Every finding on record at St Catherines Manor of Washington Court House

Based on observation, review of a facility Legionella plan and testing and monitoring documents, medical record review, and staff interview, the facility failed to ensure measures to address and prevent Legionella growth within the facility were maintained and conducted as required and failed to ensure infection control measures were maintained following urinary catheter care for a resident (#6). This had the potential to affect all 46 residents residing in the facility. The census was 46. Findings include: 1. Review of the document titled, Legionella Policy - Environmental, revealed Legionella prevention control measures of quarterly testing of chlorine levels, weekly testing of water temperatures, monitor and flushing pipes in rooms and areas that were not in use, monitor kitchen ice machines, eye wash stations, water filters, sinks and showers in resident rooms and central showers, circulation tubs and drinking fountains, water filters to be changed bi-annually, and kitchen appliances to be maintained and cleaned per manufacturer guidelines. Further review revealed the plan did not specify what monitor meant and how the areas would be checked or evaluated. Review of facility maintenance logs revealed the facility had no evidence of water filters being changed bi-annually. The documentation mentioned a filter change 04/2025. Review of temperature logs revealed the facility was testing room temperatures weekly with a goal temperature to be between 110 to 117 degrees Fahrenheit (F). The plan did not specify how to respond when temperatures measured outside that range. The logs revealed in January 2025, three temperatures were low and 15 were high. In February 2025, five temperatures were low and 27 were high. In March 2025, one temperature was low and 36 were high. In April 2025, two temperatures were low and 40 were high. In May 2025, one temperature was low and 52 were high. In June 2025, three temperatures were low and 51 were high. In July 2025, one temperature was low and 42 were high. In August 2025, five temperatures were low and 41 were high. In September 2025, 42 temperature were high. In October 2025, 35 temperatures were high. In November 2025, 32 temperatures were high. Review of flushing logs revealed no evidence of flushing vacant or infrequently used rooms from 01/01/25 to 06/30/25 and the last week in November 2025. The facility provided no evidence related to eye wash stations, sink and showers in resident rooms and central showers, circulation tubs, and drinking fountains and if these areas were monitored for potential Legionella concerns. Interview on 12/17/25 from 3:30 P.M. to 4:50 P.M. with Project Manager (PM) #250 confirmed the facility did not have documentation of what facility meant by monitor. He also confirmed the facility had no additional documentation related to missing dates of flushing plumbing, missing dates of changing water filters, and confirmed facility had no documentation related to eye wash stations, sink and showers in resident rooms and central showers, circulation tubs and drinking fountains. PM #250 confirmed the facility monitored but was unable to explain what that meant and revealed the facility did not use plumbing for eye wash stations and did not think they had drinking fountains. He also confirmed the Legionella plan/policy referred to an appendix B which then referred to logs which included the parameters and confirmed the plan did not include details on control measures, acceptable ranges and steps to take if outside the acceptable parameters. 2. Review of the medical record for Resident #6 revealed an admission date of 08/21/25. Diagnoses included fracture of the right acetabulum, anxiety disorder, and history of malignant neoplasm of the prostate. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. The resident was assessed to require setup with eating, was dependent with toileting, and required substantial assistance with bathing, dressing, and transfers. Resident #6 was assessed with an indwelling catheter. Review of the care plan dated 10/13/25 revealed Resident #6 had a urinary (Foley) catheter related to urinary retention and obstructive uropathy. Interventions included catheter care every shift, change the catheter bag as needed, notify the physician with changes in bowel or bladder habits, provide incontinence care with each incontinent episode and as needed, and provide moisture barrier cream after each incontinent episode and as needed. Review of the physician order dated 08/21/25 revealed Resident #6 was ordered indwelling catheter care every shift. Observation on 12/17/25 at 3:46 P.M. revealed urinary catheter care was completed on Resident #6 by Certified Nurse Aide (CNA) #176. CNA #176 did not remove gloves after providing catheter care and then proceeded to touch Resident #6's bedside table and bed controls. Interview on 12/17/25 at 3:54 P.M. with CNA #176 verified she did not change her gloves after providing Resident #6's urinary catheter care and then touched the bedside table and bed controller with soiled gloves.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to protect against potential contamination and spoilage. This had the potential to affect all 43 residents in the facility that receive food from the kitchen. The facility identified three (#9, #36, and #55) residents with active orders for nothing by mouth. The facility census was 46. Findings include:Observation on 12/15/25 at 8:57 A.M. revealed four opened containers of food items with no date marking in the walk-in refrigerator including one bag of yellow cheese slices, one bag of white cheese, one bag of pepperoni slices, and one package of bacon. Observation on 12/15/25 at 8:59 A.M. revealed two opened and undated bags of egg patties, one of the bags of egg patties was stored with the bag open allowing exposure to air in the freezer. Further observation of the walk-in freezer at this time revealed three bags of opened and undated vegetables, including zucchini, corn, and sweet potato fries. Interview on 12/15/25 at 9:10 A.M. with [NAME] #150 revealed opened containers of perishable food items should be date marked. Further interview at this time with [NAME] #150 confirmed there were several undated food items in both the walk-in refrigerator and the walk-in freezer. Review of facility policy titled, Storage of Perishable Foods, reviewed 03/2025, revealed all perishable goods are to be refrigerated at the appropriate temperature and in an orderly and sanitary manner. Further review of the policy revealed prepared or leftover foods should be stored tightly covered, clearly labeled, dated, and used within three days or discarded. Additional review of the policy revealed foods such as cheese and other dairy products may be served until the use by date on the package, or the use by date when the date is on the box should be transferred to a label on the package.

Based on medical record review, staff interview, and policy review, the facility failed to monitor behaviors with psychotropic medication use. This affected two (#2 and #56) of five residents reviewed for psychotropic medications. The facility census was 46.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 09/04/18. Diagnoses included type II diabetes mellitus, heart failure, dementia, Parkinson's disease, and atrial fibrillation.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers.Review of the care plan dated 03/04/25 revealed Resident #2 was at risk for complications related to psychotropic medication use related to a diagnosis of depression. Interventions included educate on risks, benefits, and side effects of Zoloft, give medications as ordered, and monitor, document, and report to physician signs and symptoms of depression unaltered by medications.Review of the medical record for Resident #2 revealed there was no documentation for behavior monitoring.Interview on 12/17/25 at 2:07 P.M. with Regional Director of Clinical Services (RDCS) #200 verified behaviors for psychotropic use should be monitored for use of the medication. RDCS #200 also verified there was no documentation for monitoring behaviors for Resident #2.2. Review of the medical record for Resident #56 revealed an admission date of 12/08/25. Diagnoses included periprosthetic fracture around an internal prosthetic right knee joint, fracture of the tibia, and major depressive disorder.Review of the admission MDS assessment dated [DATE] revealed Resident #56 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require setup with eating, and partial assistance with toileting, bathing, dressing, and transfers.Review of the care plan dated 12/10/25 revealed Resident #56 was at risk for advance effects/complications due to psychotropic medication use. Interventions included to monitor behaviors and record every shift, monitor for side effects of medication use, notify physician of any adverse side effects, and use of non-pharmacological interventions and document effectiveness.Review of the physician order dated 12/10/25 revealed Resident #56 was ordered the antianxiety medication clonazepam one (1) milligram (mg) to give one tablet by mouth three times a day for anxiety.Review of the medical record for Resident #56 revealed behavior monitoring was not completed on the mornings of 12/10/25, 12/12/25, 12/13/25, and 12/14/25.Interview on 12/18/25 at 10:48 A.M. with RDCS #200 verified no behaviors were monitored or documented on the above dates for Resident #56.Review of the facility policy titled, Psychotropic Drugs, dated 2017, revealed a psychotropic drug was any drug that affected brain activities associated with mental processes and behavior. As needed or pro re nata (PRN) psychotropic drugs should only be used when the resident had a specific condition for which psychotropic drugs were indicated and one of the following existed including used to manage unexpected harmful behavior that cannot be managed without psychotropic drugs.

