Every finding on record at Western Prairie Senior Living LLC

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 25 medication administration opportunities were observed with two medication errors identified for Resident (R) 10. This resulted in a medication error rate of eight percent.Findings included:- R10's Physician Orders, date ordered 11/21/24, recorded an order for budesonide suspension (an inhaled medication) 0.25 milligrams (mg)/ 2 milliliters (ml) vial, inhale orally via nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) two times a day related to interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue) after breathing treatment rinse mouth after use. Must be given separately. Do not mix with other nebulizer solutions.R10's Physician Orders recorded an order for Metamucil fiber (a laxative and fiber supplement), administer 2 tablespoons (Tbsp) by mouth, one time a day for bowel management, mix with eight ounces of fluid, date ordered 09/26/24.During an observation on 12/02/25 at 08:29 AM, Licensed Nurse (LN) G administered R10s budesonide suspension via nebulizer when the breathing treatment was completed. LN G removed the nebulizer mask and rinsed the equipment for another breathing treatment. LN G failed to offer R10 to rinse her mouth after use of the Budesonide suspension.During an interview on 12/02/25 at 08:50 AM, LN G reported she should have offered R10 a rinse of water after she removed the first breathing treatment.During an observation on 12/02/25 at 09:15 AM, Certified Medication Aide (CMA) R administered R10's Metamucil fiber. [NAME] pulled a stock bottle of fiber laxative from the med cart, poured some of the medication into the cap of the bottle, and then poured that into a cup. CMA R was requested to pour the medication from the cup into a plastic 30 ml medicine cup to verify the amount poured. CMA R poured the medicine into the measuring medication cup. Observed 10 ml of fiber laxative in the cup and reported that it was what she administered every day to R10, and reported that it was 2 tablespoons when she was asked what the dose was. CMA R then administered all of R10's medications.During an interview on 12/02/2025 11:47 AM, LN G reported that she expected the CMAs to provide the correct dose of medication and reported that R10 should have been administered the correct dose.During an interview on 12/02/25 at 11:51 AM, Administrative Nurse D reported she expected the LN's and CMAs to administer all medications correctly as per physician orders.The facility's policy Medication Administration General Guidelines, dated 2011, documented the medications are administered in accordance with written orders of the attending physician. Read the medication label and compare it with the medication administration record before pouring.

The facility reported a census of 33 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria.Finding included:- On 12/01/25 at 07:35 AM, the initial tour of the kitchen revealed a 50-pound bag of rice unsealed and sitting on the bottom shelf in dry storage. The following items did not have an open date: food coloring, a gallon of corn syrup, a bottle of vanilla, a gallon of milk, and a gallon of thousand island dressing. On 12/01/25 at 07:35 AM, observation of the refrigerator revealed a bag of sliced cheese unsealed, and a mixed salad with no date or label. There were food items with no dates, including a container of salsa and a bag of cauliflower. On 12/01/25 at 07:35 AM, observation of the freezer revealed a box of rolls on the floor and a bag of tamales for an employee. On 12/02/25 at 09:43 AM, Dietary Aide DD used the dishwasher. He reported he was not sure how to check the temperature and did not know about any temperature log. Observation revealed the temperature gauge showed 80 degrees Fahrenheit. The ice machine vent leaned on the floor over a dirty hole. On 12/03/25 at 10:05 AM, an observation in the kitchen revealed several stained and scratched cutting boards. A muffin tin had baked-on brown crusted areas. Further observation revealed pans with dents, scratches, and hard black substances on the cooking area surface. A large cooking pot had several dents, and the plastic lid covers were cracked and broken. On 12/03/25 at 12:25 PM, Administrative Staff A reported everything should be labeled with a date and sealed, and all kitchen equipment should be in good working order and clean. Administrative Staff A said the dishwasher temperature not being checked was a concern. The policy Dishwashing: Machine was revised on 4/27/20. The dining service staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in preparation and service of food. Appropriate documentation will be kept. The policy Food Storage, revised 04/06/20, documents the food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at an appropriate temperature and using appropriate methods to ensure the highest level of food safety. Label all food items with the name of the food and the date it was opened or prepared.

The facility reported a census of 33 residents. Based on observation, record review and interviews, the facility failed to promote a comfortable, sanitary, and homelike environment when the temperature in the activity room was below comfortable level, and chairs in the common area were worn with visible cushion-stuffing on the arms.Finding included:- During an observation on 12/01/25 at 07:33 AM, two green chairs by the 200-hall entrance had worn fabric on the arms of the chairs showing white stuffing. During an observation on 12/01/25 at 09:40 AM, Resident(R) 30, a nonverbal resident, sat in the activity room watching television, wrapped in a blanket. The room felt chilly, and upon assessment of the temperature, the ambient room temperature was approximately 64 degrees Fahrenheit (F). Further observation revealed a sign above the thermostat which directed to keep the thermostat between 70-75 degrees F. In an interview on 12/01/25 at 09:41, Administrative Staff A stated the activity room was on the cooler side of the building. Administrative Staff A approached the thermostat and increased it to 76 degrees F. On 12/01/25 at 10:00 AM, Administrative Staff A confirmed the temperature in the activity room was inadequate and said the facility would contact a service company to assess the situation. In an interview on 12/03/25 at 12:27 PM, Administrative Staff A stated the green chairs in the 200-hall lobby did have worn-down fabric and went on to say she did not think the surface of the chair arms was cleanable. On 12/02/25 at 11:56 AM, Administrative Staff stated she received an email confirmation from the service company confirming the heating valves had been closed, so no hot water was flowing through the coils. The service company opened the hot water valves and closed the cooling valves, and verified the units were heating like they should and were functioning properly at that time. The facility did not provide a policy.

The facility reported a census of 33 residents, the sample included 12 residents. Based on interview and record review, the facility failed to inform Resident (R) 17 and/or her representative regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:- R17's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R17's 11/05/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R17's MDS documented she had minimal depression and hallucinations (perceptual experiences in the absence of real external sensory stimuli), and delusions (misconceptions or beliefs that are firmly held, contrary to reality) during the look-back period. The MDS documented no behaviors. The MDS documented R17 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant (a class of medications used to treat mood disorders). R17's 11/12/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R17 was alert, oriented, and able to make herself understood and understand others. She had a diagnosis of dementia, a psychotic disorder with hallucinations. R17 received fluvoxamine (an antidepressant) and risperdal (an antipsychotic). Nursing staff would monitor for effectiveness and possible adverse reactions. The resident had feelings of sadness more than half the days. She stated she would be better off dead and related these feelings to the hallucinations she was having. She would continue to be followed by a behavioral health provider. R17's Care Plan dated 02/01/24 instructed staff to monitor R17 for any side effects from antidepressant medications such as sedation, drowsiness, dry mouth, blurred vision, urinary retention (lack of ability to urinate and empty the bladder), tachycardia (rapid heartbeat greater than 100 beats per minute), muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain. R17's Care Plan revised date 10/30/25 instructed staff to monitor R17 for any side effects from antipsychotic medications such as tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk), dry mouth, constipation, blurred vision, drowsiness, weight gain, increased risk of obesity, elevated blood glucose and high cholesterol, restlessness, stiffness, tremors and muscle spasms, contraction of the muscles of the neck, eyes, tongue, jaw and other muscle groups, and unsteady gait. R17's EMR documented an order for fluvoxamine 50 milligrams (mg) every evening for major depressive disorder dated 09/04/25. R17's clinical record lacked evidence of informed consent related to the medication. R17's EMR documented an order for risperidone 0.5 mg twice daily for dementia dated 11/20/25. R17's clinical record lacked evidence of informed consent related to the medication. R17's EMR documented an order for risperidone 0.25 mg twice daily for dementia dated 11/20/25. R17's clinical record lacked evidence of informed consent related to the medication. During an interview on 12/03/25 at 10:01 AM, Licensed Nurse (LN) G reported that Administrative Nurse E would obtain the consents for psychoactive medications from the resident or their representative. During an interview on 12/03/25 at 11:07 AM, Administrative Nurse E reported no consent was completed for R17's fluvoxamine or risperdal as of 12/03/25. Administrative Nurse E reported that a consent for psychoactive medications should have been completed when R17 was started on fluvoxamine and risperdal in September 2025, when ordered. The facility's policy Psychoactive Medications dated 12/04/24, documented psychoactive medications include antipsychotics and antidepressants. Prior to initiating or increasing a psychotropic medication, the resident, their family, and/or the resident's representative must be informed of the benefits of the medication, the risks of the medication, including any black box warning for any antipsychotic medications, and alternatives for the medication. A written consent form would serve as evidence of the resident's consent to psychotropic medication.

