Every finding on record at Shawnee Post Acute Rehabilitation Center

The facility had a census of 79 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to ensure staff performed appropriate glove changing and hand hygiene for two residents, Resident (R) 18 and R52, when they did not remove their soiled gloves after incontinence care and continued to touch other surfaces and resident belongings.Findings included:- On 02/17/26 at 07:40 AM, Certified Nurse Aide M pushed R18 in her wheelchair to the bathroom and put on clean gloves. CNA M locked the wheelchair, put her right hand under R18's left arm, and R18 grabbed the bar on the wall by the toilet and stood up. CNA M pulled down R18's pants and incontinence brief, and R18 sat down on the toilet. CNA M removed and discarded her incontinence brief and put on a clean one. CNA M had R18 stand so she could perform incontinence care. When CNA M was finished, she pulled up the incontinence brief with the same soiled gloves and pulled up R18's pants. CNA M transferred R18 back into her wheelchair, pushed her up to the sink, picked up R18's toothbrush, put toothpaste on it, and handed it to her. CNA brushed R18's hair and took a wet paper towel and wiped off R18's mouth. CNA M bagged the trash, removed the soiled gloves, and pushed R18 out to the dining room.On 02/17/26 at 07:55 AM, CNA M verified she had not removed her gloves after providing personal care and she said she should have. On 02/17/26 at 09:33 AM, Certified Nurse Aide (CNA) M pushed R52 in her wheelchair to the bathroom and CNA M donned clean gloves. CNA M locked the wheelchair, put her right hand under R52's left arm, and R52 grabbed the bar on the wall by the toilet and stood up. CNA M pulled down R52's pants and incontinence brief, and R52 sat down on the toilet. CNA M removed and discarded her incontinence brief and put on a clean one. CNA M had R52 stand so she could perform incontinence care. When CNA M was finished, she pulled up the incontinence brief with the same soiled gloves and pulled up R52's pants. CNA M transferred R52 back into her wheelchair, had her wash her hands in the sink, pushed her in her wheelchair over to a bedside table, opened up a coloring book, and gave her a container with colored pencils. CNA M removed the soiled gloves.On 02/17/26 at 09:50 AM, CNA M verified she did not change her gloves after she provided personal care and did not wash her hands.On 02/18/26 at 08:30 AM, Administrative Nurse D stated she expected staff to change her gloves and wash her hands after providing personal care to residents.The facility's Infection Prevention and Control Program policy, dated 06/21, documented that the facility personnel would conduct themselves and provide care in a way that minimized the spread of infection. Facility personnel would wash their hands after each direct resident contact for which hand washing was indicated by accepted professional practice. Validation of the personnel infection prevention and control practices is monitored by the infection preventionist through skills competency evaluation, such as observation of hand hygiene.

The facility had a census of 79. The sample included 18 residents. Based on record review, interview, and observation, the facility failed to treat residents with respect, dignity, and privacy related to nasal spray administration, and having an uncovered urinary collection bag visible to guests and other residents. Findings included: - On 02/17/26 at 12:10 PM, observation revealed R8's urinary collection bag sat between his legs in the wheelchair, as he propelled through the dining room. Continued observation revealed R8's urinary collection bag lacked a dignity cover and was half full of yellow urine. On 02/18/26 at 08:40 AM, Administrative Nurse D stated staff should not administer nasal spray at the dining room table and staff should take the resident to her room or a private area. Administrative Nurse D verified the residents catheter bag should be covered and urine not visible. The facility's Resident Rights policy, dated 03/01/25, documented, each resident would be treated with kindness, dignity and respect including privacy in treatment and in the care of personal needs.

The facility identified a census of 79 residents. The sample included 19 residents with five residents reviewed for unnecessary medications. Based on interviews, observation, and record review the facility failed to follow physician orders for an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) medication for Resident (R) 2. The facility also failed to ensure an appropriate indication, or a documented physician rationale, which included multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit reviews for the continued use of antipsychotic medication for R 78, who had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure).Findings included:- R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of altered mental status, schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) type, and need for continuous supervision. The Quarterly Minimum Data Set (MDS) dated 11/20/25 documented a staff assessment for mental status which indicated R2 had modified independence (difficulty in new situations) for daily decision making. The MDS documented R2 received antipsychotic medication, antidepressant (a class of medications used to treat mood disorders) medication, anticonvulsant (a medication that prevents or treats seizures and convulsions) medication, and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. R2's Psychotropic Drug Use Care Area Assessment (CAA), dated 10/02/25 documented she recently returned from the hospital for medication management of her schizoaffective disorder. R2's Care Plan, documented the following: 09/25/24 - Staff would encourage her to express her feelings. 09/25/24 - Staff would assist her to identify her strengths, positive coping skills and reinforce those. 10/03/24 - Staff would administer medication as ordered. 06/27/25 - Staff would monitor, record, and/or notify the physician of any mood patterns. 06/27/25 - Medication had to be given at a specific time. R2's EMR under the Orders tab revealed the following physician orders: Invega sustenna (antipsychotic) intramuscular suspension prefilled syringe 234 milligrams (mg)/1.5 milliliters (ml) (Paliperidone Palmitate). Inject 1.5 ml intramuscularly one time a day every 28 day(s) related to schizoaffective disorder; bipolar type dated 02/11/26. Review of R2's EMR under the Misc tab revealed an After Visit Summary from a hospital stay, which documented an order to start the antipsychotic medication Invega on 01/16/26. Review of R2's EMR under the Orders tab review of the January 2026 Medication Administration Record (MAR) documented the resident refused her Invega injection on 01/13/26. The facility provided documentation verifying the medication was administered by the nurse practitioner on 01/13/26. Review of R2's February 2026 MAR revealed Invega was not administered on 02/10/26 as ordered, the resident's record noted a number seven which represented for the reader to see the resident's nursing notes. Review of R2's Progress Note tab lacked any documentation or rational why the medication was not administered as ordered. On 02/12/26, the resident's antipsychotic medication Invega was administered at 31 days. On 02/17/26 at 07:40 AM, R2 laid on her bed with the blankets pulled over her head. R2's overhead lights were on in the room, and her door was closed. On 02/18/26 at 10:35 AM, Administrative Nurse F stated when R2 refused her medication, staff reattempted to offer the medication several times and if she continued to refuse the medication, the physician would be notified. Administrative Nurse F stated the Invega would be offered again the next day. A note would be documented in R2's EMR in the nurses' notes section and the physician would be notified, which would also be documented in the nurses' notes. On 02/18/26 at 11:40 AM, Administrative Nurse D stated she would expect the physician to be notified of R2's refusal of her antipsychotic medication. Administrative Nurse D stated she was not sure why the medication was not administered as the physician had ordered. The facility's Psychotropic Drug Use policy last revised 11/2024 documented it was the policy of the facility to ensure that residents who have not used psychotropic medication are not given these medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. - R78's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), delusional misidentification syndrome (a group of rare psychiatric disorders characterized by persistent false beliefs that people, places, or objects have been replaced, transformed, or duplicated), anxiety (mental or emotional reaction characterized by apprehension, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (a major depressive disorder that causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R78 had long and short-term memory problems, with severely impaired decision-making skills. R78 was dependent upon staff assistance for all activities of daily living. The MDS documented R78 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication daily. The Significant Change MDS, dated 12/29/25, documented R78 had long and short-term memory problems, with severely impaired decision-making skills. R78 was dependent upon staff assistance for all activities of daily living. The MDS documented R78 received an antipsychotic medication daily. R78's 12/30/25 Care Plan included the following interventions: 05/08/25 – Remind R78 to attend activities of choice. 05/13/25 – Administer medications as ordered and monitor for side effects and effectiveness. Consult with the pharmacy and the physician to consider dosage reduction when clinically indicated. The care plan directed staff to provide non-pharmacological interventions and encouraged them to express feelings. 02/10/26 – Monitor for episodes of psychotic behavior as evidenced by agitation. The Physician's Order, dated 05/01/25, directed staff to administer Seroquel (an antipsychotic medication), 25 milligrams (mg), by mouth at supper for anxiety. The order was changed on 10/12/25 to Seroquel 25 mg, administer 0.5mg, by mouth, in the evening for delusional misidentification syndrome. R78's EMR lacked evidence of a documented physician rational with included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for ongoing Seroquel use. On 02/17/26 at 07:45 AM, R78 was in bed, with her eyes closed. On 02/17/26 at 08:30 AM, Certified Nurse Aide (CNA) M stated R78 rarely left her room and did not have any behaviors that she was aware of. On 02/17/26 at 10:00 AM, Licensed Nurse (LN) G stated R78 did not have behaviors, did not like to attend activities, and stayed in her room most of the time. On 02/18/26 at 10:30 AM, Administrative Nurse D stated she was unable to provide a risk versus benefit or indications for the inappropriate diagnosis of the Seroquel medication. The facility's Psychotropic Drug Use policy, dated 11/24, documented that the facility would ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medication shall not be administered for discipline or convenience. The LN would review the classification of the drug, the appropriateness of the diagnosis, its indications/behavior monitors, and related adverse side effects with the attending physician.

The facility had a census of 79 residents. The sample included 18 residents, with 2 reviewed for hospitalization. Based on interviews and record review the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) and failed to provide the residents with written information regarding the facility's bed hold policy when they were transferred to the hospital for two residents, (R) 51 and R1. Findings included: - The Nurse's Notes dated 02/17/25 at 04:35 PM, documented R51 admitted to the acute care hospital for wound surgery. The Nurse's Note dated 04/02/25 at 01:13 PM documented R51 returned to the facility on a stretcher, transported by Medical Transport company. R51 had multiple wounds that were clean, dry and intact. R51's clinical record lacked a bed hold policy and a resident or resident representative signature. R51's clinical record lacked documentation staff notified the Long-Term Care Ombudsman (LTCO) of R51 s discharge from the facility to the hospital. On 02/18/26 at 08:30 AM, Social Service Designee X verified the facility was unable to provide written evidence upon request that they had a bed hold policy for R51 and stated when residents were discharged , they should have had the resident or family sign the facility bed hold policy. Social Service X verified the facility lacked evidence the LTCO was notified of R51's discharge to the hospital and verified she would send a monthly report to the Ombudsman regarding the residents who were discharged from the facility. The facility's Transfer or Discharge Noise, policy, dated March 2025, documented residents (or residents' representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language they understand. A copy of the notice must be sent to the Office of the State-Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The facility's Bed Hold, policy, dated November 2016, documented the facility would provide written information to the residents and/or the resident's representative regarding bed hold policies in the event of a transfer from the facility to a general acute care hospital or for a therapeutic leave. The bed hold policy would be provided to the resident and/or representative in a language they can understand at the time of admission, transfer to the general acute hospital, and start of the resident's therapeutic leave. The bed hold policy provides all residents and residents representative written information regarding the facility and state bed hold policies, which address holding or reserving a resident's bed during periods of absence. - The Nurse's Note, dated 11/15/25 at 10:18 AM, documented R1 admitted to the hospital for shortness of air (difficulty breathing). R1's clinical record lacked evidence of the ombudsman notification for the 11/15/25 hospital transfer. The Nurse's Note, dated 11/24/25 at 10:18 AM, documented R1 admitted to the hospital for pneumonia (an infection that inflames the air sacs in one or both lungs). R1's clinical record lacked evidence that the resident's family/representative received the bed hold notification or that the Ombudsman was notified of the hospital transfer. On 02/18/26 at 08:00 AM, Social Service X verified that the facility was unable to provide written evidence upon request that it had a bed-hold policy or an ombudsman notification for R1's hospital transfers. On 02/18/26 at 08:30 AM, Administrative Nurse D stated she was unaware R1 lacked a bed hold notification for 11/24/25, and the ombudsman should be notified monthly of hospital transfers. The facility's Admission, Transfer, and Discharge policy, dated 03/25, documented the facility would notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility would send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

The facility had a census of 79 residents. The sample included 19 residents, with one reviewed for communication. Based on observation, interview, and record review, the facility failed to ensure staff used alternative communication methods for one sampled resident, Resident (R) 18, who had a language barrier and spoke in Farsi (Persian).Findings included:- R18's Electronic Medical Record (EMR) documented diagnoses of senile degeneration of the brain (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had long and short-term memory problems with severely impaired decision-making skills. R18 required partial staff assistance with dressing, showers, toileting hygiene, mobility, and transfers. The MDS documented R18 had adequate hearing, clear speech, and usually made herself understood.R18's 01/01/26 Care Plan included the following interventions:07/22/20 - R18 spoke in Farsi and was able to communicate with the translator. R18's daughter is available to translate 24/7. R18's family provided a notebook with key phrases in Farsi to English in her room. R18 preferred using her daughter or family to translate. The care plan directed staff to anticipate and meet her needs and provide a translator as necessary to communicate with her.10/15/20 - R18 preferred to communicate in her language and directed staff to use a translator service.03/15/24 - R18 often preferred her children to translate for her.11/15/24 - Keep her television on Farsi speaking channel at all times.During an observation on 02/17/26 at 07:40 AM, Certified Nurse Aide (CNA) M told R18 she would help her get up to go to the bathroom. R18 talked to CNA M in her native language. When this surveyor asked what R18 said, CNA M stated, I don't know. When asked how CNA M knew what R18 needed or wanted, CNA M stated R18 could say a few words, like water, but otherwise CNA M did not know. CNA M stated she had worked at the facility for a short time and did not know of any other ways to communicate with R18.On 02/17/26 at 10:30 AM, Licensed Nurse (LN) G stated they use an interpreter service or the family if they try to communicate with R18 or had difficulty understanding what she wanted or needed.On 02/18/26 at 08:30 AM, Administrative Nurse D stated the family prefers they call them to translate if the staff do not know what the resident wanted or needed. Administrative Nurse D said it was easier than calling the translator service.The facility did not provide a policy regarding communication, as requested on 02/18/26 at 12:00 PM.

