Every finding on record at Stratford Commons Rehab & Health Care Center

The facility identified a census of 53 residents, with three residents sampled for elopement risk. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent newly admitted Resident (R) 1, who had documented intermittent confusion and exit-seeking/wandering behaviors, from leaving the facility on 10/18/25 between 05:20 AM and 05:30 AM, without staff knowledge. R1 remained outside of the facility (whereabouts unknown) for approximately five and a half hours, wearing only a hospital gown and no shoes, in approximately 65 degrees Fahrenheit temperature. Law enforcement located R1 at 10:50 AM, approximately one mile from the facility, wearing a hospital gown and no shoes. The facility discovered the South egress door was not locked and did not alarm when pushed. This deficient practice placed R1 in immediate jeopardy.Findings included:- R1 admitted to the facility on [DATE].R1's Electronic Medical Record (EMR) documented a diagnosis of hepatic encephalopathy (a serious brain dysfunction caused by liver failure, leading to the accumulation of toxins in the bloodstream, particularly ammonia and psychiatric changes of varying degree).R1's 10/16/25 Care Plan documented R1 had an activity of daily living (ADL) self-care performance deficit and required one staff assistance with transfers.R1's EMR revealed the following:A 10/16/25 admission Assessment documented he was alert and oriented to person and place with intermittent confusion.A 10/16/25 Elopement Assessment documented R1 was not at risk for elopement.An Orders- Administration Note dated 10/18/25 at 04:12 AM documented R1 eloped most of the shift and went into other residents' rooms. The note documented R1 peed on the floor, staff could not re-orient him, R1 walked unsteadily, and became combative with staff.A Situation, Background, Assessment, Recommendation (SBAR) Note dated 10/18/25 at 06:48 AM documented R1 experienced a change in condition of eloping. The note documented Licensed Nurse (LN) G last saw R1 between 05:15 AM and 05:30 AM when a Certified Nurse Aide (CNA) redirected R1. CNA N reported to LN G she could not find R1 and the facility immediately conducted a head count. LN G documented he and the CNAs checked around the facility and parkway. LN G notified Administrative Nurse E of the incident. The oncoming staff, Certified Medication Aide (CMA) R, searched in the neighborhood. The police arrived around 06:10 AM and asked the facility to continue to search inside while they searched the neighborhood.In a Health Status Note dated 10/19/25 at 12:36 AM, LN G documented he received shift report that R1 had been wandering and exit seeking. LN G documented earlier in the shift staff found R1 in a nearby room, where R1 unclothed himself. LN G and staff took R1 to the bathroom and redirected R1 to his room. LN G documented R1 could not stay in one place and whenever staff put socks or briefs on R1, R1 took them off. Staff found R1 in different resident rooms and the staff tried various activities to help R1 including walking R1 in the hallway, keeping R1 where the CNA sat, rehydrating R1, and reading bulletins in the activity room; but none were effective. LN G documented he tried to notify the clinical on-call, without answer. When the routine activity ended around 11:00 PM, LN G administered medication to R1 which helped him sleep for an hour. LN G witnessed R1 exit seeking on two occasions, and LN G redirected R1 and walked with him down the hall. The note revealed R1 was not communicative and became combative on one occasion, as reported by CNA N. LN G documented he notified Administrative Nurse E of the incident and he called the police while LN H called R1's representative around 05:47 AM.The facility's 10/23/25 Investigation documented on 10/18/25 at around 05:20 AM, CNA M last observed R1 in the northwest corner of the facility, sitting in the family area by the breakroom. R1 wore a (hospital) gown, no socks, and no shoes. LN G reported R1 had been wandering the facility throughout the night and staff attempted re-direction with hands-on activities and taking R1 back to his room, without success. The investigation documented the temperature was 67 degrees Fahrenheit and R1 wore a gown at the time of his departure. The investigation documented the following timeline on 10/18/25:Between 05:20 AM to 05:30 AM, CNA N noticed R1 was not sitting in the same area and immediately started a search.At 05:30 AM, LN G, LN H, CNA M, CNA N, and CNA O conducted an interior search of the facility. CNA N checked all of the rooms, bathrooms, doors, courtyard, and therapy rooms.At 05:40 AM, LN G, LN H, and CNA N conducted an exterior search of the facility. CNA N checked the parking lot of the apartments south of the facility.At 05:45 AM, CNA O drove around the neighborhood including the apartment complex south of the facility for about 20 to 25 minutes.At 05:47 AM, LN G notified law enforcement.At 05:50 AM, CNA M searched the perimeter of the community.At 05:56 AM, LN G notified Administrative Staff A and Administrative Nurse D.At 06:00 AM, CNA N did another exterior check of the facility. CMA R checked all bedrooms, bathrooms, under the beds, in closets, and doors. She walked through the laundry room to assisted living (AL) and also checked the AL unit.At 06:01 AM, LN H notified R1's representative.At 06:11 AM, Administrative Staff A spoke to R1's representative.At 06:30 AM, Administrative Staff A drove around the neighboring housing development to the southwest of the facility and around the nearby gas station. She drove around for 10 to 15 minutes.At 07:00 AM, Administrative Nurse D drove up and down the street in front of the facility for about 20 minutes.Around 08:00 AM, dispatched notified the facility they contacted all hospitals.At 08:30 AM, Administrative Nurse E notified Consultant GG.At 09:00 AM, Administrative Staff A notified R1's other listed representatives.At 09:45 AM, law enforcement notified the facility they had a drone searching for R1 and were dispatching four-wheelers in the search.At 10:50 AM, law enforcement notified Administrative Staff A they located R1 and transported him to the emergency room (ER) for evaluation. The facility notified Consultant GG that law enforcement found R1 and transported him to the ER for evaluation.At 11:11 AM, Administrative Staff A notified R1's representative that law enforcement located R1 and transported him to the ER for evaluation.At 11:14 AM, the facility spoke to the ER for an update on R1.At 04:43 PM, the ER notified the facility they transferred R1 to another hospital for an admission related to gastrointestinal concerns.At 04:54 PM, the facility notified Consultant GG that R1 transferred to another hospital for admission.According to the Kansas State University Historical Weather website, the temperature on 10/18/25 between 05:00 AM and 11:00 AM ranged between 63.9 degrees Fahrenheit and 75.3 degrees Fahrenheit.Review of Google Maps revealed the distance from the facility to the intersection law enforcement found R1, was between 0.8 mile to 1.1 miles.CNA M's untitled notarized statement, dated 10/18/25, stated she saw R1 walk up the hall at 05:15 AM and she walked him over to take a seat, since R1 would not stay in his room. CNA M stated he sat down and by 05:30 AM, R1 was missing. She stated they walked through every room and bathroom to search for R1 by 05:46 AM. She stated they searched outside and could not find R1. CNA M stated by 05:50 AM, the facility called the police and R1's representative, while staff continued searching for R1.CNA O's untitled notarized statement, dated 10/18/25, stated when he found out R1 was gone, CNA O stopped doing his rounds and looked for R1. He stated staff went room to room, looked in every bathroom, and all around the building with no signs of R1.CNA N's notarized Witness Statement, dated 10/18/25, stated she re-entered the facility from taking out the trash around 05:30 AM. She stated she opened up R1's door to his room and did not see R1. CNA N stated she checked all of her rooms and did not find R1. She stated she let the nurse and other staff know, then they conducted a full search inside and outside the building but did not find R1. CNA N stated around 05:45 AM to 05:50 AM, the facility notified R1's representative and police, while staff continued searching for R1.LN H's notarized Witness Statement, dated 10/18/25, stated she remembered seeing R1 in a gown walking in the hallways. She stated around 05:15 AM, she saw LN G searching for R1 in the building. LN H stated the facility searched in all resident rooms and bathrooms at least five times. She stated the staff checked the courtyard outside, inside the kitchen areas, inside the extra kitchen rooms, resident rooms again, employee bathrooms, the printer room, and the entrance to the memory care unit. LN H stated night and day shift staff drove in their cars around the facility property and to the apartment complexes to look for R1. She stated LN G asked her to call R1's representative while he called Administrative Nurse E. LN H stated she notified R1's representative of the situation, and he understood.LN G's notarized Witness Statement, dated 10/18/25, stated he last saw R1 around 05:15 AM and 05:20 AM by the back breakroom. He stated after a couple of minutes, one of the CNAs redirected R1 to his seat. LN G stated within five minutes, while he came from another resident's room, the CNA notified him she could not find R1. LN G documented staff immediately checked for R1 in all the residents' rooms since they had found R1 in other resident rooms before. LN G stated staff checked outside for R1, switched halls, then rechecked rooms but they could not find R1. LN G documented he notified Administrative Nurse E and called the police around 05:47 AM. LN G stated that other CNAs drove in the neighborhood to look for R1. He stated the police and administration arrived at the facility in about 20 to 30 minutes.During an observation on 10/23/25 at 12:50 PM, the South egress door had a solid red light on the handle. Administrative Staff A stood beside the South egress door, while the door was pressed, and the door immediately sounded with short beeps. After approximately 15 seconds, the door alarm changed to a sustained tone and the door opened when pushed. Administrative Staff A put a key into the door and unlocked it, and the light changed to green; and when she locked the door, it returned to a solid red light.During an observational drive on 10/23/25 at 01:22 PM, revealed two possible paths R1 traversed when he left the facility. In the first possible route, R1 could have walked on the sidewalk beside the busy street in front of the facility, which had a posted speed limit of 45 miles per hour (mph) and two lanes of traffic for each direction. The other possible route R1 could have walked had a couple of streets with posted speed limits of 25 mph to 30 mph. Observation of the street in which law enforcement found R1 revealed a posted speed limit of 25 mph and had multiple areas of missing sidewalk and construction equipment/supplies noted in the street.On 10/23/25 at 03:28 PM, R1's representative stated R1 remained in the hospital and had no injuries from the elopement. R1's representative stated he had difficulty judging R1's cognition, because one moment R1 made sense and the next moment he said something out of left field.On 10/23/25 at 03:15 PM, CNA P stated she found elopement risk residents in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), and if a resident had dementia (a progressive mental disorder characterized by failing memory and confusion), she kept an extra eye on them. CNA P stated she asked the nurse about elopement risks for newly admitted residents. CNA P stated if a resident started exit seeking or wandering, she tried to remove them from the exit and reassured them of their safety in the facility. She stated she notified the nurse of exit-seeking or wandering behaviors; and at nighttime, she let any staff know to have an extra set of eyes on the resident. CNA P stated she worked with R1 one day during his admission, and she could tell he had some wandering behaviors. She stated she encouraged him to sit in an open area for staff to keep tabs on him, and at the nurses' station to distract him with a snack. CNA P stated R1 never went to any of the doors or tried to open any doors, but he walked around the dining room, then back and forth to the nurses' station. She stated she let R1 walk around, since he maintained his independence, but she kept an eye on him. CNA P stated if R1 had gone to a door, she would have attempted to redirect him away from the exit and reassured him he was safe and warm in the facility. She stated staff distracted R1 with a football game, a snack, a drink, or a word puzzle. She stated if she heard a door alarm go off, she would radio and ask what happened, then check the doors. CNA P stated if she could not find a resident, she immediately searched the whole hallway and accounted for all her residents, while looking for the missing resident. She stated she notified the nurse, called a code yellow (which stood for missing resident) and initiated a head count of all residents. She stated that if staff did not find the missing resident, then the facility notified the police.On 10/23/25 at 03:32 PM, LN I stated the elopement book contained residents at risk for elopement and the residents' charts listed elopement risks. LN I stated management notified staff of elopement risks for new admission residents, or he received report from the hospital prior to their admission. LN I stated if a resident started wandering around without being in the elopement book, the facility put the resident in the elopement book. LN I stated he saw R1 one time last week, and R1 engaged in activities without any exit-seeking behaviors at that time. LN I stated if he could not find a resident, he would notify all staff to drop what they were doing and search for the resident. He stated if staff could not find the missing resident, the charge nurse delegated a staff member to check around the building. He stated if they did not find the resident, the facility would notify the police, the resident's family, and administration. LN I stated if he heard a door alarm go off, staff checked the surrounding areas and hopefully found whoever went out the door. He stated the nurses used to have a key to turn off the alarm and immediately re-engage the alarm. LN I stated the process to unlock the door to reset the alarm, now included calling Administrative Staff A to get the code to get the key out of the lock box in the medication room. He stated if a resident started having exit seeking or wandering behaviors, he would notify management and update the chart. LN I stated facility staff provided redirection with activities, a snack or drink, or had the resident work on something next to the nurse. He stated staff increased supervision of the residents who wandered and had CNAs look in their rooms every time they walked by.On 10/27/25 at 11:42 AM, CNA M was not available for an interview.On 10/27/25 at 12:37 PM, LN G was not available for an interview.On 10/23/25 at 04:30 PM, Maintenance Staff U stated he checked the doors every week and had checked the South egress door on 10/17/25. He stated the South egress door remained active, and staff typically did not use that door.On 10/23/25 at 03:51 PM, Administrative Nurse D stated staff knew the elopement risk residents by the elopement risk binder and the Kardex. Administrative Nurse D stated if a resident had wandering or exit-seeking behaviors, the administration talked about the residents in the morning meetings and put interventions into their care plans. She stated staff offered R1 activities, puzzle find books, cards, television, music, taking him back to his room, a quiet and calm environment, and talking with R1. Administrative Nurse D stated if staff could not find a resident, she expected staff to notify the charge nurse, and the charge nurse immediately started a facility head count, then searched inside the facility. She stated if the staff could not find the resident, they checked every door, bathroom, cubby or crevice, courtyard, and outside the facility. Administrative Nurse D stated staff kept a timeline of events and notified Administrative Staff A and Administrative Nurse D, and if they did not find the resident, staff notified police. Administrative Nurse D stated she believed the facility staff handled R1's situation and notified her when he eloped.On 10/23/25 at 12:52 PM, Administrative Staff A stated on 10/18/25 around 06:00 AM, she received a call that staff could not find R1, and they continued their search for him. She stated she and Administrative Nurse E arrived at the facility and immediately searched inside and outside of the building. Administrative Staff A stated she looked at the doors to see which door he would have exited from and found the South egress door unlocked. She stated she removed all of the keys from the nurse's station and locked a key in a lock box in the medication room that required a code to open it. Administrative Staff A stated only three people had the code, and the nurse had to call one of them to get the code. Then the code changed each time staff accessed the box. She stated on 10/18/25, the facility continued to search for R1 and maintained constant communication with the police. Administrative Staff A stated multiple staff members drove around and kept searching for R1. She stated she received report R1 had wandered in the facility during the two days he was admitted to the facility. She stated R1 was alert and oriented with mild confusion.The facility's Elopement policy, approved September 2025, directed the facility to provide residents at risk for elopement with at least one of the following: door alarms on facility exits, a personal safety device to alert staff when the resident left the building, or staff supervision. The policy directed at no time shall a personal safety alarm or door alarm be turned off without the continual supervision of the exit.On 10/23/25 at 04:30 PM, Administrative Staff A was presented with the Immediate Jeopardy (IJ) Template and notified the facility failure to provide adequate supervision to prevent the elopement of newly admitted R1 on 10/18/25, constituted immediate jeopardy at F689. The immediate jeopardy at F689 also constituted Substandard Quality of Care at 42 CFR 483.25.The facility identified, implemented, and completed the following corrective measures:1. Administrative Staff A audited all egress doors and found the South egress door unsecured on 10/18/25.2. The facility conducted an Ad Hoc- Quality Assurance and Performance Improvement (QAPI) meeting on 10/18/25.3. The facility audited all residents for elopement evaluations on 10/18/25.4. The facility educated staff on elopements, abuse, neglect, and exploitation (ANE), and egress doors on 10/18/25.5. Maintenance evaluated and assessed all facility egress doors on 10/18/25.6. Administrative Staff A removed all alarm door keys and placed them in a lock box in the medication room that required a code from designated staff to open it on 10/18/25.7. The facility started door audits on 10/18/25 and continued them two to three times daily.8. The facility conducted an elopement drill on 10/20/25 and scheduled additional elopement drills through January 2026.Due to the facility completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a J (isolated, immediate jeopardy).