The facility reported a census of 33 residents; the sample included 12 with one resident reviewed for prevent decrease in range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) and mobility. Based on observation, interview, and record review, the facility failed to provide a hand carrot (most commonly refers to a hand contracture [abnormal permanent fixation of a joint or muscle] device, a tapered, carrot-shaped medical device used to position fingers away from the palm in cases of severe hand spasticity or contraction) to Resident (R) 8. Findings included:- R8's Electronic Medical Record (EMR) revealed diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) and cerebrovascular accident (CVA-stroke- 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), and chronic pain. R8's 03/14/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of nine, which indicated moderately impaired cognition. R8's MDS recorded impairment to one side of her upper and lower extremities. The MDS recorded R8 required total dependence of all activities of daily living (ADLs). R8's 03/28/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented she was dependent on staff for ADLs and mobility needs due to hemiplegia and hemiparesis following a cerebrovascular accident affecting the left non-dominant side. R8 was participating in restorative therapy to maintain her strength and ROM. R8's Care Plan instructed staff that she was participating in restorative therapy to maintain functioning by doing ROM to her extremities three to six days a week. Staff were instructed to apply a hand carrot to keep the left hand in a more open position. Staff were instructed R8 could complete active ROM with prompting, but required passive ROM for her left extremities. R8's Physician Orders lacked documentation for ROM or a hand carrot. R8's Restorative Aide Task documented a hand carrot was to be applied daily. The task review for the last 30 days revealed the carrot was documented eight times as non-applicable, and on 11/08/25 and 11/27/25, the record lacked any documentation regarding the application of the carrot. R8's Restorative Progress Note on 5/23/2025 at 03:58 documented R8 was participating in restorative therapy to maintain functioning by doing ROM to her extremities three to six days a week for at least 15 minutes per day. She participated well with frequent prompting. She was able to perform active ROM to the right extremities, but had passive ROM to the left side. A hand carrot was also added to the left hand due to contracting. R8's Restorative Progress Note on 11/25/2025 at 10:14 AM documented R8 was participating in restorative therapy to maintain functioning by doing ROM to her extremities three to six days a week and was also using a hand carrot to keep her left hand in a more open position. During an observation on 12/01/25, 8:15 AM, R8 sat in a wheelchair with a green lift sling under her. A blue colored right arm support was on her wheelchair, and her left hand was clenched shut with no device or carrot observed in her hand. During an observation on 12/02/25 at 7:35 AM, R8 sat in a wheelchair in the lobby. Her left hand remained tightly closed, with no device or carrot observed in her left hand. During an observation on 12/02/2025 at 03:50 PM, R8 laid in her bed with her eyes closed. R8 did not have a hand carrot noted in her left hand. She was unable to open her left hand when asked. During an observation on 12/03/2025 at 07:50 AM, R8 sat in a wheelchair in the lobby. Her left hand remained tightly closed with no device or carrot observed in her left hand. During an observation on 12/03/2025 at 09:24 AM, R8 sat in a wheelchair in the exercise room with several other residents. R8 had a left-hand carrot in place. During an interview on 12/02/25 at 03:54 PM, Certified Medication Aide (CMA) R reported that CNA O was the Restorative Aide and was the only staff member to apply the hand carrot. During an interview on 12/02/25 at 04:21 PM, CNA O reported that R8 should have the left-hand carrot applied every day for one to two hours on Monday through Saturday, as no restorative was completed on Sundays. CNA O reviewed the documentation in the EMR and reported that she would document non-applicable if the resident was asleep and reported that R8 slept a lot. During an interview on 12/02/25 at 04:29 PM, Licensed Nurse (LN) G reported that R8 would wake up easily and let the staff take care of her, then R8 would fall back to sleep. LN G reported that Administrative Nurse E would monitor the restorative aide's work. During an interview on 12/03/25 at 10:04 AM, Administrative Nurse E reported that she instructed CNA O to document non-applicable if the residents were asleep. Administrative Nurse E reviewed the documentation in EMR and reported she did not realize that R8 had a lot of non-applicable documentation for the hand carrot. Administrative Nurse E reported that she had mistakenly entered the hand carrot in EMR tasks. Administrative Nurse E said she changed it today to three to six times a day. She reported she did not think that R8 was missing that many days of having the hand carrot placed. During an interview on 12/03/25 at 10:21 AM, Administrative Nurse D reported she expected the restorative aide to complete all the residents' tasks daily and reported that if the resident was asleep, the resident should be re-approached when awake. The facility's policy Restorative Nursing dated 11/18/2017 documented residents will receive restorative nursing services to promote the ability to adapt and adjust to living independently and safely as possible. A restorative nursing program would be utilized to maintain and/or improve range of motion, mobility, and ADL skills.

The facility reported a census of 33 residents which included a sample of 12 residents and one resident reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when staff failed to provide adequate supervision which allowed Resident (R) 1 to exit the facility without staff knowledge or supervision. Findings included: - R1's Electronic Health Record (EHR) documented R1 had diagnoses which included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), adjustment disorder (a condition characterized by an excessive emotional or behavioral response to a stressful event or change in a person's life) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R1's 10/29/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The assessment documented rejection of care occurred one to three days, and wandering behaviors occurred four to six days during the look-back period. R1 was dependent on staff for all cares except eating, which was performed independently. R1 was independent with locomotion and transfers except toilet transfers, which required supervision. The 10/29/25 Cognitive Loss / Dementia Care Area Assessment (CAA) documented R1 had diagnoses that included Alzheimer's and dementia with wandering and rejection of care behaviors. Staff would redirect and provide frequent monitoring. The 10/29/25 Behavioral Symptoms CAA documented R1 had diagnoses that included Alzheimer's and dementia, and had behaviors that included frequent wandering. R1 wandered into other residents' rooms. Staff would frequently monitor R1 and provide redirection and distraction. R1 had an elopement bracelet in place (a bracelet that helps monitor residents who are at risk of wandering). R1's Care Plan, documented on 10/23/25, R1 was at risk for elopement and provided the following interventions:Staff would ensure R1's elopement bracelet was on and functioning properly every shift, created and initiated on 10/23/25.Staff would take R1's picture and keep a record of R1's information in case she ever left the building unattended, to be provided to anyone assisting to locate R1, created and initiated on 10/23/25 On 11/19/25, after the incident, R1's Care Plan was updated to include staff would attempt to keep the doors to R1's hallway closed. If she left the hallway, staff would closely monitor her and redirect her back to her hall, initiated on 11/16/25 and revised on 11/20/25. R1's Behavior Note dated 11/09/25 at 05:45 PM documented R1 was pacing and wandering and became agitated when staff attempted to redirect her. R1's Behavior Note dated 11/10/25 at 06:31 PM documented R1 wandered and paced throughout the facility with a steady gait (manner or style of walking) and became agitated when staff attempted to redirect her. R1's Behavior Note dated 11/11/25 at 05:10 PM documented R1 wandered and paced throughout the facility with a steady gait and became agitated when staff attempted to redirect her. R1's Behavior Assessment Progress Note dated 11/16/25 at 06:37 PM documented R1 wandered in the hallways and at other times into other residents' rooms. R1 was unable to stop wandering. R1's Behavior Assessment Progress Note dated 11/17/25 at 06:37 AM documented R1 displayed minimal wandering behaviors. Certified Medication Aide (CMA) J's unnotarized and undated witness statement documented on 11/16/25 at approximately 05:09 PM, R1 received her medications that accompanied the evening meal. The front door alarm sounded at the time of the evening meal. CMA J went to the front door and looked outside, then turned the alarm off, let a visitor out of the building, and then went back into the building to locate all the residents. CMA J documented she was then notified that R1 was found. Dietary EE's unnotarized and undated witness statement documented on 10/04/25, Dietary EE was outside and saw R1. Dietary EE assisted R1 back into the building. During an observation on 12/01/25 at 11:45 AM, R1 sat on the bed in her spouse's room with family in the room. She had an elopement bracelet on her left wrist. During an observation on 12/02/25 at 10:15 AM, R1 ambulated in the hallway holding hands with her spouse, with an elopement bracelet observed on her left wrist. During an interview on 12/03/25 at 08:57 AM, CMA J revealed R1 had wandering behaviors and was frequently redirected by her spouse. Staff sometimes intervened and redirected R1 with distractions or went on walks with R1 around the hallway where she lived. During an interview on 12/03/25 at 09:15 AM, Licensed Nurse (LN) G revealed R1 had wandering behaviors, and the wandering has improved since the intervention was implemented to keep the doors to the hallway where she lived closed. LN G said R1 often walked the hallway with her spouse, and her spouse was frequently able to redirect her away from other residents' rooms. During an interview on 12/02/25 at 04:45 PM, Administrative Staff A revealed that on the evening of 11/16/25 at approximately 05:22 PM, when the front door alarm sounded, staff responded appropriately, performed their duty, and met the facility's expectations. Administrative Staff A revealed the investigation included the review of security camera footage where R1 was observed following a visitor out the front door. Administrative Staff A reported the front doors had signage in English that warned visitors to not allow residents to leave the building. Administrative Staff A reported the visitor who allowed R1 to exit the building was Spanish-speaking only and therefore could not read the signage in English. Administrative Staff A reported that the signage on the front doors has been changed to include English and Spanish. Administrative Staff A also revealed that visitors, when they arrived in the facility, were being verbally educated and encouraged by staff to not allow anyone else out of the building when they exited. The facility's Elopement policy, dated 11/28/17, documented the facility would provide adequate supervision and devices to deter elopement.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure medications were available for administration, as ordered by the physician, for Resident (R) 17.Findings included:- R17's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R17's 11/05/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R17's MDS documented she had minimal depression, hallucinations (perceptual experiences in the absence of real external sensory stimuli), and delusions (misconceptions or beliefs that are firmly held, contrary to reality) during the look-back period. The MDS documented no behaviors. The MDS documented R17 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant (a class of medications used to treat mood disorders). R17's 11/12/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R17 was alert and oriented and able to make herself understood and understand others. She had diagnosis of dementia, psychotic disorder with hallucinations. R17 received fluvoxamine (an antidepressant) and risperdal (an antipsychotic). Nursing staff would monitor for effectiveness and possible adverse reactions. The resident had feelings of sadness more than half the days. She stated she would be better off dead and related these feelings to the hallucinations she was having. She would continue to be followed by a behavioral health provider. R17's Care Plan dated 02/01/24 instructed staff to monitor R17 for any side effects from antidepressant medications such as sedation, drowsiness, dry mouth, blurred vision, urinary retention (lack of ability to urinate and empty the bladder), tachycardia (rapid heartbeat greater than 100 beats per minute), muscle tremor, agitation, headache, skin rash, photosensitivity (sensitive to the light), and excess weight gain. R17's EMR documented an order for fluvoxamine 50 milligrams (mg) every evening for major depressive disorder dated 09/04/25. R17's Medication Administration Record (MAR) documented six missed doses of fluvoxamine 50 mg every evening, dated 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25, and 11/19/25. R17's Orders Administration Note on 11/14/25 at 09:07 PM documented fluvoxamine 50 mg was not available. R17's Orders Administration Note dated 11/15/25 at 08:59 PM documented fluvoxamine 50 mg was not available. R17's Orders Administration Note dated 11/16/25 at 09:58 PM documented fluvoxamine 50 mg was not available. R17's Orders Administration Note dated 11/17/25 at 09:06 PM documented fluvoxamine 50 mg was not received. R17's Orders Administration Note dated 11/18/25 at 08:32 PM documented fluvoxamine 50 mg was not received. R17's Orders Administration Note dated 11/19/25 at 10:03 PM documented fluvoxamine 50 mg was not available. During an observation on 12/02/25 at 07:45 AM, R17 laid in her bed with eyes closed. During an interview on 12/03/25 at 09:18 AM, Certified Medication Aide (CMA) S reported that she would let the charge nurse know if a medication needed to be reordered when the medication was not available. CMA S reported that the nurse would order medications from the facility's pharmacy. During an interview on 12/03/25 at 09:42 AM, Licensed Nurse (LN) G reported the CMAs should let the nurse know when a medication was not available to administer and when a medication would need to be re-ordered from the facility's pharmacy. LN G reviewed R17's MAR and confirmed that R17 missed six doses of fluvoxamine in November 2025. During an interview on 12/03/25 at 10:29 AM, Administrative Nurse D reported she expected staff to order the medications and that all the residents should receive all their medications per the physician's orders. The facility's policy Ordering and Receiving Medications from Provider Pharmacy dated 2011 documented medications and related products are received from the provider pharmacy on a timely basis. Refill medications are ordered as follows: Five days in advance of need to assure an adequate supply is on hand. The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions for use or previous labeling errors. The refill order is called in, faxed, or otherwise transmitted to the pharmacy. If orders are transmitted, a copy of the confirmation should be saved by the facility.