The facility identified a census of 79 residents. The sample included 19 residents with one resident reviewed for positioning and mobility. Based on observation, record review and interview, the facility failed to ensure staff provided the physician ordered foam dressings to protect the skin integrity of Resident (R) 3's bilateral hand contractures (abnormal permanent fixation of a joint or muscle). Findings included:- R3's Electronic Medical Record (EMR) documented diagnoses of contracture of the left and right hands, and hemiparesis/hemiplegia (weakness and paralysis on one side of the body).R3's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R3 was dependent on staff for all activities of daily living (ADL). R3's Functional Abilities (Self Care and Mobility) Care Area Assessment (CAA), dated 03/14/25, documented she continued to use a Broda chair (specialized wheelchair with tilt and recline) for mobility and a Hoyer lift (total-body mechanical lift) for transfers. R3 needed assistance with peri-care and clothing management.R3's Care Plan revised on 02/02/26, directed staff to place foam or other available foam dressing in bilateral palms under nails daily or as tolerated for skin integrity. The Care Plan directed staff to please place Hydrofera blue foam (absorbent foam dressing) or other available foam dressing in both palms and under nails daily or as tolerated for skin integrity in the setting of severely contracted hands.R3's Orders tab documented an order dated 01/08/26 for Hydrofera blue foam or other available foam dressing in both palms under nails daily, or as tolerated, for skin integrity in the setting of severely contracted hands. R3's Occupational Therapy (OT) dictation from her certification period 10/27/25 to 12/01/25 documented R3 was referred due to new skin breakdown noted on bilateral palms and severely contracted hands. R3 had typically been resistive/become agitated at attempts to place palm protectors and orthotics in prior plans of care. During evaluation, R3 had small antibacterial foam placed in her palms which seemed to be protecting the palms, other than her left second fingernail digging into the skin on top of her third finger. R3 has more active range of motion in her right hand, which is more severely contracted, and the nails are curled under; less mobility in the left hand however fingertips are not curled under. R3 was pleasant to the therapist and allowed examination of her hands however upon trial of carrot orthotic she stated she was not doing that and withdraws her hand. She allowed foam to be reapplied without issue. The skin of both hands appeared dry and flaky this date with left hand more impacted than right. She would benefit from participation in skilled OT plan of care to address these deficits.On 02/16/26 at 09:11 AM, R3 sat in her Broda chair in her room. R3's bilateral hands and fingers were tightly closed with no foam support noted in the palms of her hands.On 02/17/26 at 11:25 AM, R3 sat in her Broda chair watching tv near the dining area. R3's bilateral hands and fingers did not have foam supports under her fingers for her contractures.On 02/17/26 at 11:33 AM, Licensed Nurse (LN) H said R3 should have foam in her hands but could not say why R3 did not have them in her hands.On 02/18/26 at 08:33 AM, Administrative Nurse D stated she expected R3's foam to be put in both of her hands daily. Administrative Nurse D said the staff should place the foam in the palms of her hands each morning for her contracted fingers.The Contracture Documentation policy revised 03/25 documented a resident with a limited range of motion or contracture shall receive appropriate treatment and services, based on the comprehensive assessment of the resident, to increase range of motion and/or to prevent further decrease. An assessment of the resident's joint mobility should be completed by the physical therapist or a licensed nurse to reflect the following: resident's joint limitations by category of limitation, resident's ability to participate in activities geared to stretching and range of motion (ROM) exercises, identify risk factors for secondary complications and need for special positioning, transfer and skin care precautions, resident's needs for adaptive devices to improve participation in ADL's. A program shall be developed by the Interdisciplinary Team based on the resident's comprehensive assessment and shall be included in the resident's care plan. A physician's order shall be obtained to provide the range of motion program to the resident and any recommended splints, braces, assistive devices to assist in reducing further decline in joint range of motion. The effectiveness of the program, whether improved joint mobility, or maintained mobility, or deterioration of the joint movement is observed, shall be included.

The facility had a census of 79 residents. The sample included 19 residents, with four reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment for one resident, Resident (R) 52, who sustained a skin tear after staff lowered her to the ground and was not using a gait belt during ambulation.Findings included: - R52's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), repeated falls, muscle weakness, and unsteadiness on the feet.The Significant Change Minimum Data Set (MDS), dated [DATE], documented R52 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R53 was dependent upon staff for toileting hygiene, and required partial staff assistance with transfers and personal hygiene. R52 had no functional impairment to upper or lower extremities and had no falls.The Fall Risk Assessments, dated 10/10/25, documented R52 was a medium risk for falls.R52's 12/23/25 Care Plan included the following interventions:03/25/19 - Provide R52 a safe environment, the call light within reach, and the bed in low position at night.08/23/23 - Educate R52 and remind her to call for assistance with all transfers.01/17/24 - Care in pairs.03/12/24 - Remind her to lock her braes before transfers.01/07/25 - Ensure nonskid footwear on al all ties.12/12/25 - Ensure use of a gait belt during all transfers.The Interdisciplinary Team Note, dated 12/15/25 at 11:28 AM, documented R52 had a fall on 12/12/25 at 07:30 PM. The root cause analysis determined that during the process of transferring R52 from the wheelchair to the bed, the resident's knees buckled, and the caregiver lowered her slowly to the floor. After a head-to-toe assessment was completed, a skin tear was noted on the right elbow. The intervention put into place was to ensure the use of a gait belt during transfers. The caregiver stated, R52 seemed weak, and her knees buckled, so she helped her down on the floor, and she ended up with a wound on her right arm.The Nurse's Note, dated 12/12/25 at 09:12 PM, documented a caregiver helped R52 to bed. In the process of the transfer from the wheelchair to bed, her knees buckled, and the caregiver lowered her to the floor. A head-to-toe assessment was completed after the fall, and a skin tear was noted on the right elbow. The skin tear was cleansed and covered with a Band-Aid.On 02/17/26 at 09:33 AM, Certified Nurse Aide (CNA) M pushed R52 in her wheelchair to the bathroom and put on clean gloves. CNA M locked the wheelchair, put her right hand under R52's left arm, and R52 grabbed the bar on the wall by the toilet and stood up. CNA M pulled down R52's pants and incontinence brief, and R52 sat down on the toilet. CNA M removed and discarded her incontinence brief and put on a clean one. CNA M had R52 stand so she could perform incontinence care. When CNA M was finished, she pulled up the incontinence brief with the same soiled gloves and pulled up R52's pants. CNA M transferred R52 back into her wheelchair, had her wash her hands in the sink, pushed her in her wheelchair over to a bedside table, opened up a coloring book, and gave her a container with colored pencils. CNA M then removed the soiled gloves. When this surveyor asked CNA M if she was supposed to use a gait belt during her transfers or if there was to be two staff to assist with her care, she stated, [R52] did not need a gait belt for transfers and CNA M said she did not know there R52 needed two staff in the room to provide care.On 02/17/26 at 10:00 AM, Licensed Nurse (LN) G stated she was unsure about two staff members to assist with R52's cares but due to her falls, staff were always to use a gait belt for her transfers.On 02/17/26 at 02:00 PM, Administrative Nurse D stated that staff were to follow the care plan of care in pairs and to always use a gait belt during transfers for R52.The facility's Fall Prevention policy, dated 06/17, documented the facility was to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. For those residents who continue to have falls, incident reports would be completed per facility policy, with resulting investigations followed up by interventions that are appropriate for the type of falls the resident was experiencing. Care staff would be apprised of interventions needed for that resident to assist with preventing further falls and minimizing the potential for injury.

The facility had a census of 79 residents. The sample included 19 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that the physician responded to the recommendation made by the Consultant Pharmacist (CP) to ensure that Resident (R)78's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication Seroquel had an appropriate Centers for Medicare and Medicaid Services (MS) indication for use.Findings included:- R78's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), delusional misidentification syndrome (a group of rare psychiatric disorders characterized by persistent false beliefs that people, places, or objects have been replaced, transformed, or duplicated), anxiety (mental or emotional reaction characterized by apprehension, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (a major depressive disorder that causes persistent feelings of sadness).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R78 had long and short-term memory problems, with severely impaired decision-making skills. R78 was dependent upon staff assistance for all activities of daily living. The MDS documented R78 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication daily.The Significant Change MDS, dated 12/29/25, documented R78 had long and short-term memory problems, with severely impaired decision-making skills. R78 was dependent upon staff assistance for all activities of daily living. The MDS documented R78 received an antipsychotic medication daily.R78's 12/30/25 Care Plan included the following interventions:05/08/25 - Remind R78 to attend activities of choice.05/13/25 - Administer medications as ordered and monitor for side effects and effectiveness. Consult with the pharmacy and the physician to consider dosage reduction when clinically indicated. The care plan directed staff to provide non-pharmacological interventions and encouraged them to express feelings.02/10/26 - Monitor for episodes of psychotic behavior as evidenced by agitation. The Physician's Order, dated 05/01/25, directed staff to administer Seroquel (an antipsychotic medication), 25 milligrams (mg), by mouth at supper for anxiety. The order was changed on 10/12/25 to Seroquel 25 mg, administer 0.5mg, by mouth, in the evening for delusional misidentification syndrome.R78's EMR lacked evidence of a documented physician rational with included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for ongoing Seroquel use.The Consultant Pharmacist Recommendations to the Physician, dated 05/21/25, documented the resident's diagnosis for the use of quetiapine (Seroquel) was not one of the CMS approved indications for use of the drug. The recommendation noted if the resident's physician wanted to continue with the use of the medication, they asked them to provide a risk versus benefit for the continued use, what has been tried and failed in the past, and other nonpharmacological options utilized to help with the condition. The physician responded by stating that requester should look in the resident's progress notes.The Consultant Pharmacist Monthly Medication Regimen Review, dated 06/29/25, 07/27/25, 08/28/25, 09/29/25, 10/30/25, 11/27/25, 12/26/25, and 01/22/26, did not make any further recommendations regarding R78's diagnosis for the use of Seroquel.On 02/17/26 at 07:45 AM, R78 was in bed, with her eyes closed.On 02/17/26 at 08:30 AM, Certified Nurse Aide (CNA) M stated R78 rarely left her room and did not have any behaviors that she was aware of.On 02/17/26 at 10:00 AM, Licensed Nurse (LN) G stated R78 did not have behaviors, did not like to attend activities, and stayed in her room most of the time. On 02/18/26 at 10:30 AM, Administrative Nurse D stated she was unable to provide a risk versus benefit or indications for the inappropriate diagnosis of the Seroquel medication. Administrative Nurse D stated she had not been informed by the CP that the diagnosis was incorrect. The facility's Medication (Drug) Regimen Review (MRR) policy, dated 01/22, documented that each resident's drug regimen would be reviewed at least once a month by a licensed pharmacist. A medication regimen review (MRR) included a review of the resident's medical chart. Identified irregularities would be documented on a separate written report that included the resident's name, the relevant document, and the irregularity identified. The report would be sent to the attending physician, the facility's medical Director, and the Director of Nursing Services (DNS) to be acted upon.