Based on medical record review, staff interview, and policy review, the facility failed to ensure timely follow-up on pharmacy recommendations during monthly medication reviews. This affected one (#24) of five residents reviewed for unnecessary medications. The facility census was 46.Findings include:Review of Resident #24's medical record revealed an admission dated of 04/24/17. Diagnoses included heart failure, unspecified dementia with other behavioral disturbances, type II diabetes, atrial fibrillation (A-fib), major depressive disorder, anxiety disorder, unspecified psychosis disorder, hypertension, insomnia, and history of transient ischemic attack (TIA).Review of a note to the attending physician/prescriber dated 01/16/25 revealed Resident #24 was continued on the anticoagulant medication rivaroxaban (Xarelto) 15 milligrams (mg) by mouth once daily with supper upon her readmission. Further review revealed the anticoagulant Eliquis five (5) mg by mouth twice daily would be the new recommended dose if feasible. Review of the physician/prescriber response signed and dated on 01/16/25 revealed to begin Eliquis 2.5 mg by mouth twice daily due to falls.Review of Resident #24's medication administration record (MAR) from 01/01/25 to 01/31/25 revealed an order for rivaroxaban 15 mg daily with a start date of 01/14/25 and a discontinued date of 02/04/25.Review of Resident's #24 MAR from 02/01/25 to 02/28/25 revealed an order for rivaroxaban 15 mg daily with a start date of 02/04/25 and a discontinued date of 02/27/25. The review also revealed an order for Eliquis 2.5 mg with a start date of 02/27/25.Interview with Director of Nursing (DON) #157 on 12/18/25 at 1:04 P.M. confirmed the medication recommendation to start Eliquis 2.5 mg by mouth twice daily was acknowledged and signed on 01/16/25. DON #157 stated according to the facility pharmacy policy, the facility usually has 30 days to enact the change from a pharmacy recommendation. DON #157 stated Resident #24 returned to the facility from a hospital visit dated 02/02/25 to 02/04/25 with orders from the hospital to continue rivaroxaban 15 mg. Review of the consultant pharmacist's medication regimen review dated 03/19/25 revealed a recommendation to remove the pain level attached to the aspirin order and change the diagnosis to A-fib and history of TIA. Review of the pharmacist's medication regimen review follow up section revealed the word done and a set of initials.Review of Resident #24's medical record revealed a current order for aspirin 81 mg with a start date of 02/04/25. The review of Resident #24's medical record revealed the diagnosis for aspirin 81 mg order was listed as displace fracture of olecranon process without intraarticular extension of the right ulna, subsequent encounter for closed fracture with routine healing. Interview with DON #157 on 12/18/25 at 1:04 P.M. confirmed the current aspirin 81 mg order from 02/04/25 did not have the recommended diagnosis of A-fib and history of TIA. DON #157 was not sure why the diagnosis for the medication was not changed.Review of the policy titled, Medication Regimen Review and Recommendation, dated 10/08/25, revealed non-emergency recommendations should be addressed by the end of the following month.

Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure care conferences were completed in a timely manner. This affected two (#2 and #35) of four residents reviewed for care conferences. The facility census was 46. 1. Review of the medical record for Resident #2 revealed an admission date of 09/04/18. Diagnoses included type II diabetes mellitus, heart failure, dementia, Parkinson's disease, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers. Review of the care conferences for the last 12 months for Resident #2 revealed care conferences were only completed on 04/21/25 and 09/19/25. Interview on 12/17/25 at 10:16 A.M. with Social Service Director (SSD) #156 verified care conferences were to be completed quarterly, and Resident #2 only had two care conferences for the last 12 months. 2. Review of the medical record for Resident #35 revealed an admission date of 08/19/21. Diagnoses included chronic respiratory failure with hypoxia, diabetes, depression, dependence on ventilator status. Review of the MDS assessment dated [DATE] revealed a BIMS score of 15 indicating Resident #35 had intact cognition. Review of Resident #35's interdisciplinary meeting notes revealed a care conference was held on 04/10/25 and included several members of the interdisciplinary team. Review of the interdisciplinary meeting notes revealed a care conference was held on 09/30/25 and documented only Resident #35 was in attendance. Interview on 02/15/25 at 10:19 A.M. with Resident #35 revealed she was not invited to regular care conferences. Interview on 12/17/25 at 10:30 A.M. with SSD #156 confirmed Resident #35 only had evidence of two care conferences in the last year. She also acknowledged the care conference dated 09/30/25 appeared to have been staff just completing the form and not having an actual care conference as they resident was the only one who attended. SSD #156 also confirmed the two conferences were done over five and a half months apart. Review of facility policy titled, Care Plan Policy, dated 05/2025, revealed the resident shall have the opportunity to discuss their goals of care and have involvement from an interdisciplinary team including Physician, Registered Nurse, State Tested Nursing Aide a member of the food services team and other appropriate staff involved in the residents care.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were ingested during medication administration prior to leaving the resident's room. This affected one (#14) of six residents reviewed for medication administration. The facility census was 46.Findings include:Review of the medical record for Resident #14 revealed an admission date of 05/02/24. Diagnoses included type II diabetes mellitus, chronic kidney disease, and myocardial infarction.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to require setup with eating, supervision with toileting and bathing, and substantial assistance with dressing and transfers.Observation on 12/16/25 at 8:26 A.M. revealed Licensed Practical Nurse (LPN) #133 administered medications to Resident #14 and left the room before Resident #14 took her medications.Interview on 12/16/25 at 8:29 A.M. with LPN #133 verified she thought Resident #14 took her medications prior to leaving the room but confirmed she did not see the resident ingest the medications.Review of the facility policy titled, Medication Administration - General Guidelines, dated 10/17/07, revealed the resident was always observed after administration to ensure the dose was completely ingested.

Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure residents were properly assessed for appropriateness before being placed on the secured memory care unit. This affected one (#49) of one resident reviewed for restraints. The facility census was 46. Findings include: Review of the medical record for Resident #49 revealed an admission date of 07/15/25. Diagnoses included fibromyalgia, malnutrition, dementia with mood disturbance, and kidney disease.Review of hospital discharge paperwork dated 07/15/25 revealed Resident #49 had been living at home, was hospitalized , and found to have a urinary tract infection (UTI). The hospital documentation revealed the resident had a dementia/Alzheimer's diagnosis and had wandered while in the hospital.Review of the elopement assessment dated [DATE] revealed Resident #49 was not a risk of elopement.Review of the care plan dated 07/16/25 revealed Resident #49 was at risk for elopement with interventions to reside on the locked/secured unit.Review of the progress note from the facility nurse practitioner dated 09/04/25 revealed Resident #49 had a diagnosis of dementia and was on the antidepressant medication citalopram 20 milligrams (mg) daily. It was noted the resident requested to see her personal primary care doctor outside of the community. The nurse practitioner note revealed it was not facility policy to see a provider outside the community and a care conference will be held to discuss further steps.Review of the progress note from the facility physician dated 09/23/25 revealed Resident #49 had routine follow ups and was followed by psychiatry for her psychiatric conditions. The resident was diagnosed with dementia with behavioral disturbances and was on medication (citalopram) with a plan to continue the medication and follow up with psychiatry for ongoing management. After surveyor intervention, the note was amended on 12/18/25 and documented Resident #49 was not referred to psychiatry as it was entered in the note by artificial intelligence (AI) by error. Resident #49 was to continue to be managed by the nurse practitioner for ongoing medical conditions.Review of the elopement assessment dated [DATE] revealed Resident #49 was not a risk of elopement.Review of Resident #49's care conference documentation dated 10/20/25 revealed no mention or discussion on using a different physician and no mention of psychiatric services.Review of the progress note dated 10/20/25 revealed Resident #49 scored a zero and had no history of elopements or wandering.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition.Review of the progress note dated 12/01/25 revealed a nurse practitioner was in to see Resident #49 and placed a new order for psychiatric services at the resident's request.Review of Resident #49's physician order dated 12/01/25 revealed an order for a psychiatric (psych) consultation (consult) for therapy and dementia management.Review of the psychiatric consents dated 12/04/25 revealed Resident #49 signed consent to receive psych services.Review of the progress note dated 12/08/25 from the nurse practitioner reported the resident had enough capacity to make this decision in reference to changing her code status.Review of Resident #49's medical record found no evidence of any assessment prior to being placed on the secured memory care unit.Interview on 12/15/25 at 10:51 A.M. with Resident #49 revealed she was placed in the memory care unit improperly and stated she got confused when she had a UTI and went to the hospital. She revealed she was diagnosed with Alzheimer's disease and stated it was not an accurate diagnosis. Resident #49 stated her sister had Alzheimer's disease and her son thought her UTI confusion was the onset of dementia and Alzheimer's disease. She confirmed she felt like a trapped prisoner and reported she was not aware of any assessment that led to her being placed on the locked unit, and reported she had been asking to see her regular primary care doctor and even get an evaluation from psychiatry for several months with no success in hopes of proving it was just a big misunderstanding and she could go back home.Interviews on 12/18/25 from 10:44 A.M. to 2:00 P.M. with Regional Nurse #200 confirmed the facility did not have information from prior to the hospital on Resident #49's baseline diagnosis and also confirmed the facility did not complete any assessment for her appropriateness before being placed on the locked/secured memory care unit. Regional Nurse #200 revealed the facility had two elopement assessments indicating Resident #49 had no history or risk of elopement. Regional Nurse #200 reported residents have the right to request another physician and the facility should assist in facilitating communication to see if the outside physician was willing to accept the resident as a patient. Regional Nurse #200 stated she reviewed the documentation with the facility and medical team and determined the mention of psychiatric services was a type-o, although she acknowledged facility staff should be reviewing physician notes for any changes in the resident's needs without surveyor intervention. She revealed the medical team was agreeable to the resident seeing psych services.Review of facility policy titled, Restraint policy, dated 11/02/16, revealed residents had the right to be free from restraints. The resident shall have the ability of freedom of movement with the context of their functional capacity as assessed by the facility.

Based on observation, medical record review, staff interview, and policy review, facility failed to ensure a resident room was set to a comfortable temperature. This affected one (#9) of 16 residents reviewed for environmental issues during the initial sample. The facility census was 46. Findings include: Review of the medical record for Resident #9 revealed an admission date of 06/28/21. Diagnoses included quadriplegia, chronic respiratory failure, diabetes, heart embolism, tracheostomy, contracture of multiple sites, dependence on ventilator status, anoxic brain injury, epilepsy, and heart disease.Review of the plan of care dated 11/18/25 revealed Resident #9 had a tracheostomy (trach) with interventions to ensure trach ties were secured at all times, give humidified oxygen as prescribed, elevate head of the bed, provide oral care, monitor and document for restlessness and agitation, suction as necessary, and universal precautions.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 impaired cognition. Observation on 12/15/25 at 10:02 A.M. of Resident #9 revealed the resident's room was cool in temperature.Observation and interview on 12/17/25 at 9:45 A.M. with Respiratory Therapist (RT) #143 revealed residents with tracheostomies have their rooms set colder than residents without. RT #143 was unable to explain why and stated she was not sure why but revealed Resident #9 would sweat. The room's personal heating and cooling unit was observed with RT #143 and confirmed it was set to cold with cold air blowing and the temperature at 60 degrees Fahrenheit (F). She confirmed it was cooler in the room and turned up the temperature to 70 degrees F. Resident #9 was seen with bedding sheets and blankets covering her up to her neck.Interview on 12/17/25 at 9:55 A.M. with Licensed Practical Nurse (LPN) #170 revealed residents with tracheostomies have their rooms set colder than residents without trachs. LPN #170 reported she was not sure why but revealed Resident #9 would sweat. She confirmed Resident #9 was unable to adjust the thermostat, was not responsive, and was unable to request staff turn temperature down.Review of facility policy titled, Extreme Temperature Conditions, dated 06/2017, revealed the temperature within the building including residents rooms shall be maintained from 71 to 81 degrees.

Based on medical record review, resident representative interview, and staff interview, the facility failed to provide showers to residents who were dependent on staff for assistance. This affected one (#8) of four residents reviewed for activities of daily living. The facility census was 46.Findings included:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, atrial fibrillation, acute respiratory failure with hypoxia, chronic kidney disease (stage II), candidiasis, acute embolism and thrombosis of a deep vein of a lower extremity, hypo-osmolality and hyponatremia, congestive heart failure, atrial fibrillation, hypertension, and traumatic brain injury. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 11/06/25, revealed he had mild cognitive impairment. Review of section GG revealed the resident was assessed to needed substantial/maximum physical assistance from staff for showers/bathing.Review of Resident #8's current care plan revealed he had an activities of daily living (ADL) self-care performance deficit. His interventions included requiring one to two staff participation with bathing. Also, there was no care plan and/or interventions related to Resident #8 refusing showers and a plan to implement if he did refuse showers.Review of Resident #8 shower logs/documentation, dated September to November 2025, revealed three missing showers in September 2025, seven missing showers in October 2025, and eight missing showers, with four refusals, in November 2025.Interview with Resident #8's representative on 12/15/25 at 1:34 P.M. revealed concerns related to the amount of baths/showers the facility offered Resident #8. Resident #8's representative did not feel Resident #8 was offered a bath/shower as often as he should have them. Interview with Regional Director (RD) #200 on 12/17/25 at 2:30 P.M. and on 12/18/25 at 8:40 A.M. confirmed the facility did not have a care plan for Resident #8 and refusing showers and they have not had to address his refusals. RD #200 confirmed there was confusion in Resident #8 shower schedule as to which days he was supposed to get showers. His shower log records in the electronic medical record had bathing scheduled for Mondays, Wednesdays, and Fridays until sometime in November 2025 (RD #200 could not confirmed what specific date the resident's schedule switched), but the schedule the nurse aides look at to give residents showers, had Resident #8 listed as getting showers on Tuesdays and Fridays. RN #200 stated there were multiple days in which a shower was not offered on a Monday, Wednesday, or Friday, because of the confusion as to when the resident's showers should be. Therefore, the resident was not offered showers as scheduled, because there was no clear schedule when he should be offered them.