The facility reported a census of 33 residents, with 12 residents sampled, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon thepharmacist's monthly medication regimen review (MRR) for Resident (R) 17 and R8. Findings included:- R17's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R17's 11/05/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R17's MDS documented she had minimal depression, and she had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality) during the look-back period. The MDS documented no behaviors. The MDS documented R17 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant (a class of medications used to treat mood disorders). R17's 11/12/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R17 was alert and oriented and able to make herself understood and understand others. She has diagnosis of dementia, psychotic disorder with hallucinations. R17 received fluvoxamine (an antidepressant) and risperdal (an antipsychotic). Nursing staff would monitor for effectiveness and possible adverse reactions. The resident had feelings of sadness more than half the days. She stated she would be better off dead and related these feelings to the hallucinations she was having. She would continue to be followed by a behavioral health provider. R17's Care Plan dated 02/01/24 instructed staff to monitor R17 for any side effects from antidepressant medications such as sedation, drowsiness, dry mouth, blurred vision, urinary retention (lack of ability to urinate and empty the bladder), tachycardia (rapid heartbeat greater than 100 beats per minute), muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain. R17's EMR documented an order for Neurontin (an anticonvulsant) 300 milligrams (mg) three times a day for chronic pain, dated 11/29/23. R17's EMR documented a discontinued order for Cymbalta 60 mg (an antidepressant, a class of medications used to treat mood disorders) once a day for major depressive disorder, discontinued date 07/24/25. R17's Medication Regimen Review (MRR) dated 2/17/2025 documented a periodic review was needed due to the risk of loss of coordination, respiratory suppression, irritability, suicidal thoughts, fatigue, behaviors, and depression. There is a serious increase in side effect risks if given with opioids. The MRR recommended changing Neurontin 300 mg three times a day to twice a day, or if no change, the pharmacist requested a note of benefit and continued medication. Review of R17's EMR lacked the actual report and response from the physician. R17's MRR dated 04/16/25 documented a periodic review was needed because antidepressants are associated with falls, fractures, psychosis, and sedation. The MRR recommended changing Cymbalta 60 mg every other day for five doses, then discontinue or change Cymbalta to 30 mg daily; if no change, the pharmacist requested a note of benefit and continued medication. Review of R17's EMR lacked the actual report and response from the physician. During an observation on 12/02/25 at 07:45 AM, R17 laid in her bed with eyes closed. During an interview on 12/03/25 09:40 AM, Licensed Nurse (LN) G reported that Administrative Nurse D would receive the MRR and then email or fax the reports to the required physicians. LN G reported she would only see the MRR after the physician had addressed the recommendations. During an interview on 12/03/25 at 10:21 AM, Administrative Nurse D reported she expected to receive all the MRR back completed and in a timely manner from the providers. Administrative Nurse D reported it was not acceptable to not have an MRR completed and returned. During an interview on 12/03/25 at 02:15 PM, Consultant Pharmacist HH reported he expected the provider to respond to recommendations within 30 days. Consultant HH reported he would revisit a recommendation in six months if it was not answered. The facility's policy Medication Regimen Review (Monthly Report), dated 2011, documented resident-specific MRR recommendations and findings are documented and acted upon by the facility and/or physician. If recommendations are rejected, the physician must provide a brief explanation (such as in a dated progress note). When the physician does not act upon or rejects the MRR report/recommendations, and there is potential for serious harm, the facility and/or consultant pharmacist should contact the Medical Director. - R8's Electronic Medical Record (EMR) revealed diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) and cerebrovascular accident (CVA-stroke- 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), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R8's 03/14/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of nine, which indicated moderately impaired cognition. R8's MDS recorded she received antidepressants (a class of medications used to treat mood disorders). R8's 03/28/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R8 was usually able to make herself understood and understand others. She does have disorganized thinking but is easily redirected by staff. She is taking Cymbalta (an antidepressant). R8 reported feeling sad at times due to the father being gone, but denied any further intervention needed. Nursing would monitor medication for effectiveness and possible adverse reactions. R8's Care Plan instructed staff to monitor R8 for any side effects of the antidepressant medication, such assedation, drowsiness, dry mouth, blurred vision, urinary retention (lack of ability to urinate and empty the bladder), tachycardia (rapid heartbeat greater than 100 beats per minute), muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain. R8's EMR documented an order for Cymbalta 60 milligrams (mg) daily for depression dated 08/19/23. R8's Medication Regimen Review (MRR) dated 04/16/25 documented a periodic review was needed because antidepressants are associated with falls, fractures, psychosis, and sedation. The MRR recommended changing Cymbalta 60 mg every other day for five doses, then discontinue; change Cymbalta to 30 mg daily or, if no change, the pharmacist requested a note of benefit and continued medication. Review of R8's EMR revealed the physician responded on 08/27/25, four months later, and documented no change because R8 was wheelchair bound, cooperative, and behaviors were minimal. During an observation on 12/01/25 at 8:15 AM, R8 sat in a wheelchair with a green lift sling under her. A blue colored right arm support was on her wheelchair, and her left hand was clenched shut with no device or carrot observed in her hand. During an interview on 12/03/25 at 09:40 AM, Licensed Nurse (LN) G reported that Administrative Nurse D would receive the MRR and then email or fax the reports to the required physicians. LN G reported she would only see the MRR after the physician had addressed the recommendations. During an interview on 12/03/25 at 10:21 AM, Administrative Nurse D reported she expected to receive all the MRR back completed and in a timely manner from the providers. Administrative Nurse D reported it was not acceptable to not have an MRR completed and returned. During an interview on 12/03/25 at 02:15 PM, Consultant Pharmacist HH reported he expected the provider to respond to recommendations within 30 days. Consultant HH reported he would revisit a recommendation in six months if it is not answered. The facility's policy Medication Regimen Review (Monthly Report) dated 2011 documented resident-specific MRR recommendations and findings are documented and acted upon by the facility and/or physician. If recommendations are rejected, the physician must provide a brief explanation (such as in a dated progress note). When the physician does not act upon or rejects the MRR report/recommendations, and there is potential for serious harm, the facility and/or consultant pharmacist should contact the Medical Director.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to prevent a significant medication error when the facility did not administer Resident (R)17's antidepressant (a class of medications used to treat mood disorders) medication for six consecutive and never notified the physician.Findings included:- R17's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R17's 11/05/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R17's MDS documented she had minimal depression, and she had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality) during the look-back period. The MDS documented no behaviors. The MDS documented R17 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant. R17's 11/12/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R17 was alert and oriented and able to make herself understood and understand others. She has diagnosis of dementia, psychotic disorder with hallucinations. R17 received fluvoxamine (an antidepressant) and risperdal (an antipsychotic). Nursing staff would monitor for effectiveness and possible adverse reactions. The resident had feelings of sadness more than half the days. She stated she would be better off dead and related these feelings to the hallucinations she was having. She would continue to be followed by a behavioral health provider. R17's Care Plan dated 02/01/24 instructed staff to monitor R17 for any side effects from antidepressant medications such as sedation, drowsiness, dry mouth, blurred vision, urinary retention (lack of ability to urinate and empty the bladder), tachycardia (rapid heartbeat greater than 100 beats per minute), muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain. R17's EMR documented an order for fluvoxamine 50 milligrams (mg) every evening for major depressive disorder dated 09/04/25. R17's Medication Administration Record (MAR) documented six missed doses of fluvoxamine 50 mg every evening, dated 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25, and 11/19/25. R17's Orders Administration Note on 11/14/25 at 09:07 PM documented fluvoxamine 50 mg as not available. R17's Orders Administration Note dated 11/15/25 at 08:59 PM documented fluvoxamine 50 mg as not available. R17's Orders Administration Note dated 11/16/25 at 09:58 PM documented fluvoxamine 50 mg as not available. R17's Orders Administration Note dated 11/17/25 at 09:06 PM documented fluvoxamine 50 mg as not received. R17's Orders Administration Note dated 11/18/25 at 08:32 PM documented fluvoxamine 50 mg as not received. R17's Orders Administration Note dated 11/19/25 at 10:03 PM documented fluvoxamine 50 mg as not available. R17's Behavioral Health Provider Note dated 11/19/25 at 03:30 PM, documented nursing staff confirmed R17 had been taking all her medications as prescribed. R17's EMR lacked evidence the physician was notified during the six days the resident did not receive the medication as ordered. During an observation on 12/02/25 at 07:45 AM, R17 laid in her bed with eyes closed. During an interview on 12/03/25 at 09:42 AM, Licensed Nurse (LN) G reported the CMAs should let the nurse know when a medication was not available to administer and when a medication would need to be re-ordered from the facility's pharmacy. LN G reviewed the MAR and confirmed that R17 missed six doses of fluvoxamine in November 2025. LN G reported the provider should have been notified and confirmed that the provider had not been notified of the missed medication. During an interview on 12/03/25 at 10:29 AM, Administrative Nurse D reported she expected staff to order the medications and that all the residents should receive all their medication per the physician's orders. Administrative Nurse D reported she expected the LNs to notify the provider when a medication was not administered. During an interview on 12/03/25 at 10:43 AM, Consultant Staff GG, the behavioral health provider, reported that she was not notified that R17 missed the six doses of fluvoxamine in November 2025. Consultant Staff GG reviewed the MAR on her computer and reported that she observed staff's initials for the days of the missed medication and reported that she had not noticed the number nine above the initial, which indicated to see the progress note. Consultant Staff GG expected the staff to update her on any missed doses and reported the residents should not be missing medications, and said she wondered how this happened. The facility's policy Medication Error and Drug Reactions, dated 11/28/2017, documented all medication errors and drug reactions must be immediately reported to the physician, Director of Nursing, and the resident and/or their representative. All medication errors will be reviewed by the Quality Assurance Committee.