The facility identified a census of 79 residents. The facility had five medication carts and four medication rooms. Based on observation, record review and interview, the facility failed to ensure an opened vial of tuberculin (a purified protein derivative used in skin tests to help diagnose tuberculosis [a contagious infection primarily attacking the lungs, though it can affect other organs]) in the medication room, was dated upon being opened. The facility also failed to ensure stock medication/supplements on a medication cart were not expired. Findings included: - On 02/17/26 at 07:23 AM an observation of the [NAME] Bend-1 hall medication room revealed the medication refrigerator contained an opened vial of tuberculin lacked an open date (expiration date of 11/28). On 02/17/26 at 07:25 AM, Licensed Nurse (LN) H stated she was not sure when the vial of tuberculin was opened but said it should have an open date written on the label. LN H stated she would discard the vial of tuberculin. The facility's Medication Labels and Storage policy dated March 2024, documented floor stock medications are labeled as and kept in original manufacturer's container with the expiration date and lot number clearly evident. The Date the medication was opened will be placed on the container. - On 02/16/26 at 08:30 AM, observation revealed Certified Medication Aide (CMA) M obtained medication to administer to residents from the [NAME] 2 Cart A medication cart. The cart contained one bottle of Vitamin B12 500 micrograms (mcg), 100 tablets that expired 12/2025 On 02/16/26 08:35 AM, Administrative Nurse D verified staff were to remove from stock or dispose of expired medications. The facility's Medication Labels and Storage policy dated March 2024, documented the floor stock medications are labeled and kept in the original manufacture's container with the expiration date and lot number clearly evident. The date the medication was opened would be placed on the container.

TThe facility identified a census of 80 residents. The sample included 18 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to obtain accurate weights and verify weight changes related to Resident (R)28's physician-ordered weekly weights to effectively monitor weight trends and identify concerns before a significant weight loss occurred. The facility further failed to ensure staff served R28 a diet he could safely consume. As a result of the deficient practices, R28 had a significant unplanned weight loss of 28.38 percent (%) within one month. Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion). R28's Admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated R28 had no behaviors, used a wheelchair, and was dependent on staff for mobility. The MDS indicated he had no upper or lower extremity impairments, required set-up assistance with his meals, and had problems with choking or coughing during meals. The MDS noted he weighed 147 pounds (lbs.) and was on a mechanically altered diet. R28's Nutritional Status Care Area Assessment (CAA) completed 02/27/24 noted he was on a mechanically altered diet due to his cognition. The CAA noted he had difficulty swallowing with his dysphagia. The CAA noted he was on the grazing program (a weight loss program for dementia that increased opportunities for nutritional intake) due to his dementia. R28's Activity of Daily Living Functional/Rehabilitation Potential CAA completed 02/27/24 indicated he required assistance with his care. The CAA noted he was weak and working to recover his strength. The CAA noted he was at risk for falls, depression, infections, and a decline in his activities of daily living (ADL). R28's Care Plan initiated on 02/14/24 indicated he had a nutritional problem related to his medical diagnosis. The plan instructed staff to provide his diet as ordered (02/14/24). The plan instructed staff to monitor for signs of dysphagia, coughing, drooling, and difficulty swallowing (02/27/24). The plan instructed staff to provide dietary supplements as ordered and weigh him weekly for four weeks (02/27/24). The plan noted he was placed on a grazing program on 03/21/24. The plan instructed staff to provide a slightly thick liquid consistency. R28's EMR under Orders revealed his diet was regular, minced, and moist on 03/19/24. R28's EMR under Orders noted an order dated 02/15/24 instructing staff to complete daily weights for three days, then weekly weights for four weeks, then monthly weights. A Mini-Nutritional Assessment completed on 02/16/24 revealed a score of six indicating he was malnourished (lack of nutrients, which can result in stunted growth, wasting, and underweight). A Nutrition Evaluation completed 02/16/24 indicated R28 weighed 147.5 lbs. The evaluation indicated his ideal body weight range was 142 lbs. The assessment indicated he was on a soft and bite-sized diet and required limited assistance with meals. The assessment indicated his appetite was poor and often refused meals. The assessment noted supplements were ordered and the registered dietician would be available as needed. R28's EMR under Weight History between 02/14/24 through 03/26/24 revealed his weight upon admission was 148 lbs. on 02/14/24. The EMR revealed he weighed 107 lbs. on 03/07/24, indicating a 27.70% weight loss since his admission (23 days). The EMR revealed his weight decreased to 106 lbs. on 03/12/24 indicating a 28.38% weight loss since his admission to the facility (28 days). R28's EMR under Tasks revealed the facility entered and struck out three weights marked as incorrect entries on 02/20/24 (146.5 lbs.), 03/04/24 (106 lbs.), and 03/04/24 (109.2 lbs.). The review revealed the lack of weights or reweighs for R28 between 02/17/24 and 03/07/24 during his significant weight loss timeframe. A Weight Change note completed on 03/15/24 indicated a weight warning triggered his weight as 106 lbs. on 03/07/24. The note indicated a significant weight loss occurred, but the facility was unable to assess its related concerns with weight accuracy. The note recommended reweighing R28. R28's EMR as of 03/26/24 at 08:00 AM revealed R28 had not been reweighed. On 03/27/24 at 10:00 AM the facility weighed R28 upon request. R28 weighed 108 lbs. On 03/25/24 at 08:10 AM R28 slept in his bed. His bed was in the low position with a fall mat positioned to the left side. At 11:50 AM R28's representative arrived and woke him up. She stated he slept through breakfast and needed to get up for lunch. She stated he had times of confusion and would not understand where he was or what times meals were. She stated he wore the same clothes he had on the day prior, and she had to remind the facility to give him baths and brush his teeth. On 03/26/24 at 09:09 AM R28 laid supine in his bed with the head of his bed elevated. R28 ate his breakfast of oatmeal and scrambled eggs. R28 consumed his supplement drink and reported no concerns with breakfast. R28 stated he is not always hungry and would often refuse to eat certain meals. He stated he knew he had lost a lot of weight and he stated his normal weight was 160 lbs. On 03/26/24 at 01:14 PM, R28 was in the dining room and served minced chicken and potato salad. R28's plate also contained three uncut Brussels sprouts he was unable to eat. A review of R28's meal ticket noted he was to be served a regular diet that was minced and moist. At 01:20 AM Certified Nurse Aide (CNA) Q offered to cut up the Brussels sprouts. R28 declined to eat them. On 03/26/24 at 10:00 AM, CNA Q stated each resident was weighed based on their orders. She stated some residents were weighed daily, weekly, or monthly. She stated she thought R28 had weekly weights due to his dementia and weight loss risk. She stated if a resident refused weights the nurse would be notified. She stated multiple attempts would be made to complete the weight before rescheduling the next day. She stated the nurse would be notified of the weight changes. On 03/27/24 at 10:26 AM Licensed Nurse (LN) G stated weight changes were reported to the registered dietician (RD) and medical provider. She stated weights should be completed based on the physician's orders and the risk level of the residents. She stated that missed weights should be attempted the next possible day to ensure consistent monitoring. She stated the facility had multiple scales if accuracy concerns appeared. On 03/27/24 at 02:42 PM Administrative Nurse D stated she believed R28 was on weekly weights due to his medical diagnoses. She stated she expected staff to review the weights collected and report the changes to herself, the RD, and the medical provider. She stated the interdisciplinary team (IDT) reviewed weight loss weekly and provided interventions to combat the weight loss such as dietary adjustment, snacks, supervision, supplementation, and reviews. She stated the facility implemented a Grazing Program to assist with residents with dementia. She stated R28 had recent weight loss. She stated staff should make multiple attempts to weigh the residents and reschedule the missed weight for the next possible day. The RD was not available for interview on 03/28/24. The facility provided a Weight Monitoring policy revised 01/2022 indicated the facility would establish a baseline weight upon admission and continue to weigh the resident using the same scale. The policy indicated staff were to record and report weight changes to the interdisciplinary team. The facility failed to obtain accurate weights and verify weight changes related to R28's physician-ordered weekly weights to effectively monitor weight trends and identify concerns before a significant weight loss occurred. The facility further failed to ensure staff served R28 a diet he could safely consume. As a result of the deficient practices, R28 had a significant unplanned weight loss of 28.38% within one month.

The facility identified a census of 80 residents. The facility had one main kitchen and four dining areas. Based on observation, record review and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 03/26/24 at 11:28 AM Dietary BB stated he and Dietary CC had not completed the course yet to become a CDM. Dietary BB stated he and Dietary CC had begun the courses. Dietary BB stated both himself and Dietary CC had completed the ServSafe class and said he would provide a copy of the certification. The facility did not provide a policy for Qualified Dietary Staff but did provide the Federal regulation guideline 483.60(a)(1). The facility failed to ensure the director of food and nutrition services was a certified dietary manager. This deficient practice placed the affected residents at risk for unmet dietary and nutritional needs.

The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure direct care staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life. Findings Included: - On 03/27/24 at 11:40 AM a review of the facility's training for Certified Nurses Aid (CNA) PP, CNA QQ, Licensed Nurse (LN) L, LN NN, and LN OO revealed the following: CNA PP's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she passed abuse, neglect, and exploitation (ANE) and a mental health course. CNA QQ's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE and mental health courses. LN L's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE training and mental health courses. LN NN's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE training and mental health courses. LN OO's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE training and mental health courses. On 03/27/24 at 12:45 PM Administrative Nurse D stated the selected agency that provided the staff was new to the facility. She stated the only documentation available for the agency staff was on the online portal. On 03/27/24 at 12:45 PM Administrator A stated he had very limited ability to view the online documentation provided by the contract agency for the selected employees. He stated he could not open the files of training courses noted as passed to verify what material they covered. The facility's provided Nursing Staff Competency policy revised 12/2023 indicated the facility will ensure all staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable well-being of each resident. The facility failed to ensure the completion of the required communication training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure all staff were educated on the rights of the residents and the facility's responsibility to provide proper care. This placed the residents at risk for impaired care and decreased quality of life. Findings Included: -On 03/27/24 at 11:40 AM a review of the facility's training for Certified Nurses Aid (CNA) PP, CNA QQ, Licensed Nurse (LN) L, LN NN, and LN OO revealed the following: CNA PP's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she passed abuse, neglect, and exploitation (ANE) and a mental health course. CNA QQ's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE and mental health courses. LN L's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE training and mental health courses. LN NN's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE training and mental health courses. LN OO's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE training and mental health courses. On 03/27/24 at 12:45 PM Administrative Nurse D stated the selected agency that provided the staff was new to the facility. She stated the only documentation available for the agency staff was on the online portal. On 03/27/24 at 12:45 PM Administrator A stated he had very limited ability to view the online documentation provided by the contract agency for the selected employees. He stated he could not open the files of training courses noted as passed to verify what material they covered. The facility's provided Nursing Staff Competency policy revised 12/2023 indicated the facility will ensure all staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable well-being of each resident. The facility failed to ensure all staff were educated on the rights of the residents and the facility's responsibility to provide proper care. This placed the residents at risk for impaired care and decreased quality of life.

The facility had a census of 80 residents. The sample included 18 residents and five Certified Nurse Aides (CNA) reviewed for required in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's in-service records revealed the following: CNA N, hired 06/07/19, had 3.50 hours of in-service education in the past 12 months. On 03/27/24 at 08:10 AM Administrative Staff A stated staff had from February through October to complete their yearly education and that the system flagged all of the staff that completed their assigned education for the year. Administrative Staff A stated CNA N's record showed their education as completed in the system and he was unsure as to why the system had reported so few hours. Administrative Staff A stated he compared CNA N's record with another CNA and found that the assigned education was not the same. Administrative Staff A further stated he contacted their compliance staff to discuss the issue and was unable to find an answer as to why CNA N's assigned education topics and hours were different. Administrative Staff A further stated he believed it may have been an issue with CNA N being an as-needed (PRN) employee. Administrative Staff A stated the education completion was tracked in the system, but no one reviewed the recorded hours for CNA N and it wasn't caught. Administrative Staff A stated the facility provided in-services education in addition to the online education courses; however, he stated CNA N's sister also worked at the facility and he was unable to tell the difference between their signatures to show that CNA N had completed the 12 hours of required education for the year. The facility provided a CNA Orientation and Annual Training policy with a reviewed date of 02/24 documented the facility will complete a performance review of every CNA at least once every 12 months and will provide regular in-service education. The in-service training will be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. The facility failed to ensure one of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care.