Based on observation, staff interview, medical record review, and policy review, the facility failed to check for placement of a gastronomy tube prior to administering medications through the tube. This affected one (#36) of six residents reviewed for medication administration. The facility census was 46.Findings include:Review of the medical record for Resident #36 revealed an admission date of 03/27/25. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. The resident was assessed to require substantial assistance with toileting, bathing, dressing, and transfers.Observation on 12/16/25 at 7:58 A.M. revealed Licensed Practical Nurse (LPN) #163 did not check verify placement or check for residual tube feeding prior to administering medications through Resident #36's gastrostomy tube (g-tube).Interview on 12/16/25 at 8:05 A.M. with LPN #163 verified she did not check for placement and residual prior to administering medications because there was not an order.Interview on 12/18/25 at 10:43 A.M. with Regional Director of Clinical Services #200 verified nurses should check for gastric residual prior to administering medications through a g-tube.Review of the facility policy titled, Medication Administration - General Guidelines, dated 10/17/07, revealed medications were administered as prescribed in accordance with good nursing principles and practices and only be persons legally authorized to do so. If the resident was tube-fed, medications were crushed finely to prevent clogging the tube.

Based on observation, medical record review, staff interview, review of food preparation menu and instructions, and policy review, the facility failed to prepare pureed food to a form that was safe and appropriate. This affected three (#20, #29, and #30) of three residents who had puree diet ordered. The facility census was 46.Findings include:Observation on 12/17/25 from 10:30 A.M. to 10:45 A.M. revealed [NAME] #150 placed cooked chicken, broccoli, and rice casserole into the blending canister to be pureed. She blended it, then used the spatula in which she scooped the unpureed casserole into the canister into a clean pan for the pureed food. While pouring the pureed casserole into the clean pan, two full pieces of rice were noticed by the surveyor in the puree. [NAME] #150 stated she was happy with how the food form looked, but then was told about the two full pieces of rice. She scooped them out at that time. Then, she began to puree a second batch of casserole. After pureeing the casserole and placing that batch into the existing pan of pureed casserole, the surveyor requested a taste test. There were small grains of rice still in the puree. Review of facility chicken, broccoli, and rice casserole menu and puree instructions revealed the puree instructions were described as blend the food until smooth using small amounts of chicken broth to result in smooth product.Interview with [NAME] #150 on 12/17/25 at 10:40 A.M. confirmed after pureeing the second batch of casserole and placing it in the pan, she confirmed it was to the form that was acceptable to her and she would serve it. When asked about the grainy pieces in the pureed form, she stated it was very difficult to puree rice fully. She confirmed a pureed texture should be smooth and able to hold its form.Interview with [NAME] #149 on 12/17/25 at 10:40 A.M. confirmed she tried the pureed casserole from the pan and agreed with the surveyor that it needed to be blended further to be more smooth. Observation on 12/17/25 at 10:42 A.M. confirmed [NAME] #150 placed the pureed casserole back into the blender and blended it to an acceptable texture.Review of Resident #20, Resident #29, and Resident #30's medical records confirmed all three had dietary orders for pureed texture diets, which included the chicken, broccoli, and rice casserole.Review of facility regular pureed diet policy, dated 04/29/25, revealed the regular pureed diet was designed for the resident who has some difficulty in swallowing or chewing, or who has poor coordination of tongue and lips. The texture of the food is smooth, thick, and moist, holds shape, required little or no chewing, and is easy to swallow.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure timely implementation of a therapy recommended splint and failed to ensure orders were followed regarding contractures. This affected one (#9) of one residents reviewed for range of motion. The facility census was 46.Findings include: Review of the medical record for Resident #9 revealed an admission date of 06/28/21. Diagnoses included quadriplegia, chronic respiratory failure, diabetes, heart embolism, tracheostomy, contracture of multiple sites, dependence on ventilator status, anoxic brain injury, epilepsy, and heart disease.Review of the plan of care dated 02/28/24 revealed Resident #9 had an alteration in musculoskeletal status related to extremity contractures with interventions to anticipate needs, use supportive devices, hand roll or equivalent in the right palm as ordered, and treatment per orders to fingers, elbows, and wrists. The care plan dated 10/16/24 revealed the resident was unable to make her needs known due to brain injury. Resident #9 did not speak and needs shall be anticipated by staff.Review of Resident #9's physician orders dated 07/15/25 revealed an order for fingers on bilateral hands to be washed and thoroughly dried between all fingers, cover each finger webspace with remedy antifungal powder, and weave interdry between fingers daily and as needed. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 00 indicating impaired cognition stating resident was unable to respond.Review of Resident #9's occupational therapy assessment dated [DATE] revealed proper hand function was limited by need for a right hand finger/digit splint. Resident #9 demonstrated need for a right hand splint to promote hand alignment during functional tasks. The assessment revealed the resident's range of motion was impacting caregiver performance with hygiene and per staff report, the resident typically did not move limbs independently. The occupational therapist recommended a palm protector type splint for positioning and finger separator to promote open palm and finger separation for hand hygiene.Observation on 12/15/25 at 10:02 A.M. of Resident #9 revealed she had bilateral contractures of her hands/wrists. Resident #9 had what appeared to be a thin fabric in her right hand and no materials in the left hand.Interview and observation on 12/16/25 at 1:50 P.M. with Licensed Practical Nurse (LPN) #133 confirmed typically Resident #9 had a towel in her left hand, but it fell out easily and no intervention was present for the left hand. LPN #133 also confirmed Resident #9 had interdry between her fingers on the right hand, verified this was the only item in place, and the interdry fabric was a moisture wicking towelette that was to be changed twice daily. LPN #133 confirmed Resident #9 did not have a splint in place and she had never seen one used for Resident #9.Interview on 12/16/25 at 2:25 P.M. with Certified Occupational Therapy Assistant (COTA) #210 confirmed she assessed Resident #9 on 12/11/25 and recommended a hand roll/splint with finger separators. COTA explained it was similar to a pedicure toe separator along with a palm protectant. She revealed Resident #9 was able to open her hand enough to get a rolled towel in it, but staff were concerned about hygiene and rough material of the towel. COTA #210 revealed she spoke with a supervisor who was to speak with facility management about getting a splint ordered.Interview on 12/16/25 at 2:50 P.M. with Infection Control Registered Nurse (ICRN) #144 revealed the therapy staff sent electronic mail (email) regarding the recommendation of a splint for Resident #9 and stated they were still awaiting approval from the Administrator prior to ordering. IC RN #144 confirmed the therapy team sent two to three options on 12/11/25 that could be ordered from an online retailer. ICRN #144 confirmed the facility had orders for bilateral hand rolls that were not in place and interdry fabric between bilateral fingers which was only in place on the right hand.Interview on 12/16/25 at 3:00 P.M. with Therapy Manager #215 revealed she spoke with facility management on 12/11/25 and were just waiting on approval from facility and for the device to be ordered for Resident #9.Review of facility policy titled, Range of Motion Policy, dated 04/29/16, revealed a resident with limited range of motion shall receive appropriate treatment and services to increase range of motion and/or prevent further decrease in range in motion.