The facility reported a census of 33 residents with 12 residents sampled. Based on observation, interview and record review the facility failed to maintain an effective infection control practices for three residents, Resident (R) 7, R4, nd R2 related to incorrect use of personal protective equipment (PPE - gowns, face shields and/or eyeglasses/goggles, and gloves), lack of appropriate hand hygiene and inadequate enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) during high contact cares. The facility further failed to initiate contact precautions while awaiting culture results for clostridium difficile (C-diff- contagious bacterial infection characterized by foul-smelling frequent loose bowel movements).Findings included:- Review of R7's Electronic Health Record (EHR) under the Orders tab revealed a one-time order for a stool culture that included screening for c-diff, dated 11/20/25. Review of the scanned documents in R7's EHR revealed no results for the stool culture that included screening for c-diff. During an observation on 12/02/25 at 09:21 AM, Certified Nurse Aide (CNA) L and CNA K performed incontinence care for R7. Both CNA staff entered R7's room and donned gloves and a plastic gown without performing hand hygiene or putting the cuff of the gloves over the sleeves of the gown. They removed R7's blankets and lowered the bed to a flat position. They removed R7's brief, and CNA K cleaned R7's left and right inguinal folds (the groin crease where the leg joins the trunk), then cleaned stool off R7's genitals without obtaining a new wipe or folding to a clean portion of the wipe. CNA K pushed the soiled wipe between R7's legs below his genitals. CNA K then obtained a new wipe and further cleaned stool off R7's genitals and pushed the soiled wipe between his legs below his genitals. CNA L rolled R7 to his left side, and CNA K cleaned R7's buttocks and anus. CNA K removed her gloves, performed hand hygiene, donned new gloves, then removed the soiled wipes from between R7's legs but did not change her gloves or perform hand hygiene before continuing to the clean phase of incontinence care. CNA K placed a partially rolled up mattress protector pad and brief under R7, and both CNAs rolled the resident to his right and then onto his back for proper brief and mattress protector placement. CNA K cleaned R7's genitals wearing the same soiled gloves. CNA K then doffed the gloves, performed hand hygiene, and donned new gloves. CNA L doffed the PPE without performing hand hygiene and left the room to retrieve supplies for a full-body mechanical lift. When CNA L returned to the room, she donned gloves without performing hand hygiene and did not put on a gown. Both CNA staff positioned the sling for the mechanical lift under the resident and assisted R7 into his wheelchair. CNA L cleaned the handles of the mechanical lift and the crossbar for the mechanical lift with a disinfectant wipe. Both CNA staff removed their remaining PPE without performing hand hygiene and exited the room with the lift. During an interview on 12/02/25 at 09:49 AM with CNA K and CNA L, both CNA staff confirmed the observation findings and stated they should have performed hand hygiene upon entering R7's room prior to putting on any PPE. CNA K stated she should have changed gloves and performed hand hygiene when she removed the soiled wipes from between R7's legs and after cleaning R7's genitals before continuing with placement of the clean brief and mattress protector pad. CNA L revealed she should have performed hand hygiene after removing the PPE when she left the room to retrieve the mechanical lift. During an interview on 12/03/25 at 09:15 AM, Licensed Nurse (LN) G revealed prior to incontinence care, staff should perform hand hygiene before putting on any applicable PPE. LN G stated during incontinence care, the facility's procedure for cleaning residents allows the staff to wipe the resident, then fold the wipe once to expose a clean area of the wipe, then discard the wipe and retrieve a new wipe for additional cleaning if needed. LN G stated that every time gloves were removed, hand hygiene should be performed before putting on new gloves. LN G stated for EBP, the cuff of the gloves should be placed over the end of the sleeves on the gown. During an interview on 12/03/25 at 09:30 AM, Administrative Nurse D revealed staff were allowed to fold the wipe after use and utilize a clean portion of the wipe for a second pass if needed, and then the wipe should be discarded and a new wipe obtained if additional cleaning was required or necessary. During an interview on 12/03/25 at 01:20 PM, Administrative Nurse D confirmed the order for R7's stool to be cultured for c-diff and that the results had not been received from the laboratory. Administrative Nurse D revealed R7 should have been placed under contact isolation precautions instead of EBP when the provider ordered a c-diff culture. Administrative Nurse D stated staff should perform hand hygiene before putting on any PPE, when changing gloves during cares, and immediately following the removal of PPE before leaving the residents' rooms. Administrative Nurse D said that when putting on PPE for EBP, staff should put the gown on first, then the gloves, and tuck the sleeves of the gown inside the cuff of the gloves. The facility's Enhanced Barrier Precautions [sic] (EBP) policy, dated 04/01/25, documented EBP employed targeted gown and glove use during high-contact resident care activities. The policy did not outline the order in which the PPE would be applied or removed by staff. The facility's Hand Hygiene policy, dated 11/28/17, documented hands would be cleaned with soap and water after care for a resident with known or suspected c-diff infection. The policy documented hands would be cleaned with an alcohol-based hand-rub (ABHR) before and after contact with a resident and after removing PPE. If hands were visibly soiled, hands should be washed with soap and water. The facility's Isolation policy, dated 04/16/20, documented isolation precautions would be utilized when there is a reason to believe a resident has an infection or communicable disease.

The facility reported a census of 33 residents. Based on observation, record review and interviews the facility failed to promote a safe, sanitary environment on the ceilings throughout the residents rooms as well as the dining room and activity room. Findings included:- On 12/2/25 at 01:03 PM, observations during the environment tour with Maintenance Staff U revealed 31 of the 33 residents had missing ceiling tiles in their room next to the ceiling heat vent. Ceiling tiles in hall 200 and hall 300 near the dining room and activity room were discolored. On 12/2/25 at 1:03 PM, the dishwasher temperature was at 80 degrees Fahrenheit (F); the dishwasher is a low-temperature sanitation. Maintenance Staff U reported the plumber came into the facility while he had been gone to work on the dishwasher and connected the plumbing incorrectly to the cold piping. Maintenance Staff U fixed the plumbing and retested the temperature, which then measured 127 degrees F. On 12/02//24 at 01:03 PM, Maintenance Staff U said the ceiling tiles in the resident's room were not in place because the heating and cooling system was old and caused the ceiling tiles to get wet, causing them to be discolored and fall from the suspended ceiling. He said the facility removed the ceiling tiles to visualize the drips of water so they would know if there was a concern to address. The facility did not provide a policy.

The facility reported a census of 39 residents. Based on interview and record review, the facility failed to staff the facility with a Registered Nurse (RN) for eight consecutive hours each day, as required. Findings included: - The facility's time sheets, schedules, and staff posting, reviewed from 07/01/22 through 06/30/2023, the last four quarters, revealed the following dates without the required eight consecutive hours of registered nurse (RN) staff: July of 2022: 07/02-04/22, 07/09/22, 07/16-17/22, 07/23-24/22, and 07/30-31/22. August of 2022: 08/06/22, 08/13/22, 08/20-21/22, and 08/27-28/22. September of 2022: 09/03/22, 09/10-11/22, 09/18/22, and 09/24/22. October of 2022: 10/08-09/22, 10/15-16/22, and 10/29-30/22. November of 2022: 11/05-06/22, 11/12/22, and 11/19-20/22. December of 2022: 12/03-04/22, 12/10-11,22, 12/17-18/22, and 12/24/22. January of 2023: 01/01/23, 01/14/23, 01/22/23, and 01/29/23. February of 2023: 02/04/23, 02/11/23, and 02/19/23. March of 2023: 03/05/23, 03/19/23, and 03/26/23. April of 2023: 04/02/23, 04/09/23, 04/15-16/23, and 04/30/23. May of 2023: 05/07/23, 05/13/23, 05/20/23, 05/21/23, June of 2023: 06/03/23, 06/04/23, 06/10/23, 06/11/23, and 06/18/23. The facility lacked RN coverage for 63 days of the previous four quarters of staffing reviewed. On 12/07/23 at 02:00 PM, Administrative Staff A, confirmed the facility lacked the required RN staffing as noted above. He reported the facility had difficulty recruiting RNs in the facility rural setting. The facility failed to provide a policy to address the eight consecutive hours of registered nursing staff as required. The facility failed to provide RN coverage for eight consecutive hours each day for the residents of the facility as required on 63 occasions over the previous four quarters.

The facility reported a census of 39 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff coverage 24 hours a day and Registered Nurse (RN) coverage for eight consecutive hours each day. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for the fourth quarter of fiscal year (FY) 2022, (07/01/22 through 09/30/22), revealed the lack of a License Nurse (LN) for 24 hours/seven days a week (24/7) on 07/21/2022, 08/03/22, 08/06/22, 08/07/22, 08/09/22, 08/10/22, and 09/26/22 (seven days of the quarter). Review of the facility's time sheets for licensed nursing staff on the above dates, revealed the facility had the required licensed nursing staff 24 hours each day, as required. The facility reported inaccurate staffing data for seven days of the above quarter. Additionally, the Payroll Base Journal (PBJ) Staffing Data documented the facility lacked Registered Nurse (RN) coverage for eight consecutive hours each day on 22 dates which included 08/07/22, during the above timeframe. Review of the facility's time sheets for licensed nursing staff on the above dates revealed the facility had the required RN coverage for 8 consecutive hours on 08/07/22. The facility reported inaccurate staffing data for seven days of the above quarter. Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter one of 2023, (10/01/23 through 12/31/23), revealed the lack of a License Nurse (LN) for 24 hours/seven days a week 24/7) on 10/09/22, 11/20/22, and 12/10/22. Review of the facility's time sheets for licensed nursing staff on the above dates revealed the facility had the required licensed nursing staff 24 hours each day, as required. The facility had reported inaccurate staffing data. Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter two of 2023 (01/01/23 through 06/30/23), documented the facility lacked RN staffing for eight consecutive hours each day on 10 dates which included 01/02/23, and 01/29/23, during the above timeframe. Review of the facility's time sheets for licensed nursing staff on the above dates revealed the facility had the required RN coverage for 8 consecutive hours on 01/02/23 and 01/29/23. The facility submitted inaccurate staffing information. On 12/07/23 at 02:00 PM, Administrative Staff A confirmed the facility PBJ reporting to CMS lacked accurate data to reflect direct care provided by administrative nursing staff (RN) when providing direct care. He stated the facility did have 24-hours of a LN on duty each day. The above dates on the PBJ which did not reflect LN staffing was not accurate. He also confirmed the RN coverage documentation was not accurate as noted above. The facility lacked a policy to address the submission of accurate PBJ staffing report to CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff and RN coverage.