The facility had a census of 80 residents. The sample included 18 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift. This placed the 14 residents with controlled substances on the cart at risk for misappropriation of medications. The facility also failed to ensure Resident (R) 42's physician-prescribed medication was available from the pharmacy for administration. This placed R42 at risk for ineffective medication regimen and related complications. Findings included: - On 03/26/24 at 08:14 AM, observation on the Maple Hill One medication cart Controlled Drug Record flow sheet lacked evidence the staff completed the narcotic reconciliation for day shifts on 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/09/24, 02/10/24, 02/12/24, 02/16/24, 02/19/24, 02/23/24 02/26/24, 02/27/24, 03/01/24, 03/02/24 03/03/24, 03/04/24, 03/07/24, 03/08/24, 03/09/24, 03/15/24, 03/16/24, 03/17/24, 03/18/24, 03/22/24, and 03/25/24, for night shifts; 02/01/24, 02/02/24, 02/03/24, 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/16/24, 02/19/24, 02/12/24, 02/26/24, 02/27/24, 03/01/24, 03/02/24, 03/03/24, 03/06/24, 03/14/24, 03/15/24, 03/16/24, 03/17/24, 03/18/24, and 03/25/24 (forty-eight times out of possible 109 work shifts). On 03/26/24 at 08:15 AM, Licensed Nurse (LN) J stated nurses were expected to count the narcotics with another nurse each shift. LN J stated the nurse coming on duty and the nurse going off duty should ensure the narcotic count is correct each shift. LN J stated the facility has a policy regarding controlled substances, and everyone was educated on the policy and expectations of counting narcotics. On 03/27/24 at 02:41 PM, Administrative Nurse D stated she expected the nurse coming on duty and the nurse leaving duty to count their narcotic cards and bottles on all carts. Administrative Nurse D stated nurses or medication aides count each card, and the total number was recorded. Administrative Nurse D stated the two nurses together determined the count was correct. The Controlled Medication policy revised 12/2023 stated controlled medications reconciliation is conducted by two licensed nurses and is documented on an audit record at each shift change. Any discrepancies in the controlled medication should be reported to the Director of Nursing Services immediately. The facility failed to provide a consistent reconciliation of controlled drugs at the end of daily work shifts, placing the 14 residents with controlled substances on the cart at risk for misappropriation of medications by staff. 41713 - The electronic medical record for R42 documented diagnoses of hypothyroidism (a condition characterized by decreased activity of the thyroid gland), hypotension (low blood pressure), and dementia (progressive mental disorder characterized by failing memory, and confusion). R42's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R42 utilized a walker and wheelchair for mobility. R42 required setup to supervision/touching assistance with his activities of daily living (ADLs). R42 had no history of falls since the last assessment. R42's ADL Care Area Assessment (CAA) dated 02/22/24 documented he needed assistance with his care. R42 ambulated with a walker. Nursing provided ADL, mobility, and transfer assistance as needed. R42's Care Plan last revised 02/27/24 directed staff to administer medications as ordered. R42's Order Summary Report documented an order dated 03/17/22 for levothyroxine (a medication used to treat hypothyroidism) 75 micrograms (mcg) by mouth 30 minutes before breakfast daily for hypothyroidism. R42's January 2024 Medication Administration Record (MAR) on 01/01/24, 01/02/24, and 01/03/24 recorded a seven (7- other/see nurse notes) in the administration box for his levothyroxine. On 01/1/24 at 05:36 AM an eMAR-Medication Administration Note documented staff were waiting on the delivery from the pharmacy. On 01/2/24 at 05:09 AM an eMAR-Medication Administration Note documented levothyroxine sodium tablet 75 mcg; the medication was not available, and the pharmacy was notified. On 01/3/24 at 04:13 AM an eMAR-Medication Administration Note documented staff continued waiting on a delivery from the pharmacy. Staff would notify the day nurse to call the pharmacy. On 03/26/24 at 08:38 AM R42 sat in a chair at the dining table eating breakfast; his walker was beside his chair. On 03/27/24 at 01:55 PM Certified Medication Aide (CMA) S stated she would let the pharmacy know when a resident had five or fewer doses left of a medication to ensure that the medication was received before the medication was out. CMA S stated if she noticed that a resident was out of medication, she would immediately call the pharmacy to order the medication as well as notify the nurse that the medication was out and had been ordered. On 03/27/24 at 01:58 PM Licensed Nurse (LN) I stated a medication that was almost out should be ordered several days to a week before being completely out to ensure that the medication was received before completely out. LN I stated at times medications were not available from the pharmacy to be delivered due to a holiday or some other circumstance. LN I stated she would not expect a resident to be without medication for more than one day and would expect the nurse to document a reason why the medication was not available. On 03/27/24 at 03:15 PM Administrative Nurse D stated nursing staff had been educated numerous times to make sure that medication was ordered at least five days before being out to ensure the medication was received before being out. Administrative Nurse D stated she could not say for certain why R42's medication had run out or had not been ordered/received. The Pharmacy Services/Nursing Services policy revised in July 2015 documented drugs and biologicals that were required to be refilled must be ordered from the issuing pharmacy not less than three days before the last dosage being administered to ensure that refills were on hand. The facility failed to ensure R42's physician-ordered levothyroxine was available for administration. This deficient practice placed R42 at risk for ineffective medication regimen and related health consequences.

The facility identified a census of 80 residents. The facility had one main kitchen and four kitchenettes with dining areas. Based on observation and interview, the facility failed to ensure staff stored, prepared and served food items and maintained the freezer unit in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness, and cross-contamination (the transfer of harmful substances to food). Findings included: - Observation during the initial kitchen tour on 03/25/24 at 07:15 AM revealed in the kitchen storage freezer were two open bags of fried potatoes that had no label or date and were not in a sealed bag. The walk-in freezer unit leaked and had ice around some of the pipes. The walk-in freezer had an area of what appeared to be water that had dripped from the freezer unit and froze on the floor. Observation during the lunchtime services of food on 03/25/24 at 12:23 AM in the Maple Hills 2 dining area revealed that plates, bowls, and saucers were stored right-side up on the counter. An unidentified dietary staff wore gloves while serving food on the resident's plates. She left the serving area to obtain a bowl from the cupboard and returned to the serving area without changing her gloves or performing hand hygiene. Observation on 03/26/24 at 11:18 AM revealed during the preparation of the puree foods by Dietary CC failed to sanitize the metal food container and the lid after each food item was pureed. Dietary CC rinsed the food container and lid under hot water at the sink after each food item. On 03/26/24 at 11:35 AM Dietary CC stated normally he washed and sanitized the food container and lid in the dishwasher. Dietary CC stated he was running behind and it was a simple mistake he made since the surveyor was observing him. On 03/26/24 at 11:15 AM Dietary BB stated that any staff that was assisting during the dining task should be washing their hand and performing hand hygiene after serving each resident. The dietary staff serving the food did wear gloves but were expected to change the gloves and perform hand hygiene if they had left the serving line. Dietary BB stated staff would be re-educated to ensure proper hand hygiene was being performed during food service. Dietary BB stated Dietary CC should have properly washed and sanitized the container and lid after pureeing each food item. On 03/27/24 at 03:15 PM Administrative Nurse D stated staff was expected to perform hand hygiene during meal service just as they would during care of the residents. Hand hygiene should be performed after the service of each resident. The Routine Procedures- General Food Handling/Storage/Preparation policy reviewed in 2021 documented that it was the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. This included the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. Refrigerated items should be covered, labeled, and dated with an expiration date indicated. Dishes should be cleaned and sanitized using the proper water temperature and with the appropriate concentration of sanitizer solution. The dishes must be held in the sanitizing solution for the proper amount of time, and all dishes must be air-dried. Nurses, CNAs, and other staff members who handle and distribute food to residents must receive training on good food safety practices. The facility failed to ensure staff stored, prepared and served food items and maintained the freezer unit in accordance with the professional standards for food service safety. This placed residents at risk of food-borne illness, and cross-contamination.

The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 21 was treated with respect, and dignity related to personal hygiene, and the facility also failed to ensure a dignified dining experience when staff stood over R25 and R57 instead of sitting beside him while assisting them with meals. These deficient practices placed the residents at risk for negative psychosocial outcomes and decreased dignity. Findings included: - R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, and need for assistance with personal care. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R21 required partial to moderate assistance from staff for her hygiene. R21's Functional Abilities Care Area Assessment (CAA) dated 02/15/24 documented she required assistance with activities of daily living. R21's Care Plan dated 11/03/23 directed staff she required maximum assistance with personal hygiene. On 03/25/24 at 08:01 AM R21 propelled her wheelchair in the hallway toward the dining room for breakfast. R21's hair was uncombed and was sticking up on the back of her head. On 03/26/24 at 08:08 AM R21 sat in her wheelchair at the dining room table as she drank a cup of coffee. R21's hair was uncombed and was sticking up. On 03/27/24 at 07:38 AM R21 sat at the dining room table and drank her coffee. R21's hair was uncombed and sticking up. R21 stated the staff did not always offer or assist her with combing her hair. R21 stated she was too old to ask for help. On 03/27/24 at 01:01 PM, Certified Medication Aide (CMA) R stated R21 needed more assistance after she was sick. CMA R stated R21 started to be stronger and was doing more for herself. CMA R stated she did not always have to assist R21 with her hygiene. On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated staff should offer R21 assistance with her care. LN K stated R21's hair should be combed and not standing straight upwards. On 03/27/24 at 02:43 PM, Administrative Nurse D stated she expected staff to assist or offer R21 with personal hygiene. Administrative Nurse D stated staff should make sure R21's hair was combed. The facility's Promoting/Maintaining Resident Dignity policy dated 01/01/23 documented it was the practice of the facility to protect and promote a resident's right and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances a resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The facility failed to ensure R21 was assisted with combing her hair. This deficient practice placed R21 at risk for negative psychosocial outcomes and decreased dignity. - On 03/25/24 at 12:16 PM R25 sat in his high-back wheelchair at the dining room table. Certified Medication Aide (CMA) R stood next to him and assisted him with his lunch. On 03/26/24 at 12:30 PM, R57 sat upright in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining room table, she was served a ham sandwich and cheese puffs. The ham sandwich consisted of white bread and deli-styled ham. Certified Nurse Aide (CNA) O stood beside R57's Broda chair and assisted her with a few bites and walked away and did not offer R57 a drink. On 03/26/24 at 12:33 PM, R25 sat at the dining room table in his high-back wheelchair at lunchtime. CMA R stood beside his wheelchair and offered him a few bites of his meal. On 03/27/24 at 12:28 PM, R57 sat upright at the dining room table in her Broda chair. CMA R stood on R57's right side and assisted her with eating. On 03/26/24 at 12:33 PM, R25 sat at the dining room table in his high-back wheelchair at lunchtime. CMA R stood beside his wheelchair and offered him a few bites of his meal. On 03/27/24 at 01:01 PM, CMA R stated she stood next to the resident during mealtime because she could not give her attention to only one resident. CMA R stated she must help everyone in the dining room, so she needed to be able to move around all the time. On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated the staff cannot always sit and help only one person. LN K stated it depends on how many residents are in the dining room that require assistance. LN K stated the staff must be able to help everyone. On 03/27/24 at 02:43 PM, Administrative Nurse D stated she expected staff to sit down and assist a resident who required assistance. The facility's Promoting/Maintaining Resident Dignity policy dated 01/01/23 documented it was the practice of the facility to protect and promote a resident's right and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances a resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The facility failed to ensure R25 and R57 were treated with dignity during dining. This deficient practice placed the residents at risk for weight loss and impaired dignity.

The facility identified a census of 80 residents with 18 residents included in the sample. The facility identified 54 residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 49 and R 336. This failure placed the residents at risk for decreased autonomy and impaired decision-making. Findings included: - R49's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 12/19/23 and ended on 03/09/23. R49 remained in the facility for custodial care. The facility issued SNF ABN 10055 lacked an estimated cost for continued services. R336's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 12/11/23 and ended on 01/03/24. R336 remained in the facility for custodial care. The facility issued SNF ABN 10055 lacked an estimated cost for continued services. On 03/26/24 at 10:45 AM Social Services X stated that she was unaware that form 10055 needed an estimated cost for continued services if the resident was staying in the facility. The facility did not provide a policy for advance beneficiary notices. The facility failed to ensure the forms provided at the end of skilled services contained the required information for the residents to make informed choices and appeal the non-coverage decisions. This failure placed the residents at risk for decreased autonomy and impaired decision-making.