Based on observation, staff and resident representative interviews, and medical record review, the facility failed to contact the physician and implement an order for bowel function. This affected one (#23) of two residents reviewed for bowel function. The facility census was 47. Findings included: Review of Resident #23's medical record revealed an admitted [DATE]. Medical diagnoses included pneumonia, heart failure, septicemia, Alzheimer's disease, and diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23 was assessed to require an extensive two person assistance for bed mobility, transfers and toilet use. Resident #23 was assessed as frequently incontinent of bowel and bladder. Interview with the Resident #23's Power of Attorney (POA) on 03/06/23 at 11:02 A.M. stated Resident #23 had been having explosive diarrhea. Review of Resident #23's bowel tracker from 02/07/23 through 03/07/23 revealed there were 30 episodes of loose bowel movements in medium to large in size during that time frame. Review of progress notes from 02/07/23 through 03/07/23 revealed the physician was not notified and there were no orders to treat Resident #23's diarrhea. Interview with Licensed Practical Nurse (LPN) #331 on 03/07/23 at 9:42 A.M. stated she was not aware of Resident #23's diarrhea, but could be due to Resident #23's colon polyps. LPN #331 stated could call the physician. Observation of incontinence care for Resident #23 on 03/07/23 at 10:53 A.M. with State tested Nurse Aide (STNA) #207 and STNA #128 revealed Resident #23's incontinence brief was saturated with liquid stool. Interview with the Nurse Practitioner (NP) #235 on 03/08/23 at 10:20 A.M. stated her protocol would be for the facility to let her know about the diarrhea, how long it had been going on, and how much. NP #235 stated she would make a determination from that information on what orders would be put into place. NP #235 stated, depending on that finding, she would order a kidney, ureter and bladder (KUB) x-radiation (x-ray) and an anti-diarrhea medication. NP #235 stated she came into the facility on [DATE] and LPN #331 reported to her there was some concerns for bowel movements for Resident #23, but the nurse reported he did not have any diarrhea, but had some history for polyps. NP #235 stated she had not been informed of Resident #23's diarrhea for the past 30 days.

Based on medical record review, resident and staff interview, fall investigation review, and policy review, the facility failed to complete a root cause analysis as part of their fall investigations and implement resident appropriate fall interventions. This affected three (#16, #23, and #200) of seven residents reviewed for falls. The facility census was 47. Findings include: 1. Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses included unspecified fracture of the lower right femur (12/09/2022), fracture of the left pubis (11/09/2022), displaced simple supracondylar fracture without intercondylar fracture of the left humerus (11/09/2022), repeated falls, diabetes mellitus type II, unspecified depression, adult failure to thrive, and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 required a two-person total assistance with bed mobility, dressing, toileting, and personal hygiene, required extensive assistance with transfers and locomotion, and required supervision with eating. Review of a care plan dated 11/09/2022 revealed Resident #16 was a high risk for falls related to a recent history of a fall with fracture prior to admission. Interventions included to keep the call light in reach and encourage use of the call light for assistance, provide a safe environment (the bed in low position, personal items within reach, call light within reach, and clutter-free), review information on past falls and attempt to determine the cause, record possible root causes of falls, and educate the resident, family, and caregivers of the causes of falls. Review of a facility investigation dated 11/28/2022 revealed Resident #16 was found sitting on the floor beside her bed with her back resting on the bed. There was no apparent injury. The investigation had no witness statements. An intervention was created for the fall as a sign would be placed on bathroom door to remind Resident #16 to call for assistance. There was no root cause analysis included in the facility's investigation which identified the cause of the fall. Review of a facility investigation dated 12/03/2023 revealed the nurse at the nurse's station heard Resident #16 scream, and when the nurse went to Resident #16's room, the nurse found Resident #16 on the floor in front of chair with her right leg bent up to her body. Resident #16 was immediately sent to hospital due to abnormal right lower extremity. There was no root cause investigation included in the facility's investigation which identified the cause of the fall. Interview on 03/07/23 at 3:31 P.M. the Director of Nursing (DON) stated they discussed root cause analysis in an interdisciplinary team (IDT) meeting after falls occurred, but there was no documentation of a root cause analysis. The DON stated the team discussed falls in IDT meetings to make sure interventions in place at the time the of the fall were appropriate. 34291 2. Review of Resident #23's medical record revealed an admitted [DATE]. Medical diagnoses included pneumonia, heart failure, septicemia, Alzheimer's disease, and diabetes. Review of fall assessments dated 11/13/22, 12/30/22, 01/20/23 and 03/05/23 revealed Resident #23 was a moderate fall risk. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23's functional status was assessed to require an extensive two person assistance for bed mobility, transfers and toilet use, and required supervision for eating with setup help only. Review of a progress note for Resident #23 dated 12/30/22 revealed the nurse heard a crash coming from the resident's room. Resident #23 was discovered sitting on his bottom and rolled onto his side and the bedside table was broken in half. Resident #23 was toileted by physical therapy (PT) prior and had a bowel movement in his brief. There was no injury noted and a new intervention was to place a sign in Resident #23's room to be sure to use the call light for assistance. Review of an investigation for the fall on 12/30/22 at 3:07 P.M. revealed Resident #23 was observed on the floor on his bottom then laid down and rolled to his side. Resident #23 fell on to the bedside table and broke it. Resident #23 was trying to use the bathroom and had his slipper socks on. Resident #23 had a bruise to his upper rear iliac crest. Resident #23 was oriented to person, but was confused, and had issues with his gait balance, impaired memory, and was ambulating without assistance. There were no witnesses found. Resident #23 was toileted by PT, but had bowel movement in his brief. There was no evidence a root cause analysis was completed for this fall. Interview with the DON on 03/08/23 at 8:42 A.M. stated Resident #23 used the call light in the past but agreed he had safety awareness issues. The DON confirmed she had not done a root cause analysis for this fall. During a telephone interview on 03/09/2023 at 11:15 A.M. Registered Nurse (RN) #338 stated it was his opinion that implementing a verbal reminder to use the call light after a fall was a nonsense intervention for a resident with dementia, and it was inappropriate. Observation and interview with Resident #23 on 03/09/23 at 12:43 P.M. revealed when asked if he could read the yellow sign on the wall to the right side of his bed and the orange sign on the wall in front of his bed which read, Use call light for help, Resident #23 was able to look at the sign but could not verbalize what the sign read. Review of a progress note dated 03/04/23 at 5:09 A.M. for Resident #23 revealed the resident was observed on the floor. Resident #23 wanted to get out of his bed and sit in his chair. The resident was conscious, vital signs were normal, neurological checks were normal, and there were no injuries. The immediate intervention was to place Resident #23 in his chair. Review of the investigation dated 3/4/23 revealed Resident #23 was observed sitting on the floor and he was calling for help. Resident #23 was calm, conscious, and would like to sit in his chair. Resident #23's neurological assessments were completed with no concerns, and his call light was put into reach, and informed to press his call light when he needed help. There were no injuries observed. Resident #23 was confused and there were no witnesses found. The IDT collaborated and decided they would place a fall mat to the left side of Resident #23's bed. Further interventions were to encourage use of Resident #23's walker and there were signs in the room to to remind the resident to use the call light for assistance. There was not any evidence there was a root cause analysis completed for this fall. Interview with the DON on 03/0823 at 8:53 A.M. revealed she did not do a root cause analysis and felt like a fall mat was appropriate to put as a new intervention. The DON stated the IDT review falls when they happen, but confirmed there was room for improvement and would be working on a new system. 3. Review of Resident #200's medical record revealed an admitted [DATE]. Medical diagnoses included progressive neurological conditions, Parkinson's disease, coronary artery disease, anxiety, and depression. Review of the MDS assessment dated [DATE] revealed Resident #200 was assessed as cognitively intact. Resident #200 was assessed to require an extensive assistance of two-person assistance for bed mobility, transfers and toilet use. Resident #200 required supervision for eating with set-up help only. Review of a fall assessment dated [DATE] revealed Resident #200 was a high fall risk. Review of subsequent fall risk assessments on 02/05/23, 02/07/23, 02/12/23, and 02/16/23 revealed Resident #200 was assessed at moderate risk. Review of a progress note dated 02/12/23 revealed a nurse heard yelling and immediately ran to see what happened. The nurse observed Resident #200 on the floor on the right side of the bed. All interventions were in place and vital signs were taken with no concerns. Resident #200 was assisted back to bed and was confused and indicating she was in pain; however, the notes indicated the staff were unable to assess the pain. Review of a fall investigation dated 02/12/23 revealed Resident #200 was observed on the floor on the right side of the bed with all interventions in place. There were no witnesses to the fall and Resident #200 was oriented to person only and was confused. A fall mat was implemented as a new intervention, and the care plan was updated to reflect the new intervention. Interview with the DON on 03/08/23 at 9:02 A.M. confirmed there was not a root cause analysis for this fall for Resident #200. Review of a policy titled, Fall Reduction Policy, dated 04/29/16, revealed it is the policy of the facility to identify residents at risk for falls and to implement a fall reduction program to reduce the risk of falls and possible injury. Follow-up investigations will be done to ascertain the cause of the incident to reduce the risk of further occurrences.