The facility had a census of 57 residents. The facility had six medication carts and two medication rooms. Based on observation, interview, and record review, the facility failed to remove outdated or expired medication from potential administration to residents.Findings included:- On 09/29/25 at 07:42 AM, the Blue Medication cart contained two expired medications:Heartburn relief liquid antacid, 12 fluid ounces, with the expiration date of 10/2024. Vitamin D3, 50 micrograms (mcg), bottle of soft gels, expired April 2023.On 09/30/25 at 09:00 AM, the Blue medication room had an emergency kit box with two vials of Ativan (antianxiety drug) with an expiration date of 07/2024. On 09/29/25 at 07:45 AM, Certified Medication Aide (CMA) S verified the expiration dates on the medications. On 09/30/25 at 09:00 AM, Administrative Nurse F verified the expiration dates on the two vials of Ativan. On 09/30/25 at 09:22 AM, Administrative Nurse D verified the pharmacist should have removed the expired vials of Ativan medication from service. She verified staff should have removed the non-narcotic expired medications from service. The facility's Medication Storage in the Facility policy, dated May 2019, documented that outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled, or without a secure closures would be immediately withdrawn from stock by the facility. They would be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists.

The facility identified a census of 57 residents. The facility identified 15 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control practices related to wearing personal protective equipment (PPE) related to residents on EBP.Findings Included: - On 09/30/25 at 07:36 AM, Certified Nurse Aide (CNA) M and CNA N used a total lift to transfer Resident (R) 23, who had wounds and a urinary catheter, from his bed to a wheelchair. The CNAs did not wear gowns for infection control during the transfer. On 09/30/25 at 07:45 AM, Licensed Nurse (LN) G verified staff should have worn gowns when transferring R23, as his physician ordered on 09/26/25. On 09/30/25 at 02:32 PM, Administrative Nurse E verified that staff should have worn gowns during the transfer. The facility's Infection Prevention and Control Manual Enhanced Barrier Precautions policy, undated, stated Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics) in nursing homes. EBP involved gown and gloves used during high-contact resident care activities for residents at increased risk for MDRO acquisition (such as residents who have wounds or indwelling medical devices). EBP expands the use of a gown and gloves to focus on resident care activities that have been demonstrated to result in the transfer of MDROs to the hands and clothing of healthcare personnel. - Resident (R) 13's Electronic Medical Record (EMR) documented diagnoses of urinary tract infection (UTI- an infection in any part of the urinary system), sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), acute kidney failure, retention of urine, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R13's admission Minimum Data Set (MDS) dated [DATE] documented R13 had intact cognition, had functional range of motion impairment of both lower extremities, and used a wheelchair. R13 was dependent on staff for toileting, bathing, lower body dressing, rolling side to side in bed, and sit-to-stand transfers. R13 required partial to moderate assistance with upper body dressing and chair/bed transfers. The MDS further documented that R13 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and a UTI in the past 30 days. R13's Urinary Incontinence Care Area Assessment (CAA) dated 09/26/25 documented R13 had two nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion) tubes and a suprapubic (urinary bladder catheter inserted through the abdomen into the bladder) catheter. R13's Feeding Tube (g-tube- the introduction of a nutrient solution through a surgically inserted tube into the stomach through the abdominal wall) CAA dated 09/26/25 documented R13 had a feeding tube that was only used for flushing each shift. R13's Care Plan dated 09/16/25 documented that R13 was on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) due to catheters, nephrostomy, and g-tube. The Care Plan directed staff to wash/sanitize hands before entering the room and when leaving the room, and to wear a gown and gloves when performing high-contact activities. The Physician Order dated 09/18/25 directed staff to use EBP with dressing, bathing, transfers, changing linens, providing hygiene, toileting or peri care, device care, or wound care. On 09/30/25 at 10:25 AM, Licensed Nurse (LN) J prepared R13's medication for administration through the g-tube. LN J sanitized hands by using alcohol gel, placed gloves on, and entered the room. R13's door had a sign with information regarding EBP and a clear plastic pocket container with blue plastic gowns. LN J proceeded to administer medications and water through the g-tube without wearing a protective gown. On 09/30/25 at 01:03 PM, LN J verified that gloves and gowns should be worn during the administration of medications through R13's g-tube. On 09/30/25 at 01:25 PM, Administrative Nurse D and LN H both verified R13 had EBP, and the use of gloves and gowns were to be worn while administering g-tube medications. The facility's undated Infection Prevention and Control Manual-Enhanced Barrier Precautions policy documented EBP as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics) in nursing homes. EBP expands the use of gowns and gloves beyond anticipated blood and body fluid exposures. EBP is recommended for residents with any of the following: infection or colonization with an MDRO or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with an MDRO. Indwelling medical devices include central venous (blood vessel) catheters, urinary catheters, feeding tubes, or tracheostomies (opening through the neck into the trachea through which an indwelling tube may be inserted)/ventilators (a medical device that provides breath to persons who cannot breathe on their own).

The facility reported a census of 57 residents. The sample included 15 residents reviewed for dignity. Based on observations, interviews, and record review, the facility failed to ensure a dignified care environment for Resident (R) 8 when staff spoke to her in a disrespectful manner when the resident asked for assistanceFindings Included:- R8's Electronic Medical Records (EMR) included diagnoses of depression, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, and dysphagia (difficulty swallowing). R8's Quarterly Minimum Data Set (MDS) completed 07/31/25 indicated a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. The MDS noted upper extremity impairment on one side. The MDS noted she required substantial to maximal assistance for transfers, bathing, dressing, toileting, bed mobility, personal hygiene, and putting on footwear. The MDS noted she was frequently incontinent of urine. The MDS noted she had one non-injury fall since admission. R8's Functional Abilities Care Area Assessment (CAA) completed 12/13/24 indicated she required staff assistance for her activities of daily living. The CAA noted she was to anticipate her needs to prevent falls, skin breakdown, incontinence, and potential decline in her activities. R8's Care Plan initiated 12/06/25 indicated she required assistance from one staff member for bed mobility, dressing, toileting, transfers, bathing, and putting on her footwear. The plan noted she was at risk for falls. The plan instructed staff to anticipate her needs, keep personal items within reach, and encourage her to use her call light before transferring. The plan indicated she was to have a Call, Don't Fall sign in her room. A review of the facility's Monthly Grievance Logs indicated R8 filed a grievance on 09/10/25 related to Certified Nurse's Aide (CNA) M's conduct. A review of the grievance report revealed it was documented as a staff concern. The grievance indicated CNA M was repeatedly rude to R8. The grievance indicated that CNA M told R8 that all the direct care staff did not like her because she had to go to the bathroom too much. The report indicated CNA M denied making the comment, but indicated she was short with R8 and had not provided good customer service. The report indicated CNA M was given corrective action and instructed not to provide care for R8. The note indicated R8 felt safe. The report indicated R8's family felt safe with the resolution on 09/12/25. On 09/30/25 at 01:20 PM, members of the facility's resident council indicated R8 struggled with being bullied by CNA M. The council report concerns that the facility did not talk to R8 about how the incident affected her. On 09/30/25 at 01:40 PM, R8 asked to talk about CNA M and became tearful. R8 indicated she asked for help from staff to use the bathroom. and said CNA M entered her room and told he she would have to wait to go to the bathroom, and indicated to the resident that staff were upset that the resident was wet all the time. R8 reported that it made her feel like a burden to staff, and she said she did not want to be around people who did not like her. On 09/30/25 at 02:00 PM, Administrative Staff A was notified, and he stated that he had the facility immediately suspend CNA M. He stated he had no awareness of R8's potential psychosocial trauma, but the facility would immediately screen R8. On 09/30/25 at 02:20 PM, Certified Nurse's Aide (CNA) N stated that staff were expected to treat all residents with respect and dignity. She stated any rudeness from staff would be reported immediately to Administrative Staff A and Administrative Nurse D. On 09/30/25 at 02:00 PM, Administrative Nurse A stated that staff were trained annually and frequently on resident rights, dignity, and abuse topics. She stated that staff were expected to be polite and respectful to all residents. The facility's Resident Rights policy (undated) indicated the facility was to ensure all residents were treated in a dignified manner. The policy indicated the facility was to provide ongoing education and In-service.

The facility had a census of 57 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 3 received care and services for dialysis (a procedure where impurities or wastes were removed from the blood) consistent with professional standards of practice, which include ongoing communication and collaboration with the dialysis facility. Findings included:- R3's Electronic Medical Record (EMR) included diagnoses of acute osteomyelitis (local or generalized infection of the bone and bone marrow) of the left foot and ankle, sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), non-pressure chronic ulcer, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), end-stage renal disease, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), muscle weakness, and fatigue.R3's admission Minimum Data Set (MDS) dated [DATE] documented that R3 had intact cognition, functional range of motion limitation in both upper and lower extremities and used a wheelchair. R3 required substantial to maximal assistance with eating, oral care, personal hygiene, and upper body dressing. R3 was dependent on toileting, bathing, lower body dressing, rolling side to side in bed, sitting to lying and lying to sitting, sitting to standing, and transfers. The MDS further documented that R3 had pain almost constantly, unhealed pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) present upon admission, and a surgical wound. R3 received nutrition or hydration interventions to manage skin problems, pressure and surgical wound care, application of nonsurgical dressings other than to the feet, and application of dressing to the feet. The Dehydration/Fluid Maintenance Care Area Assessment (CAA) dated 08/22/25 documented R3 had a Multidrug-Resistant Organism (MDRO- common bacteria that have developed resistance to multiple types of antibiotics) of the left ankle wound and received antibiotic therapy while at dialysis after the treatment. R3's Care Plan dated 08/16/25 documented R3 needed hemodialysis (a procedure where impurities or wastes are removed from the blood) related to renal failure. A Care Plan revision, dated 08/21/25, directed staff to fill out a communication sheet and send it with R3 to dialysis and ensure that it is returned and completed. The Physician Order dated 09/16/25, directed staff to fill out the Dialysis Communication sheet and send it with R3 to dialysis and ensure that it was returned and completed. Upon review of the Dialysis Communication Form (which states to utilize each visit and then scan it into the EMR), the facility failed to provide the portion of the form's Resident Condition on 08/19/25, 08/30/25, 09/02/25, 09/09/25, 09/16/25, 09/20/25, and 09/27/25.On 09/30/25 at 10:00 AM, staff assisted R3 with transferring into a wheelchair for travel to the dialysis center. On 09/30/25 at 03:49 PM, Administrative Nurse D and Licensed Nurse (LN) H verified that the facility staff were to provide information on the resident's condition on the Dialysis Communication Sheet and had failed to do so on the dates previously noted.The facility's Dialysis Communication policy, dated 12/2024, documented that a dialysis communication form would be used to send information to and from the facility to the dialysis center and back. The nurse in charge of the care of the resident on the days scheduled for dialysis shall initiate the dialysis communication form and ensure the form is sent with the resident.

The facility reported a census of 57 residents. The Sample included 15, with three reviewed for falls. Based on observations, record review, and interviews, the facility failed to implement Resident (R) 8's fall interventions related to fall prevention signs.Findings Included:- R8's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, and dysphagia (difficulty swallowing). R8's Quarterly Minimum Data Set (MDS) completed 07/31/25 indicated a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. The MDS noted upper extremity impairment on one side. The MDS noted she required substantial to maximal assistance for transfers, bathing, dressing, toileting, bed mobility, personal hygiene, and putting on footwear. The MDS noted she was frequently incontinent of urine. The MDS noted she had one non-injury fall since admission. R8's Functional Abilities Care Area Assessment (CAA) completed 12/13/24 indicated she required staff assistance for her activities of daily living. The CAA noted she was to anticipate her needs to prevent falls, skin breakdown, incontinence, and potential decline in her activities. R8's Care Plan initiated 12/06/25 documented she required assistance from one staff member for bed mobility, dressing, toileting, transfers, bathing, and putting on her footwear. The plan noted she was at risk for falls. The plan instructed staff to anticipate her needs, keep personal items within reach, and encourage her to use her call light before transferring. The plan indicated she was to have a Call, Don't Fall sign in her room. On 09/29/25 at 07:22 AM, an inspection of R8's room revealed no Call Don't Fall sign in place in her room or bathroom. R8 was unable to locate the signs in her room. On 09/30/25 at 09:00 AM, an inspection of R8's room revealed no Call Don't Fall sign in place in her room or bathroom. On 09/30/25 at 01:20 PM, Certified Nurse's Aide (CNA) N stated that fall signs were usually placed by the bed or toilet to prevent the residents from self-transferring. On 09/30/25 at 02:00 PM, Administrative Nurse A stated nurses were responsible for ensuring the fall interventions were implemented in the resident rooms. She stated the interdisciplinary team reviewed the intervention effectiveness weekly, and the interventions were expected to be implemented immediately to prevent falls. The facility's Accidents policy, revised (undated), stated that the facility would ensure a safe environment for all residents. The policy indicated staff would assess each resident's potential risks, including functional abilities, potential falls, assistive devices, and environment, to ensure resident safety.

The facility had a census of 57 residents. The sample included 15 residents, with six residents reviewed for pressure ulcers (PU- localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to thoroughly assess Resident (R) 41's Stage three PU (full-thickness pressure injury extending through the skin into the tissue below) and Stage four PU (a deep pressure wound that reaches the muscles, ligaments, or even bone).Findings included: - R41's Electronic Medical Record (EMR) documented a diagnosis of osteomyelitis (infection of the bone and bone marrow) of the sacrococcygeal region (area at the very base of the spine), encompassing the sacrum (a triangular bone) and the coccyx (the tailbone).R41's admission Minimum Data Set (MDS), dated [DATE], was in progress. R41's Care Plan dated 09/19/25 documented R41 had an actual pressure injury to his left gluteus (buttocks muscle) and right heel. R41's Physician Order dated 09/22/25 directed staff to provide wound care to R41's right heel and left gluteus, ensure heel protectors were on while he was in bed, provide a low air loss mattress, and have Wound Care Plus evaluate and treat R41. R41's Skin Assessment dated 09/22/25 included measurements of the gluteal PU, 3.5 centimeters (cm) by 2.7 cm by 0.3 cm deep when the resident returned from the hospital. The assessment lacked documentation of the characteristics of the PUs.R41's Skin Assessment dated 09/29/25 documented the gluteus PU measured 18.1 cm by 5.5 cm. The right heel PU measured 3.5 by 2.7 cm. The assessment lacked depth measurement or characteristics of the wound.The facility lacked documentation the physician was informed of the increased size of the PU. On 09/29/25 at 01:33 PM, Licensed Nurse (LN) F and LN I performed wound care for R41's PUs. The nurses washed hands and donned personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) prior to the wound care. LN F cleaned the gluteus wound, which was approximately two to three cm deep, and five cm long by five cm wide. LN F took a picture for the measurements, but did not measure the depth. LN F applied collagen to the wound bed and covered it with a silicone-faced dressing. LN F also provides wound care to R41's right heel. On 09/30/25 at 02:36 PM, Administrative Nurse D stated R41 was admitted with pressure ulcers on 09/17/25. She verified staff were to measure and assess PU weekly and document the results. She stated R41's physician had been notified of the increase in size, but the facility did not have documentation. The facility's Pressure Injury Assessment and Treatment Guideline, dated January 2025, documented the following information should be recorded in the resident's electronic medical record: type of wound and location, stage of the pressure wound, wound measurements, undermining or tunneling, drainage or odor. Staff were to document assessment of the wound bed, including type and amount of tissue visualized, the wound edges, and the surrounding tissue.

The facility had a census of 57 residents. The sample included 15 residents, with five reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 6 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without a proper indication for use written by the physician. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of neurocognitive disorder with Lewy bodies (a type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function) and a cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).R6's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R6 required maximum or full staff assistance with activities of daily living and received antipsychotic medication. R6's Psychotropic Drug Use Care Area Assessment (CAA) dated 08/23/25 stated R6 was at risk for side effects due to the daily use of quetiapine (an antipsychotic). R6's Care Plan dated 08/18/25 included the Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for quetiapine which stated elderly patients with dementia (progressive mental disorder characterized by failing memory, confusion)-related psychosis treated with antipsychotic drugs were at an increased risk of death and quetiapine was not approved for the treatment of patients with dementia-related psychosis. The care plan directed staff to request the physician review and evaluate medications, review pharmacy consult recommendations, and follow up. The Physician Order dated 08/17/25 directed staff to administer quetiapine, 25 milligrams (mg) by mouth at bedtime, for mood disorder. R6's September 2025 Medication Administration Record (MAR) for antipsychotic medication monitoring lacked documentation of any abnormal behaviors. R6's EMR lacked a written physician rationale for the use of an antipsychotic, quetiapine, without an approved indication of use. On 09/29/25 at 07:20 AM, Certified Medication Aide (CMA) R administered medications to R6 in his room. He took the pills whole without problems and was polite and thanked the CMA R. On 09/30/25 at 02:19 PM, Administrative Nurse D verified the pharmacist's recommendation included choices for the physician to indicate the use of quetiapine, and the physician did not write a rationale for the use of the unapproved antipsychotic. She stated psychiatry had not been to the facility to assess the resident. The facility's Psychotropic (alters mood or thought) Medication Use policy, dated February 2025, stated residents would only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. The policy stated antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders: Schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), Tourette's Disorder (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds), or Huntington Disease (rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder). Diagnoses alone do not warrant the use of psychotropic medication.

The facility reported a census of 57 residents. The sample included 15, with one reviewed for advance directives. Based on observations, interviews, and record review, the facility failed to follow Resident (R) 59's chosen advanced directives (legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves) related to her do not resuscitate (DNR) wishes for cardio pulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating). Findings Included:- R59's Electronic Medical Records (EMR) included diagnoses of muscle weakness, atrial fibrillation (rapid, irregular heartbeat), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), heart failure, and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R59's admission Minimum Data Set (MDS) completed [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. The MDS noted no upper or lower extremity impairments. The MDS noted she required moderate to substantial assistance with bathing, dressing, bed mobility, personal hygiene, and toileting. The MDS noted she was continent of bowel and bladder. R59's Cognitive Loss Care Area Assessment (CAA) completed [DATE], noted she triggered related to her poor insight, reduced memory recall, and poor safety judgment. The CAA noted that a plan of care was implemented to address her potential risks related to her cognitive decline. R59's Care Plan initiated [DATE] indicated her advanced directives listed her as a DNR on [DATE]. The plan instructed staff to honor her advanced directives and end-of-life decision. R59's EMR under Miscellaneous revealed a Do Not Resuscitate Directive signed by R59 and her medical provider on [DATE]. R59's EMR under Physicians Orders revealed she had a DNR order started on [DATE]. A Facility Incident Report #0354 completed on [DATE] indicated R59 was found unresponsive by staff on [DATE] at 04:55 PM. The report indicated that the staff noted her nursing report sheet indicated she was a full code. The report revealed staff began CPR on R59 without verifying R59's advanced directives in her EMR. At 04:57 PM, Emergency medical services (EMS) arrived and took over CPR. The report indicated R59's pulse returned, and she was transported to an acute medical facility for treatment. On [DATE] at 01:20 PM, Certified Nurse's Aide (CNA) N stated she would check the care plan with the nurse to verify a resident's code status. On [DATE] at 01:27 PM, Licensed Nurse (LN) G stated staff were expected to check either the orders or the care plan for updated advanced directives. She stated the forms were signed upon admission and updated for the care plan, Kardex (nursing tool that gives a brief overview of the care needs of each resident), and orders. She stated that direct care staff were expected to check with the nurse during emergencies. On [DATE] at 02:00 PM, Administrative Nurse A stated that staff were expected to verify the code status of each resident in the care plan or orders before attempting CPR. She stated that if changes were made to a resident's code status, it was immediately relayed to the team. The facility did not provide a policy related to advance directives as requested on [DATE]. The facility implemented the following corrective actions related to this incident:1. The facility completed an audit of current residents to verify the appropriate code statuses for each resident on [DATE].2. The facility completed staff education for all direct care staff related to advanced directives and where the appropriate place to find the code status for each resident on [DATE].3. The facility will complete five staff interviews weekly to ensure staff knowledge of advanced directives starting on [DATE]. 4. The facility will complete practice codes weekly on alternating shifts to ensure staff knowledge for six weeks starting on [DATE]. 5. The facilities Quality Assurance team reviewed the results of the audits and interviews to ensure ongoing compliance starting on [DATE]. This deficient practice was deemed as past non-compliance when the facility implemented the following corrective actions on [DATE], prior to the surveyor entering the facility.

The facility identified a census of 54 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens and failed to ensure sanitary storage of respiratory equipment. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 02/07/24 at 08:33 AM Certified Nurse Aide (CNA) N pushed R29 in the wheelchair into R29's room and stepped onto the nasal cannula on the floor as she pulled the bedding down on R29's bed. CNA N moved the nasal cannula from the floor and placed the cannula onto the oxygen concentrator. CNA N removed the oxygen tubing connected to the portable oxygen tank from R29's nose and placed the oxygen tubing in a plastic bag that was attached to R29's wheelchair. CNA N placed a gait belt around R29's waist, and using the gait belt, assisted R29 into a partial standing position, then pivoted R29 onto the bed. CNA N then placed the oxygen nasal cannula that was stepped on into R29's nostrils. On 02/07/24 the facility provided a policy related to Legionella testing but was unable to provide a risk assessment with a diagram of the facility water flow map that identified weak areas. The policy lacked a plan for empty rooms, the frequency of monitoring the at-risk areas, or who was responsible for the monitoring. On 02/07/24 at 08:40 AM Certified Nurse Aide (CNA) N stated the oxygen tubing was not on the floor but was wrapped around the oxygen concentrator. CNA N stated it was not stored in the plastic bag attached to the oxygen concentrator. CNA N stated she would change the nasal cannula if it was soiled. CNA N stated she knew what to set the oxygen flow at by reviewing R29's care plan. CNA N stated the nasal cannula should be stored in a clear plastic bag attached to the oxygen concentrator when not in use. On 02/07/24 at 10:09 AM Licensed Nurse (LN) G stated all staff had access to the care plan and Kardex. LN G stated the Kardex contained the information for R29's oxygen care and administration. LN G stated the oxygen tubing should be changed weekly7 and stored in the clear plastic bag attached to the wheelchair or oxygen concentrator when not in use by R29. On 02/08/24 at 11:45 AM Maintenance Director U provided a diagram that lacked a map of the facility's water flow which identified the at-risk areas. On 02/08/24 at 12:37 PM Administrative Nurse D stated oxygen tubing was changed weekly and should be stored in a clear plastic bag when not in use. Administrative Nurse D stated a nasal cannula should never be stored on the floor and should be replaced immediately. On 02/08/24 at 02:37 PM Administrative Staff A stated he was not aware the water management plan/policy did not meet the required components for the monitoring and prevention of Legionella disease and other opportunistic waterborne pathogens. The facility's Oxygen Administration policy reviewed 01/2017 documented that staff would verify that there was a physician's order for this procedure for oxygen administration; the date and time that the procedure was performed; the rate of oxygen flow and route; the frequency and duration of the treatment and the reason for as-needed administration. The facility failed to implement appropriate infection control practices. This placed the residents at risk for transmission of infectious diseases.

The facility identified a census of 54 residents. Based on observation, record review, and interviews, the facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 54 residents residing in the facility. Findings included: - A review of the Facility assessment dated [DATE] provided by the facility revealed the assessment listed the number and types of admissions for the past year to date. The assessment sections were not completed in the sections that documented the staffing level, competencies required, equipment, and physical or environmental needs to address the facility's specific resident population and acuity. On 02/08/24 at 02:37 PM Administrative Staff A stated he was not aware the assessment of the facility did not meet the requirements needed to determine the staff and other critical elements necessary for the care of the residents that resided in the facility. On 02/08/24 at 02:54 PM Administrative Staff B reviewed the Facility Assessment that was provided during the survey and confirmed it lacked necessary elements. The facility did not provide a policy related to the development of a facility assessment. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 54 residents residing in the facility.

The facility identified a census of 54 residents. Based on record review and interview, the facility failed to ensure Licensed Nurse (LN) staff possessed the required skills and competencies to administer medication intravenously (IV- administered through a vein directly into the bloodstream). This placed all residents with IV medications at risk for medication errors and adverse outcomes. (Refer to F760) Findings included: - An SBAR Communication Form and progress note -V 2 under the Assessments tab in R47's EMR recorded in the Situation section, documented the wrong IV antibiotic was administered on 12/13/24. The form was signed by Administrative Nurse F on 12/15/24. The facility's report #74 Med Error, dated 12/13/23, documented the wrong IV antibiotic medication was administered to R47. The document further recorded R47 received Unasyn (antibiotic) instead of the ordered Rocephin. The document recorded that the IV medication was stopped, R47's provider was notified and R47 went to the hospital. The report documented None to the predisposing environment, physiological and situational factors. The report lacked a root cause analysis. The facility provided a Seminar/Training Sign-In Sheet dated 12/20/23 which indicated education on the Five Rights of Medication Administration was provided by Administrative Nurse F. A review of Administrative Nurse F's Licensed Nurse Competency Validation Checklist revised 08/2018 revealed Administrative Nurse F was hired on 10/31/23. The checklist listed a section for Procedures/Skills Checks. The section included validation sign-off for administration of eye drops, medications via a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach), nebulized (medications converted to mist for inhalation) medication, oral medication, oral inhalers, intramuscular (given via injection into a muscle) medications, subcutaneous (SQ- beneath the skin) medications, intradermal (given into the second layer of the skin) medication, transdermal ( through the skin) patches, eye ointment and insulin (hormone that lowers the level of glucose in the blood) via a flex pen from 11/02/23 through11/03/23. The competency validation checklist lacked a skill check for IV medication administration. The checklist did include the insertion of an IV catheter (a small tube inserted into the vein used to administer the medication directly into the bloodstream) and a peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period) dressing change though those competencies were not documented as assessed. Upon request for Administrative Nurse F's competency checks, the facility provided multiple checklists for Administrative Nurse F which included the following: Skills Checklist for Head to Toe Assessment; Check Skin; Code Status Competency for Nurse; Elopement Process Competency; Fall Program Competency for nurses; Skills Checklist Handwashing; Skills Checklist Glucometer Cleaning; Skills Checklist Blood Glucose Monitoring; and Skills Checklist Personal Protective Equipment. Upon request for Administrative Nurse F's computer-based training, the facility provided a list of trainings though none had to do with medication administration or IV medication administration. On 02/08/24 at 12:01 PM Licensed Nurse (LN) I stated she was new to the facility and had only worked for a few weeks. LN I stated she had previous training on how to insert and administer medication through an IV before working at the facility. LN I stated that she did not receive any additional training or a skills check-off at the facility as she stated she already knew how to administer medications through an IV. LN I stated staff showed her where the supplies were and how to set everything up to start an IV but did not provide any additional training. On 02/07/24 at 03:33 PM Administrative Nurse F stated the nurse on duty at the time of the incident was not IV certified and staff asked Administrative Nurse F to administer R47's IV ceftriaxone. Administrative Nurse F stated she went into the medication storage room to get the ceftriaxone and there was more than one type of IV antibiotic in the medication storage room. Administrative Nurse F stated she grabbed what she believed was the ceftriaxone and administered it to R47. Administrative Nurse F further stated she realized she had hung the wrong IV antibiotic, so she stopped the antibiotic, obtained vitals on R47, and contacted R47's doctor. Administrative Nurse F stated after the incident, staff education was provided on the five rights of medication administration (standard medication practice used to ensure the right patient, the right drug, the right time, the right dose, and the right route are correct before medications are administered), and risk management was completed. Administrative Nurse F stated the facility had adequate staff at the time of the event and she was unsure why she did not look to check for the right medication or the resident's name on the medication. Administrative Nurse F stated she felt perhaps she had too much going on. On 02/07/24 at 03:40 PM Administrative Nurse D stated the five rights of medication administration were not followed which led to the medication error. Ad Administrative Nurse D verified the facility had not attempted to determine why Administrative Nurse F did not follow the rights of medication administration and stated the facility did not assess each nurse's competency with IV medication administration as the LN would have learned the skill in school but went on to say the electronic training forum did have training for the topic. The facility did not provide a policy on competency assessment for nurses. The facility failed to ensure LN staff possessed the required skills and competencies to administer IV medication. This placed all residents with IV medications at risk for medication errors and adverse outcomes. (Refer to F760)

The facility identified a census of 54 residents. The sample included 14 residents with 14 residents reviewed for care plans. Based on observation, record review, and interviews, the facility failed to revise the care plan with the relevant hospice information for Resident (R) 29. The facility also failed to revise R10's care plan with the unsuccessful attempts for nonpharmacological interventions that had been tried prior to the administration of as-needed psychotropic (alters mood or thoughts) medication. This deficient practice placed these residents at risk for impaired care due to uncommunicated care needs. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, need for assistance with personal care, chronic respiratory failure, emphysema (a long-term, progressive disease of the lungs characterized by shortness of breath), muscle weakness, lack of coordination, and difficulty in walking. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R29 was dependent on staff assistance for transfers from chair/bed-to-chair transfers. The MDS documented R29 received oxygen during the observation period. The Significant Change MDS was in progress. R29's Functional Abilities Care Area Assessment (CAA) dated 12/30/23 documented she required assistance with her activities of daily living. R29's Care Plan dated 01/26/24 documented the facility would consult with the physician and social services to have hospice care for R29. R29's Care Plan dated 01/31/24 documented hospice would manage the plan of care to include treatment and medications. The plan of care lacked the name of the hospice provider and a description of the services provided by the hospice. R29's EMR under the Orders tab revealed the following physician order: Hospice to evaluate and treat as indicated dated 01/24/24. A review of the communication book provided by hospice lacked a hospice care plan, signed admission paperwork with the physician documentation of a terminal diagnosis for admission to hospice services, services or equipment that would be provided, and medications that were covered by hospice. Observation on 02/07/24 at 08:33 AM R29 requested a pink disposable pad be placed on the bed. Certified Nurse Aide (CNA) N told R29 she was out of disposable pads and staff would have to notify R29's family to bring more to the facility. CNA N placed a gait belt around R29's waist, and using the gait belt, assisted R29 into a partial standing position, then pivoted R29 onto the bed. On 02/07/24 at 08:40 AM Certified Nurse Aide (CNA) N stated the staff had access to the plan of care and Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA N stated R29 had just recently been admitted to hospice services. CNA N stated she did not know what supplies the hospice provided. CNA N stated she would let the nurse know if R29 needed supplies. On 02/07/24 at 10:09 AM Licensed Nurse (LN) G stated all staff had access to the care plan and Kardex. LN G stated the Kardex contained the information for R29's hospice services. LN G reviewed the hospice communication book for R29 and confirmed the communication book lacked a hospice care plan, signed admission paperwork with the admitting terminal diagnosis for admission to hospice services, services hospice would provide, and medication covered by hospice. On 02/07/24 at 12:09 PM Administrative Nurse D stated R29 had been admitted to hospice on a weekend so the facility had overlooked updating the care plan. Administrative Nurse D stated the hospice provider had been contacted and the provider faxed the admission paperwork with the physician's order for hospice admission, along with the care plan which covered the services provided and the list of medication that would be covered by hospice. The facility's Care Planning-Interdisciplinary Teams policy reviewed 01/2017 documented every resident would be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual to assess each resident's strengths, weaknesses, and care needs. The facility failed to ensure the relevant hospice information was on R29's care plan This deficient practice placed R29 at risk of impaired care due to uncommunciated care needs. - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and insomnia (inability to sleep). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R10 had received antianxiety (class of medications that calm and relax people), anticoagulant (class of medications used to prevent the formation of blood clots), diuretic (medication to promote the formation and excretion of urine), and opioid (a class of medication used to treat pain) for seven days during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 had received antianxiety medication, anticoagulant medication, diuretic, and opioid medication during the observation period. R10's Psychotropic Drug Care Area Assessment (CAA) dated 07/20/23 documented R10 received routine antianxiety medication. R10's Care Plan dated 06/08/23 documented staff would administer medications as ordered and monitor for any side effects. R10's EMR under the Orders tab revealed the following physician orders: Benadryl (allergy medication with hypnotic qualities used to induce sleep) allergy oral tablet 25 milligrams (mg) give two tablets by mouth every 24 hours as needed for insomnia dated 09/06/23. Clonazepam (antianxiety medication)) oral tablet 0.5mg give one tablet by mouth every four hours as needed and administer at bedtime for insomnia dated 01/29/24. Clonazepam oral tablet 0.5mg give one tablet by mouth every 4 hours as needed for insomnia for three days a second dose can be repeated in four hours for insomnia if needed dated 01/29/24. R10's clinical record lacked evidence of documentation of any nonpharmacological attempts or person-centered attempts to manage the symptoms prior to the administration of the as-needed psychotropic medication for R10. Observation on 02/06/24 at 10:53 AM R10 sat in her wheelchair in the dining room and drank a cup of coffee during the resident council meeting. On 02/06/24 at 02:01 PM Administrative Nurse E stated behavior monitoring was documented on the Treatment Administration Record (TAR). Administrative Nurse E stated the facility did not document any person-specific nonpharmacological attempts to manage symptoms of as-needed psychotropic medication. On 02/08/24 at 11:19 AM Licensed Nurse (LN) G stated he was not aware of any documentation of nonpharmacological successful or unsuccessful attempts to manage a resident's symptoms prior to administering as-needed psychotropic medication. On 02/08/24 at 12:37 PM Administrative Nurse D stated that nonpharmacological attempts to manage insomnia should be provided prior to administration of as-needed medication. Administrative Nurse D stated she expected staff to document the effects of the medication administered. The facility's Care Planning-Interdisciplinary Teams policy reviewed 01/2017 documented every resident would be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. To assess each resident's strengths, weaknesses, and care needs. The facility failed to ensure nonpharmacological attempts of symptom management prior to administering as-needed psychotropic medication was included in the care plan for R10. This deficient practice placed these residents at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 54 residents. The sample included 14 residents with one sampled for activities of daily living (ADL). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 32 received supportive care and services to promote and maintain his quality of life when the facility did not implement tools and/or strategies to allow R32, who had aphasia (a condition with disordered or absent language function), to communicate his wants, needs, or feelings. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings included: - R32's Electronic Medical Record (EMR) from the Diagnoses tab documented cerebral infarction (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), aphasia following cerebral infraction, hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infraction affecting the right dominate side, dysphagia (swallowing difficulty), cognitive social or emotional deficit following cerebral infraction, major depressive disorder (major mood disorder which causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R32's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status was not conducted because the resident was rarely or never understood. The MDS documented that the interview for personal preferences was not conducted with R32 or his representative. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/27/23 documented R32 had cognitive social or emotional deficit following cerebral infraction and due to this he had severely impaired cognition. The Communication CAA dated 06/27/23 documented R32 has aphasia due to cerebral infarction is rarely or never understood and rarely or never understands others. R32's Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status was not conducted because the resident was rarely or never understood. The MDS documented the resident's cognitive skills were severely impaired. The MDS documented R32 was dependent on staff for all self-care ADLs. The MDS documented R32 received scheduled pain medication but did not receive non-medication pain interventions. The MDS documented R32 received antidepressant medication (a class of medication to treat depression) during the observation period. R32's Care Plan dated 06/21/22 documented he had impaired cognition. The plan directed staff to communicate with R32's family regarding his capabilities and needs. The plan directed staff to use the resident's name and to identify themselves. R32's Care Plan directed staff to turn off the television to reduce distractions. The care plan dated 01/18/23 documented R32 had a communication problem and was nonverbal. R32's Care Plan directed staff to use communication techniques that enhanced interaction. The plan directed staff to talk to R32 while providing care, even if he did not respond. The plan directed staff to turn off the TV and radio as needed to reduce environmental noise. R32's Care Plan directed staff to ask yes or no questions, and to use brief, consistent words or cues. A review of R32's Speech Therapy Plan of Care from June 2023 through January 2024 lacked evidence a communication system or picture board was trialed. On 02/05/24 at 07:35 AM R32 lay in bed on his back. R32 had fall mats on both sides of the bed. R32's television was on. R32 nodded yes in response to all questions. There were no communication tools/boards visible in R32's room. On 02/06/24 at 08:46 AM observation revealed Licensed Nurse (LN) H administered R32's morning tube feeding. LN H completed the tube feeding without speaking to R32. After the feeding was complete LN H asked R32 if everything was ok and gave the resident a thumbs-up sign. R32 responded with a thumbs-up sign. LN H asked R32 to demonstrate a thumbs-down sign, and R32 gave a thumbs-down sign. LN H stated R32 would sometimes [NAME] if everything was ok. LN H did not ask R32 any further questions. On 02/07/24 at 07:55 AM R32 lay in bed on his back. His television was on. When R32 was asked if he liked what he was watching on the television, R32 reached out and held the surveyor's hand. R32 smiled in response to all further questions and was reluctant to let go of the surveyor's hand. On 02/08/24 at 08:25 AM R32 lay in bed on his back and watched television with the remote on the bedside table. When asked if he liked the show on the television, R32 did not gesture but he reached out to hold the surveyor's hand. There was no communication board visible in R3's room. On 02/05/24 at 10:41 AM in a telephone interview, R32's representative stated R32 was unable to communicate with the staff that did not know him well. R32's representative stated R32 pointed at what he wanted, but the staff did not always understand what he wanted. On 02/08/24 at 10:26 AM Certified Nurse Aide (CNA) N stated R32 pointed at things but never pressed his call light. CNA N said R32 had no way to tell staff his wants or needs; staff had to ask R32 the right questions. On 02/08/24 at 09:43 AM CNA M stated R32 blinked once for yes and twice for no. CNA M stated R32 was unable to tell staff if he was cold, wet, or lonely. She stated staff kept R32 him on a routine to ensure he was taken care of. On 02/08/24 at 09:37 LN G stated he thought R32 had a communication board at one time and said it might be in the closet. LN G stated staff asked R32 yes and no questions and made sure he had a routine. LN G stated he asked R32 to squeeze his hand in answer to questions and said he always made, sure to make eye contact with R32 to ensure the resident was well. LN G verified R32 had no way to communicate something to staff if staff did not ask directly about it. On 02/08/24 at 12:37 Administrative Nurse D stated R32 had a brain injury and was unable to let staff know how he was feeling or what he wanted. Administrative Nurse D stated when staff changed R32, staff watched R32's face to communicate. Administrative Nurse D stated no matter what the facility tried, R32 had not been able to communicate. Administrative Nurse D stated that R32's representative was very involved with his care. The facility did not provide a policy related to promoting effective communication with nonverbal residents. The facility failed to ensure R32 received supportive care and services to promote and maintain R32's ability to communicate his wants, needs, or feelings. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity.

The facility identified a census of 54 residents. The sample included 14 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff followed the care plan for safe transfers for Resident (R) 29 and the facility also failed to ensure staff placed a fall mat next to R9's bed per his plan of care. These deficient practices placed these residents at risk for falls and possible injuries related to falls. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, need for assistance with personal care, chronic respiratory failure, emphysema (a long-term, progressive disease of the lungs characterized by shortness of breath), muscle weakness, lack of coordination, and difficulty in walking. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R29 was dependent on staff assistance for transfers from chair/bed-to-chair transfers. The MDS documented R29 received oxygen during the observation period. R29's Functional Abilities Care Area Assessment (CAA) dated 12/30/23 documented she required assistance with her activities of daily living. R29's Care Plan last revised on 12/27/23 documented R29 required the Hoyer (total body mechanical lift) for transfers with the assistance of two staff members. Observation on 02/07/24 at 08:33 AM Certified Nurse Aide (CNA) N placed a gait belt around R29's waist, and using the gait belt, assisted R29 into a partial standing position, then pivoted R29 onto the bed. On 02/07/24 at 08:40 AM, CNA N stated the staff had access to the plan of care and Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA N stated she would find the information on how R29 transferred to the Kardex. CNA N stated therapy determined the safest mode of transfer for each resident. On 02/07/24 at 10:09 AM Licensed Nurse (LN) G stated all staff had access to the care plan and Kardex. LN G stated the Kardex contained the information for R29's mode of transfer. On 02/07/24 at 10:49 AM Consultant Physical Therapist HH stated R29 had not been reevaluated for therapy since her recent return from a hospitalization on [DATE]. Consultant Physical Therapist HH stated R29 was transferred with a Hoyer lift, then worked with therapy to transfer with a gait belt, but recently had a decline and was using the Hoyer lift at times. On 02/07/24 at 12:09 PM Administrative Nurse D stated the plan of care or Kardex should be reviewed on a daily basis to know each resident's level of assistance needed for activities of daily living. Administrative Nurse D stated R29's care plan was updated for staff to use a gait belt along with stand/pivot transfer and staff could also use the Hoyer lift with two people. The facility's Falls policy last revised on 09/17/19 documented the purpose of the fall management program was to develop, implement, monitor, and evaluate an interdisciplinary team's fall prevention approach and manage strategies and interventions that foster resident independence and quality of life. The fall management program promotes the safety, prevention, and education of both staff and residents. The facility failed to ensure staff transferred R29 with a Hoyer lift and the assistance of two staff members as care planned to prevent falls or injuries. This deficient practice placed R29 at risk for falls and possible injuries. 49634 - R9's Electronic Medical Record (EMR) documented diagnoses of chronic osteomyelitis (local or generalized infection of the bone and bone marrow) of the left tibia (bone of the lower leg )and fibula (one of the two bones of the lower leg), repeated falls, symptoms and signs involving cognitive functions and awareness, acquired absence of the right toe, difficulty walking, muscle weakness, Stage 3 (full thickness pressure injury extending through the skin into the tissue below), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the left hip and left and right heels. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R9 required partial to moderate assistance from staff for bed mobility. R9 was dependent on staff for all transfers and toileting needs. The facility was unable to determine if the resident had any falls before admitting to the facility. The Pressure Ulcer Care Assessment (CAA) dated 10/17/23 documented R9 had chronic osteomyelitis of the left and right tibia and fibula sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) and repeated falls. R9 needed assistance with bed mobility and was incontinent. R9 was admitted with multiple pressure injuries. R9's Care Plan dated 10/12/23 documented staff would place R9's fall mat at the bedside when he was in bed. The plan directed staff to place the bed in a low position. The Physician's order dated 01/19/24 ordered a fall mat at R9's bedside. On 02/05/24 at 08:25 AM observation revealed R9 laid in bed on his right side, with his head against the wall. R9's bed was in a high position. There was no fall mat on the floor next to R9's bed. On 02/06/24 at 01:58 PM observation revealed R9 laid in bed, turned to his right side. There was no fall mat on the floor next to his bed. Further observation revealed no fall mat in R9's room. On 02/08/24 at 09:46 AM Certified Nurses Aid (CNA) M stated R9 should be turned toward the wall so he does not fall. CNS M said R9 should not lay on the wound vac. CNA M said R9 should have a pillow placed under his feet for floating the heels, CNA M stated the fall mat should be placed on the right side of the bed, and the bed should be in the lowest position. On 02/08/24 at 10:29 AM, CNA N stated R9 should have a pillow between legs. R9's heels should be elevated on a pillow and his fall mat should be placed by his bed. CNA N stated she could find the information on how to care for the resident in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 02/08/24 at 10:19 AM LN G stated R9's bed should be left in a low position and his mat placed on the side of his bed. On 02/08/24 at 01:31 PM Administrative Nurse D stated she expected the nursing staff to put R9's bed in the lowest position and his fall mat in place. Administrative Nurse D stated the fall mat was picked up for some reason, either for room changes or cleaning, and was not put back in place. She stated she expected staff to follow the care plan and ensure R9's fall mat was in place and his bed was in a low position. The facility's Falls policy last revised on 09/17/19 documented that the purpose of the fall management program was to develop, implement, monitor, and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The fall management program promotes the safety, prevention, and education of both staff and residents. The facility failed to ensure R9's bed was in the lowest position and his fall mat was in place per his plan of care. This deficient practice placed R9 at risk for falls and fall-related injuries.

The facility identified a census of 54 residents. The sample included 14 residents with two sampled for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). based on observation, interviews, and record reviews the facility failed to ensure staff implemented the care plan interventions for Resident (R) 9 who had multiple pressure-related injuries and remained at risk for the development of pressure ulcers. This deficient practice placed R9 at risk for delayed healing, new pressure injuries, and related complications. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of chronic osteomyelitis (local or generalized infection of the bone and bone marrow) of the left tibia (bone of the lower leg )and fibula (one of the two bones of the lower leg), repeated falls, symptoms and signs involving cognitive functions and awareness, acquired absence of the right toe, difficulty walking, muscle weakness, Stage 3 (full thickness pressure injury extending through the skin into the tissue below), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the left hip and left and right heels. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R9 required partial to moderate assistance from staff for bed mobility. R9 was dependent on staff for all transfers and toileting hygiene. R9's MDS documented R9 received scheduled pain medication but no as-needed pain medications and did not receive any non-medicinal pain interventions. The MDS recorded R9 was always incontinent of both urine and bowel and was not on a toileting program. The MDS recorded R9 had one Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters), two Stage 3 pressure ulcers, one unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) and a surgical wound. The MDS documented R9 was at risk for developing pressure ulcers and had a pressure-reducing device on his bed and wheelchair. R9 received pressure ulcer care, surgical wound care, and nonsurgical dressings and ointments but not a turning or repositioning program. The Pressure Ulcer Care Assessment (CAA) dated 10/17/23 documented R9 had chronic osteomyelitis of the left and right tibia and fibula, sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) and repeated falls. R9 needed assistance with bed mobility and was incontinent. R9 was admitted with multiple pressure injuries. R9's Care Plan dated 10/11/23 and revised on 02/04/24 documented R9 had pressure wounds to his left and right heels, left hip, and right inner ankle; he had a vascular wound (wound resulting from poor circulation) on his right foot and leg. The plan directed staff to administer R9's treatments and medications as ordered and shearing while repositioning in bed. Interventions dated 10/14/23 directed staff to float R9's bilateral (both sides) heels on a pillow when R9 was in bed as tolerated and ensure a pressure-reducing cushion was placed in the chair when R9 was up to his chair. An intervention dated 10/14/23 directed staff to offer R9 a urinal and check and change his every two to three hours and as needed (i.e., upon rising, after all meals, and before bed); check routinely throughout the night. R9's Care Plan dated 10/12/23 and revised on 10/14/23 documented R9 had an ADL self-care deficit and was non-weight bearing on his legs. The plan directed staff R9 required a full body mechanical lift (Hoyer) with assistance from two staff for all transfers and required assistance from one staff for bed mobility and repositioning. An intervention dated 10/27/23 directed staff to encourage R9 to get out of bed daily; R9 was able to tolerate being up two to three hours at a time. On 02/05/24 at 08:25 AM observation revealed R9 laid in bed on his right side, with his head against the wall. R9's feet and heels rested directly on the mattress with no evidence of a pillow or device in use for floating. There were visibly soiled sheets wadded on the left side of R9 in the bed. There was a foul odor noted and R9's negative-pressure wound-vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) did not make an audible alarm though the screen indicated a leak alert. On 02/06/24 at 01:58 PM observation revealed R9 laid in bed, turned to his right side. There was no fall mat on the floor next to his bed. R9's feet and heels rested directly on the mattress with no evidence of a pillow or device in use for floating. On 02/06/24 at 07:38 AM Administrative Nurse E pushed R9 from his room to the dining room table in a wheelchair. R9 wore socks on both feet and his feet rested directly on the wheelchair pedals. On 02/06/24 at 09:36 AM R9 remained in his wheelchair at the dining room table. R9 wore socks on both feet and his feet rested directly on the wheelchair pedals. On 02/06/24 at 10:51 AM R9 sat in his wheelchair which was parked next to R9's bed. R9 leaned forward in his chair so that his upper body and head rested on his bed. R9's eyes were closed, and he appeared to be asleep. On 02/06/24 at 01:32 PM, R9 sat in his wheelchair at the dining room table. His eyes were closed, and he appeared to be asleep. On 02/06/24 at 01:54 PM, R9 sat in his wheelchair. His pants were visibly saturated to his mid-thigh area. Certified Nurse Aide (CNA) O and Administrative Nurse E prepared to transfer R9 into bed. On 02/06/24 at 02:18 PM, CNA O stated R9 had not been laid down or changed since 08:00 AM because CNA O had been busy. CNA O further stated R9 used to have pressure-relieving boots for his heels but those disappeared. She went on to say she knew how to access the resident's plan of care in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 02/06/24 at 02:30 PM, R9 lay in bed on his right side with a pillow between his legs. His right heel rested directly on the mattress. On 02/08/24 at 09:46 AM CNA M stated R9 should be turned toward the wall so he did not fall and did not lay on the wound vac. CNA M said R9 should have a pillow placed under his feet for floating his heels. CNA M stated R9 should be changed every two to three hours. On 02/08/24 at 10:29 AM CNA N stated R9 should have a pillow between his legs and R9's heels should be elevated on a pillow. CNA N said the Kardex informed staff of each resident's care needs. CNA N said R9 should be changed every two to three hours. On 02/08/24 at 01:31 PM Administrative Nurse D stated R9 was able to talk and communicate his needs. She said she expected staff to check and change R9 every two hours and to put him down (in bed) in between meals. Administrative Nurse D said all staff knew R9 was at high risk for skin breakdown and needed to be changed frequently. Administrative Nurse D stated it was the routine process for the CNA staff to reposition R9 at least every two hours. She said R9 had a lot of wounds when he was admitted . Administrative Nurse D stated she expected staff to follow the resident's care plan. The facility policy Pressure Ulcer/Pressure Injury Prevention revised on 03/2022 recorded that the first step in the prevention of pressure ulcers/injuries was the identification of the resident at risk for developing pressure-related injuries. That was followed by the implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. The facility failed to ensure R9's interventions were implemented consistently to prevent new pressure injuries and to promote the healing of the existing pressure wounds. This placed R9 at risk for delayed healing, new pressure injuries, and related complications.

The facility identified a census of 54 residents. The sample included 14 residents with three reviewed for range of motion. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 5 received services/interventions to prevent a reduction of range of motion (ROM) and contractures (abnormal permanent fixation of a joint or muscle). This deficient practice left R5 at risk for further decline and decreased ROM or mobility. Findings included: - The Diagnoses tab of R5's Electronic Medical Record (EMR) documented diagnoses of chronic inflammatory demyelinating polyneuropathy (CIDP - a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), generalized muscle weakness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R5 required substantial assistance, where staff did more than half the effort, for eating and oral hygiene. The MDS further documented R5 was dependent on staff for toileting hygiene, bathing, dressing, transfers, and mobility. The Quarterly MDS dated [DATE], documented R5 was dependent on staff for eating, oral hygiene, and personal hygiene. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 08/15/23, documented R5 required assistance with ADLs. R5's Care Plan with an initiated date of 09/17/23, documented R5 had an ADL self-care performance deficit and both arms, hands, and legs were contracted. An intervention with an initiated date of 08/31/23, directed staff to provide passive range of motion/stretching to both legs every shift. R5's Care Plan lacked evidence of any interventions to address the contractures to his hands and arms. The Safe Transitions Goals/Functional Maintenance Plan with a program start date of 08/31/23, for R5, directed staff to perform passive range of motion/stretching within tolerance one time per shift for contracture management. The maintenance plan lacked information regarding which contractures were being managed with this plan. R5's Documentation Survey Report for 01/01/24 - 01/31/24 had an intervention/task for a restorative program for staff to provide passive range of motion/stretching to both legs every shift. 27 shifts out of 62 were documented as not applicable, eight out of 62 shifts were documented as refused, and 20 shifts out of 62 lacked any documentation. R5's Documentation Survey Report for 01/01/24 - 01/31/24 lacked evidence of any restorative intervention/task for R5's hands or arms. On 02/05/24 at 10:50 AM R5 was in his room in bed. R5's hands were closed into a fist and his fingernails were approximately an inch long on both hands. R5 stated he did not have any brace/cushion for his hands and that the staff did not perform any exercises/stretches on his hands. On 02/08/24 at 08:37 AM R5 was in his room in bed. R5's hands were closed into a fist, and he rested them on his chest. On 02/08/24 at 11:29 AM Certified Nurse Aide (CNA) O stated staff would try performing leg exercises with R5; however, CNA O stated R5 would refuse and state that the exercises were painful. CNA O stated staff were supposed to raise R5's legs up and down for one to two minutes a shift. CNA O stated physical therapy instructed staff and demonstrated the exercises staff were expected to do with R5. CNA O Further stated staff were not doing any exercises/stretches with R5's hands. CNA O stated R5 had refused the exercises/stretches several times so staff would mark not applicable in his EMR and not ask him if he wanted to do them due to refusals. CNA O stated sometimes staff would ask R5 if he wanted to do them, and sometimes they wouldn't. On 02/08/24 at 11:50 AM Licensed Nurse (LN) G was not sure about R5's current restorative program. LN G stated therapy had tried a brace/palm pillow for R5's hands before, but R5 didn't care for them so the staff did not apply them very often. On 02/08/24 at 12:37 PM Administrative Nurse D stated the facility did not have a formal restorative program. Administrative Nurse D stated the facility was still doing restorative interventions for some residents despite not having a formal program and the exercises would have been in the resident's care plan. Administrative Nurse D further stated she expected staff to work with a resident's hands and joints during baths or clothing changes. Administrative Nurse D stated she did not believe staff had specific training for restorative/ROM training and all staff were expected to monitor for decline and were to report any noted change to physical therapy or clinical management. A ROM/restorative policy was not provided by the facility. The facility failed to ensure R5 received services/interventions to prevent a reduction of ROM and contractures. This deficient practice left R5 at risk for further decline and decreased ROM or mobility.

The facility identified a census of 54 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide ADL care including trimming his fingernails/toenails for Resident (R) 5. The facility also failed to provide ADL care and assistance to R9. This deficient practice placed the residents at risk for poor hygiene, decreased self-esteem, and impaired health. Findings included: - The Diagnoses tab of R5's Electronic Medical Record (EMR) documented diagnoses of chronic inflammatory demyelinating polyneuropathy (CIDP - a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), generalized muscle weakness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R5 required substantial assistance, where staff did more than half the effort, for eating and oral hygiene. The MDS further documented R5 was dependent on staff for toileting hygiene, bathing, dressing, transfers, and mobility. The Quarterly MDS dated [DATE], documented R5 was dependent on staff for eating, oral hygiene, and personal hygiene. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 08/15/23, documented R5 required assistance with ADLs. R5's Care Plan with an initiated date of 09/17/23, documented R5 had an ADL self-care performance deficit and both arms, hands, and legs were contracted (abnormal permanent fixation of a joint or muscle ). An intervention with an initiated date of 08/06/23 documented R5 required two staff assistance with bathing and directed staff to offer to assist with bathing twice per week and as needed. An intervention with an initiated date of 08/06/23, documented R5 required two staff assistance to reposition and turn him in bed. An intervention with an initiated date of 08/06/23, documented R5 required one staff assistance to eat. An intervention with an initiated date of 08/06/23, documented R required assistance of one staff for personal hygiene and oral care. The intervention further directed staff to use oral swabs to provide oral care upon rising, after meals, and before bed. An intervention with an initiated date of 08/06/23, documented R23 required a Hoyer (total body mechanical lift) and two staff assistance for transfers. An intervention with an initiated date of 08/31/23, directed staff to provide passive range of motion/stretching to both legs every shift. R5's EMR lacked evidence that he refused to have his fingernails trimmed. On 02/05/24 at 10:50 AM R5 was in his room in bed. R5's hands were closed into a fist and his fingernails were approximately an inch long on both hands. R5 stated his fingernails needed to be cut, but felt staff were too busy to cut them for him. R5 stated that he wanted to have his hair cut and beard trimmed as well. R5's hair and beard were unkempt, he had body odor, and dry skin on his face/beard area, hands, and feet. R5's toenails were thick and approximately half an inch long. R5 stated he did not like the way he felt with his hair, beard, and nails grown out. On 02/08/24 at 08:37 AM R5 was in his room in bed. R5's hands were closed in a fist and his fingernails remained approximately an inch long on both hands and his toenails remained approximately half of an inch. R5's hair and beard were unkempt, he continued to have body odor and dry skin on his hands and feet. R5 stated he did not like having a beard and hoped it, and his hair would be trimmed that day. He further stated a staff member mentioned trimming his nails, but that it was not done. R5 stated he believed staff were too busy to trim them. On 02/08/24 at 11:50 AM Licensed Nurse (LN) G stated Certified Nurse Aides (CNA) should trim R5's fingernails on his bath days. LN G stated if R5 refused a bath or to have his fingernails trimmed, the refusal would have been documented in his EMR as a progress note. On 02/08/24 at 12:37 PM Administrative Nurse D stated CNAs and nurses were able to trim a resident's fingernails and that it would normally have been done on the resident's bath days. Administrative Nurse D stated R5's fingernails were too thick, and he was placed on a list to see a specialist to have them trimmed. Administrative Nurse D further stated R5 was sent to the hospital and missed his appointment to have his nails trimmed. Administrative Nurse D stated if a resident missed their appointment with the specialist, then the facility would have attempted to reschedule as soon as possible, and the resident would have been placed on a list to be seen when the specialist was scheduled to return to the facility. An ADL policy was not provided by the facility. The facility failed to provide ADL care for R5 which included trimming his fingernails and toenails. This deficient practice had the risk of poor hygiene, decreased self-esteem, and impaired health for R5. 40688 - R9's Electronic Medical Record (EMR) documented diagnoses of chronic osteomyelitis (local or generalized infection of the bone and bone marrow) of the left tibia (bone of the lower leg )and fibula (one of the two bones of the lower leg), repeated falls, symptoms and signs involving cognitive functions and awareness, acquired absence of the right toe, difficulty walking, muscle weakness, Stage 3 (full thickness pressure injury extending through the skin into the tissue below), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the left hip and left and right heels. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R9 required partial to moderate assistance from staff for bed mobility. R9 was dependent on staff for all transfers and toileting hygiene. The MDS recorded R9 was always incontinent of both urine and bowel and was not on a toileting program. The MDS recorded R9 had one Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters), two Stage 3 pressure ulcers, one unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) and a surgical wound. The MDS documented R9 was at risk for developing pressure ulcers and had a pressure-reducing device on his bed and wheelchair. R9 received pressure ulcer care, surgical wound care, and nonsurgical dressings and ointments but not a turning or repositioning program. The Incontinence Care Area Assessment (CAA) dated 10/17/23 documented R9 had chronic osteomyelitis of the left and right tibia and fibula, sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) and repeated falls. R9 needed assistance with using the toilet and was incontinent. R9's Care Plan dated 10/11/23 and revised on 02/04/24 documented R9 had pressure wounds to his left and right heels, left hip, and right inner ankle; he had a vascular wound (wound resulting from poor circulation) on his right foot and leg. An intervention dated 10/14/23 directed staff to offer R9 a urinal and check and change his every two to three hours and as needed (i.e., upon rising, after all meals, and before bed); check routinely throughout the night. R9's Care Plan dated 10/12/23 and revised on 10/14/23 documented R9 had an ADL self-care deficit and was non-weight bearing on his legs. The plan directed staff R9 required a full body mechanical lift (Hoyer) with assistance from two staff for all transfers and required assistance from one staff for bed mobility and repositioning. An intervention dated 10/27/23 directed staff to encourage R9 to get out of bed daily; R9 was able to tolerate being up two to three hours at a time. On 02/06/24 at 07:38 AM Administrative Nurse E pushed R9 from his room to the dining room table in a wheelchair. R9 wore socks on both feet and his feet rested directly on the wheelchair pedals. On 02/06/24 at 09:36 AM R9 remained in his wheelchair at the dining room table. R9 wore socks on both feet and his feet rested directly on the wheelchair pedals. On 02/06/24 at 10:51 AM R9 sat in his wheelchair which was parked next to R9's bed. R9 leaned forward in his chair so that his upper body and head rested on his bed. R9's eyes were closed, and he appeared to be asleep. On 02/06/24 at 01:32 PM, R9 sat in his wheelchair at the dining room table. His eyes were closed, and he appeared to be asleep. On 02/06/24 at 01:54 PM, R9 sat in his wheelchair. His pants were visibly saturated to his mid-thigh area. Certified Nurse Aide (CNA) O and Administrative Nurse E prepared to transfer R9 into bed. On 02/06/24 at 02:30 PM, R9 lay in bed on his right side with a pillow between his legs. His right heel rested directly on the mattress. On 02/06/24 at 02:18 PM, CNA O stated R9 had not been laid down or changed since 08:00 AM because CNA O had been busy. CNA O further stated R9 used to have pressure-relieving boots for his heels but those disappeared. She went on to say she knew how to access the resident's plan of care in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 02/08/24 at 09:46 AM CNA M stated R9 should be turned toward the wall so he did not fall and did not lay on the wound vac. CNA M stated R9 should be changed every two to three hours. On 02/08/24 at 10:29 AM CNA N stated R9 should have a pillow between his legs and R9's heels should be elevated on a pillow. CNA N said the Kardex informed staff of each resident's care needs. CNA N said R9 should be changed every two to three hours. On 02/08/24 at 01:31 PM Administrative Nurse D stated R9 was able to talk and communicate his needs. She said she expected staff to check and change R9 every two hours and to put him down (in bed) in between meals. Administrative Nurse D said all staff knew R9 was at high risk for skin breakdown and needed to be changed frequently. Administrative Nurse D stated it was the routine process for the CNA staff to reposition R9 at least every two hours. She said R9 had a lot of wounds when he was admitted . Administrative Nurse D stated she expected staff to follow the resident's care plan. The facility did not provide a policy related to the provision of care with ADL. The facility failed to provide ADL assistance and services for R9 who was dependent on staff for transfers and toileting. This placed R9 at risk for avoidable complications and impaired quality of life.

The facility identified as census of 54 residents. The sample included 14 residents with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24's discharge summary included medication reconciliation and instructions. This placed R24 at risk for not receiving timely and appropriate care. Findings included: - The Electronic Medical Record (EMR) for R24 documented diagnoses of atrial fibrillation (A-fib: a rapid, irregular heartbeat), hypertension (HTN- an elevated blood pressure), syncope (fainting or passing out), and transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain). The Admission Minimum Data Set (MDS) dated [DATE] documented R24 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The Functional Care Area Assessment (CAA) dated 01/25/24 for R24 documented she was receiving skilled services and was seen by therapy with the goal of returning home. Improvement was anticipated as she worked with therapy. R24 required assistance with her activities of daily living (ADLs). R24's Discharge Care Plan initiated 01/24/24 directed staff to arrange for home health services with a company of R24's choice. Staff was directed to assist as needed with R24's post-discharge follow-up appointments. Staff was directed to provide R24, her family, and/or the responsible party with written discharge instructions upon her discharge from the facility. R24's EMR documented a Health Status Note dated 02/01/24 at 12:40 PM to document that R24 had been discharged home with home health services. R24 was sent home with her medications, her discharge instructions, and personal belongings. R24's medications were called to her pharmacy of choice. R24's transportation was provided by her family. A review of R24's Discharge Summary Form dated 02/02/24 revealed the lack of a medication reconciliation and medication instructions. On 02/08/24 at 11:19 AM Licensed Nurse (LN) G stated the nurse would review medications and provide a copy of the current physician's medication orders to the resident at the time of discharge. LN G stated he was not sure if a copy of the current medication orders was scanned into the EMR with the discharge summary. On 02/08/24 at 12:37 PM Administrative Nurse D stated social service staff initiated the discharge process for the residents. Administrative Nurse D stated the nursing staff reviewed any future physician appointments, current medication orders, and treatment orders with the resident prior to discharge. Administrative Nurse D stated the medications should be included in the discharge summary. The Discharge Summary and Plan policy revised in November 2022 documented that the discharge plan would include resident and family/caregiver education needs and would initiate or maintain collaboration between the nursing facility and the other post-acute providers to support the resident's transition to community living. The discharge plan, instruction, and summary provided a recapitulation or summary of the resident's stay. The nurse would review discharge instructions and medications with the resident/resident representatives. A copy of the disposition of medication form would be given to the resident/resident representative and a copy scanned into the medical record. The nurse would document a discharge note in the progress notes section of the resident's medical record. The discharge note would include- a skin assessment, who the resident was discharged with, where the resident was discharged to, what belongings were sent with them, and other pertinent information. The facility failed to ensure R24's discharge summary included medication reconciliation and instructions. This placed R24 at risk for not receiving timely and appropriate care.