The facility identified a census of 80 residents. The sample included 18 residents with two residents sampled for hospitalization and one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide written notice of transfer as soon as practicable to Resident (R) 27 and R43 or their representative for their facility-initiated transfers and/or discharge. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R27 and R43. Findings included: - The electronic medical record (EMR) for R27 documented diagnoses of hypertension (HTN- elevated blood pressure), hemiplegia and hemiparesis following cerebral infarction (paralysis and muscle weakness on one side of the body after a stroke), and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R27 had both short and long-term memory problems. R27 had severely impaired cognitive skills for daily decision-making. R27 utilized a wheelchair for mobility. R27 was dependent on staff for all activities of daily living (ADLs). R27's Discharge MDS dated [DATE] documented a discharge to an acute hospital with a return anticipated 12/02/23. The Nutrition Care Area Assessment (CAA) dated 12/27/23 documented R27 was on a mechanically altered diet, had a history of hemiplegia and hemiparesis, and needed assistance to be fed. R27 had his gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) removed. The area was not completely closed, and he had drainage. R27 will be care planned for nursing to assist with nutrition and hydration. A Nursing Note dated 12/02/23 at 02:25 PM documented R27 had not tolerated his 08:00 AM or 12:00 PM G-tube flush. R27 had significant residual from his G-tube noted. R27's stomach was severely distended (swollen due to pressure from the inside) when assessed and palpated. R27's dressing to his G-tube was saturated with bodily fluids and significant drainage from the G-tube was noted. R27's provider was called and notified. An order was received from the provider to send the resident out to the hospital for further evaluation. The emergency contact was called with no answer. The resident was transported by emergency medical services (EMS). An Admission Note dated 12/13/23 at 11:40 PM documented R27 had readmitted to the facility at 07:15 PM via a stretcher and was accompanied by his wife and the transport drivers. R27's provider was notified of his readmission at that time. The Misc. tab of the EMR lacked any document for discharge summary. The facility was unable to provide the required written notification of discharge for R27's 12/02/23 discharge upon request. On 03/26/24 at 07:45 AM R27 rested in bed. His bed was in a low position, with fall mats on both sides of the bed. On 03/26/24 at 10:35 AM Administrative Staff A stated the facility normally would just call the representative to notify them when a resident was being discharged to the hospital. Administrative Staff A was not aware that a written notification needed to be sent/mailed to the resident and or resident representative with the required information on it. Administrative Staff A stated he would begin providing the written notification from here forward. The facility provided an Admission, Transfer, and Discharge Rights policy revised in October 2023 that the subject matter was for discharge planning. This policy did not address the aspect of the required written notice of transfer/discharge. The facility failed to provide written notice of transfer as soon as practicable to R27 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R27. 49634 - The electronic medical record (EMR) for Resident (R)43 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting left non-dominant side, and epilepsy (brain disorder characterized by repeated seizures). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS indicated R43 was dependent on staff for all activities of daily living (ADLs). R43's Functional Care Area Assessment (CAA) dated 12/14/23 documented R43 needs assistance with his care due to a CVA, right hip fracture, seizures, and COPD. The Discharge MDS dated [DATE] for R43 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R43's Entry MDS dated [DATE] documented a reentry to the facility from an acute hospital. R43's Care Plan dated 01/18/24 documented R43 had no plans to be discharged from the facility and planned to stay at the facility. R43's Care Plan dated 01/18/24 documented to monitor his progress and revise his plan as needed. A Progress Note dated 03/20/24 documented that R43 was lethargic with a half-full bag of red bloody urine. The provider gave a verbal order to send R43 to the emergency department (ED) for evaluation. Staff called the ambulance and it arrived at the facility and transported R43 to the hospital. The nurse notified R43's daughter of the resident's condition. A Progress Note dated 03/25/24 documented that R43 was readmitted to the facility from an acute care hospital visit. The facility was unable to provide evidence a written notification of transfer or discharge was provided to the resident and/or representative for the facility-initiated transfer to the hospital from 03/20/24 to 03/15/24. The facility was unable to provide evidence notification of the transfer was sent to the LTCO. On 03/26/24 at 08:12 AM R43 lay in bed resting comfortably. On 03/26/24 at 10:35 PM Administrative staff A stated facility does not have the written notification of transfer. Administrative staff A stated that R43's daughter was notified verbally when he was transferred and given an update on his condition. The facility policy Admission, Transfer and Discharge Rights policy revised 10/2023 documented it is the policy of the facility that discharge planning and evaluation will be provided by the Social Services staff for each resident. Discharge planning involves the resident, family or responsible party, interdisciplinary team (IDT), and others involved in the resident's care plan. The facility failed to provide written notice of transfer as soon as practicable to R43 and their representative and failed to provide notification to the LTCO as well. This placed the resident at risk for miscommunication between the facility and the resident/family and possible missed opportunities for healthcare service for R43.

The facility identified a census of 80 residents. The sample included 18 residents with three residents sampled for hospitalization and discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 43 or to their family representative when R43 was transferred to the hospital. This deficient practice placed R43 at risk for impaired ability to return to the facility or his same room. Findings include: - The electronic medical record (EMR) for R 43 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting left non-dominant side, and epilepsy (brain disorder characterized by repeated seizures). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS indicated R43 was dependent on staff for all activities of daily living (ADLs). R43's Functional Care Area Assessment (CAA) dated 12/14/23 documented R43 needs assistance with his care due to a CVA, right hip fracture, seizures, and COPD. The Discharge MDS dated [DATE] for R43 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R43's Entry MDS dated [DATE] documented a reentry to the facility from an acute hospital. R43's Care Plan dated 01/18/24 documented R43 had no plans to be discharged from the facility and planned to stay at the facility. R43's Care Plan dated 01/18/24 documented to monitor his progress and revise his plan as needed. A Progress Note dated 03/20/24 documented that R43 was lethargic with a half-full bag of red bloody urine. The provider gave a verbal order to send R43 to the emergency department (ED) for evaluation. Staff called the ambulance and it arrived at the facility and transported R43 to the hospital. The nurse notified R43's daughter of the resident's condition. A Progress Note dated 03/25/24 documented that R43 was readmitted to the facility from an acute care hospital visit. The facility was unable to provide evidence a bed hold notification was provided to the legal representative when R43 transferred to the hospital from 03/20/24 to 03/15/24. On 03/26/24 at 08:12 AM R43 lay in bed resting comfortably. On 03/26/24 at 10:35 AM Administrative Staff A stated he only had the bed hold notification the resident signed on admission. Administrative Staff A stated he did not have a bed hold notice for R43 for the 03/20/234-03/25/24. The facility was unable to provide a policy related to bed hold notification. The facility failed to provide a bed hold with the required information to R43 and his family representative when R43 transferred to the hospital. This deficient practice placed R43 at risk for impaired ability to return to the facility or his same room.

The facility had a census of 79 residents. The sample included 17 residents with seven reviewed for nutrition. Based on observation, interview, and record review, the facility failed to respond to an unplanned, ongoing weight loss and failed to identify and implement further interventions to prevent weight loss for Resident (R)22 who had a significant unplanned weight loss of 14.29 percent ( in six months. Findings included: -The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] recorded R22 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R22 required extensive assistance for most activities of daily living (ADL) except eating, for which she required limited assistance of one staff. The MDS recorded R22 was 57 inches tall, weighed 91 pounds (lbs.), had no issues with chewing, and no known weight loss. The Quarterly MDS, dated [DATE], documented R22 had moderately impaired cognition, had no [CONDITION(S)] (sudden severe confusion, disorientation and restlessness), [CONDITION(S)] (any major mental disorder characterized by a gross impairment reality testing), or behaviors. R22 required limited assistance of one staff with eating. She had no known issues chewing or swallowing but received mechanically altered diet, weighed 86 lbs. and had no known weight loss. The Nutrition Care Area Assessment (CAA), dated 05/04/22, documented R22 received a mechanically altered diet and required assistance from staff with feeding and encouragement. R22's Care Plan recorded an intervention dated and last revised on 03/16/22 which directed R22 could hold her cup, feed herself, and eat finger foods independently. R22's Care Plan initiated on 03/02/21 and last revised on 07/12/22 recorded she had a nutritional problem related to protein calorie malnutrition (PCM), gastro- [CONDITION(S)] reflux (GERD, backflow of stomach contents to the esophagus), dysphagia; she needed supplements and a mechanically altered diet. The care plan documented nutrition diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's Care Plan documented on 07/05/22, R22 triggered for weight loss of 7.5 percent in 90 days and 10% in 180 days . R22's Care Plan recorded interventions dated 03/09/21 which directed staff to monitor, document and report to the medical doctor signs and symptoms of malnutrition, emaciation, significant weight loss. R22's Care Plan revised on 04/11/21 further directed staff to offer and encourage snacks and fluids between meals and directed staff to assist and cue at meals as needed. The care plan recorded an intervention revised on 01/06/22 which directed staff to provide supplements as ordered; Med Pass (liquid high calorie nutritional supplement) 120 milliliters three times daily (TID), nectar thick fluids and liquid protein TID. On 01/06/22 Magic cup (fortified nutritional ice cream product) two times daily for 10 days was added . On 03/03/21 a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/20/21 a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutrition Progress Note dated 01/14/22 recorded staff notified the RD of R22's continued poor oral intake. The note recorded the Magic Cup was increased to three times a day and continue to monitor . A Weight Change Note dated 01/25/22 documented a weight warning with a weight of 87.6 lbs., which indicated a loss of 7.5%. The note recorded R22 triggered for weight loss, had Covid (potentially life-threatening respiratory infection) and was on Magic Cup twice daily for 10 days. The note recorded the registered dietician (RD) would restart the Magic Cup and monitor. On 01/25/22 a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/01/22 a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's EMR recorded the following weights: 03/01/22: 98.0 lbs. 04/04/22: 94.0 lbs. 05/02/22: 90.8 lbs. 05/17/22: 90.0 lbs. A Nutrition Evaluation dated 04/04/22 by Consultant GG recorded R22 had a weight drop that month. R22 had weight loss and abnormal nutrition-related labs due to overall decline in condition, and advanced age with suboptimal oral intake. The note directed to encourage oral intake, and monitor weight trends. The Weight Warning Progress Note, dated 05/18/22, documented a significant weight loss of 7.5 % noted in 90 days. R22's base line weight was 95-100 lbs. Nutrition interventions in place included multiple supplements: liquid protein, Magic Cup and Med Pass. R22 received a regular pureed diet. No new recommendations were made. R22's EMR recorded a weight of 86.4 lbs. on 06/01/22 which indicated a 11.84% loss in 90 days. The Weight Warning Progress Note, dated 06/07/22, documented a 7.5% change and 10% change. R22 triggered for continued slow weight loss. R22 was a variable eater, received liquid protein and Med Pass three times a day, and Magic cup twice a day. The note lacked any new recommendations or interventions to address the loss. R22's EMR recorded a weight of 86 lbs. on 07/01/22. A Nutrition Evaluation dated 07/03/22 by Consultant GG recorded R22 had a wound to her buttocks and coccyx (area at the base of the spine). R22's weight was 86 lbs. and intake at meals varied but was usually greater than 50%. R22 had weight loss and abnormal nutrition-related labs due to overall decline in condition, and advanced age with suboptimal oral intake. The note directed to encourage oral intake, and monitor weight trends, continue current diet and supplements as ordered. The Weight Warning Progress Note, dated 07/05/22, documented a 7.5% change and 10% change. R22 was at risk for continued weight loss with 7.5% loss for three months. R22 was a variable eater and received liquid protein and Med Pass three times a day, and Magic Cup twice a day. The note lacked new interventions for continued weight loss. R22's EMR recorded a weight of 85.5 lbs. on 08/01/22. The Weight Warning Progress Note, dated 08/02/22, documented a 10% weight change. R22 was at risk for weight loss and was down 10% since March. R22 continued supplements. The physician and resident's representative were updated on R22's weight loss of 10% in 180 days. No new orders were received. The note lacked new interventions to address the continued weight loss. R22's EMR recorded a weight of 84 lbs. on 09/06/22 which indicated a 14.29 % loss in six months. The Weight Warning Progress Note, dated 09/07/22, documented R22 had a weight loss of 10% in five months. R22 continued supplements; her appetite varied. The note directed staff to continue to monitor. The note lacked new interventions to address the significant weight loss. A Nutrition Evaluation dated 09/28/22 by Consultant GG recorded R22 had a current weight of 84 lbs. and intake at meals varied but was usually greater between 50-75%. R22 had weight loss and abnormal nutrition-related labs due to overall decline in condition, and advanced age with suboptimal oral intake. The note directed to encourage oral intake, and monitor weight trends, continue current diet and supplements as ordered. On 10/04/22 at 12:20 PM, observation revealed R22 sat in the dining room in a wheelchair. R22 requested help because she could not find her silverware. Staff brought R22's silverware. R22 asked for help. Staff spooned several bites of chili into the resident's mouth, then left the table. R22 then asked for assistance again and staff stood next to R22 and spooned several more bites of chili and then left the table again . On 10/04/22 at 12:28 PM, observation revealed R22 repeatedly stated I can't reach you, could you help me? Staff responded and said they would help her but walked away briefly before returning to the table to assist the resident with eating. On 10/05/22 at 08:35 AM, Certified Nurse Aide (CNA) M reported staff must cue and encourage R22 with each bite at all meals. The CNA said R22 was able to drink independently. On 10/05/22 at 07:46 AM, Licensed Nurse (LN) G reported R22 received three different supplements due to weight loss. LN G reported an interdisciplinary team reviewed the weights and notified the physician of weight changes. On 10/05/22 at 09:33 AM, Administrative Nurse D verified R22 had weight loss of 10% in the past six months. Administrative Nurse D verified the interdisciplinary team monitored the weight loss but had not implemented new intervention to prevent R22's continued loss. On 10/05/22 at 11:31 AM, Consultant GG verified R22 received three dietary supplements for weight loss. She verified R22 had a significant weight loss and noted the lack of new intervention to attempt to prevent further weight loss. On 10/06/22 at 09:25 AM, Consultant HH said R22 had weight loss and the facility should attempt interventions to prevent further weight loss. The facility Weight Monitoring policy, dated 01/2022, documented the facility to regularly monitor the weight of all residents and address those residents at risk or that experience a variance in weight, either unintended loss, or unanticipated gain. Significant weight loss/gain is monitored monthly by the Dietary Manager and/or the Registered Dietician. Additionally, the resident is referred to the weight committee, an interdisciplinary team that meets weekly to identify individuals' interventions that may be beneficial in maintaining current weight and avoid further weight loss or gain. A weight variance protocol is completed to ensure a systematic review that ranges resident meal/food choices, meal monitoring, current diet and hydration, medication, commercial supplements, and ability to perform ADL's (meal assistance) as necessary adaptive devices of potentially contributing factors to weight loss. Alternatives such as prescribed appetite stimulants may be considered for those residents that continue to lose weight, after careful consideration and other measures have been exhausted. The facility failed to respond to an unplanned, ongoing weight loss and failed to identify and implement further interventions to prevent weight loss for R22 who had a significant unplanned weight loss of 14.29% in six months .

The facility reported a census of 88 residents. The sample included 3 residents reviewed for elopement. Based on observation, record review, and interview, the facility failed to ensure 1 residents (#1) received adequate supervision and appropriate interventions to prevent elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge). Resident #1 who was not assessed for elopement risk, exited the facility on 5/17/19 between approximately midnight and 1 A.M. through an allegedly malfunctioning door, walked approximately 2 tenths of a mile (1056 feet) to a nonsecure, unsupervised location, fell , sustained a broken nose, a subdural hematoma (bleeding in the brain), and abrasions and was found by a motorist. A police officer (summoned by the motorist) found resident #1 outside of the facility, lying in the middle of a street, bleeding from the face. Resident #1 was found in an urban metropolitan area with 4 lane traffic with changing speeds, and significant hazards, such as changing elevations and cross streets. The temperature was 69 degrees and resident #1 was dressed in shorts, socks, shoes, and a T- shirt. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's (MONTH) 2019 electronic medical record (EMR) documented [DIAGNOSES REDACTED]. More-serious [MEDICAL CONDITION] can result in bruising, torn tissues, bleeding and other physical damage to the brain. These injuries can result in long-term complications or death). The 5-day admission Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with a Brief Interview for Mental Status score of 3 which indicated he/she had severely impaired cognition, and poor safety awareness. The MDS documented the resident experienced hallucinations (an experience involving the apparent perception of something not present) during the assessment period. He/she ambulated (walked) with supervision and staff member assistance and used a rolling walker. The MDS recorded the resident was at risk for falls, had one fall prior to admission and one after admission to the facility. The Care Area Assessment (CAA) dated 5/8/19 for cognition, visual and communication documented the resident had [DIAGNOSES REDACTED].) restlessness (inability to relax ), and hallucinations. He/she had impaired safety awareness and judgement, wore glasses, had impaired communication, wore hearing aids, and had difficulty finding words to make his/her needs known and understanding others. A care plan would be developed to address these areas. The Care Area Assessment (CAA) dated 5/8/19 for activities of daily living (ADLs) and falls documented: the resident needed assistance of 1-2 with bed mobility, transfers, toileting, dressing, personal hygiene and bathing. He/she was able to feed him/herself with supervision and received therapy services. The resident had one fall prior to admission and one since admission. He/she was impulsive, and a care plan would be developed to address ADL's and Fall risk. The resident admission nurses data assessment dated [DATE] inaccurately documented the resident was not ambulatory. Due to the inaccurate entry on the assessment for question 7-part A, the elopement risk was not triggered or completed. The resident's record/EMR lacked documentation of an initial elopement risk assessment. The physician progress notes [REDACTED]. He/she had mild foot drop on the left, and he/she ambulated with a walker. The physician's note continued to record the resident's cognitive function was improved, however insight and attention remained a weakness for him/her; His/her gait did not appear particularly apraxic (a condition characterized by an inability to initiate the process of walking). The care plan last revised on 5/16/19 recorded the resident ambulated with a rolling walker with one staff assistance and enjoyed sitting in his/her recliner. To prevent falls, the care plan directed staff to provide self-directed activities, continue with therapy, ensure his/her call light was within reach and encourage it's use to call for assistance as needed. It directed staff to keep his/her bed in the lowest position, ensure he/she was wearing appropriate footwear when ambulating or in a wheelchair and other interventions. The care plan dated 5/16/19 lacked documentation/information to identify the resident had a history of [REDACTED]. The care plan lacked documentation resident #1 was at risk for elopement and /or interventions to prevent an elopement. Review of the facility nurse's notes (late entry) dated 5/17/2019 at 12:00 P.M. documented the resident was actively exit seeking, walking down the hall towards the east exit door, stating he/she was going home to eat dinner and be with his/her spouse. Staff directed the resident back to his/her room, offered food, and he/she declined, stating he/she was going to eat with his/her spouse. Staff re- oriented the resident, assisted to bed, removed his/her shoes, and placed the resident's walker at bedside. At or around 1:00 A.M. local police officer L informed licensed nurse H a resident eloped from the facility. Nurse H informed officer L the resident had exited through a malfunctioning door on the building's east side. Officer L informed licensed nurse H the resident fell and sustained a suspected fractured (broken) nose. The resident was sent to the hospital by emergency medical services. His/her family, the facility director of nursing, and physician were notified. A report was called into the hospital emergency department nurse and a data sheet and resident history and physical were faxed to the hospital. The facility-initiated safety checks on a malfunctioning door. The facility investigation reviewed on 5/23/19 lacked any additional evidence the resident had exited the facility due to an alarm malfunction. The investigation documented the alleged malfunctioning door was assessed by Fire One and no defect was noted. The investigation recorded the cause of the alleged malfunction was unknown. According to a report filed with Adult Protective Services on 5/17/19 at 5:06 A.M. by police officer L resident #1 was found lying in the middle of the street. The resident fell and had a large amount of blood on his/her face and nose. It was unknown how long he/she had been lying on the ground. He/she was found by a passerby who was driving and called police. Police arrived on the scene. The resident was very disoriented and thought he/she was in Wichita, Kansas. It was determined that he/she was from the nearby facility. The facility staff determined that he/she walked out through a back door that was not properly secure. Per Officer L report, the resident was supposed to have 24/7 staff supervision due to him/her being a fall risk and his/her dementia. The resident was transported to the hospital and was receiving treatment. The resident had been at the facility since 5/1/19. The hospital admission report dated 5/17/18 at 8:41 A.M. recorded resident #1 admitted to a local hospital with alertness and orientation to self only, (disoriented to time, place and situation.) The admission physician [DIAGNOSES REDACTED]. infection of the skin), and hypertension. As part of the facility investigation, the facility presented 6 undated, unsigned and non-notarized witness statements on 5/22/19 at 12:00 P.M. Administrative licensed nurse D stated staff would be in throughout the day and he/she would have staff sign them. Administrative licensed nurse D assured this writer the typewritten information was what he/she collected on the night and early morning of 5/1719. The following witness statements were verified by this writer via telephone communications and notarized on 5/22/19 between 3:33 P.M. and 4:14 P.M. Licensed nurse H signed, notarized (5/22/19 at 3:33 P.M.), witness statement documented: Around midnight, nurse H noticed resident walking in hallway and he/she assisted the resident back to his/her room, took his/her shoes off and assisted him/her into bed. Nurse H then proceeded to the room of a newly admitted resident to complete cares and admission process. Around 1:00 A.M. nurse H's coworkers notified him/her of a police officer in the building. The officer was stating that person who was suspected to be a resident fell about half a block from the facility and was being taken to the emergency room . Nurse H went to the resident #1's room and found he/she was not in the room and his/her shoes were gone. Nurse H then went to the East exit door with three other staff members and a police officer and found the door to be unlocked and without an active alarm. Nurse H then began walking towards where the officer stated the resident fell , which was about half a block south on the street. Nurse H recorded he/she could see the lights of the police car and ambulance. nurse H stated the resident was transported by emergency technicians to the hospital for treatment before he/she could assess the resident. It was reported to staff H by police that the resident appeared to have an injured nose. Nurse H notified the Director of Nursing of the incident around 1:15 A.M. and he/she arrived around 1:45 A.M. The Director of Nursing and nurse H went to the east Exit door to check the door which did alarm at that check. Staff began a one- on -one with the east exit door and completed a facility head count. Nurse H stated he/she did not hear a door alarm between midnight and 1:00 AM. Licensed nurse I's notarized (5/22/19 at 4:48 P.M.), witness statement documented: Between the hours of Midnight and 1:00 A.M. nurse I was working as the 2nd charge nurse. Nurse I did notice the other nurse (staff H) with resident #1 around midnight helping him/her to his/her room. Staff H was working with one of his/her new admission residents and staff I was completing rounds and cares on his/her assignment. Around 1:00 A.M. staff came down the hall with a police officer who showed a photo to me and asked me if the person in the photo a resident was. Nurse I confirmed the photo was of a resident and alerted staff H. Staff H then took over and nurse I went to a residents room. At no point between midnight and the arrival of police officer L did nurse I hear the door alarm sound. Nurse I documented the director of nursing arrived around 1:45 A.M. and went with staff H to check the exit door. Staff then completed a facility head count and were directed to do one -on -one with the exit door. Per direct care staff O notarized witness statement: documented on 5/17/19 around 1:00 A.M. to 1:15 A.M. Staff O went to the east exit door with police officer L and three other staff members to see if the door was unlocked. The door opened when it was pushed without the alarm sounding, Per direct care staff P notarized (5/22/19 at 4:00 P.M.), witness statement: Between the hours of midnight and 1:00 A.M. on 5/17/19 staff P was the certified nursing assistant (CNA) and was passing ice and completing his/her rounds and did not hear any door alarms at any time. Per direct care staff Q undated, unsigned, non-notarized witness statement: Around 1:00 A.M. a police officer came to the facility. Staff Q with the officer to the East Exit door and the door was able to be opened without an alarm sounding Administrative licensed nurse D signed notarized witness statement: At 1:13 A.M. staff D received a phone call from staff H and was notified that police were in the facility because a had resident left the facility. The resident walked up the street and fell . Nurse H stated he/she was going to go to where resident was and asses him/her. Staff D told him/her staff D was on the way. Staff D documented he/she arrived to the facility around 01:45 A.M. and immediately went to the east exit door with staff H and pushed the door. The door was locked, and the alarm sounded at this time. Staff D initiated a one on one with the exit door due to report of the door not alarming. Staff also completed a head count and validated that all other residents were accounted for in the facility. Staff D asked staff H if he/she assessed the resident and he/she let staff D know the EMT took the resident to the ER before Nurse H was able to assess. Staff D then initiated a log for the one on one for the door, gave directions for the oncoming shift and left the facility around 4:00 A.M., after doing one shift on the door. Interviewed on 5/22/19 at 2:45 P.M. administrative licensed nurse D stated he/she used the incorrect elopement risk identification form on the resident on admission. Interviewed on 5/22/19 at 3:00 P.M. administrative staff A stated he/she received information the door alarm malfunctioned and that this particular door was just checked the day before on 5/16/18 in the A.M. Staff A stated the facility immediately posted staff one-on one- on the door and had the alarm company come out and check it. The facility provided a receipt from alarm company dated 5/17/19 that recorded all outside doors were tested and passed. Administrative staff A stated nursing staff were directed to do elopement assessments on admission and as required. The facility did not have an elopement book, (a tool used to help staff identify residents at risk for elopement) but had one in progress at this time. During a telephone interview on 5/28/19 at 9:01 A.M. resident #1's family member stated he/she was very upset about the incident. He/she reported that when the resident was admitted to the facility, he/she had concerns with the staff's ability to care for the resident. He/she also stated he/she had discussed with Staff A the safety concerns and concerns regarding the amount of a staff available to provide assistance to the resident. He/she stated that administrative staff A told him/her that the resident would be safe at the facility. He/she also verbalized that at the time of the occurrence he/she was told by the facility the resident was being sent to the hospital but was not told any of the circumstances until later. He/she stated he/she was informed by staff D the door alarms did not work and that is what caused the occurrence. He/she also stated this accident had negatively affected the resident and his/her progress towards recovery. The facility's policy and procedures for Elopement revised 10/2007 documented: it is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility. The facility policy documented its purpose to ensure that residents at risk for elopement were properly monitored and to ensure that residents who do leave the facility are located quickly and safely. The policy documented that residents who were at risk for elopement would have an appropriate plan of care developed to address the risk. This same policy recorded a procedural guide to search and locate and provide notifications for a missing resident. The policy lacked documentation when (how often, such as admission, quarterly etcetera,) a resident would be assessed and/or how (what contributing factors) would be used to determine a residents at risk status. The facility failed to ensure this resident, who staff incorrectly assessed and failed to identify as an elopement risk, received adequate supervision and appropriate interventions to prevent an elopement. Resident #1 exited the facility on 5/17/19 without staff knowledge, was found outside of the facility approximately 1 hour later and required immediate hospitalization for injuries sustained from a fall during the elopement. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 5/22/19 at 7:15 PM by implementing the following: All doors were checked for proper functioning and 1:1 continuous supervision was initiated with the door until it was passed by Fire One. Head count was completed, and all facility residents were present. In-servicing was initiated by DON All residents with cognitive impairment and physical ability to exit the doors have the potential to be affected. A full house review was completed, and elopement risk assessments were audited and completed at necessary. Care plans were updated as needed. Elopement drill testing will be completed utilizing an employee as the resident and coordinated by the administrator/designee. These will be completed weekly x 4 weeks, monthly thereafter; these will be conducted on various days and shifts. Any deviation from the policy will result in immediate education. Results of these drills will be taken to monthly QA. All current residents have an elopement assessment completed and care plans undated to reflect plan of care. Ongoing education will continue with random testing on elopement procedures with focus on responding to alarms and reporting, and coordination of care with vendors providing care to facility residents. Administrator/designee will audit door and alarm audits daily. Results of these audits will be taken to our monthly QA for review. Ongoing education will continue with random testing on elopement procedures with focus on responding to alarms and reporting. DON/Designee will review 24-hour report to audit that interventions have been implemented and care plan and Kardex updated DON/Designee will review new admissions The deficient practice remains at a scope and severity of a G

The facility identified a census of 43 residents. The sample included 3 residents. Based on record review and interviews the facility failed to secure and/or clarify, upon admission, physicians orders for immediate care related to insulin use (an injectable protein hormone that is used as a medication to treat high blood glucose) and the monitoring of blood sugars for one sampled resident (#1) when the resident's blood sugar level dropped to a critical level and he/she required hospitalization . Findings included: - Resident #1 electronic medical record (EMR) recorded the resident admitted on [DATE] at 8:15 P.M. with [DIAGNOSES REDACTED]. (aftercare for a [DEVICE] -an artificial way to supply medications and/or nutrients) and need for assistance with personal cares. The initial nurses' data assessment dated [DATE] documented staff assessed the resident as cognitively aware, alert and oriented to person, place, and time. He/she required extensive assistance of one to two staff with activities of daily living such as bed, mobility, transfers, dressing, and toilet use. This same assessment recorded the resident had occasional bowel and bladder incontinence, was 6 feet 4 inches tall, weighed 293 pounds, and lacked any specific diet order and or use of insulin. The initial care plan dated 11/30/18 documented, for nutrition, the resident was at risk for potential problems and directed staff to evaluate and treat the resident per the physician's orders [REDACTED]. Review of the nurses' progress notes dated 11/30/18 at 12:06 A.M. documented the resident arrived at the facility on a stretcher, took his/her medication by mouth, and medications were verified with the physician and faxed to the pharmacy. Review of the post hospitalization discharge orders recorded the following: An order dated 11/15/18 directed staff to administer [MEDICATION NAME] (Humalog) (a short acting) insulin 10 units subcutaneously (SQ) (in fatty tissue) three times a day before meals for 30 days for diabetes mellitus. This document had a handwritten inscription to seek physician clarification. An order dated 11/15/18 directed staff to administer [MEDICATION NAME] ([MEDICATION NAME]) (a long acting) insulin 35 units SQ at bedtime for diabetes mellitus. The facilities electronic physician order [REDACTED]. Review of the November/December (YEAR) medication administration record (MAR) Recorded the resident received no insulin on 10/29/18 at bedtime and his/her fist dose of [MEDICATION NAME] on 11/30/18 at bedtime. The November/December 2108 MAR lacked documentation of the resident blood sugar was checked on 11/29/18 at bedtime and his/her first administration of [MEDICATION NAME] 35 units was on 11/30/18 at 8:00 P.M. the MAR and nurses progress notes lacked documentation why the physician order [REDACTED]. The November/December (YEAR) MAR further lacked documentation staff checked the resident's blood sugar on 11/30/18 before breakfast, lunch, and dinner on 11/30/18. The first recording of the resident blood sugar levels was on 12/1/18 at 8:15 A.M. when the reading was HIGH. And the first documentation the resident received scheduled Humalog insulin was on 12/1/18 at breakfast (No time recorded). Review of nurse H statement recorded: He/she arrived to work on Saturday 12/1/18 at approximately 8:00 A.M. to assist another nurse with A.M. medication pass. The other nurse stated resident's blood sugar reading was high. Nurse H documented he/she administered the resident's scheduled dose of A.M. meal insulin. (10 Units Humalog). Review of a nurses note dated 12/1/18 at 4:46 P.M. recorded this nurse went to give resident his/her intravenous antibiotic and noted a foul smell in room. Nurse noted that the resident's Peg tube (a surgically inserted tube into the stomach through the abdominal wall) was opened, and the cap was off with fluid flowing freely on the bed and on the resident. Nurse cleaned the bile and fluids off the resident and got the resident comfortable in bed with all clean linens and gown. During this time the resident's family told this Nurse {resident} is not acting right, he needs his Blood Sugar (BS) checked, he drops fast. Nurse checked BS, and BS was 42 milligrams (mg) per deciliter (dl). The resident's vital signs were stable. Nurse obtained glucose gel from E-kit (emergency kit), attempted to administer, but the resident was unable to make a swallowing motion. The resident's jaw locked up and his/her eyes rolled back into his/her head. Nurse then rechecked BS, BS was 27 mg/dl; 911 (emergency response activated) was called by the nurse at bedside of resident per nursing judgment and family request. Interviewed on 12/12/18 at 10:32 A.M. licensed nurse H stated he/she remembered the resident and was asked to make a statement after his/her shift ended. Nurse H stated he she arrived late to work on 12/1/18 to help another nurse. Resident #1 was to have 10 units insulin before meals. The other nurse already checked resident's blood sugar and it read HIGH (records high if over 550 mg/dl). The patient tolerated it well Patient tolerated and was watching something on TV, {resident| consumed all breakfast wanted more to eat Cereal or oatmeal. At Noon {resident} was lying in bed there were no concerns he/she watched TV and a recheck of the BS revealed a reading of 65 mg/dl or 62 mg/dl, (Normal values are 80/120 mg/dl). So, I went and got orange juice and stayed at bed side until {resident} consumed it. Nurse H Stated he/she would return after lunch to recheck his/her blood sugar again. After lunch and he/she got busy and returned about 2:30 P.M. At that time the he/she pulled back the covers and noticed the [DEVICE] was leaking. Nurse H cleaned all, secured the [DEVICE] with gauze and medical tape. The resident was alert and ok and talking with a family member. At this time another family member arrived and stated {resident} did not look right, he/she was kind of twitching. I rechecked his/her BS and it was now 42 mg/dl. The family member stated, you need to do something and I went to get some glucose tablets. The resident consumed ½ tablet and could not swallow, so I obtained the E-Kit to get some glucose gel. The family member tried to administer water via straw and I asked him/her to stop. A recheck of the resident BS revealed it was now 27 mg/dl. On 12/12/18 at P.M. during an interview with the resident's family member revealed when he/she arrived the resident's call light was not in reach. The facility staff said it was not their fault that they did not get the information from the hospital. The family member stated they should have been monitoring the resident's BS and when I asked what it was at lunch they just said High and it had to be greater than 550 mg/dl. They gave the resident ten units of some- kind -of insulin and then when it dropped to 21 mg/dl. The family member stated the resident went to hospital, stabilized, and was now at a different facility. On 12/12/18 at 4:30 P.M. administrative licensed nursing staff D stated the resident's admission to the facility was enacted the day before admission, but when the transfer orders were received from the hospital they were incomplete and unclear. They had paperwork from two other residents mixed in with this resident. On 12/12/18 at 4:30 P.M. the resident's Physician AA was unavailable for comment. The facility policy title Admission/ Transfer/discharged Rights, revised 9/2018, lacked documentation related to the clarification (with the physician) transcription, and implementation of orders needed for resident care. The facility failed to ensure clarification of physician's orders [REDACTED].

The facility reported a census of 77 residents. The sample included 3 residents reviewed for falls. Based on record review, observation, and interview, the facility failed to prevent a fall which resulted in a fracture of the second cervical vertebrae (a broken bone in the spine at the level of the neck), a scalp laceration (a cut on the scalp) that required 15 staples, and bruising for 1 of 3 residents (#1). Findings included: - The electronic medical record (EMR) documented resident #1 admitted to the facility on [DATE], had a fall with injury on 9/2/17, which led to hospitalization . Staff readmitted the resident to the facility on [DATE]. The EMR documented [DIAGNOSES REDACTED]. The initial nurse's data assessment dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The readmission Minimum Data Set ((MDS) dated [DATE] recorded a BIMS score of 11, which indicated moderately impaired cognition. The resident continued to require extensive assistance of one staff with most activities of daily living such as bed mobility, transfers, toileting, and personal hygiene. He/she used a wheelchair for mobility. He/she was not steady and/or able to stabilize him/herself without staff assistance. The resident experienced one injury fall in the previous 6 months. The care area assessments (CAA) dated 9/14/17 recorded staff readmitted the resident after a fall which resulted in a large scalp laceration and fracture of the second cervical vertebrae (a broken bone in the spine at the level of the neck). Staff identified the cause of his/her fall as the low air loss mattress shifted the resident's weight and resulted in the fall. The CAA further documented staff assessed the resident as a risk for falls due to his/her history of falls and due to severe kyphosis (also known as a round back or hunchback, a condition in which the spine in the upper back has an excessive curvature). The admission fall risk assessment dated [DATE] documented the resident scored 9 on the evaluation tool (a score of 10 or greater indicated a high risk). The resident's initial care plan dated 8/27/17 directed staff to ensure the resident's call light was within reach, ensure the resident wore appropriate footwear when ambulating or wheeling in his/her wheelchair, and to keep the resident's bed in the lowest position. A nurse's note dated 9/2/17 at 11:27 P.M. documented staff found the resident on the floor in his/her room next to his/her bed. He/she hit his/her head on a bedside table, which resulted in a laceration to his/her head. Staff evaluated the resident and sent him/her to the hospital. The resident received 15 staples to fix the laceration. The facility's investigation documented the resident fell on [DATE] (no time noted), transferred to the emergency room and admitted to the hospital. In addition to the staples received, the resident had a blackened eye and a broken neck. This same report recorded the resident's neck fracture was permanent and would not heal, and he/she required a firm neck brace for 6 to 8 weeks, and then a neck brace made of cloth to be worn indefinitely. The resident returned to the facility on [DATE]. This investigation failed to identify the root cause of the resident's fall. Review of direct care staff P's notarized witness statement revealed on 9/2/17 at 11:30 A.M., he/she repositioned the resident in the middle of the bed for his/her lunch. Staff P positioned the resident with pillows under his/her right and left arms and behind his/her head. On 9/2/17 at approximately 12:30 P.M. direct care staff P responded to a page for assistance in the resident's room. Staff P documented the resident was alert, talked to staff, and laid on his/her side next to the bed with blood on the carpet. Direct care staff P documented the resident's bed was not in the lowest position, but waist high. On 9/27/17 at 8:44 A.M. the resident sat in his/her wheelchair with his/her head slumped forward and wore the firm neck brace. Observation revealed an approximately 9 centimeter (cm) horseshoe-shaped, closed wound to the top of his/her scalp, right eye with bluish-black bruising and bluish-brown bruising behind his/her right ear. On 9/27/17 at 8:26 A.M. therapist S arrived with the resident's breakfast and stated the resident fed him/herself prior to the fall, but now required assistance with meals. Staff S further stated before the resident fell , he/she received a regular diet, but now the resident required a pureed diet with nectar thickened liquids. On 9/27/17 at 8:44 A.M. the resident spoke slowly and stated he/she did not remember his/her fall. On 9/27/17 at 11:05 A.M. direct care staff P verified the facts contained in his/her witness statement. On 9/27/17 at 3:00 P.M., administrative licensed nurse E stated staff provided the resident with a new bed with side perimeters to define bed boundaries. On 10/19/17 at 11:10 A.M., health care provider K stated the on-call physician notified him/her and the resident's physician of the resident's fall and felt the facility responded appropriately. The facility's Fall Prevention policy, revised 5/2007, documented staff would identify contributing factors and make recommendations and care plan changes for all residents who experience a fall. The facility would revise care plans and/or update them to reflect changes in interventions. The facility failed to ensure resident #1's bed was in low position as care planned. The resident had cognitive impairment and staffed assessed him/her as at risk for falls. The resident experienced a fall on 9/2/17 that required hospitalization for a neck fracture, laceration that required staples, and bruising.