Based on observation, medical record review, staff and Power of Attorney (POA) interview, the facility failed to ensure a skin condition was assessed and a treatment was put into place. This affected one (#23) of three residents reviewed for skin conditions. The census was 47. Findings included: Medical record review for Resident #23 revealed an admitted [DATE]. Medical diagnoses included pneumonia, heart failure, septicemia, Alzheimer's disease, and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23 required extensive assistance with two person assistance for bed mobility, transfers and toilet use. Resident #23 required supervision for eating with setup help only and was assessed frequently incontinent for bowel and bladder. Interview with Resident #23's POA on 03/06/23 at 10:52 A.M. stated Resident #23 had a black spot on his toe, but was not able to identify which toe. Observation on 03/07/23 at 10:51 A.M. revealed Resident #23 had a black circle the size of a dime on the bottom of his right great toe. Review of skin assessments dated 02/23/23 at 1:13 P.M. revealed State tested Nurse Aide (STNA) #128 identified the area on Resident #23's skin. Review of physician orders from 02/23/23 to 03/01/23 revealed there were no orders for treatment of the wound on Resident #23's right great toe. Review of Resident #23's progress notes dated 02/23/23 revealed there were no progress notes reporting the skin condition on the right great toe. Interview with Licensed Practical Nurse (LPN) #331 on 03/07/23 at 11:02 A.M. confirmed she did not know anything about the black spot on Resident #23's toe and there was not any kind of a treatment in place for it. Interview with STNA #128 on 03/07/23 at 11:45 A.M. confirmed she saw the black spot on Resident #23's right great toe, reported it to the nurse on duty, and said the nurse came and looked at it, and identified it as blood blister. STNA #128 stated she documented the condition on Resident #23's shower sheet dated 02/23/23. Interview on 03/09/23 at 8:52 A.M. with Wound Nurse Practitioner (WNP) #240 stated she was not informed of the black spot on Resident #23's right great toe. WNP #240 stated she was in the facility on 02/23/23 and on 03/02/23 and would have expected the facility to have told her about it on one of these visits.