The facility reported a census of 39 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff, failed to clean a full body mechanical lift between resident uses, to change gloves and perform hand hygiene between phases of incontinence care and to perform hand hygiene between resident room contacts when delivering laundry to resident rooms. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility. Findings include: - On 12/06/23 at 10:00 AM, Certified Nurse Aide (CNA) G and CNA H moved a full body mechanical lift from Resident (R)14's room out into the hallway and into R24's room. Staff failed to clean the mechanical lift after use. On 12/06/23 at 10:08 AM, CNA G moved the mechanical lift from R24's room out into the hallway and into a supply storage closet. Staff failed to clean the mechanical lift after use. On 12/06/23 at 10:09 AM, CNA G confirmed the mechanical lift was not cleaned between resident uses or before storage. CNA G revealed that correct procedure was to clean the mechanical lift between resident uses and before the mechanical lift was placed in storage. On 12/07/23 at 12:09 PM, Administrative Nurse C revealed that lifts were to be cleansed/disinfected after every use. The facility failed to provide a policy related to cleaning of lifts as requested on 12/07/23. The facility failed to maintain an effective infection control program with the failure of staff to clean a mechanical lift between resident uses. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident that required a mechanical lift in the facility. - On 12/06/23 at 10:46 AM, R7 was in bed, and Certified Nurse Aide (CNA) G and CNA H provided incontinent cares. Staff pulled R7's slacks down and removed the soiled disposable brief. CNA G and CNA H cleansed R7's perineum (area of the body between genitals and anus) and buttocks. CNA G and CNA H placed a clean brief on R7. Staff failed to change their gloves and perform hygiene after dirty phase of incontinence care and before clean phase of incontinence care. On 12/06/23 at 11:06 AM, CNA G and CNA H confirmed that staff should perform hand hygiene and change their gloves between phases of incontinence cares and confirmed that they failed to perform hand hygiene and change gloves between phases of incontinence care. On 12/06/23 at 11:08 AM, Licensed Nurse (LN) D revealed that staff were to change their gloves and should perform hand hygiene between dirty and clean phases of incontinence care. On 12/06/23 at 11:08 AM, Administrative Nurse C revealed that staff where to change their gloves and perform hand hygiene between dirty and clean phases of incontinence care. On 12/06/23 at 11:16 AM, Administrative Nurse B revealed that her expectation was for staff to change gloves and perform hand hygiene between dirty and clean phases of incontinence care. The facility's Hand Hygiene policy, dated 11/28/17 documented staff were to perform hand hygiene after contact with body fluids or objects and surfaces in the resident's environment. The facility failed to maintain an effective infection control program with the failure of staff to change gloves and perform proper hand hygiene between phases of incontinence care. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility. - On 12/06/23 at 02:09 PM, Laundry Staff J observed delivering laundry to multiple resident rooms without performing hand hygiene with alcohol-based hand rub (ABHR) between resident rooms. On 12/06/23 at 02:10 PM, Laundry Staff J confirmed that she did not perform hand hygiene with ABHR between resident rooms. On 12/07/23 at 11:24 AM, Maintenance Manager K revealed that his expectation was for laundry personnel to perform hand hygiene with ABHR between resident rooms while delivering laundry. On 12/07/23 at 12:09 PM, Administrative Nurse C revealed that her expectation was for staff to perform hand hygiene with ABHR between resident room contacts for any reason. Further revealed that all staff have access to individual pocket-sized containers of ABHR as provided by the facility. The facility's Hand Hygiene policy, dated 11/28/17 documented that staff were to perform hand hygiene with ABHR after contact with objects and surfaces in the resident's environment. The facility failed to maintain an effective infection control program with the failure of staff to perform hand hygiene between resident room contacts when delivering laundry to resident rooms. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility.

The facility census totaled 39 residents. Based on observation, interview, and record review the facility failed to provide a sanitary environment by the failure to have lids on the trash cans in the soiled utility rooms. This deficient practice had the potential to be an unsanitary environment which would affect all residents in the facility. Findings included: - On 12/07/23 at 11:24 AM, Maintenance Manager K, identified three soiled utility rooms in the facility during environmental tour: 1. On the 200-hall, the trash can in the soiled utility room lacked a lid or cover. 2. On the 300-hall, the trash can in the soiled utility room lacked a lid or cover. 3. On the 400-hall, the trash can in the soiled utility room lacked a lid or cover. On 12/07/23 at 11:30 AM, Maintenance Manager K revealed that all trash cans in the soiled utility rooms should be always covered with a lid. On 12/07/23 at 12:22 PM, Administrative Nurse B revealed that all trash cans in the soiled utility rooms should be always covered with a lid. On 12/07/23 at 12:30 PM, Administrative Staff A revealed that all trash cans in the soiled utility rooms should be always covered with a lid. The facility failed to provide a policy related to lids or the covering on trash cans in the soiled utility rooms as requested on 12/07/23. The facility failed to provide a sanitary environment by the failure to have lids or covers on the trash cans in the soiled utility rooms. This deficient practice had the potential to be an unsanitary environment which would affect all residents in the facility.

The facility census totaled 39 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to complete an accurate Minimum Data Set (MDS) for two sampled residents including, Resident (R)7 by the failure to include the resident's pressure ulcer and (R) 29's indwelling urinary catheter use on the MDS. Findings included: - R7's pertinent diagnoses from the signed Physician's Order dated 11/23/23 included Alzheimer's disease with late onset (progressive mental deterioration characterized by confusion and memory failure), severe dementia (progressive mental disorder characterized by failing memory and confusion), with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 7/17/23 Significant Change in Status MDS revealed a BIMS of 99 indicating severely impaired cognition. R7 required extensive assistance of one to two staff for all cares and was always incontinent of bowel/bladder. The assessment indicated no current pressure ulcer and the resident was not at risk for a pressure ulcer. The resident had pressure relieving devices on his bed/chair with a turn/reposition program. The 09/14/23 readmission Significant Change in Status Minimum Data Set (MDS) revealed the resident as unable to complete a Brief Interview for Mental Status (BIMS) with memory problems and severely impaired cognition. R7 required total dependence of two staff for all cares and was always incontinent of bowel/bladder. The assessment indicated no current pressure ulcer and the resident not at risk for a pressure ulcer. The resident had pressure relieving devices on his bed/chair with a turn/reposition program. The facility failed to include a coccyx wound/pressure ulcer identified by staff upon acute care readmission on 09/07/23, for an accurate MDS. The 09/14/23 Care Area Assessment (CAA) documented: Pressure Ulcer CAA-Resident had Alzheimer's and dementia. She was non-verbal and rarely understood or able to understand others. Staff need to pay attention to non-verbal cues and anticipate needs/wants. She was incontinent and requires staff assistance for all Activities of Daily Living (ADLs) including incontinent brief check and change. Staff need to reposition the resident every two hours. The resident has a pressure reducing mattress and cushion to the wheelchair. The record lacked documentation of a coccyx wound/pressure ulcer. The 12/06/23 Care Plan lacked instructions related to the resident's coccyx wound, wound prevention, or wound treatment when the resident readmitted to the facility with the wound/pressure ulcer on 09/07/23. The Electronic Health Records (EHR) Physician Orders dated 11/03/23 documented instructions to staff to apply a Mepilex dressing to the resident's coccyx and to change it one time a day, every three day(s) and as needed PRN. Staff to monitor the coccyx dressing site each shift. The Treatment Administration Record (TAR) documented 11/03/23 to 12/06/23 the staff changed of the dressing to the resident's coccyx and dressing checks of the resident's coccyx dressing. This record lacked documentation of the coccyx wound/pressure ulcer care prior to 11/03/23. The wound was first documented on readmission to the facility from acute care on 09/07/23 as a coccyx slit. The Progress Notes dated 09/07/23 at 04:30 PM, documented the resident readmitted from acute care with Hospice services at 03:30 PM. Hospice in the facility to assess the resident. Skin assessment revealed an open slit to the resident's coccyx. Staff changed the Mepilex dressing to the resident's coccyx pressure ulcer. The note lacked further description or measurement of the area. R7's EHR lacked weekly documentation with description of the coccyx wound/pressure ulcer. On 9/14/2023 a Braden Scale for Predicting Pressure Sore Risk identified the resident with a score of 12 (high risk). On 11/03/23 at 06:29 AM, a Skin/Wound Note documented R1 had a two centimeter (cm) open area to the coccyx. The surrounding skin was within normal limits. Staff applied a Mepilex dressing and notified the wound care nurse. The EHR reviewed, revealed no further documentation with description or measurements of the wound. Review of Hospice progress notes revealed: On 09/07/23 documented skin as progressing without additional documentation found. On 09/21/23 documented skin as progressing. On 10/05/23 documented skin as progressing. On 10/19/23 documented no skin integrity issues. On 11/02/23 documented no skin integrity issues. On 11/16/23 documented 1 cm area of concern to coccyx. Observations on 12/06/23 from 08:30 AM to 10:46 AM, (two hours and 16 minutes) revealed the resident sat in her recliner with feet elevated and without staff offering the resident a change of position. On 12/06/23 at 10:46 AM Certified Nursing Assistant (CNA) G, CNA H and Licensed Nurse (LN) C entered the resident's room and assisted R7 onto the bed. The staff rolled R7 to her right side, with clothing removed and loosened the brief. The staff removed the resident's brief. LN C removed the border gauze dressing to the resident's coccyx. CNA G then performed incontinence care with R7's skin on the bottom/coccyx area appearing red in color. LN C provided the wound measurement as one cm x one half cm. She then dated/initialed the dressing after she applied it to the wound. Interview on 12/06/23 at 10:58 AM with CNA G revealed the staff completed every two-hour check and change of the resident for incontinence. On 12/06/23 at 11:08 AM LN C reported she identified the resident's coccyx wound as a pressure wound that would open and close but stated that hospice was managing the wound. LN C stated she did a weekly skin assessment on all residents with wounds. LN C reported the wound was closed on 11/28/23 so no wound assessment was completed on that date. LN C reported she was not on duty when the resident readmitted from acute care and staff did not notify her of the resident's wound. The floor nurses were responsible for inputting the weekly skin assessment for residents with their showers. On 12/07/23 at 11:30 AM Administrative Nurse F confirmed the MDS completed on 09/14/23 was inaccurate by not including the resident's pressure ulcer on the assessment. On 12/07/23 at 12:22 PM Administrative Nurse B reported she expected the MDS, care plans and weekly skin/wound assessments to be accurate and completed. A policy for MDS assessments was requested on 12/07/23. The facility used the RAI manual as reference per facility staff. The facility failed to complete an accurate Minimum Data Set (MDS) for R7 by the failure to include the resident's pressure ulcer on the assessment. 49590 - The Electronic Health Records (EHR) documented R29 had the following diagnoses that included 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 sacral region (small triangular bone at the base of the spine) and urinary tract infection (UTI - an infection of the lower urinary tract including the bladder and urethra [the tube that carries urine from the bladder to the outside of the body]). The 09/07/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment documented R29 did not have an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The 09/07/23 Care Area Assessment (CAA) documented R29 had an indwelling catheter to promote wound healing. The Care Plan updated 09/20/23, documented R29 required a urinary catheter, and instructed staff to perform catheter care each shift and as needed. The Physician Orders documented 08/23/23 to continue the Foley catheter on admission. The Treatment Administration Record (TAR) from 8/31/23 to 12/08/23 documented indwelling catheter care performed each shift. The EHR documented the following: On 8/31/23 the EHR's -Bowel and Bladder Assessment documented R29 had a urinary catheter. Review of the progress notes revealed on 09/02/23, staff inserted a urinary catheter into the resident. On 09/04/23, R29's urinary catheter came out. On 09/06/23, R29's urinary catheter slipped out with fully inflated bulb during wound care. On 12/06/23 at 01:06 PM, Administrative Nurse F revealed that corporate personnel complete sections of the MDS and confirmed the MDS as inaccurate. On 12/07/23 at 01:18 PM, Consultant Nurse I confirmed the MDS was inaccurate. The expectation was that assessments were to be accurate per the guidelines of the Resident Assessment Instrument (RAI manual is an assessment that helps facility staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan). On 12/07/23 at 01:40 PM, Administrative Nurse B revealed that her expectation was for all assessments, including the MDS assessments, to be accurate. The facility's MDS policy dated 11/28/17, documented that residents would receive an accurate assessment reflective of the resident's status at the time of the assessment by staff who were qualified to assess and knowledgeable about the resident's status. The facility failed to accurately assess the MDS for R29 related to indwelling catheter. This placed the resident at risk for uncommunicated care needs including catheter care.

The facility census totaled 39 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to develop a comprehensive care plan for Resident (R)7 by the failure to include the resident's pressure ulcer. Findings included: - R7's pertinent diagnoses from the signed Physician's Order dated 11/23/23 included Alzheimer's disease with late onset (progressive mental deterioration characterized by confusion and memory failure), severe dementia (progressive mental disorder characterized by failing memory and confusion), with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 7/17/23 Significant Change in Status MDS revealed a BIMS of 99 indicating severely impaired cognition. R7 required extensive assistance of one to two staff for all cares and was always incontinent of bowel/bladder. The assessment indicated no current pressure ulcer and the resident was not at risk for a pressure ulcer. The resident had pressure relieving devices on his bed/chair with a turn/reposition program. The 09/14/23 readmission Significant Change in Status Minimum Data Set (MDS) revealed the resident as unable to complete a Brief Interview for Mental Status (BIMS) with memory problems and severely impaired cognition. R7 required total dependence of two staff for all cares and was always incontinent of bowel/bladder. The assessment indicated no current pressure ulcer and the resident not at risk for a pressure ulcer. The resident had pressure relieving devices on his bed/chair with a turn/reposition program. The facility failed to include a coccyx wound/pressure ulcer identified by staff upon acute care readmission on 09/07/23, for an accurate MDS. The 09/14/23 Pressure Ulcer Care Area Assessment (CAA) documented the resident had Alzheimer's and dementia. She was non-verbal and rarely understood or able to understand others. Staff need to pay attention to non-verbal cues and anticipate needs/wants. She was incontinent and requires staff assistance for all Activities of Daily Living (ADLs) including incontinent brief check and change. Staff need to reposition the resident every two hours. The resident has a pressure reducing mattress and cushion to the wheelchair. The record lacked documentation of a coccyx wound/pressure ulcer. The 12/06/23 Care Plan lacked instructions related to the resident's coccyx wound/pressure ulcer, wound prevention, or wound treatment when the resident readmitted to the facility with the wound/pressure ulcer on 09/07/23. The Electronic Health Records (EHR) Physician Orders dated 11/03/23 documented instructions to staff to apply a Mepilex dressing to the resident's coccyx and to change it one time a day, every three day(s) and as needed PRN. Staff to monitor the coccyx dressing site each shift. The Treatment Administration Record (TAR) documented 11/03/23 to 12/06/23 the staff changed of the dressing to the resident's coccyx and dressing checks of the resident's coccyx dressing. This record lacked documentation of the coccyx wound/pressure ulcer care prior to 11/03/23. The wound was first documented on readmission to the facility from acute care on 09/07/23 as a coccyx slit. The Progress Notes dated 09/07/23 at 04:30 PM, documented the resident readmitted from acute care with Hospice services at 03:30 PM. Hospice in the facility to assess the resident. Skin assessment revealed an open slit to the resident's coccyx. Staff changed the Mepilex dressing to the resident's coccyx pressure ulcer. The note lacked further description or measurement of the area. On 11/03/23 at 06:29 AM, a Skin/Wound Note documented R1 had a two centimeter (cm) open area to the coccyx. The surrounding skin was within normal limits. Staff applied a Mepilex dressing and notified the wound care nurse. The EHR reviewed, revealed no further documentation with description or measurements of the wound. Review of Hospice progress notes revealed: On 09/07/23 documented skin as progressing without additional documentation found. On 09/21/23 documented skin as progressing. On 10/05/23 documented skin as progressing. On 10/19/23 documented no skin integrity issues. On 11/02/23 documented no skin integrity issues. On 11/16/23 documented a one cm area of concern to coccyx. Observations on 12/06/23 from 08:30 AM to 10:46 AM, (two hours and 16 minutes) revealed the resident sat in her recliner with feet elevated and without staff offering the resident a change of position. On 12/06/23 at 10:46 AM Certified Nursing Assistant (CNA) G, CNA H and Licensed Nurse (LN) C entered the resident's room and assisted R7 onto the bed. The staff rolled R7 to her right side, with clothing removed and loosened the brief. The staff removed the resident's brief. LN C removed the border gauze dressing to the resident's coccyx. CNA G then performed incontinence care with R7's skin on the bottom/coccyx area appearing red in color. LN C provided the wound measurement as one cm x one half cm. She then dated/initialed the dressing after she applied it to the wound. Interview on 12/06/23 at 10:58 AM with CNA G revealed the staff completed every two-hour check and change of the resident for incontinence. On 12/06/23 at 11:08 AM LN C reported she identified the resident's coccyx wound as a pressure wound that would open and close but stated that hospice was managing the wound. LN C stated she did a weekly skin assessment on all residents with wounds. LN C reported the wound was closed on 11/28/23 so no wound assessment was completed on that date. LN C reported she was not on duty when the resident readmitted from acute care and staff did not notify her of the resident's wound. The floor nurses were responsible for inputting the weekly skin assessment for residents with their showers. On 12/07/23 at 11:30 AM Administrative Nurse F confirmed the Comprehensive Care Plan completed on 09/14/23 was inaccurate by not including the resident's pressure ulcer on the care plan, on 09/07/23, when returning from acute care with it. On 12/07/23 at 12:22 PM Administrative Nurse B reported she expected the MDS, care plans and weekly skin/wound assessments to be accurate and completed. A policy for care plans was requested on 12/07/23 with no policy provided. The facility failed to develop a comprehensive care plan for R7 by the failure to include the residents pressure ulcer on the plan of care, on 09/07/23 when R7 returned from acute care with it.