The facility identified a census of 50 residents. The sample included 31 residents, with 15 residents sampled for medications. Based on observation, interview, and record review, the facility failed to ensure 1 of 15 residents sampled for medications (#115) was free from significant medication errors when the facility failed to obtain and provide pharmaceutical services (including the accurate acquiring, receiving, dispensing and administering of [MEDICAL CONDITION] drug) for 31 of 31 doses ordered. This deficient practice placed this resident in immediate jeopardy. Findings included: Resident #115's electronic physician's orders [REDACTED]. The 10/10/16 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The 14 day MDS dated [DATE] noted a BIMS of 12, which indicated moderately impaired cognition. The care plan initiated on 10/3/16 directed staff to give the [MEDICAL CONDITION] (used of drugs to [MEDICAL CONDITION]) medication palbociclib (a medication to treat [MEDICAL CONDITION]) as ordered. Staff would monitor, document and report to the physician side effects and effectiveness including [MEDICAL CONDITION] (low red blood cell count), anorexia (lack or loss of appetite), bleeding, abnormal blood counts (blood cell counts outside the normal range) , chills, constipation, diarrhea, fatigue, nausea, vomiting, flu-like symptoms, malaise (a general feeling of being ill or having no energy), hair loss, stomatitis (inflamed and sore mouth), heartburn, infection, dry or cracked lips, mood problems, muscle soreness, weakness, [MEDICAL CONDITION] (weakness, numbness and pain from nerve damage, usually in the hands and feet), skin changed, swallowing problems sore mouth or weight changes. The physician's orders [REDACTED].#115 was to receive palbociclib capsule, 100 milligrams, by mouth, in the morning every day for [MEDICAL CONDITION] beginning on 10/4/16. Review of the resident's electronic Medical Administration Record (MAR) for October and November 2016 documented the resident did not receive palbociclib [MEDICAL CONDITION] medication as ordered. The MAR documented Code 7, Other- See nurse's note on 24 out of 31 days. The October 2016 MAR documented licensed staff VV initialed on 10/4/16 for palbociclib 100 mg medication, indicating it was administered to the resident. The October 2016 MAR documented licensed staff XX initialed on 10/12/16 for palbociclib 100 mg medication, indicating it was administered to the resident. The October 2016 MAR documented licensed staff WW initialed on 10/18/16 for palbociclib 100 mg medication, indicating it was administered to the resident. The October 2016 MAR documented licensed staff J initialed on 10/24/16 for palbociclib 100 mg medication, indicating it was administered to the resident. The October 2016 MAR documented licensed staff N initialed on 10/28/16,10/29/16, and 10/30/16 for palbociclib 100 mg medication, indicating it was administered to the resident. Nursing notes dated 10/5/16, 10/6/16, 10/7/16, 10/8/16, 10/9/16, 10/10/16, 10/11/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/25/16, 10/26/16, 10/27/16, 10/31/16, 11/1/16, 11/12/16 and 11/3/16 documented the resident did not receive his/her palbociclib capsule for [MEDICAL CONDITION] on those days because the medication was not available. On 11/3/16 at 9:26 A.M. resident #115 sat in bed in his/her room. During an interview on 11/2/16 at 11:26 A.M. resident #115 stated he/she thought he/she received [MEDICAL CONDITION] medication daily. He/she stated I get a pill every day and probably will have to take it for a long time. He/she had no concerns with the [MEDICAL CONDITION], stating staff gave him/her the [MEDICAL CONDITION] drug daily since he/she admitted to the facility. The resident was never told the medication was not available and that he/she had not received it consistently since the time he/she admitted to the facility. On 11/9/16 at 4:32 P.M. the resident's family member confirmed that the resident had [MEDICAL CONDITION], that it had metastasized ([MEDICAL CONDITION] spreads from an organ or part of the body to another without being directly connected to it) to the resident's lung and he/she took palbociclib for metastatic [MEDICAL CONDITION]. He/she stated when he/she toured the facility to determine if he/she would admit resident #115 to the facility, the administrative staff who gave the tour assured him/her that the facility could provide services for #115, including medications. The family member had concerns about resident #115's medications because he/she had toured another facility and they denied #115 admission due to not being able to get the medication. Facility staff confirmed that this would not be an issue at this facility because this facility could provide all the medications resident #115 needed with no problem. The family member confirmed the facility never notified him/her that they did not have resident #115'[MEDICAL CONDITION] medication. He/she stated he/she had plenty of medication at his/her home to provide, if only he/she had been notified that the facility needed it to administer to the resident. On 11/3/16 at 9:28 A.M. licensed staff H reported if the resident was out of a medication the nurse should place an order to the pharmacy. The pharmacy delivered medications several times a day as needed. On 11/7/16 at 3:16 P.M. licensed staff I stated if a resident was low on medications or was out of a medication it was up to the nurse to put in a request to the pharmacy to have the medication refilled. Nursing staff should document the medication was not available by documenting a nursing note in the resident's electronic medical record. The pharmacy could get the medication to the facility within a few hours. It was the responsibility of the nurse to put in the request and not to put it off to the next nurse. On 11/8/16 at 7:34 A.M. administrative nursing staff B stated on admission an order for [REDACTED]. He/she stated the pharmacy may deliver up to 4 times per day. It was his/her expectation that if a resident did not have a medication and the next delivery would not be timely, the nurse should use medication out of the e-kit (a locked container filled by a pharmacy with common medications to be used with a physicians order before the medication could be filled by the pharmacy) however Palbociclib was a specialty medication and was not available in the e-kit. Administrative nursing staff B expected staff to notify the physician and the pharmacy if a medication was not available, to see if a substitute was available. Administrative nursing staff B further stated all medications should be available and administered in a timely manner. On 11/14/16 at 3:09 P.M. administrative nursing staff G confirmed the resident did not receive his/her [MEDICAL CONDITION] medication from 10/5/16 through 11/3/16 by reviewing the resident's October 2016 and November 2016 MAR and the corresponding nursing notes. On 11/14/16 at 3:30 P.M. administrative nursing staff G stated when a medication was not available nursing staff needed to do everything attainable to make sure the resident received his/her medications. The expectation was for the nurse to call the physician and notify of not having a medication. If a medication order was sent to the pharmacy it could not be a screen shot of the medication from the electronic MAR, it must be the signed physician's orders [REDACTED]. On 11/9/16 at 10:52 A.M. consultant staff II stated palbociclib was a phase 2 clinical trial drug used with the intention for anyone taking this drug to be progression free of [MEDICAL CONDITION]. Consultant staff II stated the pharmacy could not get the medication from the wholesaler or the manufacturer; only the family could provide palbociclib for this resident. Consultant staff II stated the medication helped prevent progression of [MEDICAL CONDITION]. On 11/14/16 11:15 A.M. consultant staff II confirmed the pharmacy filled medications for the facility when there was a request made by the facility. He/she confirmed the facility never requested to fill this medication. He/she confirmed the facility faxed a screen shot of the medication from the resident's MAR to the pharmacy but never requested the medication be filled, nor did the facility follow-up with communication related to the fax. Consultant staff II stated the normal process to fill a medication was for the facility to use a request sticker or write out the medication on an order sheet. If resident #115 did not receive his/her medication, there could definitely be a negative outcome for the resident, as it was possible [MEDICAL CONDITION] could grow in size while not receiving the medication 24 out of 31 days. If the medication was not available, the pharmacy would expect the facility to call the pharmacy, and in this case call the family, to ensure the family would bring the medication from home. Consultant staff II stated, (He/she) was not surprised that the family could have had the medication on hand the whole time because of the lack of adequate communication from the facility. On 11/9/16 at approximately 3:40 P.M., the attending oncology physician for resident #115 was not available for interview. On 11/9/16 at 3:45 P.M. consultant physician staff JJ confirmed palbociclib was an FDA (Federal Drug Administration) approved drug to treat metastatic [MEDICAL CONDITION]. If the facility was unclear how or when to administer the medication or if the facility had trouble obtaining the medication he/she would expect to be contacted by either the facility or the family to see if the physician wanted to make changes to the medication order. Consultant physician staff JJ further stated if the resident did not receive this medication consistently his/her treatment (for the life [MEDICAL CONDITION]) would be delayed. On 11/14/16 at approximately 12:06 P.M. the attending oncology physician for resident #115 was not available for interview. On 11/14/16 at 12:09 P.M. consultant physician staff JJ stated the prescribing physician was not notified the facility had difficulty getting the [MEDICAL CONDITION] medication (palbociclib), was not notified that the medication was not available at the facility to administer to the resident, and was not notified the resident had not received the medication for 24 out of 31 days. Consultant physician staff JJ stated the physician would expect to be notified if the resident did not receive the medication so that they could be made aware of the situation and decide if another course of action needed to be taken. If the facility said that they could supply the medications for that person then the expectation of the physician is that they honor that statement. If the resident did not receive his/her medication for 24 out of 31 days, there could be a delay in treatment and there was always a potential that [MEDICAL CONDITION] could spread. On 11/15/16 at 4:02 P.M. administrative nursing staff B stated the facility never had the medication, Palbociclib capsule 100 mg, in the facility. He/she stated the facility dropped the ball for this resident's medication not being filled or notifying the physician that it was not being given. Administrative nursing staff B stated he/she would not expect a licensed staff member to document a medication was given if it was not in the facility. He/she further stated the facility notified the resident's family and physician the medication had not been administered as ordered after the survey team brought this concern to the facility's attention. On 11/15/16 at 4:58 P.M. administrative staff A stated the [MEDICAL CONDITION] medication (palbociclib) was not given as ordered to the resident. On 11/21/2016 at 8:11 A. M. licensed nursing staff J verified that a checkmark on the MAR indicated licensed staff had administered the medication. He/she reviewed the resident's MAR and verified that he/she documented the medication as administered on 10/24/16. He/she stated he/she did not remember this medication and could not provide an explanation as to why it would have been marked as administered if it was not available in the facility. He/she stated if the medication was not available it should have been documented as not available and he/she should have followed up with the pharmacy and the physician. The Medication Administration Policy provided by the facility dated July 2015 identified the facility would administer medications as prescribed by the attending physician and if a medication was unavailable or not administered at the scheduled time, the documentation would be reflected in the clinical record and physician notification. The facility failed to obtain and provide [MEDICAL CONDITION] medication for this resident with metastatic [MEDICAL CONDITION] as ordered by the physician on admission. This deficient practice placed this resident in immediate jeopardy. The facility abated the immediate jeopardy on 11/17/16 at 7:00 P.M. by: 1) Performed an all-house audit for medication orders and availability for all residents. 2) Conducted face-to-face in-service with all licensed nursing staff on the facility's policy and procedure for medication administration and physician orders. 3) Implemented a change of shift report to ensure medication availability and timely follow-up. 4) Daily monitoring of medication and follow-up with review by the quality assurance committee. The deficient practice remained at a scope and severity of a G.