Based on observation, staff and resident representative interview, and medical record review, the facility failed to timely notify a physician or nurse practioner when a change in a resident's condition was identified. This affected one (#23) of three residents reviewed for skin conditions and one (#23) of two residents reviewed for bowel function. The facility census was 47. Findings included: 1. Medical record review for Resident #23 revealed an admitted [DATE]. Medical diagnoses included pneumonia, heart failure, septicemia, Alzheimer's disease, and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23 required extensive assistance with two person assistance for bed mobility, transfers and toilet use. Resident #23 required supervision for eating with setup help only and was assessed frequently incontinent for bowel and bladder. Interview with Resident #23's Power of Attorney (POA) on 03/06/23 at 10:52 A.M. stated Resident #23 had a black spot on his toe, but was not able to identify which toe. Observation on 03/07/23 at 10:51 A.M. revealed Resident #23 had a black circle the size of a dime on the bottom of his right great toe. Review of skin assessments dated 02/23/23 at 1:13 P.M. revealed State tested Nurse Aide (STNA) #128 identified the area on Resident #23's skin. Review of physician orders from 02/23/23 to 03/01/23 revealed there were no orders for treatment of the wound on Resident #23's right great toe. Review of Resident #23's progress notes dated 02/23/23 revealed there were no progress notes reporting the skin condition on the right great toe. Interview with Licensed Practical Nurse (LPN) #331 on 03/07/23 at 11:02 A.M. confirmed she did not know anything about the black spot on Resident #23's toe and there was not any kind of a treatment in place for it. Interview with STNA #128 on 03/07/23 at 11:45 A.M. confirmed she saw the black spot on Resident #23's right great toe, reported it to the nurse on duty, and said the nurse came and looked at it, and identified it as blood blister. STNA #128 stated she documented the condition on Resident #23's shower sheet dated 02/23/23. Interview on 03/09/23 at 8:52 A.M. with Wound Nurse Practitioner (WNP) #240 stated she was not informed of the black spot on Resident #23's right great toe. WNP #240 stated she was in the facility on 02/23/23 and on 03/02/23 and would have expected the facility to have told her about it on one of these visits. 2. Interview with Resident #23's POA on 03/06/23 at 11:02 A.M. stated Resident #23 had been having explosive diarrhea. Review of Resident #23's bowel tracker from 02/07/23 through 03/07/23 revealed there were 30 episodes of loose bowel movements in medium to large in size during that time frame. Review of progress notes from 02/07/23 through 03/07/23 revealed the physician was not notified and there were no orders to treat Resident #23's diarrhea. Interview with Licensed Practical Nurse (LPN) #331 on 03/07/23 at 9:42 A.M. stated she was not aware of Resident #23's diarrhea, but could be due to Resident #23's colon polyps. LPN #331 stated could call the physician. Observation of incontinence care for Resident #23 on 03/07/23 at 10:53 A.M. with State tested Nurse Aide (STNA) #207 and STNA #128 revealed Resident #23's incontinence brief was saturated with liquid stool. Interview with the Nurse Practitioner (NP) #235 on 03/08/23 at 10:20 A.M. stated her protocol would be for the facility to let her know about the diarrhea, how long it had been going on, and how much. NP #235 stated she would make a determination from that information on what orders would be put into place. NP #235 stated, depending on that finding, she would order a kidney, ureter and bladder (KUB) x-radiation (x-ray) and an anti-diarrhea medication. NP #235 stated she came into the facility on [DATE] and LPN #331 reported to her there was some concerns for bowel movements for Resident #23, but the nurse reported he did not have any diarrhea, but had some history for polyps. NP #235 stated she had not been informed of Resident #23's diarrhea for the past 30 days.

Based on medical record review, staff interview, and facility policy review, the facility failed to obtain resident weights as ordered and failed to provide alternates when meal intakes were below desired levels. This affected one (#300) of four residents reviewed for nutrition. The census was 47. Findings include: Review of Resident #300's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II, atherosclerotic heart disease, hypertension, cervicalgia, muscle weakness, colostomy status, fusion of the spine, dysphagia, hyperlipidemia, ischemic cardiomyopathy, and bradycardia. Review of his Minimum Data Set (MDS) assessment, dated 01/06/23, revealed Resident #300 was cognitively intact. Review of Resident #300's orders revealed he was to have weekly weights taken, for the first four weeks, which was dated from 09/28/22 to 10/24/22. Further review of the orders revealed, beginning on 10/19/22, the order was continued for weekly weights. The was to continue until 01/19/23. Review of Resident #300's weights, dated 09/28/22 to 02/01/23, revealed Resident #300 weighed 164.4 pounds on 10/04/22, weighed 154.8 pounds on 10/08/22, weighed 163.4 pounds on on 11/17/22, weighed 164.8 pounds on 11/22/22, weighed 159.0 pounds on 12/01/22, weighed 159.4 pounds on 12/04/22, weighed 159.4 pounds 12/14/22, weighed 149.9 pounds on 01/11/23, weighed 146.8 pounds on 01/18/23, weighed 150.8 pounds on 01/31/23, and weighed 150.8 pounds on 02/01/23. The facility did not take an initial weight for Resident #300 until six days after admission. There was a significant weight decrease from 10/04/22 to 10/08/22, and no re-weight was taken to verify the weight loss. Also, there was a significant weight increase from 10/08/22 to 11/17/22, and a re-weight was not taken until five days later. There was a significant weight decrease from 12/14/22 to 01/11/23, and there was no re-weight taken until seven days later. Finally, there were multiple entries missing to meet the order of taking weekly resident weights from 09/28/22 to 01/19/23. Review of Resident #300 nutritional care plan revealed the facility is to obtain weights per order. Also, the facility staff will offer a substitute if the resident eats less than 75% of his meals. Review of Resident #300 meal intake documentation and meal substitutes offered documentation, dated 11/10/22 to 02/01/23, revealed Resident #300 ate less than 75% of meals and was not offered a substitute 59 different times. Interview with Dietary Technician (DT) #400 on 03/08/23 at 2:20 P.M. confirmed the facility had a challenge with getting weights in a timely manner and as ordered, but have been working better at obtaining resident weights. DT #400 confirmed Resident #300's weights were no taken as ordered, and confirmed if Resident #300 ate less than 75% of meals, the electronic medical record would automatically generate another question as to whether a substitute was offered. DT #400 stated the facility staff would have to answer and document if a substitute was offered each time it was required. Interviews on 03/09/23 at 9:01 A.M. with Licensed Practical Nurse (LPN) #216, at 9:14 A.M. with LPN #337, and at 9:32 A.M. with Director of Nursing (DON) confirmed staff should be entering substitutes and the amount of the substitute the resident ate in the electronic medical records. All three staff members also confirmed they are to follow physician and nutritional orders for taking resident weights. DON confirmed the facility had an issue with getting weights obtained timely a couple months ago, but they have worked to do better. Review of a facility weight policy, dated March 2017, revealed weight is an indicator and method of monitoring resident nutritional status. Resident weight will be monitored on a monthly basis, or more frequently when indicated. This data will be used to identify those residents with significant weight variance and as an indicator of nutritional risk. All weight orders are to be written as follows: weights weekly for four weeks and then monthly and as needed unless otherwise ordered or specified. An in-house weight will be obtained within 24 hours of admission and recorded in the resident health record. Residents will be reweighed in 24 hours if their weight change meets the following criteria: resident weight less than 150 pounds with a three pound (or more) weight change or resident weight more than 150 pounds with a five pound (or more) weight change. This deficiency represents non-compliance investigated under Master Complaint Number OH00137211 and Complaint Number OH00136526.

Based on record review, staff and resident interview and policy review, the facility failed to ensure quarterly care conferences were completed. This affected one (#40) of three residents reviewed for care conferences. The census was 54. Findings Include: Review of the medical record for Resident #40 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Interdisciplinary Meeting dated 08/20/19 revealed a care conference was held on 08/20/19 and the resident attended the care conference. Review of the medical record for Resident #40 revealed no care conference was held since 08/20/19. Further review of the medical record revealed the facility completed a Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #40 is cognitively intact. Interview with Resident #40 on 12/26/19 at 10:01 [NAME]M. revealed he could not remember the last time he had a care conference. Interview with Social Services Designee #96 on 12/27/19 at 12:39 P.M. revealed care conferences are held every quarter. The interview verified quarterly care conference was completed since 08/20/19 and a care conference should have been held in (MONTH) 2019. Review of the facility policy titled Resident Education, last revised 11/2009, revealed the resident is involved in care and care decisions through the interdisciplinary care planning process.