The facility identified a census of 54 residents. The sample included 14 residents with 14 residents reviewed for quality of care. Based on observation, record review, and interview, the facility failed to apply Geri Sleeves (sleeves used to protect the skin on the arms and legs against damage caused by friction and shearing) to Resident (R) 23 per her care plan and the facility failed to follow physician ordered daily weights for R10 who required the use of a diuretic (a medication used for the formation and secretion of urine and reduce excess fluids). This deficient practice placed R23 at risk for skin injury and placed R10 at risk for excess fluid accumulation and physical complications. Findings included: - R23's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Annual Minimum Data Set (MDS) dated [DATE] noted the Brief Interview for Mental Status (BIMS) assessment was unable to be completed. The MDS documented R23 had problems with recall ability and short-term and long-term memory. The MDS further documented R23 had severely impaired decision-making abilities. The MDS documented R23 required substantial assistance where staff did more than half the effort, for oral hygiene, personal hygiene, upper body dressing, and transfers. The MDS further documented R23 was dependent on staff for bathing, lower body dressing, and mobility through the use of a wheelchair. The MDS documented the resident had skin tears. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 01/03/24, documented R23 had advanced dementia and memory impairment. R23's Care Plan with an initiated date of 01/07/21, documented R23 was at risk for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) development related to immobility and compounded by incontinence. An intervention with an initiated date of 03/11/21, directed staff to apply Geri Sleeves on bilateral (both sides) lower extremities (BLE) and bilateral upper extremities (BUE) for skin protection. On 02/05/24 at 09:20 AM R23 was in a common area and sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) in front of a TV. R23 did not have Geri Sleeves applied to her BLE or BUE. On 02/07/24 at 02:03 PM, R23 sat in her Broda chair, in a common area, in front of a TV. R23 did not have Geri Sleeves applied to her BLE or BUE. On 02/08/24 at 11:24 AM R23 sat in her Broda chair, in a common area, in front of a TV. R23 picked at the skin on the side of her nose and caused it to bleed. R23 did not have Geri Sleeves applied to her BLE or BUE. R23's EMR lacked evidence the Geri Sleeves were being offered to R23 or that she had refused to use them. On 02/08/24 at 11:29 AM Certified Nurse Aide (CNA) O stated R23 had used the Geri Sleeves before, but R23 had not worn them for a few weeks. CNA O stated R23 would scratch herself and that was why the sleeves were used. CNA O stated R23 sometimes refused to let staff put them on her, and CNA O would notify the nurse when that happened so the refusal could be documented. On 02/08/24 at 11:50 AM Licensed Nurse (LN) G stated the care plan should have stated as needed for the Geri Sleeves. LN G further stated staff placed the sleeves on R23 when she would pick at her arms. LN G stated R23 would fixate on a location, such as a sore, and that she would pick at it. LN G further stated R23 did not pick at her skin all of the time and the sleeves were placed when she did it. LN G stated refusal to wear the Geri Sleeves would have been entered as a progress note. On 02/08/24 at 12:37 PM Administrative Nurse D stated it was not always possible to place the Geri Sleeves on R23 as it would sometimes agitate her. Administrative Nurse D went on to say staff were expected to at least try each day to place the sleeves on R23. The facility provided a Wound Prevention policy, with a reviewed date of 08/2023, documented the facility would provide initial and ongoing training to all clinical staff members on wound prevention techniques, early identification of wounds, and appropriate care interventions. The policy further documented all wound prevention measures, assessments, and interventions should be documented in the resident's service plans and medical records. The facility failed to apply the care planned Geri Sleeves to R23. This deficient practice placed R23 at risk for skin injury. 41037 - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and insomnia (inability to sleep). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R10 had received antianxiety (class of medications that calm and relax people), anticoagulant (class of medications used to prevent the formation of blood clots), diuretic (medication to promote the formation and excretion of urine), and opioid (a class of medication used to treat pain) for seven days during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R10 received antianxiety medication, anticoagulant medication, diuretic, and opioid medication during the observation period. R10's Psychotropic Drug Care Area Assessment (CAA) dated 07/20/23 documented R10 received routine antianxiety medication. R10's Care Plan dated 01/24/23 documented staff would obtain a daily weight related to diuretic medication. The plan of care documented the physician would be notified of a two-pound gain in 24 hours or a five-pound gain in five days. R10's EMR under the Orders tab revealed the following physician orders: Daily weight related to the use of diuretics one time a day. Notify the physician of a two-pound weight gain in 24 hours or a five-pound weight gain in five days dated 01/24/23. Furosemide (diuretic) tablet 40 milligrams (mg) give 60mg by mouth in the evening for edema, administer at 04:00 PM dated 01/04/24. Review of R10's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 11/01/23 to 02/05/24 (97 days) lacked evidence staff measured and recorded R10's weight on the following 10 dates 11/01/23, 11/10/23, 11/15/23, 11/24/23, 11/25/23, 12/18/23, 12/19/23, 12/24/23, 01/05/24, and 02/02/24. R10's refused on the following 26 dates for staff to obtain her daily weight on the following dates 11/06/23, 11/29/23, 12/05/23, 12/06/23, 12/15/23, 12/16/23, 12/17/23, 12/20/23, 12/21/23, 12/23/23, 12/25/23, 12/26/23, 12/27/23, 12/30/23, 01/03/24, 01/08/24, 01/09/24, 01/14/24, 01/15/24, 01/17/24, 01/18/24, 01/22/24, 01/23/24, 01/26/24, 01/28/24, 02/04/24, 02/05/24, and 02/06/24. Not Available was documented on the following two dates 12/28/23 and 01/02/24. See Progress notes was documented two times on the following dates 12/08/23 and 01/27/24. Sleeping was documented on 11/11/23. A weight gain of five pounds was noted on two occasions on the following dates 11/20/23 and 12/29/23. The clinical record lacked evidence of physician notification the daily weight was not obtained, refused, or the weight gain of five pounds. Observation on 02/06/24 at 10:53 AM R10 sat in her wheelchair in the dining room and drank a cup of coffee during the resident council meeting. On 02/08/24 at 11:05 AM Certified Medication Aide (CMA) R stated the nurse let the staff know who needed a daily weight. CMA R stated the nursing staff would notify the nurse of the resident's weight. On 02/08/24 at 11:19 AM Licensed Nurse (LN) G stated the facility would honor a resident's right to refuse their daily weight. LN G stated the physician should be notified if the resident would refuse frequently to be weighed daily when monitoring for edema; the nurse documented in the clinical record when the physician was notified and the physician's response. On 02/08/24 at 12:37 PM Administrative Nurse D stated the physician should be notified a resident had refused to be weighed daily as ordered or notified of a weight gain. Administrative Nurse D stated the nurse would document the notification in the EMR. The facility was unable to provide a policy related physician notification of weight monitoring for diuretic medication. The facility failed to follow a physician's order for daily weights to monitor weight gain for fluid overload for R10 who had edema and received a diuretic medication. This deficient practice placed R10 at risk of adverse side effects from unnecessary medication or complications related to fluid overload.

The facility identified a census of 20 residents. The sample included 3 residents reviewed for advanced directives (a written document which indicated the medical decisions for health care professionals when the resident could not speak). The facility identified 15 residents with advance directives of a Full Code status (indicating they wanted CPR, cardiopulmonary resuscitation with cessation of heartbeat and pulse). Based on observation, record review, and interview, the facility failed to provide CPR as desired when staff found resident #1, a full code resident without a blood pressure, pulse and was not breathing. The resident died . This placed the resident in immediate jeopardy. The facility also failed to have a system in place to accurately identify residents' code status in the facility. The facility listed resident #2 on the list of full code residents, when he/she had a Do Not Resuscitate (DNR) order in place. Findings included: - RESIDENT # 1's 5 day Minimum Data Set ((MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] recorded the resident with a BIMS of 15, and required assistance for ADLs. The care plan revised on [DATE] recorded the resident had an advanced Directive: Full Code. The resident's goal was for Advanced Directives and end of life care to be honored. The intervention was for Full Code Status and to provide advanced directives to appropriate entities upon any transfer. Progress note dated [DATE] recorded at 2:52 PM on [DATE], staff found the resident without breath sounds or pulse. Both feet and legs were mottled, the resident was cold to touch, and was turning blue around the lips. Staff told the nurse practitioner and told him/her the resident was a full code. Staff asked the nurse practitioner for an order to release body to mortuary of the family's choice; as there wasn't one listed on the chart. The clinical record lacked documentation that staff performed CPR on the Full Code resident. Observations were unavailable as the resident was deceased . On [DATE] at 12:44 PM, direct care staff F stated licensed nursing staff I went to the computer at the nurse ' s station to see what the resident's code status was. Direct care staff I stated that the resident was a full code. Licensed nursing staff I was calling the doctor and did not instruct direct care staff F to initiate, nor did licensed nursing staff I initiate CPR. At the time that staff found the resident, no vital signs were taken. The resident was a little cold, his/her feet were gray and he/she felt no pulse. Direct care staff F stated he/she was trained in CPR, but the nurse never told him/her to start CPR, and just called the doctor. The documentation of the code status is on the electronic chart and that is why the nurse went to check it. Direct care staff F stated there was a code book at the nurses' station 0n [DATE] at 4:05 PM, direct care staff G stated that during training, staff covered CPR and that if he/she found someone not breathing or unconscious, he/she should hit the emergency button and start CPR. Direct care staff G continued that there was an area in his/her tablet that recorded if the resident was a Full Code or a DNR. Direct care staff G stated he/she would ask a nurse if he/she didn't have the tablet, but would start CPR until the nurse arrived in the room, as staff trained him/her to start CPR until told otherwise. 0n [DATE] at 9:47 AM, direct care staff H stated the resident was a full code. On [DATE] at 11:39 AM, Licensed Nursing Staff B stated that staff could look in the computer system, the physician orders, the care plan, or the code status book at the nurses' station for the advanced directives. Licensed nursing staff B further stated that the Certified Nursing Assistants (CNAs) would know by looking at the code status book; there was not anything on the resident's door that would identify them as a full code or as a DNR. [DATE] 1:11 PM Licensed Nursing Staff I stated he/she was working the night the resident passed away, and around 4:03 AM during rounds staff identified the resident was not breathing. Licensed staff J came in and stated the resident was ice cold, and had probably been dead for 2 hours. He/she went to the computer to check and said the resident was a full code, but the resident was dead so he/she was not going to CPR at this time. Licensed staff J also made the comment that there is no way he/she was putting his/her mouth on anyone but his/her family. Licensed nursing staff I stated the resident was cold and kind of marble skin and left eye was slightly open and he/she closed the resident's eye. 0n [DATE] at 8:42 AM, licensed nursing staff C stated the computer profile provided the information if a resident is a full code or a DNR, and there was also a book at the nurse's station that showed the code status of the residents. Licensed nursing staff C stated if he/she went into a resident's room and they were unresponsive, he/she would have to check the areas to see code status. 0n [DATE] at 8:52 AM, licensed nursing staff D stated the best way locate a resident's code status was to look on the computer, or in a book at nurses station, with the Code Status. Licensed nursing staff D stated if he/she walked into a resident's room and found a resident unresponsive, he/she would go to his/her computer to check whether a resident was a Full Code or a DNR. On [DATE] at 11:04 AM, Administrative nursing staff A stated he/she would have expected the nurse to do CPR. The nurse would have to check the code status on the computer, because there was no way we can have that in the room. Administrative nursing staff A stated his/her expectation would have been for the nurse to go in with a stethoscope and assess and check code status and send the CAN to call 911 while he/she did CPR. The facility's undated policy titled Advance Directives recorded every elder admitted to the facility would receive life support, including resuscitation, unless a decision not to resuscitate has been previously made. It was the policy of this facility to recognize the right of elders and/or representatives to prepare Advance Directives. The policy directed staff to initiate CPR when [MEDICAL CONDITION] occurs for an elder who has requested CPR in the Advance Directives. The facility failed to perform CPR for this resident who requested to be Full Code Status. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy when they reviewed code status of all residents to ensure code status being reported in the resident's electronic record was current and reflective of the resident's wishes on [DATE].The facility educated staff on [DATE] on the DNR policy and how to enter and/or update code status on the electronic medical record. The facility also educated staff that regardless of the condition of the resident at the time of discovery, the staff must initial CPR per the physicians order. Even if the resident appeared to have been without vital signs for an extended period of time, CPR must be initiated and 911 called. - The 5 day Minimum Data Set (MDS) for resident #2 dated ,[DATE] recorded a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition The care plan revised on [DATE] recorded the resident had an advanced directive and was a full code. The resident ' s wishes were for Advanced Directives and end of life care will be honored. Observation on [DATE] at 10:20 A.M revealed the resident walked in the hall with therapy and walker. During an interview on [DATE] at 10:23 AM, the resident stated when he/she admitted to the facility, the staff talked with him/her regarding advanced directives when I came here. During an interview on [DATE] at 10:25 AM, the resident's family member stated he/she was a DNR. During an interview on [DATE] at 11:10 AM, administrative nursing staff A stated the social service staff was to check the code status when doing the care plan. Review of the clinical on [DATE] face sheet listed the resident as a FULL CODE when interview the resident at 10:23 AM he/she stated that the facility spoke with him/her and daughter on admission regarding advanced directives and that he/she made it known that it was to be a Do Not Resuscitate (DNR). The facility's undated policy titled Advance Directives recorded every elder admitted to the facility would receive life support, including resuscitation, unless a decision not to resuscitate has been previously made. It was the policy of this facility to recognize the right of elders and/or representatives to prepare Advance Directives. The policy directed staff to initiate CPR when [MEDICAL CONDITION] occurs for an elder who has requested CPR in the Advance Directives. The facility failed to maintain accurate documentation regarding the residents' code status in the facility. This deficient practice remained at the scope and severity of a F.