The facility census totaled 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified missing parameters for [MEDICATION(S)] (blood pressure medication), identify missing Abnormal Involuntary Movement Scale (AIMS), and notify the facility of an inappropriate diagnosis for the use of [MEDICATION(S)] (an antipsychotic) for Resident (R)11. The facility also failed to respond to the recommendation to attempt a Gradual Dose Reduction (GDR) of [MEDICATION(S)] (an antidepressant) for R1. Findings included: - R1's Order Summary Report dated 11/09/21 revealed a diagnosis of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not completed. R1 had short-term memory problems. R1 received an antidepressant six days during the lookback period. The Quarterly MDS dated [DATE] revealed a BIMS score of 11 indicating moderately impaired cognition. R1 received an antidepressant daily. The Cognitive Loss / Dementia CAA dated 04/29/21 revealed R1 had a diagnosis of major depressive disorder. The Care Plan dated 11/15/2021 revealed staff were to watch R1 for any side effects associated with the use of [MEDICATION(S)]. An order dated 11/02/21 for [MEDICATION(S)] 30 milligrams (mg), instructed staff to administer 90 mg by mouth daily for depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Medication Regimen Review (MRR) dated 09/20/21 revealed a recommendation for a GDR for [MEDICATION(S)] from 90 mg to 60 mg daily. There was no follow-up by the physician to this request. An observation on 01/25/22 at 07:47 AM revealed R1 sat in her wheelchair at the dining room independently eating breakfast. R1did not show any signs or symptoms of depression. In an interview on 01/26/22 at 10:15 AM, Administrative Nurse B stated pharmacist recommendations should be given to the physician for follow-up and expected back within a week, and if the physician did not agree with the recommendation they should provide a risk versus benefits statement stating why they disagreed with this request. The consulting pharmacist was unavailable for interview as attempted on 01/27/22 at 09:30 AM and 01/31/22 at 09:05 AM. The Medication Regimen Review (Monthly Report) policy dated 01/21 revealed: MRR recommendations and findings are acted upon and documented by the facility staff and/or prescriber per time-frame outlined in the facility policy .Prescriber accepts and acts upon suggestion, or rejects and provides an explanation for disagreeing. Per CMS regulations, if recommendations are rejected, the prescriber must provide a brief explanation . The facility failed to ensure the physician followed up on the consultant pharmacist recommendation of a GDR regarding [MEDICATION(S)] for R1. - The Order Summary Report dated 12/07/21 documented a diagnosis for dementia (progressive mental disorder characterized by failing memory and confusion) and hypertensive [CONDITION(S)] (elevated blood pressure). The Quarterly Minimum Data Set (MDS) dated [DATE] documented R11 had both short-term and long-term memory problems and received an antipsychotic and a diuretic daily during the last seven days. The Care Plan did not address the use of [MEDICATION(S)] or parameters. The Care Plan dated 01/10/22 documented R11 experienced behavioral symptoms. Interventions included to administer [MEDICATION(S)] (medication to treat mental disorders) as ordered to help manage her behaviors. The 10/15/19 Physicians Orders documented [MEDICATION(S)] (medication to treat high blood pressure) 50 milligrams (mg) by mouth two times a day for hypertension. Hold medication and contact physician if pulse is less than 50 beats per minute. The 06/01/21 Physicians Orders documented [MEDICATION(S)] 0.25 milligrams (mg) by mouth at bedtime for increased agitation secondary to dementia. The 10/02/21 Physicians Orders documented [MEDICATION(S)] 0.25 mg by mouth in the morning and 0.5 mg by mouth at bedtime related to dementia. The Electronic Medication Administration Record (EMAR) from November 2021 through January 2022 documented R11 received [MEDICATION(S)] and [MEDICATION(S)] twice daily as ordered. The facility completed an AIMS assessment on 11/04/21. There was no AIMS assessment completed prior to initiating [MEDICATION(S)] on 10/02/21. The Medication Regimen Reviews for R11 from 01/01/21 through 01/24/22 documented no recommendations from consulting pharmacists regarding AIMS assessments, inappropriate diagnosis for [MEDICATION(S)], or pulse parameters for [MEDICATION(S)]. Observation on 01/25/22 at 07:50 AM revealed R11 sat at a table in her wheelchair in the dining room eating breakfast independently. She appeared relaxed and calm and did not appear agitated, anxious, withdrawn, or in pain. Staff treated her with respect and asked periodically if she needed anything. On 01/26/22 at 09:48 AM Certified Medication Aide (CMA) H stated R11 exhibited angry outburst behaviors. Staff removed her from the situation, took her back to her room, and gave her space. There were no parameters for pulse when administering [MEDICATION(S)] to R11. On 01/26/22 at 10:34 AM Licensed Nurse (LN) F stated nurses monitored for side effects of medications daily, but she did not know if periodic AIMS assessments were completed. She stated there were parameters for pulse for [MEDICATION(S)] administration. The Certified Medication Aide (CMA) obtained R11's pulse before administering [MEDICATION(S)] each time. LN F monitored the pulse in R11's Electronic Health Record (EHR) and the CMA would report to her if the pulse was out of parameter range. The pulse was documented in R11's EHR under the weights and vitals tab. She checked each shift if pulse was within parameters as ordered by the physician. On 01/26/26 at 02:09 PM Administrative Nurse B stated she expected AIMS assessments be completed for residents taking antipsychotic medications. She believed dementia was an inappropriate diagnosis for the use of [MEDICATION(S)] and consulted with R11's physician about the order. She expected pulses be obtained and parameters followed per physician's order for [MEDICATION(S)]. The consulting pharmacist was unavailable for interview as attempted on 01/27/22 at 09:30 AM and 01/31/22 at 09:05 AM. The facility's Abnormal Involuntary Movement Scale (AIMS) Examination policy revised 11/28/17 documented AIMS examinations will be performed on each resident prior to initiation of an antipsychotic medication or [MEDICATION(S)], every six (6) months thereafter and with any significant change while receiving antipsychotic medications. The facility's Medication Monitoring Medication Regimen Review (Monthly Report) policy dated 01/2021 documented: The consultant pharmacist identifies irregularities through a variety of sources including: medication administration records (MARs); prescriber's orders; progress notes of prescribers, nurses, and/or consultants; care plans; laboratory and diagnostic test results, behavior monitoring information, the facility staff and attending physician, and from interviewing, assessing, and/or observing the resident. The consulting pharmacist failed to identify AIMS assessment not completed prior to initiating [MEDICATION(S)], an inappropriate diagnosis for [MEDICATION(S)], and missing pulse parameters before administering [MEDICATION(S)] for R11.

The facility census totaled 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure parameters were documented for [MEDICATION(S)] (blood pressure medication) for Resident (R)11, and the facility failed to notify the physician of blood glucose results outside of parameters for R1 and R4. Findings included: - R1's Order Summary Report dated 11/09/21 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not completed. R1 had short-term memory problems. R1 received insulin six days during the lookback period. The Quarterly MDS dated [DATE] revealed a BIMS score of 11 indicating moderately impaired cognition. R1 received insulin daily. The Care Plan dated 11/15/21 revealed staff were to check R1's blood sugars according to the orders and let the doctor or Advanced Practice Registered Nurse (APRN) know if the level was outside of parameters. An order dated 11/02/21 for blood glucose monitoring before meals and at bedtime for diabetes mellitus. Notify physician if blood glucose was greater than 400 milligrams/deciliter (mg/dL) or less than 100 mg/dl and as needed for elevated blood glucose. Review of the November 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 11/01/21 for a blood sugar of 87. 11/06/21 for a blood sugar of 97. 11/07/21 for a blood sugar of 91. 11/10/21 for a blood sugar of 93. 11/16/21 for a blood sugar of 88. 11/25/21 for a blood sugar of 94. 11/29/21 for a blood sugar of 90. Review of the December 2021 EMAR revealed the physician was not notified on the following dates when blood sugars were out of parameters (mg/dL): 12/01/21 for a blood sugar of 93. 12/04/21 for a blood sugar of 86. 12/17/21 for a blood sugar of 96. 12/25/21 for a blood sugar of 93. 12/26/21 for a blood sugar of 73. 12/30/21 for a blood sugar of 99. Review of the January 2022 EMAR revealed the physician was not notified on the following dates when blood sugars were out of parameters (mg/dL): 01/05/22 for a blood sugar of 90. 01/05/22 for a blood sugar of 89. 01/09/22 for a blood sugar of 89. 01/11/22 for a blood sugar of 98. An observation on 01/25/22 at 07:47 AM revealed R1 sat in her wheelchair at the dining room independently eating breakfast. R1did not show any signs or symptoms of [CONDITION(S)] (less than normal amount of glucose in the blood) or [CONDITION(S)] (greater than normal amount of glucose in the blood). In an interview on 01/26/22 at 09:45 AM, Licensed Nurse (LN) F stated R1 received insulin which had parameters to notify the physician if her blood sugars were less than 100 or greater than 400. LN F stated she would assess the resident for signs or symptoms and then notify the physician and document this in the progress notes. In an interview on 01/26/22 at 01:06 PM, LN C stated she would include a progress note if the physician was notified about blood sugars out of parameters. LN C stated if there were no progress notes written then the physician was not notified. In an interview on 01/26/22 at 10:15 AM, Administrative Nurse B stated she expected the nursing staff to follow the parameters associated with medications and notify the physician if R1 was out of parameters. Administrative Nurse B stated the physician should be notified and document physician notifications either in the regular progress notes or on the administration progress notes. The Clinician Notification policy dated November 2017 revealed, It is the policy that notification of physicians and other clinicians will be done on a timely basis .Decision making regarding notification parameters for clinical signs and symptoms will be based on Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to ensure the staff notified the physician as ordered for blood sugars less than 100 mg/dL for R1. - Resident (R) 4's Order Summary Report dated 11/30/21 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating a BIMS could not be obtained and received insulin daily. The Quarterly MDS dated [DATE] revealed a BIMS score of 99 indicating a BIMS could not be assessed and received insulin daily. The Care Plan dated 06/29/21 revealed staff were to check R4's glucose levels as ordered by my physician and to administer medications for controlling blood sugars per physician orders. An order dated 11/02/21 for blood glucose monitoring every morning and at bedtime related to diabetes mellitus and notify physician if blood glucose was greater than 400 milligrams/deciliter (mg/dL) or less than 60 mg/dl. Review of the November 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 11/20/21 for a blood sugar of 442. Review of the December 2021 EMAR revealed the physician was not notified on the following dates when blood sugars were out of parameters (mg/dL): 12/04/21 for a blood sugar of 407. Review of the January 2022 EMAR revealed the physician was not notified on the following dates when blood sugars were out of parameters (mg/dL): 01/02/22 for a blood sugar of 435. 01/05/22 for a blood sugar of 405. 01/08/22 for a blood sugar of 413. An observation on 01/25/22 at 07:59 AM revealed R4 sat in her wheelchair at the dining room eating breakfast. R4 did not show any signs or symptoms of [CONDITION(S)] (less than normal amount of glucose in the blood) or [CONDITION(S)] (greater than normal amount of glucose in the blood). An interview on 01/26/22 at 09:53 AM, Licensed Nurse (LN) F stated R4 took medications that had parameters associated with them and were to notify the physician if blood sugars were greater than 400 or less than 60. LN F stated she would assess R4 if her blood sugars were out of parameters, notify the physician and document this in a progress note. In an interview on 01/26/22 at 10:15 AM, Administrative Nurse B stated she expected the nursing staff to follow the parameters associated with medications and notify the physician if R1 was out of parameters. Administrative Nurse B stated the physician should be notified and document physician notifications either in the regular progress notes or on the administration progress notes. The Clinician Notification policy dated November 2017 revealed, It is the policy that notification of physicians and other clinicians will be done on a timely basis .Decision making regarding notification parameters for clinical signs and symptoms will be based on Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to ensure the staff notified the physician as ordered for blood sugars more than 400 mg/dL for R4. - The Order Summary Report dated 12/07/21 documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented R11 had both short-term and long-term memory problems and received a diuretic daily during the last seven days. The Care Plan dated 09/03/19 documented R11 took medications that have black box warnings. Staff were to watch out for the indicated reactions and notify her doctor right away. The 10/15/19 Physicians Orders documented [MEDICATION(S)] 50 milligrams (mg) by mouth two times a day for hypertension. Hold medication and contact physician if pulse is less than 50 beats per minute. The Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No parameters were documented. Observation on 01/25/22 at 07:50 AM revealed R11 sat at a table in her wheelchair in the dining room eating breakfast independently. She appeared relaxed and calm and did not appear agitated, anxious, withdrawn, or in pain. Staff treated her with respect and asked periodically if she needed anything. On 01/26/22 09:48 AM Certified Medication Aide (CMA) H stated there were no parameters for pulse when administering [MEDICATION(S)] to R11. On 01/26/22 10:34 AM Licensed Nurse (LN) F stated there were parameters for pulse for [MEDICATION(S)] administration. The Certified Medication Aide (CMA) obtained R11's pulse before administering [MEDICATION(S)] each time. LN F monitored the pulse in R11's Electronic Health Record (EHR) and the CMA would report to her if the pulse was out of parameter range. The pulse was documented in R11's EHR under the weights and vitals tab. She checked each shift if pulse was within parameters as ordered by the physician. On 01/26/26 at 02:09 PM Administrative Nurse B stated she expected pulses be obtained and parameters followed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Medication Monitoring Medication Regimen Review (Monthly Report) policy dated 01/2021 documented: The consultant pharmacist identifies irregularities through a variety of sources including: medication administration records (MARs); prescriber's orders; progress notes of prescribers, nurses, and/or consultants; care plans; laboratory and diagnostic test results, behavior monitoring information, the facility staff and attending physician, and from interviewing, assessing, and/or observing the resident. The facility failed to obtain the R11 pulse before administering [MEDICATION(S)].

The facility reported a census of 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure one of five residents did not receive unnecessary medications when the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment before initiating [MEDICATION(S)] (antipsychotic medication) and the facility did not ensure an appropriate indication for prescribing [MEDICATION(S)] for Resident (R)11. Findings included: - The Order Summary Report dated 12/07/21 documented diagnosis for dementia (progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented R11 had both short-term and long-term memory problems and received an antipsychotic daily during the last seven days. The Care Plan dated 01/10/22 documented R11 experienced behavioral symptoms. Interventions included to administer [MEDICATION(S)] as ordered to help manage her behaviors. The 06/01/21 Physicians Orders documented [MEDICATION(S)] 0.25 milligrams (mg) by mouth at bedtime for increased agitation secondary to dementia. The 10/02/21 Physicians Orders documented [MEDICATION(S)] 0.25 mg by mouth in the morning and 0.5 mg by mouth at bedtime related to dementia. The State Operations Manual, Appendix PP documented, If antipsychotic medications are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement care-planned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of these interventions. The Electronic Medication Administration Record (EMAR) from November 2021 through January 2022 documented R11 received [MEDICATION(S)] twice daily as ordered. The facility completed an AIMS assessment on 11/04/21. There was no AIMS assessment completed prior to initiating [MEDICATION(S)]. Observation on 01/25/22 07:50 AM revealed R11 sat at a table in her wheelchair in the dining room eating breakfast independently. She appeared relaxed and calm. She did not appear agitated, anxious, withdrawn, or in pain. Staff treated her with respect and asked periodically if she needed anything. On 01/26/22 09:48 AM Certified Medication Aide (CMA) H stated R11 exhibited angry outburst behaviors. Staff removed her from the situation, took her back to her room, and gave her space. On 01/26/22 10:34 AM Licensed Nurse (LN) F stated nurses monitored for side effects of medications daily, but she was not aware if periodic AIMS assessments were completed. On 01/26/26 at 02:09 PM Administrative Nurse B stated she expected AIMS assessments be completed for residents taking antipsychotic medications. She believed dementia was an inappropriate diagnosis for the use of [MEDICATION(S)] and consulted with R11's physician about the order. The facility's Abnormal Involuntary Movement Scale (AIMS) Examination policy revised 11/28/17 documented AIMS examinations will be performed on each resident prior to initiation of an antipsychotic medication or [MEDICATION(S)], every six months thereafter and with any significant change while receiving antipsychotic medications. The facility failed to complete an AIMS assessment prior to initiating [MEDICATION(S)] and failed to provide an appropriate diagnosis.

The facility census totaled 46 residents with 1 resident reviewed for pain. Based on observation, interview, and record review, the facility failed to manage acute pain exhibited by resident #46 after he/she fell and injured his/her right wrist/hand area. The facility staff failed to implement non-pharmacological orders to assist with controlling the resident's pain, for at least 6 hours after staff received the order. Findings included: - Resident #46's diagnoses, per physician progress notes [REDACTED]. Review of the admission minimum data set (MDS), dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating intact cognition. The resident required extensive assistance of 2 staff members with transfers and locomotion on and off the unit. The resident received as needed (PRN) pain medications and non-medication interventions for pain rated 7 out of 10 (scale from 0 - 10) and the resident reported the pain interfered with his/her sleep, during the 5-day review period. Review of the activities of daily living (ADL) care area assessment (CAA), dated 10/22/18, revealed the resident admitted to the facility due to his/her need for increased assistance with his/her ADLs and for skilled services from physical therapy, occupational therapy, and speech therapy. The pain CAA, dated 10/22/18, revealed the resident reported pain, primarily to his/her left heel secondary to a 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) with recent debridement (surgical removal of dead tissue). He/she had orders for as needed (PRN) narcotic pain medication. The residents plan of care, dated 11/20/18, did not include any guidance to the facility staff as to his/her potential indicators of pain and/or direct staff in monitoring and treating the resident's pain. review of the resident's medical record revealed [REDACTED]. There were no further nurse's notes located in the medical record after that entry. Review of the witnessed fall report dated 12/11/18 at 2:54 PM, provided by administrative nursing staff B, revealed the resident was sitting upright on the floor between bed and wheelchair and the resident's family member witnessed the fall. The resident reported he/she attempted to get into his/her wheelchair without assistance and lost his/her balance. He/she caught his/herself with his/her hands. The immediate action the nursing staff provided was to assess the resident and obtain his/her vital signs. The resident had no obvious injuries and did not complain of pain. Approximately 15 minutes after the fall, the resident complained of pain to the right wrist area. Staff notified the physician and he/she ordered an X-Ray for the right wrist. Review of the medication administration record (MAR) revealed staff administered [MEDICATION NAME] 650 milligrams (mg) to the resident at 6:29 PM on 12/11/18 for a reported pain level of 8 out of 10 and documented the medication as effective. There was no further documentation of narcotic or non-narcotic pain medication administration to the resident since that time. Observation on 12/12/18 at 8:42 AM revealed the resident in bed, moaning and stated his/her hand hurt like crazy and he/she could not get any sleep last night due to the pain in his/her hand. The resident had facial grimacing and made soft moaning sounds in between his/her statements. At that time, direct care staff C arrived in the room and assisted direct care staff F with getting the resident dressed and out of bed. The resident continued to moan and complained of pain during the care, with direct care staff C reported that licensed nursing staff D was aware of the resident's pain. Observation revealed [MEDICAL CONDITION] (swelling) to the right wrist area of the resident and staff applied an ice pack. Observation on 12/12/18 at 9:34 AM revealed the resident sat at the dining room table and required assistance with eating from direct care staff C. He/she continued to complain of his/her right-hand hurting. The resident reported he/she had not received any medication for pain. The ice pack was still in place but was warm to touch. He/she continued with the facial grimacing. Observation on 12/12/18 at 9:47 AM revealed direct care staff C wheeled the resident to the nurse's station for licensed nursing staff D to apply a splint and ACE wrap. The resident verbally commented about his/her pain but did not display any non-verbal indicators of pain. Observation on 12/12/18 at 1:11 PM revealed the resident at the dining room table, he/she held a mug in his/her hands and he/she did not display any facial grimacing or vocalization of pain. Interview with the resident on 12/12/18 at 8:42 AM revealed the resident complained of his/her right arm/wrist hurting and that he/she could not sleep very well last night due to the pain. He/she stated the only thing that had been done was the X-Ray of his right arm and he/she did not know what else had been ordered for the treatment. On 12/12/18 at 1:32 PM, the resident reported the pain was much better and manageable. Interview with direct care staff C on 12/12/18 at 8:59 AM revealed the resident could communicate his/her pain status and the injury to the right hand/wrist area was from a fall resident #46 had yesterday. Staff C knew the physician ordered X-Rays of the extremity last night, but he/she did not know the results or of any other interventions for the resident. Interview with licensed nursing staff D on 12/12/18 at 9:40 AM revealed the physician extender notified him/her resident #46's x-ray was inconclusive, and the determination of a fracture could not be made at that time due to the amount of swelling to the area. Staff I was given an order to apply and ACE wrap and ice to the affected area at that time. Staff I reported he/she was going to apply the ACE wrap when he/she arrived, but the facility was out of ACE wraps. Staff I reported the resident had been out of his/her narcotic pain medication for several days since the facility had been waiting for the written prescription from the physician to refill the medication. Interview with licensed nursing staff P on 12/13/18 at 5:35 AM revealed he/she was not providing care to the resident the night of the fall. He/she did report the resident had received a narcotic pain medication at 11:40 AM on 12/12/18 after the new prescription for the medication had been picked up and resident #46's pain had been well managed since then. During an interview with administrative nursing staff B on 12/12/18 at 10:11 AM revealed he/she could not find any documentation regarding the resident's fall that occurred on 12/11/18 in his/her medical record. He/she could not find any orders for an X-Ray, Ice Pack, ACE wrap, or splint in the medical record as well. Staff B went to the risk management reports and located a report about the resident's fall. Staff B stated he/she did not know the resident complained of being in pain and that he/she reported not being able to sleep. At 2:36 PM on 12/12/18, Staff B reported he/she went to the physician's office and obtained the written prescription for the narcotic pain medication and then went to the pharmacy to get it filled for resident #46. He/she reported the resident had been declining the narcotic pain medication prior to this injury, but since he/she fell , the resident reported needing them again. During an interview with physician extender I on 12/12/18 at 1:40 PM revealed there was no fracture, but the resident had a contusion (bruise) to the right wrist area. He/she advised staff to continue monitoring the area. Physician O asked licensed nursing staff D if the resident had asked for the narcotic pain medication regularly, and licensed nursing staff D reported resident #46 asked, but the facility had been out of it for a little bit. At 3:28 PM on 12/12/18, physician extender I reported he/she did not know licensed nursing staff D had not been at the facility when he/she contacted them on the evening of 12/11/18 and gave the orders for the ACE wrap, Ice pack, and X-Ray. He/she did not know the ACE wrap had not been applied until 12/12/18 at 9:47 AM and if he/she would have known that, he/she would have brought the supplies up to the facility last night and placed them on the resident. He/she reported the splint and ACE wrap were going to assist with the pain control the most. Review of the policy entitled Pain management, revised 11/28/17, revealed ongoing pain monitoring would be conducted at least 3 times daily and recorded on the medication administration record (MAR). The history of the residents PRN pain medication usage would be evaluated to determine if there is a need to request routinely scheduled pain medication. The pain management analysis-verbal would be used for any resident able to state their pain status. The facility failed to ensure resident #46 had adequate pain control after an acute (sudden) injury. Facility staff failed to apply ACE wraps as ordered and did not monitor or document the resident for changes in pain status or administer narcotic and/or non-narcotic pain medications as indicated.