Based on medical record review, observations and staff interview, the facility failed to staff implemented Resident #8's skin treatments for a pressure ulcer and pressure ulcer preventative as physician ordered. This affected one (#8) of two residents reviewed for pressure ulcers. The facility census was 54. Findings include: Record review of Resident #8 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the modified quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance for transfer, locomotion on and off unit, toilet use and bathing. Resident #8 required extensive assistance of two people for bed mobility, dressing and personal hygiene. The Resident had an indwelling urinary catheter and was always incontinent of bowel. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of nursing wound documentation dated 12/26/19 revealed on 12/23/19 the left heel measurements were 5.5 centimeters (cm) in length by 6.0 cm in width with no depth. The left heel wound was considered a deep tissue injury pressure ulcer with eschar and no drainage. There was no pressure ulcer documentation on the right heel. Observation of Registered Nurse (RN) #83 completing Resident #8 dressing change on 12/27/19 at 1:36 P.M. revealed she applied skin prep to the left heel pressure ulcer and [MEDICATION NAME] to the right foot which did not have a pressure ulcer. Interview with RN #83 on 12/27/19 at 1:40 P.M. verified she applied skin prep to the left heel pressure ulcer and [MEDICATION NAME] to the right foot which did not have a pressure ulcer. RN #83 verified after checking the physician orders [REDACTED].

Based on medical record review and staff interview, the facility failed to obtain laboratory (lab) values as physician ordered. This affected one (#3) out of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record for Resident #3 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of physician telephone order dated 10/28/19 revealed an order to start [MEDICATION NAME] for dementia with behavioral disturbance and in ten days obtain a Complete Blood Count (CBC) and a [MEDICATION NAME] Acid level. Review of labs in medical record revealed last CBC done was on 07/09/19 and a [MEDICATION NAME] acid level only was obtained on 11/07/19. Interview was conducted on 12/28/19 at 2:16 P.M. with the Director of Nursing (DON) and she verified that the CBC level was not drawn as ordered.

Based on closed medical record review, staff interview and review of policy the facility failed to ensure residents were free of significant medication errors. This affected one (#83) of three residents reviewed for hospitalization . This resulted in actual harm to Resident #83 when she did not receive her prescribed long acting insulin for two nights. The resident had increased lethargy, slurred words, and instability with ambulation. The resident had a high blood sugar reading and was sent to the hospital. The facility identified only one resident as an uncontrolled diabetic. The facility census was 66. Findings include: Review of the closed medical record for Resident #83 revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE] revealed the resident was cognitively intact. She required supervision for all activities of daily living except personal hygiene, dressing, locomotion on and off the unit and walking out of the room was a limited assistance. The resident was discharged on [DATE]. Review of the hospital discharge record final report dated on 03/16/16 at 12:59 P.M. revealed recommendation to continue Detemir (a long acting insulin) 6 units subcutaneously at bedtime. Further review of the hospital discharge records revealed Detemir 6 units was last given on 03/15/16 at 8:49 P.M. Further review revealed insulin [MEDICATION NAME] (a fast acting insulin) three times a day before meals per conservative scale. A clarification was obtained for the conservative scale: 151-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units and if greater than 401 give 12 units and call the doctor. Review of the progress notes dated 03/16/16 at 8:00 P.M. revealed Resident #83 was admitted from a local hospital. Registered Nurse (RN) #75 documented clarification of insulin orders with a staff member from the hospital. The note was silent to a finger blood sugar testing. Review of the March 2016 Medication Administration Record [REDACTED]. The first finger blood sugar was recorded on the morning of 03/17/16 as HIGH. Review of the progress notes dated 03/17/16 at 2:30 P.M. written by RN # 86 revealed the resident's morning blood sugar (no time given) was HIGH and the resident was noted to have increased lethargy and instability with ambulation. The resident stated she didn't feel well. [MEDICATION NAME] 12 units was given per the sliding scale orders. A recheck of the blood sugar was completed at 11:30 A.M. and the reading was HIGH. Another 12 units of [MEDICATION NAME] was given per the sliding scale. Nurse Practitioner (NP) #300 was called after the 12 units of insulin was given and an order was received for [MEDICATION NAME] 20 units in addition to what was previously given. Resident #83's blood sugar was rechecked at 1:30 P.M. and was still reading as HIGH. At 2:30 P.M. her blood sugar was rechecked and the reading was 531. Further review of the March MAR indicated [REDACTED]. Review of the progress notes dated 03/18/16 at 3:00 P.M. written by RN #86 revealed the morning blood sugar reading was HIGH and the resident had increased lethargy, slurred words and no appetite. Sliding scale insulin of 12 units was given. The blood sugar was checked again at 11:30 A.M. and the reading remained HIGH. NP #300 was notified and an order was received for 20 units of [MEDICATION NAME]. The blood sugar was rechecked at 2:00 P.M. and the reading remained HIGH. Review of the progress note written on 03/18/16 at 7:30 P.M. revealed the physician was notified of the resident having a HIGH reading at supper time and that the reading had been HIGH all day. A new order was received for [MEDICATION NAME] 20 units now. Review of the progress note written on 03/18/16 at 9:30 P.M. revealed the physician was notified because the resident was very pale and loopy. The blood sugar continued to read HIGH. At 10:00 P.M. an order was received to send Resident #83 to the emergency room for evaluation and treatment. The resident returned on 03/19/16 at 3:35 A.M. During an interview on 06/02/16 at 12:50 P.M., NP #300 revealed she could not remember if she received a call on the evening of 03/17/16 concerning holding the Detemir 6 units. She further revealed it could be a nursing judgement for holding the insulin, but revealed there was no protocol for this or parameters. Interview on 06/02/16 at 1:42 P.M. with RN #86 revealed she worked days (7:00 A.M. - 7:00 P.M.) and received report from RN #75 on the morning of 03/18/16 that the Detemir was held for a blood sugar reading of 104. She revealed she notified the physician every time Resident #83's blood sugar reading was HIGH, but stated she might not have documented the notification. She could not verify what time she called the physician or what the physicians response was. A subsequent interview on 06/02/16 at 2:00 P.M. revealed there wasn't any specific parameters to hold long acting insulin. She stated holding a long acting insulin would be nursing judgement, but the physician should be notified if a medication is held. She indicated a HIGH reading on the glucose machine for a finger blood sugar meant the reading was over 600. Interview on 06/02/16 at 2:55 P.M. with RN #75 revealed she did not give the prescribed 6 units of Detemir 6 on 03/16/16 to Resident #83 because she was busy passing medications. She further stated by the time she clarified the insulin orders from the hospital, Resident #83 was already asleep. She stated she knew the resident from previous admissions and the resident had episodes of [MEDICAL CONDITION]. She stated she held the prescribed 6 units of Detemir on the evening of 03/17/16 based on past experiences with Resident #83 of having low blood sugars. She stated she didn't know the parameters for holding long acting insulin. She stated she didn't notify the physician of holding the insulin because she wanted to see if what the hospital recommended would work. She stated she believed she did check the resident's blood sugar on admission on 03/16/16 but may not have documented it. Review of the policy entitled Blood Glucose Monitoring and dated 08/2010 indicated if a result Hi or Lo is obtained, observe the resident for physical signs and symptoms and repeat test to be sure of accuracy. Notify physician according to resident specific ranges if ordered or presents with signs and symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION].