected fall investigations to be completed and written in such a manner that the reader would be able to visualize what happened without going to the area where the fall occurred. Administrative Nurse D stated floor nurses had the authority to create care plan interventions, however she was unsure if floor nurses had the authority to create interventions on the care plan. Additionally, Administrative Nurse D stated the facility did not have a fall packet to prompt staff on duty on what to document and where to document in the EHR to correctly and completely document a fall.The facility's undated admission Fall Prevention Protocol policy documented that each resident in the facility would be provided services and care that ensured the environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents.

The facility identified a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility.Findings included:- Review of the Infection Control Log for tracking and trending infections from March 2025 through February 2026, lacked evidence of organism identification, duration of prescribed antibiotics, and the infections treated. The facility was unable to provide this upon request. On 03/10/26 at 10:39 AM, Administrative Nurse D confirmed she was also the facility's Infection Preventionist. She said she tracked who was taking an antibiotic in the Electronic Medical Record (EMR). She stated she was unable to provide tracking and trending for antibiotics. Administrative Nurse D stated the floor nurses would open the infection document for tracking, but the nurses would not fill out the form. She stated the only documents she had were the antibiotics the residents had taken for infections.The facility's Infection Preventionist policy undated, documented The Infection Preventionist is responsible for the effective direction, management and operation of the infection prevention program, including education of facility staff members and independent practitioners, and consulting with County and State Department of Health and Environment. The Infection Preventionist utilizes evidence-based practices such as those published by the Centers for Disease Control (CDC). Additionally, the Infection Preventionist ensures compliance with regulations and requirements from the Centers for Medicare and Medicaid Services (CMS) and other accrediting healthcare organizations and State regulatory agencies.

The facility identified a census of 29 residents. Based on record review and interviews, the facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist, responsible for the facility's Infection Prevention and Control Program.Findings included: - During the entrance conference Administrative Staff A stated Administrative Nurse D was the Infection Preventionist for the facility. He stated she was a Licensed Nurse (LN) and had been continuing education for infection prevention.The facility provided documentation of continuing education topic for Enhanced Barrier Precautions (EHB) and how to implement a surveillance plan for antibiotic stewardship.On 03/10/26 at 10:36 AM, Administrative Nurse D stated she had been doing the Infection Preventionist duties for the facility. She stated she had been doing continuing education hours but did not have her certificate as an Infection Preventionist. Administrative Nurse D stated the facilities plan was for her to take the course and get her Infection Preventionist certificate.The facility's Administration of Antibiotic undated, documented antibiotics were essential treatments for serious infections and remain one of the most significant treatment options for control of microbials. The purpose of this policy is to provide guidance for staff on appropriate administration and follow-up of administration of antibiotics. Following the facility antibiotic stewardship policy, the facility and the practitioners ordering antibiotics would order antibiotic therapy only when indicated by laboratory testing and would be ordered for the shortest amount of time.

The facility reported a census of 29 residents. Based on observation, interview and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight continuous hours daily as required. Additionally, the facility failed to employ a full-time RN to serve in the role of Director of Nurses (DON). Findings included:- Observation of the daily staffing posting sheet in the facility on 03/09/26 at 08:00 AM, 03/10/26 at 09:00 AM and 03/11/26 at 10:00 AM revealed no RN hours documented. Review of the Payroll Based Journal Staffing Data Report for fiscal year (FY) Quarter 4 2025 (July 1 to September 30) documented no RN hours on the following dates:07/01 Tuesday (TU); 07/02 Wednesday (WE); 07/04 Friday (FR); 07/05 Saturday (SA); 07/06 Sunday (SU); 07/07 Monday (MO); 07/08 (TU); 07/09 (WE); 07/10 (TH); 07/11 (FR); 07/12 (SA); 07/13 (SU); 07/14 (MO); 07/15 (TU); 07/16 (WE); 07/17 (TH); 07/20 (SU); 07/21 (MO); 07/22 (TU); 07/23 (WE); 07/24 (TH); 07/25 (FR); 07/26 (SA); 07/27 (SU); 07/28 (MO); 07/29 (TU); 07/31 (TH) 08/01 (FR); 08/02 (SA); 08/03 (SU); 08/04 (MO); 08/05 (TU); 08/06 (WE); 08/07 (TH); 08/09 (SA); 08/10 (SU); 08/11 (MO); 08/14 (TH); 08/17 (SU); 08/18 (MO); 08/19 (TU); 08/20 (WE); 08/21 (TH); 08/22 (FR); 08/23 (SA); 08/24 (SU); 08/25 (MO); 08/26 (TU); 08/27 (WE); 08/28 (TH); 08/29 (FR); 08/30 (SA); 08/31 (SU) 09/01 (MO); 09/02 (TU); 09/03 (WE); 09/04 (TH); 09/07 (SU); 09/08 (MO); 09/09 (TU); 09/10 (WE); 09/14 (SU); 09/15 (MO); 09/16 (TU); 09/17 (WE); 09/18 (TH); 09/21 (SU); 09/22 (MO); 09/23 (TU); 09/24 (WE); 09/25 (TH); 09/28 (SU); 09/29 (MO); 09/30 (TU) On 03/09/26 at 02:34 PM, Administrative Staff A stated the facility has not had an RN to serve in the roll of DON since 2023. Administrative Staff A stated the facility does not provide any skilled services since those services are provided by the hospital next door. Administrative Staff A confirmed the PBJ report to be accurate for dates with no RN coverage and declined to review the dates with the survey team. Administrative Staff A reported that the Licensed Nurse (LN) currently serving in the role of DON is a Licensed Practical Nurse (LPN) and is in a RN program with estimated completion date of 05/2026. Administrative Staff A stated the facility was actively recruiting RN staff but has been unsuccessful. On 03/11/26 at 12:07 PM, Administrative Staff A provided a document Job Description - Director of Nursing that did not specify the incumbent of the role of DON was required to hold an active and unincumbered license as an RN. The facility's undated Registered Nurse policy documented the facility would employ the services of an RN for at least eight consecutive hours, seven days per week.

The facility identified a census of 29 residents with 12 residents sampled. Based on interview and record review, the facility did not ensure completion of four residents comprehensive Minimum Data Set (MDS) assessments related to completion of the Care Area Assessments (CAA). Findings included:- R1's 09/28/25 Annual MDS triggered the following CAA areas, but were not completed:Activity of Daily Living (ADL) Functional / Rehabilitation PotentialUrinary Incontinence and Indwelling CatheterFallsNutritional StatusDehydration/Fluid MaintenanceDental CarePressure Ulcer/InjuryPsychotropic Drug Use R3's 10/07/25 Annual MDS triggered the following CAA areas, but were not completed:Cognitive Loss / DementiaCommunicationUrinary Incontinence and Indwelling CatheterBehavioral SymptomsFallsPressure Ulcer/InjuryPsychotropic Drug UsePain R4's 08/25/25 Annual MDS triggered the following CAA areas, but were not completed:Activity of Daily Living (ADL) Functional / Rehabilitation PotentialUrinary Incontinence and Indwelling CatheterNutritional StatusPressure Ulcer/InjuryPhysical RestraintsPain R20's 04/16/25 Annual MDS triggered the following CAA areas, but were not completed:Cognitive Loss / DementiaCommunicationUrinary Incontinence and Indwelling CatheterMood StateFallsNutritional StatusDental CarePressure Ulcer/InjuryPsychotropic Drug UsePain On 03/10/26 at 04:06 PM, Administrative Nurse D acknowledged the above findings and stated the CAA should be filled out to more accurately trigger care plan interventions. Administrative Nurse D said she was still learning how to complete MDS assessments and missed the CAAs on the residents listed. Additionally, Administrative Nurse D stated she expected MDS assessments to accurately reflect each resident's status. The facility's undated Minimum Data Set (MDS) Accuracy Audits policy documented the facility was committed to ensuring the accuracy, timeliness and completeness of all MDS assessments.

The facility identified a census of 29 residents, with 12 residents sampled. Based on interview and record review, the facility did not ensure accurate completion of five residents' Minimum Data Set (MDS) assessments related to the utilization of bedrails as restraints. Findings included:- R2's 01/20/25 Quarterly MDS documented bed rails were utilized as physical restraints daily during the look-back period. R4's 11/25/25 Quarterly MDS documented bed rails were utilized as physical restraints daily during the look-back period. R10's 01/16/26 Quarterly MDS documented bed rails were utilized as physical restraints daily during the look-back period. R11's 02/15/26 Quarterly MDS documented bed rails were utilized as physical restraints daily during the look-back period. R24's 12/20/25 Quarterly MDS documented bed rails were utilized as physical restraints daily during the look-back period. On 03/10/26 at 04:06 PM, Administrative Nurse D confirmed she had indicated bed rails as restraints on the MDS assessments of residents in the facility whose beds had bed rails installed on them, regardless of whether or not the resident used them. Administrative Nurse D confirmed the bed rails did not restrict the above-mentioned residents mobility and therefore did not meet the definition of a restraint. Administrative Nurse D stated she expected MDS assessments to accurately reflect each resident's status. The facility's undated Minimum Data Set (MDS) Accuracy Audits policy documented the facility was committed to ensuring the accuracy, timeliness and completeness of all MDS assessments.

The facility reported a census of 29 residents, with one medication room, three medication carts, and one treatment cart. Based on observation, interview, and record review, the facility failed to ensure safe and secure medication storage for unauthorized staff and residents when licensed nursing staff left a medication cart unlocked and unsupervised. Findings included:- During an observation on 03/09/26, at 02:08 PM, Licensed Nurse (LN) H approached a medication cart parked directly outside of the nurse's station. She prepared medications in a small cup, locked her computer screen, and walked away from the medication cart that remained unlocked. LN H then walked down the hall into a resident's room, leaving the unlocked medication cart unattended by staff. The medication cart's lock remained outward, indicating the lock was not engaged, which left the cart accessible to anyone who attempted to access it. When the LN returned to the cart, she logged into her computer, prepared medications for another resident, locked her monitor screen and after closing the medication drawer she walked down the same hall into another resident's room and out of visual range. The medication cart remained unlocked and unsupervised during this time. When LN H returned to the medication cart, she logged back into her computer and noted her medication cart remained locked at this time. During an interview with LN H at 02:15 PM, on 03/09/26, she verified the medication cart and computer monitor should be locked every time it is left unattended. An interview with Administrative Nurse D on 03/11/26 at 12:46 PM revealed she expected staff to lock the medication cart before walking away. The Medication Labeling and Storage policy, dated 06/05/24, states all medications must be stored in a secure, locked location, accessible only to designated staff.

The facility identified a census of 29 residents. The facility identified two residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure Resident (R)1'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 R9, R7, and R6's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks were stored in a sanitary manner when not in use. The facility failed to ensure staff were wearing proper personal protective equipment (PPE) for EBP when doing direct care. The facility failed to transport dirty laundry using acceptable infection control practices. Findings included:- On 03/09/26 at 07:48 AM, during the initial walk-through of the facility, R1's CPAP mask laid directly on her bedside table. R1's CPAP mask was not stored in a sanitary container. R9's nebulizer mask laid on her bedside tablet. R9's nebulizer mask was not stored in a sanitary container.R7's nebulizer mask laid on her bedside table. R7's nebulizer mask was not stored in a sanitary container.R6's nebulizer mask hung over her side table and laid in her magazine rack. R6's nebulizer mask was not stored in a sanitary container.On 03/09/26 at 08:12 AM, Certified Nurses Aide (CNA) M carried unbagged dirty laundry from the bottom of Hall 2 holding the dirty clothing next to their uniform. CNA M was carrying the dirty laundry to a dirty laundry barrel in the middle Of Hall 2.On 03/10/26 at 07:36 AM, CNA 0 held a graduated cylinder (cylindrical vessel made of transparent plastic or glass, marked with precise, horizontal lines to measure liquid volumes), that contained dark amber colored urine. CNA 0 was wearing gloves only. CNA O was not wearing appropriate PPE for a resident with a urinary catheter.On 03/10/26 at 07:44 AM, CNA O stated she should have been wearing the proper PPE for EBP. CNA 0 stated all CNAs were trained on EBP. She stated there was a sign on the door to inform staff of the proper PPE to wear when taking care of residents with urinary catheters.On 03/11/26 at 09:55 AM, Licensed Nurse (LN) H stated all respiratory equipment should be rinsed and laid to dry, and the equipment should be covered while drying. LN H stated the equipment should be placed in a marked bag when not in use. She stated all staff were trained on proper PPE to wear when doing resident personal care for residents on EBP. She stated a gown and gloves should be worn when doing personal cares with a resident who had a urinary catheter.On 01/10/26 at 12:49 AM, Administrative Nurse D stated all respiratory equipment that was not in use should be placed in a bag labeled with the resident's name and date. She stated she expected staff to place respiratory equipment in a bag when the equipment was not in use. Administrative Nurse D stated all staff were trained on EHB precautions, each staff know when PPE was required when doing cares for residents. She stated staff should never carry dirty laundry next to their clothing; staff were to move the laundry tub next to the resident's door.The facility's Respiratory Care policy undated, documented the facility was committed to providing high-quality respiratory care to residents in accordance with evidence-based best practices, regulatory requirements, and physician orders. Nursing staff are responsible for ensuring proper assessment, intervention and monitoring of residents with respiratory conditions, whether acute or chronic. The purpose of this policy is to establish guidelines for the assessment, management, and monitoring of residents with any respiratory condition to ensure optimal respiratory function, prevent complications, and promote overall resident well-being. This policy applies to all nursing staff, respiratory therapists, physicians, and other healthcare professionals involved in the care of residents with respiratory conditions.The facility's Laundry Protocols policy undated, documented it was the policy of this facility to prevent the spread of infection by appropriate separation, collection, laundry and storage of laundry. Facility staff will handle, store, process, and transport linens in a method to prevent the spread of infectionThe facility was unable to provide a policy for EHB as requested on 03/11/26.

The facility identified a census of 29 residents. The sample included 12 residents, with one resident reviewed for dignity. Based on observation and interviews, the facility failed to ensure dependent Resident (R)20 was clothed appropriately when sitting in the TV area with her peers.Findings Included:- R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), pain, major depressive disorder (major mood disorder that causes persistent feelings of sadness), aphasia (condition with disordered or absent language function), and dementia (a progressive mental disorder characterized by failing memory and confusion). R20's Quarterly 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 R20 was dependent on staff for all activities for daily living (ADLs). R20's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) lacked analysis.R20's Care Plan dated 03/19/22 documented R20 was at risk for impaired communication and directed staff to allow adequate time for R20 to respond and to provide clear instructions while doing care.On 03/09/26 at 10:37 AM R20 sat in her Broda (special wheelchair with the ability to tilt and recline) chair in the TV room. R20 wore a green hospital gown and had a white sheet over her lap. R20 was moving her hands in an up and down motion and raised her sheet and gown. R20's white incontinence brief was visible to the two male peers who sat in the TV room with her.On 03/11/26 at 10:04 AM, Certified Nurse's Aide (CNA) O stated R20 should be dressed or completely covered. She stated residents should not be exposed to other residents.On 03/11/26 at 09:54 AM, Licensed Nurses (LN) H stated residents should not be in the TV room wearing only a gown and sheet. She stated residents should be left in their rooms until the bath aide was ready for them.On 03/10/26 at 12:49 PM, Administrative Nurse D stated the facility protocol was for residents to be dressed and groomed before leaving their room. She stated she expected residents to be fully dressed when out in the TV area and said their incontinence brief should never be exposed.The facility's Residents Rights Policy undated documented each resident residing in this facility had the right and would be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility without interference, coercion, discrimination or reprisal. No staff member or contracted provider of care would hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights. It was the responsibility of all who work in this facility, including employees of the facility and any others who provided services to the residents of the facility, to advocate and protect the rights of each resident. All staff members are trained in this Resident Right Policy at the time of employment, prior to providing care to residents, and at least annually to ensure full understanding and competency related to ensuring each resident's Resident Rights. Each resident would have the opportunity to exercise his/her rights as a citizen, or a resident of the United States and staff members will assist with exercise of those rights as needed by any/all residents.

The facility identified a census of 29 residents. The sample included 12 residents, with five residents reviewed for unnecessary medication. Based on record review and interviews, the facility failed to ensure Resident (R)21's as-needed lorazepam (antianxiety medications that calm and relax people) cream had a 14-day stop date, or a specified duration with a physician's rationale for extended use.Findings included:- R21's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (elevated blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin),R21's Quarterly Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R21 needed substantial/maximal assistance for all activities of daily living except eating. The MDS documented R21 received an antidepressant (a class of medications used to treat mood disorder), hypnotic (a class of medications used to induce sleep), and an antianxiety medication during the observation period.R21's Psychotropic Use Care Area Assessment (CAA) dated 09/28/25 documented R21 had no adverse reactions noted related to her antidepressant treatment.R21's Care Plan documented:03/05/25 R21 would be free from medication side effects.03/05/25 Consult Pharmacist was to review R21's medication.03/05/25 R21 would be free from symptoms and side effects related to Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). Education would be provided to durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) and R21.R21's EMR under Orders documented the following physician's order:Lorazepam cream 0.5 milligrams (mg), apply every eight hours and as needed related to dementia. The order lacked a 14-day stop date or specified duration,R21's EMR lacked a physician's rationale for the extended use of as needed lorazepam.On 03/11/26 at 09:54 AM, License Nurse (LN)H stated the nurse taking the order should inform the physician the medication required a stop date. She stated the Director of Nursing was the second check for all orders.On 03/10/26 at 12:49 PM, Administrative Nurse D stated the facility's policy was to follow the regulations for as needed psychotropic medication. She stated all nurses taking orders would let the physician know as needed lorazepam required a stop date.The facility did not provide an unnecessary psychotropic drug policy as requested on 03/11/26.

The facility identified a census of 29 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to conduct a thorough facility wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. Findings included:- On 03/09/26 at 10:45 AM, Administrative Staff A provided an undated Long-Term Care Self-Assessment.Review of the assessment revealed the following:The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse's Aide (CNA) needed for each unit, patient acuity, and census. The assessment lacked staffing levels required for each shift to include evenings and weekends.The assessment failed to fully document the condition reports of the residents in the facility or document any potential extenuating circumstances that would make the condition report unusual.The assessment failed to document staff competencies and skill sets necessary to provide the level and types of care needed for specific resident populations.The assessment failed to fully document contractual agreements to outside providers for services available to residents in the facility for laboratory, radiology, therapy, hospital or transportation. Additionally, the facility failed to document contracts for lawn care and/or snow removal. On 03/11/26 at 09:11 AM, Administrative Staff A stated he reviewed the assessment annually and this was last performed on 10/23/25. Administrative Staff A reviewed the assessment and stated the facility does not have a vision or mission statement. He said he was unaware that the orange boxes on the assessment should be filled in per the assessment's instructions. Administrative Staff A stated staffing breakdown per unit should be completed and confirmed the assessment did not contain this information. Administrative Staff A confirmed the competencies that were unchecked indicated the listed staff were not responsible for the competency after he observed Safety and Missing Resident for All Staff were unchecked. Administrative Staff A stated he expected the facility assessment to be accurate. The facility's Facility Assessment Policy documented the assessment is the foundation to determine staffing levels and competencies and the facility would evaluate the resident population and identify the resources needed to provide the necessary care and services the residents require on an annual basis and any time significant changes are made to the care or service provided by the facility. The purpose included to consider specific staffing needs for each shift and adjust as necessary based on the resident population. The assessment would address the care required by the resident population as well as the staff competencies and skill sets necessary to provide the level and types of care required. The assessment would also address the facility's resources such as equipment, services provided, contracts and personnel (including education and/or training and competencies related to resident care). The assessment would include evaluations of any contracts or understandings that included third party agreements to provide goods, services and equipment to the facility during normal operations and emergencies.

The facility identified a census of 31 residents. There were 12 residents in the sample with one reviewed for abuse. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 14 remained free from neglect when the facility failed to provide the necessary care and services, including supervision required by R14 to promote his safety and well-being. On 04/14/24 at approximately 02:00 PM Certified Nurse Aide (CNA) M assisted R14 into the courtyard off the dining room. CNA M then left for the day while R14 remained outside with no ability to contact the facility or get back inside. Around supper time, at approximately 04:00 to 05:00 PM, staff noted R14's absence. CNA P found R14 outside and R14 was unresponsive. Staff brought R14 inside the facility and assessed his vital signs. R14's body temperature was 104.9 degrees Fahrenheit (F.), and he had a pulse of 144 beats per minute. Staff began cooling measures and R14 became more responsive. R14 went to the Emergency Department where he received intravenous (IV-administered directly into the bloodstream via a vein) fluids for rehydration. The facility failed to ensure R14 received the care and services, including supervision to promote his safety and well-being. This failure placed R14 in immediate jeopardy. Findings included: - R14's Electronic Health Record (EHR) revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive staff assistance with activities of daily living (ADL) and was dependent on staff for chair-to-bed transfers and sit-to-lying positioning. R14 used a wheelchair for mobility. The resident received opioids (a class of medications to relieve pain), antianxiety (a class of medications that calm and relax people) medication, antidepressants (a class of medications used to treat mood disorders), hypoglycemic medications (medication used to lower blood sugar) and anticoagulant (class of medication used to prevent and treat blood clots) medications. R14's Care Plan, dated 02/23/24, directed staff to assist R14 with all ADL and self-care. The plan documented the resident used a wheelchair for mobility and required extensive assistance from two staff and a total body lift for transfers. The plan documented R14 enjoyed sitting outside daily when the weather was acceptable. The plan directed staff to monitor, document, and report any signs or symptoms of immobility, contractures (abnormal fixation of a joint or muscle) formation or worsening, skin breakdown, and fall-related injuries. The care plan directed staff to cue, reorientate, and supervise R14 as needed. The Nurses Notes, dated 04/14/24 at 05:15 PM, recorded R14 was found outside, unresponsive, in his wheelchair with no shirt on. Staff wheeled him back in and obtained vital signs. The note recorded R14 had drool down his frontside, and his head was turned down to the left. R14 groaned when spoken to and he was able to minimally squeeze staff's hand with his left hand, but not with his right. Staff placed cold wet towels on the resident's neck, under his arms, and on his forehead and then wheeled the resident to the nurse's station; staff called Emergency Medical Services (EMS). R14 started to cool down and he became more responsive. He was then able to sip on some water and take his evening medications before EMS arrived. When EMS arrived, R14 was loaded onto their cot via a full-body lift. The notes documented staff notified Administrative Nurse D, Administrative Staff A, and the resident's representative of the transfer. A review of R14's EHR lacked evidence of a facility investigation including witness statements and analysis of causative factors regarding the event. Upon request, the facility was unable to provide an investigation related to the event. On 05/14/24 at 03:00 PM observation revealed R14 sat in a wheelchair outside on the front patio. R14 wheeled from one door to the other trying to open each side of the double doors and was unable to do so. The surveyor summoned Administrative Staff B and asked if R14 was ok outside and if he could get back inside on his own. Administrative Staff B went to the door and assisted R14 inside. R14 stated he could not get in. Administrative Staff B asked R14 if he had his walkie-talkie. Administrative Staff B helped him locate his walkie-talkie which was rolled up in the front tail of R14's t-shirt. He appeared unaware he had it or how to use it. On 05/15/24 at 10:20 AM Administrative Nurse D stated that on 04/14/24, a CNA took R14 outside to the [NAME] patio around 02:00 PM. She said the CNA was going off shift and the evening shift was coming on. Administrative Nurse D said apparently, the evening shift staff was not informed the resident was outside. She stated when the nurse was doing the afternoon medication pass, the nurse looked for R14 and found him outside on the patio, unresponsive and drooling. Administrative Nurse D said staff immediately brought R14 inside, did the assessment, and called EMS; R14 was transported to the hospital and received two bags of IV fluids then returned to the facility to be monitored. Administrative Nurse D verified R14 did not have any means to contact the facility to request assistance while he was outside. Administrative Nurse D said the facility did not conduct a written investigation and did not have a formal staff in-service related to the incident. She said the facility administrative staff just went around and talked to the staff after the incident. On 05/15/24 at 12:39 PM, Administrative Staff A stated when the resident came to the facility, he was more mobile and got around easier in his wheelchair. Administrative Staff A stated the resident had a flip phone he took out with him, and he used to be able to open the door and let himself outside. Administrative Staff A stated more recently, the resident relied on staff to let him out, and staff should provide R14 a walkie-talkie and 30-minute visual checks while he is outside. Administrative Staff A stated on 04/14/24, CNA M let R14 outside as she went off duty and the oncoming aides and agency nurse did not check on him or possibly, did not even know he was outside. Administrative Staff A stated the facility was still gathering information regarding the event. On 05/15/24 at 01:25 PM, CNA M stated she let R14 outside on the patio sometime after 01:00 PM on 04/14/24. CNA M said another staff was in the dining room at that time and knew R14 was going outside. CNA M said an agency nurse was also in the dining room. CNA M said she got off work at 02:00 PM and the nurse would get off at 06:00 PM. CNA M stated CNA P found the resident outside on the patio more than three hours later. CNA M said that CNA P told Administrative Staff A that she was not informed the resident was outside when she came on duty. CNA M stated the resident should have the walkie-talkie to call for staff while he is outside but then said she did not think R14 knew how to use it. The facility's Abuse, Neglect, and Exploitation policy, undated, recorded the facility would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by implementation of specific procedures listed in the required components of the policy. The policy recorded that each resident would be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents would be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type would be tolerated, and residents and staff would be monitored for protection. The facility would strive to educate staff members, volunteers, contractors, residents family members visitors, and other applicable individuals in techniques to protect all parties. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator would report abuse to the state agency per State and Federal requirements. It is the policy of the facility that all allegations and reports of, mistreatment, and neglect, including injuries of unknown sources, exploitation, and misappropriation of property are thoroughly investigated. The investigation is the process used to determine what happened. The designated facility personnel would begin the investigation immediately. A root cause investigation and analysis would be completed, and the investigation gathered would be given to the Administrator. The individual conducting the investigation would review the incident report, the resident's clinical record, and other pertinent documentation. All witness statements obtained would be filed with the investigation report. The investigation would include who was involved, resident statements, resident's roommate statements, involved staff and witness statements of events, injuries present, and environmental considerations. All investigations related to abuse, neglect, exploitation, or mistreatment would be reviewed by the Quality Assurance Performance Improve Committee (QAPI) and interventions would be monitored for continued improvement. On 05/15/24 at 02:35 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template' and was informed of the facility's failure to ensure R14 received the care and services, including supervision to promote his safety and well-being placed R14 in immediate jeopardy. The facility submitted a corrective action plan to remove the immediacy which included the following: The facility will no longer employ the nurse on duty that day. The facility will train all current staff and will train all future employees including the agency staff on outdoor safety and neglect. The facility provided re-training on the Abuse, Neglect, and Exploitation Policy. The facility created a procedure specific to the incident that all staff were trained on. The administration will monitor outdoor times and safety on an ongoing basis. Staff will ensure residents outside receive adequate visual checks and adequate hydration. On 05/16/24 during a partial extended survey, the surveyor verified the removal of the immediacy for R14. The scope and severity remained at a G.

The facility had a census of 31 residents. Based on observation, record review, and interview, the facility failed to provide a full-time Registered Nurse as Director of Nursing (DON) and failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week placing all residents who resided in the facility at risk of lack of inadequate care. Findings included: - A review of the January - December 2023 nursing schedule revealed no Registered Nurse for eight consecutive hours on more than 50 dates. On 05/15/24 at 09:44 AM, Administrative Staff A verified the facility did not employ a full-time RN as DON. Administrative Staff A verified the lack of Registered Nurse coverage on the dates reviewed and stated he had not been able to get an RN for eight consecutive hours. Administrative Staff A stated he was unable to get an RN except every once in a while from an agency. The facility's Job Description-Director of Nursing Policy, undated, documented the purpose under the direction of the facility administrator, the DON's primary responsibility was to ensure the provision of quality nursing care on a 24-hour basis to the elders of this facility in accordance with Federal, State and Local standards and regulations. The facility's Nursing Services-Registered Nurse (RN) Policy, revised in February 2023, documented the facility would utilize the services of an RN for at least eight consecutive hours per day, seven days per week. The facility would designate an RN to serve as the Director of Nursing on a full-time basis. The facility failed to employ a full-time DON and failed to have RN coverage for eight consecutive hours daily. This placed the 31 residents at risk for inadequate care.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella) and other waterborne pathogens. This placed the residents in the facility at risk for infectious disease. Findings Included: - On 05/16/24 at 11:00 AM, Maintenance Staff U verified he was not aware of any routine facility water management checks and verified the 300 hall was presently not in use. Maintenance Sraff U stated staff do not flush water in the unoccupied rooms but did occasionally use the shower room in the 300 hall for one resident at the facility. On 05/16/24 at 11:20 AM, Administrative Staff A verified the city checked the water monthly but stated he did not have any records of the monthly checks. Administrative Staff A verified the facility lacked a system to check regarding standing water and potential growth inside the facility and lacked a system to mitigate the risk of Legionella. The facility's Legionella Surveillance policy, undated, documented the purpose of the policy was to ensure as far as possible, all users of the facility are protected from the incidence of Legionnaire's disease. The Director of Environmental Services is responsible for all relevant details regarding roles and responsibilities and testing regimens contained in the policy and procedure. It is the policy of the facility to ensure that appropriate precautions for the control of Legionella bacteria are identified through the Legionella risk assessment process and appropriate control measures implemented to ensure, so far as is reasonably practicable, the health, safety, and welfare of residents, visitors, staff members, and volunteers. The minimum standards to be met included but not limited to: Carrying out suitable and sufficient Legionella assessments. Description of building water systems. Identification of areas where Legionella could grow and spread. Preparation of an action plan or written scheme for preventing or controlling the risk, where appropriate. (Include in the plan of any area where medical procedures may expose residents to water mists including hydrotherapy and respiratory therapy services.) Implementation. Management monitoring and recording of precautions to include regular inspection, microbiological monitoring, temperature checks, and flushing where appropriate. Plans to intervene when control limits are not met. Continuous monitoring of program compliance. Documentation of all monitoring. Seeking suitable advice and assistance from competent persons and Specialist consultants, where appropriate. Appointment of a person or persons to be managerially responsible for the water system at each premise. The facility has established and maintained, an infection prevention and control group designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy further documented the requirements will be met by the following: inspection of water storage tanks, water would be measured at 86 degrees or below after two minutes of running, and hot water storage or distribution would be measured at 122 degrees at outlets after one minute of running. All cases of Legionella would be reported to the local health department and the State health departments. The facility failed to implement a water management program to test and manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards with staff left a gallon chemical bottle in an unlocked bottom cabinet in one of three kitchenettes. This placed the 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. Findings included: - On 05/13/24 at 11:44 AM, observation revealed an unlocked cabinet underneath the sink, in a kitchenette, located off the family dining room. The unlocked cabinet contained a plastic gallon bottle of Attack [NAME] Enzyme (a molecule that enhances cleaning performance while decreasing environmental impact) odor digester, drain opener, and maintainer. The label on the bottle reads Keep out of reach of children, avoid contact with eyes, and may cause skin irritation. On 05/13/24 at 11:48 AM, Licensed Nurse (LN) G verified the above finding and stated the cabinet should be locked. LN G took the bottle to the locked housekeeping closet. On 05/15/24 at 11:29 AM, Administrative Nurse D stated she expected staff to store chemicals in a locked cabinet. Upon request, the facility did not provide a chemical storage policy. The facility failed to ensure an environment free from accident hazards when staff stored harmful chemicals in an unlocked cabinet. This placed the 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the physician acknowledged and responded to the Consultant Pharmacist's recommendation for the required stop date for Resident (R)19's as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R19 at risk for unintended effects related to psychotropic (alters mood or thoughts) drug medications. Findings include: - R19's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear,) and hypertension (HTN-elevated blood pressure.) R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had moderately impaired cognition. The MDS recorded R19 was independent with most activities of daily living (ADL.) The MDS recorded R19 received an antianxiety and antidepressant (medication used to treat depression) medication during the observation period. R19's Care Plan, dated 01/17/24 recorded R19 had trouble sleeping and behavior problems and received lorazepam (antianxiety medication) two tablets at bedtime, and may take one additional dose in the middle of the night. The care plan documented the staff would monitor the times the resident had insomnia and report any adverse reactions to the anti-anxiety medication. The Physician's Order, dated 03/05/24, directed the staff to administer lorazepam (antianxiety) oral concentrate 0.5 milligrams (mg)/milliliter (ml), Give 0.5 ml every 24 hours PRN for anxiety, one dose during the night. The order lacked a stop date. R19's EMR lacked evidence of a physician-ordered duration which included a rationale for the extended use of the PRN lorazepam. A review of the Consultant Pharmacist's monthly review for R19 revealed on 03/08/24 the pharmacist recommended the lorazepam needed a 14-day stop date. R19's clinical record lacked evidence the physician responded to the recommendation. On 05/14/24 at 07:30 AM, observation revealed R19 sat in a recliner in the 400-hall living room dressed in street clothes watching TV. Continued observation revealed Certified Medication Aide (CMA) U administered the resident's morning medications. On 05/14/24 at 10:00 AM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. Administrative Nurse D verified the pharmacist had sent monthly reviews to the facility for concerns and had recommended a stop date for the lorazepam. Administrative Nurse D said the recommendation was sent to the physician however he had not responded with a duration for use and rationale or discontinuation of the medication. The facility's Use of Psychotropic Drug Use policy, undated, documented the resident's need for psychotropic medication would be monitored, as well as when the resident received an optional benefit from the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The resident admitted to the facility with a PRN psychotropic medication would have a 14-day stop date. Before the end of the 14 days, the ordering practitioner would assess the resident's response to the PRN medication and would document a thoughtful risk-benefit rationale statement for continued use of the medication. If the assessment indicates continued use of the medication, a specific duration would be included in the re-order of the medication. No PRN antipsychotic may be ordered longer than 14 days. The facility failed to ensure the physician acknowledged and responded to the Consultant Pharmacist's recommendation for R19. This placed the resident at risk for unnecessary psychotropic medication side effects.

The facility had a census of 31 residents. The sample included 12 residents with three reviewed for abuse. Based on observation, record review, and interview the facility failed to report an incident of neglect for Resident (R) 14 to the State Agency as required. This placed the resident at risk for ongoing neglect. Findings included: - R14 ' s Electronic Health Record (EHR) revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive staff assistance with activities of daily living (ADL) and was dependent on staff for chair-to-bed transfers and sit-to-lying positioning. R14 used a wheelchair for mobility. The resident received opioids (a class of medications to relieve pain), antianxiety (a class of medications that calm and relax people) medication, antidepressants (a class of medications used to treat mood disorders), hypoglycemic medications ( medication used to lower blood sugar) and anticoagulant (class of medication used to prevent and treat blood clots) medications. R14's Care Plan, dated 02/23/24, directed staff to assist R14 with all ADL and self-care. The care plan documented the resident used a wheelchair for mobility and required extensive assistance from two staff and a total body lift for transfers. The plan documented R14 enjoyed sitting outside daily when the weather was acceptable. The care plan directed staff to monitor, document, and report any signs or symptoms of immobility, contractures (abnormal fixation of a joint or muscle) formation or worsening, skin breakdown, and fall-related injuries. The care plan directed staff to cue, reorientate, and supervise R14 as needed. The Nurses Notes, dated 04/14/24 at 05:15 PM, recorded R14 was found outside, unresponsive, in his wheelchair with no shirt on. Staff wheeled him back in and obtained vital signs. The note recorded R14 had drool down his frontside and his head was turned down to the left. R14 groaned when spoken to and he was able to minimally squeeze staff's hand with his left hand, but not with his right. Staff placed cold wet towels on the resident's neck, under his arms, and on his forehead and then wheeled the resident to the nurse ' s station; staff called Emergency Medical Services (EMS). R14 started to cool down and he became more responsive. He was then able to sip on some water and take his evening medications before EMS arrived. When EMS arrived, R14 was loaded onto their cot via a full-body lift. The notes documented staff notified Administrative Nurse D, Administrative Staff A, and the resident's representative of the transfer. A review of R14 ' s EHR lacked evidence an investigation including witness statements and analysis of causative factors was done regarding the event. Upon request, the facility was unable to provide an investigation related to the event. On 05/14/24 at 03:00 PM observation revealed R14 sat in a wheelchair outside on the front patio. R14 wheeled from one door to the other trying to open each side of the double doors and was unable to do so. The surveyor summoned Administrative Staff B and asked if R14 was ok outside and if he could get back inside on his own. Administrative Staff B went to the door and assisted R14 inside. R14 stated he could not get in. Administrative Staff B asked R14 if he had his walkie-talkie. Administrative Staff B helped him locate his walkie-talkie which was rolled up in the front tail of R14's t-shirt. He appeared unaware he had it or how to use it. On 05/15/24 at 12:39 PM, Administrative Staff A stated on 04/14/24, CNA M let R14 outside as she went off duty and the oncoming aides and agency nurse did not check on him or possibly, did not even know he was outside. Administrative Staff A stated the facility was still gathering information regarding the event. The facility ' s Abuse, Neglect, and Exploitation policy, undated, recorded the Nursing Home Administrator would report abuse to the state agency per State and Federal requirements. The facility failed to report an incident of neglect for R14 to the State Agency as required. This placed the resident at risk for ongoing neglect.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate an incident of neglect for Resident (R)14. This placed R14 at risk for unidentified and ongoing neglect. Findings included: - R14 ' s Electronic Health Record (EHR) revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive staff assistance with activities of daily living (ADL) and was dependent on staff for chair-to-bed transfers and sit-to-lying positioning. R14 used a wheelchair for mobility. The resident received opioids (a class of medications to relieve pain), antianxiety (a class of medications that calm and relax people) medication, antidepressants (a class of medications used to treat mood disorders), hypoglycemic medications ( medication used to lower blood sugar) and anticoagulant (class of medication used to prevent and treat blood clots) medications. R14's Care Plan, dated 02/23/24, directed staff to assist R14 with all ADL and self-care. The care plan documented the resident used a wheelchair for mobility and required extensive assistance from two staff and a total body lift for transfers. The plan documented R14 enjoyed sitting outside daily when the weather was acceptable. The care plan directed staff to monitor, document, and report any signs or symptoms of immobility, contractures (abnormal fixation of a joint or muscle) formation or worsening, skin breakdown, and fall-related injuries. The care plan directed staff to cue, reorientate, and supervise R14 as needed. The Nurses Notes, dated 04/14/24 at 05:15 PM, recorded R14 was found outside, unresponsive, in his wheelchair with no shirt on. Staff wheeled him back in and obtained vital signs. The note recorded R14 had drool down his frontside and his head was turned down to the left. R14 groaned when spoken to and he was able to minimally squeeze staff's hand with his left hand, but not with his right. Staff placed cold wet towels on the resident's neck, under his arms, and on his forehead and then wheeled the resident to the nurse ' s station; staff called Emergency Medical Services (EMS). R14 started to cool down and he became more responsive. He was then able to sip on some water and take his evening medications before EMS arrived. When EMS arrived, R14 was loaded onto their cot via a full-body lift. The notes documented staff notified Administrative Nurse D, Administrative Staff A, and the resident's representative of the transfer. A review of R14 ' s EHR lacked evidence an investigation including witness statements and analysis of causative factors was done regarding the event. Upon request, the facility was unable to provide an investigation related to the event. On 05/14/24 at 03:00 PM observation revealed R14 sat in a wheelchair outside on the front patio. R14 wheeled from one door to the other trying to open each side of the double doors and was unable to do so. The surveyor summoned Administrative Staff B and asked if R14 was ok outside and if he could get back inside on his own. Administrative Staff B went to the door and assisted R14 inside. R14 stated he could not get in. Administrative Staff B asked R14 if he had his walkie-talkie. Administrative Staff B helped him locate his walkie-talkie which was rolled up in the front tail of R14's t-shirt. He appeared unaware he had it or how to use it. On 05/15/24 at 10:20 AM Administrative Nurse D stated that on 04/14/24, a CNA took R14 outside to the [NAME] patio around 02:00 PM. She said the CNA was going off shift and the evening shift was coming on. Administrative Nurse D said apparently, the evening shift staff was not informed the resident was outside. Administrative Nurse D verified R14 did not have any means to contact the facility to request assistance while he was outside. Administrative Nurse D said the facility did not conduct a written investigation and did not have a formal staff in-service related to the incident. She said the facility administrative staff just went around and talked to the staff after the incident. On 05/15/24 at 12:39 PM, Administrative Staff A stated on 04/14/24, CNA M let R14 outside as she went off duty and the oncoming aides and agency nurse did not check on him or possibly, did not even know he was outside. Administrative Staff A stated the facility was still gathering information regarding the event. The facility ' s Abuse, Neglect, and Exploitation policy, undated, recorded it is the policy of the facility that all allegations and reports of, mistreatment, and neglect, including injuries of unknown sources, exploitation, and misappropriation of property are thoroughly investigated. The investigation is the process used to determine what happened. The designated facility personnel would begin the investigation immediately. A root cause investigation and analysis would be completed, and the investigation gathered would be given to the Administrator. The individual conducting the investigation would review the incident report, the resident's clinical record, and other pertinent documentation. All witness statements obtained would be filed with the investigation report. The investigation would include who was involved, resident statements, resident's roommate statements, involved staff and witness statements of events, injuries present, and environmental considerations. All investigations related to abuse, neglect, exploitation, or mistreatment would be reviewed by the Quality Assurance Performance Improve Committee (QAPI) and interventions would be monitored for continued improvement. The facility failed to thoroughly investigate an incident of neglect for R14. This placed R14 at risk for unidentified and ongoing neglect

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 26's Care Plan with interventions for the care of R26's stasis ulcers (open wound caused by problems with blood flow (circulation ) in your leg veins) on her shins. This deficient practice placed the resident at risk for decreased quality of care due to uncommunicated care needs. Findings included: - R26's Electronic Medical Record (EMR) documented R26 had diagnoses of weakness, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented R26 required partial to moderate staff assistance with most activities of daily living (ADLs). The MDS documented R26 had one unhealed unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R26's Care Plan, revised 05/01/24, documented R26 had localized edema in bilateral extremities and received Magic Cup (a frozen nutritional supplement)twice a day for wound healing. The care plan documented R26 required limited staff assistance with most ADLs. The care plan lacked a section regarding skin integrity with instructions to staff on how to care for R26's bilateral lower legs. The Physician Clinical Visit, dated 05/03/24, documented R26 had bilateral venous ulcerations to her legs. Physical therapy (PT) would see R26 weekly for wound care. On 05/14/24 at 07:41 AM, observation revealed R26 sat in a recliner in her room. Her lower legs were covered by her pants. On 05/15/24 at 10:17 AM, Licensed Nurse (LN) G stated R26 had venous stasis ulcers to her bilateral lower legs. LN G was unaware of what the ulcers looked like or what treatment was ordered for R26's ulcers since the resident went to the hospital for her wound care. On 05/16/24 at 09:37 AM, Administrative Nurse D verified R26's Care Plan lacked a section regarding skin integrity. Administrative Nurse D stated she was responsible for updating the care plan regarding skin integrity and stated that R26 should have one. The facility's Care Plan Revisions Policy, undated, documented changes in resident's condition always require changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the plan of care. The facility failed to update R26's Care Plan with information regarding the venous ulcers on her bilateral lower legs. These deficient practices placed the residents at risk for decreased quality of care due to uncommunicated care needs.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for R19's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R19 at risk for unintended effects related to psychotropic (alters mood or thoughts) drug medications. Findings include: - R19's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear,) and hypertension (HTN-elevated blood pressure.) R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had moderately impaired cognition. The MDS recorded R19 was independent with most activities of daily living (ADL.) The MDS recorded R19 received an antianxiety and antidepressant (medication used to treat depression) medication during the observation period. R19's Care Plan, dated 01/17/24 recorded R19 had trouble sleeping and behavior problems and received lorazepam (antianxiety medication) two tablets at bedtime, and may take one additional dose in the middle of the night. The care plan documented the staff would monitor the times the resident had insomnia and report any adverse reactions to the anti-anxiety medication. The Physician's Order, dated 03/05/24, directed the staff to administer lorazepam (antianxiety) oral concentrate 0.5 milligrams (mg)/milliliter (ml), Give 0.5 ml every 24 hours PRN for anxiety, one dose during the night. The order lacked a stop date. R19's EMR lacked evidence of a physician-ordered duration which included a rationale for the extended use of the PRN lorazepam. On 05/14/24 at 07:30 AM, observation revealed R19 sat in a recliner in the 400-hall living room dressed in street clothes watching TV. Continued observation revealed Certified Medication Aide (CMA) U administered the resident's morning medications. On 05/14/24 at 10:00 AM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. The facility's Use of Psychotropic Drug Use policy, undated, documented the resident's need for psychotropic medication would be monitored, as well as when the resident received an optional benefit from the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The resident admitted to the facility with a PRN psychotropic medication would have a 14-day stop date. Before the end of the 14 days, the ordering practitioner would assess the resident's response to the PRN medication and would document a thoughtful risk-benefit rationale statement for continued use of the medication. If the assessment indicates continued use of the medication, a specific duration would be included in the re-order of the medication. No PRN antipsychotic may be ordered longer than 14 days. The facility failed to ensure R19 lorazepam had a 14-day stop date or a physician-ordered specified duration with the rationale. This placed R19 at risk for adverse psychotropic medication side effects.